The ream and run - the CRITICAL first 6 weeks of rehabilitation

The ream and run shoulder arthroplasty is now widely used for the management of glenohumeral arthritis in patients who wish to avoid the risks and limitations associated with the plastic glenoid component that is used in conventional total shoulder arthroplasty.

In addition to (a) proper patient selection, (b) preoperative patient education and (c) excellent surgical technique (d) proper postoperative rehabilitation is essential to achieving the desired outcome. 

Here we present our basic rehabilitation program. The surgeon will modify program according to the specifics of the surgery or the patient.

But first, a few important things to remember:

(1) patients should plan to be in town for at least 5 days after surgery

(2) for the first six weeks after surgery, patients should not drive a car, attempt to lift the arm by itself, carry anything heavier than a coffee cup. 

(3) patients should plan to wear clothes that are easy to get on and off (slip on shoes without socks), button (not pull over) short sleeve shirts, pants that can be easily pulled up. 

(4) patients should ask lots of questions before surgery

 

    The UW Ream and Run Rehabilitation Program

Without question, the patients who achieve 150 degrees of assisted elevation before leaving the hospital the morning after surgery do the best after the ream and run procedure. 

However, unless it comes easily and comfortably, stretching beyond 150 in the first six weeks may challenge the subscapularis repair. More than 150 is not more!

While motion can be improved after discharge, preventing stiffness can get increasingly challenging with successive weeks after the procedure.  For this reason we ask all patients to study the information presented here before surgery, to familiarize themselves and their support team with the exercises, and to ask questions before surgery.

Step 1: Postoperative rehabilitation begins before the patient leaves the operating room.  The surgeon documents that the shoulder has a full range of active elevation. We take a photo to document the range of flexion after wound closure and show it to the patient for education and inspiration.

Step 2: The patient starts assisted elevation using the supine stretch on the evening of their surgery. Brachial plexus blocks are avoided so that the patient sees that the desired motion of 150 degrees of assisted flexion can be achieved using analgesics that they can take at home. In the supine stretch, the opposite arm slowly raises the relaxed surgical arm to the full overhead position as shown below. The relaxed surgical arm is held in the full overhead position for 20 seconds. Starting immediately after surgery, three repetitions of this exercise are performed four times per day. Emphasis is placed on slow relaxed motion while the surgical arm is passively raised and lowered by the opposite arm.

Step 3: For the first six weeks after surgery, the patient continues assisted elevation using this supine stretch at home using the opposite arm to move the relaxed surgical arm. The relaxed surgical arm is held in the full overhead position for 20 seconds. Three repetitions of exercise are performed four times per day. Each week the patient emails the surgeon a photo taken from the side showing the range of motion achieved (see example below). This enables the surgeon to carefully track the recovery.

While this supine stretch exercise is the most effective exercise for maintaining the range of motion after surgery, two other exercises may be used - not as a substitute - but in addition. One is pulley elevation in which the relaxed surgical arm holding on to the pulley handle is lifted by the opposite arm that pulls down on the rope. Several repetitions of the pulley exercise can be used as a warm up before the supine stretch.

Another effective exercise is the table slide. This, like the pulley, is useful when the opposite arm is painful or stiff. In the table slide, the surgical arm slides forward on a smooth surface while the body leans forward. The relaxed surgical arm is held in the stretch position for 20 seconds. Three repetitions of this exercise are performed four times per day

The goal of each of these exercises is to keep the "critical angle" (shown in red), open to at least 150 degrees.

150 degrees

Because keeping this motion is so critical to the success of the ream and run, we ask each patient to send us a photo like the below each week for the first six weeks after surgery so we can be sure they are on track.

During the first six weeks after surgery, some patients become concerned that they cannot raise the surgical arm by itself. It is important to remind these patients that they are not supposed to attempt active elevation of the arm until given the go ahead by the surgeon because healing of the subscapularis tendon repair needs to take place first.

Step 4: Protect the subscapularis.

At the conclusion of the ream and run procedure, the subscapularis tendon is repaired to the humerus.

Although we go to every effort to make a strong repair, the tendon takes several months to become securely attached to the humerus. During this time the patient must protect the repair from (A) stretching beyond the "handshake" portion

and from (B) falls or internal rotation against any resistance (such as closing a car door). The exercise below are avoided.

Failure to protect the subscapularis can result in failure of any type of anatomic shoulder joint replacement, including the ream and run.

Step 5: Sideways lean. At two weeks after surgery, the sideways lean can be started. With the forearm resting securely on a smooth table surface, lean to the side so that the angle between the arm and the body is opened. The relaxed surgical arm is held in the stretch position for 20 seconds. Repeat three times, four times per day.

Step 6: Sleeper stretch. At four weeks after surgery, begin the sleeper stretch. Lie on the side of the surgical shoulder with the arm out in front and the elbow bent to a right angle. Rotate the forearm downward using the opposite hand. The relaxed surgical arm is held in the stretch position for 20 seconds. Repeat three times, four times per day.

Step 6: Cross body stretch. With the opposite hand on the elbow of the surgical arm, bring the elbow towards the opposite shoulder. The relaxed surgical arm is held in the stretch position for 20 seconds. Repeat three times, four times per day.

Comment: Patients need to familiarize themselves with these exercises before surgery so that they can plan to perform them after surgery. Patients also need to plan for protecting the subscapularis repair.

Comments welcome at shoulderarthritis@uw.edu

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).