Outpatient Physical Therapy as Treatment for Reverse Total Shoulder Arthroplasty

The glenohumeral joint, otherwise known as the shoulder joint, is made up of the head of the humerus, clavicle, and the scapula. In the shoulder joint, stability has been sacrificed to provide the most freely moving joint of the body. The shoulder is a ball-and-socket joint. The large hemispherical head of the humerus fits in the small, shallow glenoid cavity of the scapula, like a golf ball sitting on a tee.

There are multiple reasons why individuals may need to have a shoulder replacement. Some of those reasons may be osteoporosis, rheumatoid arthritis, avascular necrosis, or even a fracture if severe enough. Functional results after TSA vary, depending largely on the underlying cause.2 The most common cause is usually due to a rotator cuff tear or normal wear and tear leading to arthritis. This often leads to difficulty doing everyday tasks that involve reaching overhead, or sometimes behind the back, hence why people need to have shoulder replacements. Shoulder replacements aren’t as common as hip or knee replacements; however, they are just as effective in relieving joint pain most of the time.

There are three different types of shoulder replacement procedures; a total shoulder arthroplasty, partial shoulder arthroplasty, and a reverse shoulder arthroplasty. A total shoulder arthroplasty procedure consists of replacing the whole shoulder joint, whereas the partial shoulder surgery just consists of replacing the head of the humerus. A reverse total shoulder arthroplasty is not as common as the other two types of shoulder replacements, but is necessary for those in an instance that the rotator cuff muscles are severely damaged, don’t function as needed, or result from a severe fracture. During a reverse total shoulder replacement the artificial hardware the surgeon puts in place makes the head of the humerus the socket and they place a ball into the shoulder joint space. With the procedure being done this way, the ball-and-socket joint is now reversed from how it normally is. For an individual who has had a reverse total shoulder arthroplasty, their outcome isn’t the same as someone who has a normal total shoulder arthroplasty procedure. Due to how a reverse total shoulder replacement is performed, those who have this procedure done aren’t expected to regain full range of motion (ROM).

Typical physical therapy treatment for any type of shoulder replacement consists of strengthening and restoring range of motion, and sometimes the use of manual therapy or modalities to help manage pain. Just like any joint replacement surgery, early mobilization is a key intervention to restore range of motion because joint motion is a necessary component of most functional tasks.3

This patient is an 82-year-old female who I will refer to as Jane. Due to pain in the right shoulder, and deteriorating rotator cuff muscles, Jane ended up having a reverse total shoulder arthroplasty. Her past medical history includes a heart condition and a previous eye surgery. Jane also has reported that she has arthritis, scoliosis, and stenosis all in her back. She has no allergies, and her current medications were reviewed with the referring doctor. Also, Jane’s grandson lives with her as he does all the cooking and any other tasks that she’s unable to do, which is very discouraging to her.

Jane presents to therapy for her initial evaluation on January 20, 2020 with a diagnosis of stiffness in both of her shoulders, as well as the right wrist and elbow, effusion of the right hand, muscle weakness (generalized), and pain in the left shoulder. She had a reverse total shoulder arthroplasty on her right shoulder on December 5, 2019. Her doctor referred her to physical therapy when she had a check up and noticed her hand was swollen. Jane hasn’t had any pain in her right shoulder since the surgery; however, her left shoulder is causing her pain as she states that it needs replaced as well. The worst the pain in her left shoulder has been she rated as an 8/10, and the best it has ever been is a 2/10.

Jane also complains of feeling very weak and has trouble putting it in certain positions. She reports independence with dressing and bathing; however, with her being right hand dominant she claims that it takes a long time to do so. Due to weakness and lack of motion, Jane can’t eat with her right hand anymore, drive, or even sign a check. The doctor has instructed her not to lift anything heavier than a gallon of milk. Before coming to therapy, Jane started working on some exercises at home that she remembered she was given at the hospital following her surgery. These exercises included pendulums, shoulder flexion by sliding her hand up the wall, and using her thera-putty. Jane’s goals are to restore her strength and range of motion so that she may become more independent and achieve maximum functional mobility.

Range of Motion: Jane’s upper extremities were tested actively with the following objective findings for the left shoulder: flexion was 108˚, and abduction was 85˚. The following were the objective findings for the right shoulder: flexion was 108˚, and abduction was 98˚.

Strength: Grip strength was measured using a hand-held dynamometer. Jane’s grip strength on the right side was 20 pounds, and the left was 40 pounds.

Goals: Jane’s plan of care includes duration of 8 weeks at 2 times per week, for a total of 16 visits. She is a moderate complexity case due to 1-2 personal factors and/or comorbidities that impact the plan of care. Jane’s rehab potential is fair, and she has given verbal informed consent to proceed with treatment.