Monday, April 18, 2016

Rehabilitation after shoulder arthroplasty - cautions!

A key to success after shoulder replacement for arthritis is the post operative exercise program. Click on this link: rehabilitation program to see our usual approach, although this may be modified in certain circumstances.

One of the key facts to keep in mind during the first 3 months after shoulder joint replacement is that the subscapularis muscle is cut off the front of the humerus early in the surgical operation to gain access to the joint. In the figure below, the subscapularis has been retracted to the right with two sutures.


Near the end of the case, repair sutures are placed through the bone.
Once the humeral implant is in position, the subcapularis is repaired to the previously placed sutures.
Although this repair is usually strong enough for Phase I of the early motion program, advanced healing of the repair is necessary before the shoulder can be stretched in passive external rotation or strengthened in active internal rotation. For this reason the two sets of exercises shown below are AVOIDED. 


EXTERNAL ROTATION STRETCHING  



INTERNAL ROTATION STRENGTHENING



 Our resident Zlomislic demonstrated that the tension is not evenly distributed across the repair sutures and that the superior suture takes the preponderance of the load in the activities shown above - activities that put it at risk of pulling through the tendon.


One our concerns is that patients may stress their rotator cuff after shoulder arthroplasty. It is important to keep in mind that in the arthritic shoulder, the rotator cuff is disused. After shoulder arthroplasty, the joint is freed up and mobile, but the cuff is not ready for heavy use and is at risk for failure as observed here.

The web is wonderful, but it may tempt folks to exercises that are not ideal for their shoulder situation. The following exercises sent to me by one of our patients are NOT recommended after shoulder arthroplasty.








The safest exercise program is shown here.

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