Post-Operative Shoulder Replacement – Case Report

History: The patient presented approximately two weeks following a right total shoulder replacement (TSR). He had previously undergone a left total shoulder replacement, with both surgeries involving anatomical shoulder prostheses. The patient reported experiencing less bruising and pain after the right shoulder surgery compared to the left. He noted that the surgeon used a larger prosthetic head on the right side and had an easier time accessing the shoulder joint through the deltoid during the procedure. Post-operatively, the patient has been performing Codman’s exercises at home. He was advised that he could resume driving at four weeks post-operation and is scheduled for a follow-up appointment with his surgeon approximately six weeks after beginning therapy. The patient has successfully discontinued pain medications. He has been instructed to continue wearing his sling when outside the home but may remove it while at home. Sling use is not required during sleep. The patient reports some difficulty sleeping, primarily due to trying to sleep on his back, whereas he prefers sleeping on his right side. The patient is left-handed, and his rehabilitation goals include returning to climbing and playing tennis.

Functional Limitations:

• Reaching over head
• Lifting anything over 1-2 lbs
• Lack of shoulder range of motion for bathing and dressing
• Unable to sleep on his R side
• Unable to play tennis or climb

Objective Measurements:

• Shoulder active range of motion L shoulder flexion and abduction was 150 degrees. R shoulder active range was not tested due to surgical precautions at 2 weeks post op. R elbow active range of motion was 0-140 degrees.
• R shoulder passive range of motion. flexion 90deg abduction 70deg IR 65deg ER 30deg.
• Upper Extremity Quick DASH 66% disability.
• Positive ecchymosis, incision were healing well.

Treatment:

Manual Therapy– High emphasis on manual therapy at the start of therapy due to surgical precautions. Massage was utilized to assist with swelling, decrease tightness and improve healing. Majority of initial visits were focused on passive range of motion at the shoulder with the goal to improve range of motion. As the patient progressed through stages of the rehabilitation added scapular mobilizations, gentle glenohumeral joint mobilizations, manual resistance with rhythmic stabilization and longer sustained holds for stretching to the muscles surrounding the R shoulder.

Exercise

Initial focus of exercises focused on assisted range of motion, including table slides and pulleys. Started with light postural retraining including scapular retraction and scapular PNF. Able to progress to active range of motion and finally stretching.

Strength training started once the patient was able to initiate isometrics per surgical protocol. Progression continued with deltoid, rotator cuff and scapular strengthening. Examples of exercises included side lying external rotation, side lying abduction, prone rows, prone mid trap, and shoulder extension. As scapular stabilization with shoulder elevation improved, a greater focus was put on deltoid and shoulder flexion strength including chest press, wall slides with weight and overhead press.

Functional Loading
Worked on loading through the shoulder joint as well as push and pull movements for return to rock climbing.

Results: The patient was seen for 23 visits. The patient demonstrated a right overhead reach of greater than 130 degrees, tested at 4+/5 or greater in shoulder strength in all directions and only reported a 9% disability on QuickDash form for functional mobility. The patient had returned to rock climbing and playing tennis without pain. The patient had a quicker and easier recovery than his L TSR, despite the same surgery by the same surgeon.