Andrew Gardner, presented at NWULG February 2012

1. Andrew Gardner
ESP Upper Limb physiotherapist
Lancashire Teaching Hospitals NHS Trust

2. FIGURE
Effect of rotator cuff deficiency
 Centring forces lost.
 Superior humeral migration.
 GH joint cartilage
destruction.
 Superior glenoid erosion.
 Synovial fluid leak.
 Osteoporosis.
 Humeral head destruction.
F
 Articulation with acromion,
 Coraco -acromio ligt erosion.
 Acromio clavicular joint
destruction.

3. Problems with Rotator cuff tear and
traditional TSR
 Joint mechanics altered.
 Centre of rotation superiorly shifted
during elevation.
 Increased shear forces.
 Glenoid loosening.
 Humeral head migrates superiorly.
 90° Flexion typical.
 High functional return unrealistic.
 Pain relief?
 Overhead motion unlikely.

4. Reversed Prosthesis (rTSR)
 Grammont et al (1993)
 Salvage procedure. (Boileau et al) 2005

5. Indications for rTSR
 Pain associated with rotator cuff tear arthropathy (most
common).
 Failed hemiarthroplasty with irreparable rotator cuff
tears.
 Pseudoparalysis .(i.e. inability to lift the arm above the
horizontal)
 Reconstructions after tumour resection.
 Fractures of the shoulder .(Neer three-part or four-part #)
 Non-union #.
 Severe rheumatoid arthritis.

6. Biomechanical effects of reversed
prosthesis
-The lever arm distance (L) is
increased and deltoid force
(F)is increased by lowering
and medializing the centre of
rotation which is now also
fixed.
-Torque (F x L) in abducting
the arm is increased.
-Deltoid tension increased on
lifting and lowering arm.
-↑ Joint compression.
-105° elevation +.

7.  Medialising the centre of rotation recruits
more of the deltoid fibres for elevation or
abduction but…

8. Effects of reversed prosthesis on
muscle lengths and tensions.
 Fewer posterior deltoid fibres are available for external rotation.
 Remaining Cuff length tension is decreased.
 Teres minor dysfunction→ No rotation (Boudreau et al 2007).
 30° External rotation= optimum required for function.
 Teres minor/posterior cuff and deltoid therefore vital for function.
 However 35°+ External rotation→ posterior notching. Care with passive external rotation for
stability.

9. Complications of rTSR
 Scapula notching (most common).
 Infection.
 Dislocation.
 Component instability/loosening.
 Acromion #.
 Hardware failure.
 Nerve damage.
 Intra-operative #.

10. Pre op Status. ROM
(Age, co-morbidity, Social, family support) Muscle function
Sling Pre-0p assessment Timescales(ADL)
Patient Patient Walking aids
expectations education
(chair/bed transfers,
personal hygiene etc)

11. Surgeon/physio
communication
 Pre-op Status
 Surgical approach
 Cuff repair
 Implant type
 Additional procedures
 Component stability
 Complications
 Rehab expectations

12. Immediate post op.
Cryotherapy
 Ensure Interscalene block has worn off.
 Early phase of rehabilitation.
 Analgesic effect (15-16° tissue temperature)
 Post rTSR (Speer et al 1996)
No =50.
24 hours hourly Rx.
4-6x daily until 10/7.
- Easier pain
-Easier movement (10 days)
-Better sleep.

13. Immobilisation
1st approach
 Sling for comfort only 2-3/52. (Static joint control
more important)
 Remove as pain starts to settle.(Blacknall et al 2011)
2nd approach
 ?Abduction sling in 30°elevation and Abduction
recommended by (Boudreau 2007).
 Patient “to see the elbow”.
 4-6 weeks immobilisation if the shoulder is a revision.
 15° External rotation of sling if posterior cuff repaired. Less
muscle stiffness.

14. Precautions
 Avoid adduction + Internal
Rotation (Anterior-inferior
dislocation).
 Other sources advocate no ABER.
 Consensus is to avoid extension
beyond neutral.
 Avoid hand behind back in early
stages of rehabilitation.
 No Lifting. (Limited to cup/eating
utensils).
 No weight bearing through limb.

15. Early Rehabilitation (1-6weeks)
Rehabilitation is different compared with a
conventional TSR
 Check post-op notes. Implant fixation.
 ?Subscapularis repair (osteotomy of tuberosity)/
Latissimus dorsi repair.
 Mackensie incision. Deltoid split. No deltoid or active
ROM 6/52. Isotonic deltoid exercises at 12/52.
 Acromial stress #?. Stop AROM or deltoid isometrics for
4-6/52 or until pain subsides.
 Nerve Block resolution.(Deltoid and sensory function
affected)

16. Early rehabilitation (1-6weeks)
 Hand, wrist, elbow exercises.
 Scapular setting and postural control.
 Restore PROM.
-Flexion -90° in scapula plane,
-Abduction -Nil-20°,
-External Rotation in scapula plane 0-30°.
 ½ lever exercises/pulley.
 Sub maximal (less than 30%) isometric periscapula
exercises at 2/52 & deltoid exercises at 4/52.
 Active assisted exercises within a “safe zone” at 4/52.
 No active IR ROM or hand behind the back for 6/52.

17. Phase 1 Rehabilitation for rTSR
(after Blacknall 2011)
Protected mobilisation phase
-Sling as comfortable.
-Assisted flexion /Pulley to 90° because the Delta 3 implant
impinges at 90°.
-Focus on scapula dissociation with movements.
-Supine 30° passive external rotation.
-Static joint holds at 90°.
-Functional Base Test .
-Movement up to 90° active assisted flexion in supine with a
stick at 4/52.
-Constrained active assisted exercises and static joint
control.

18. Static hold &Functional Base Test

19. Phase 2 Rehabilitation. Movement control
phase.
• Progress to AROM and joint control exercises through
previously active assisted ranges in a logical manner.
• No elevation restriction.
• Address previously learned abnormal movement patterns.
• Address any scapula dyskinesis.
N.B. Increased scapular upward rotation in rTSR.
• Focus on Neuromuscular control.
Progression criteria:
-Pain free
-No instability
-Completed functional base test.
• Little and often rule. Avoid fatigue .Full control of movement.

20. Rehabilitation exercises and strategies (Phase 2)
• Short lever flexion to long lever.
• Incline glenohumeral dissociation.
• Increase ER control in different
positions.
• Scapula dynamic control
exercises/rehabilitation.
• Use biofeedback++
Mirrors, Video, therapist verbal and
tactile input, US, Surface
electromyography.
• Incorporate exercises into function.
• Posterior Cuff/Lat Dorsi rehab (as
appropriate)
• Hand behind back and extension
control. Anterior deltoid control
essential for this.
• Wrist & elbow strengthening.

21. Functional Rehabilitation 4months +. (Phase
3)
 Progress deltoid rehabilitation. 20-30 reps no fatigue.
 Resisted shoulder external rotation and belly press
exercises.
 Functional specific training in standing.
 Progress strength and endurance through functional
activity.
 Limit 4.5-6.8 kg maximum.
(Boudreau et al 2007, Blacknall et al 2011)

22. Function guide
 Dextrous activities at low level (Crafts), feeding, personal
care and dressing.
 Functional loaded movement.
 Gardening without overhead or loaded activity e.g.
pruning or digging.
 Walking, ballroom dancing, stationary bicycling allowed.
 Swimming, bowls and golf only allowable with movement
control.
 Technique change.
 No sporting activity that could lead to a fall e.g. Skiing,
Tennis, Step aerobics etc...(Magnussen et al 2010)

23. Reasons for non/slow progression
• Deficiency in posterior cuff.
Positive external rotation lag
sign.
• Abnormal scapula control.
• Additional procedures.
• Neural deficit.
Axillary nerve.
Long thoracic nerve.
Spinal accessory nerve.
Help
• Counselling.
• Hydrotherapy.
• Occupational Therapy.
• Pain Management.

24. Research

25. Summary
 rTSR rehabilitation is different from traditional shoulder
replacement.
 Pre-op assessment, includes discussion of expectations and post
op social circumstances to prevent possible complications.
 Therapists must have good communication with the surgeon.
Each case should be dealt with on an individual basis.
 Papers report differing positions for instability of the rTSR.
• The consensus is that rehabilitation in the initial stages focuses
on stability and protection of the prosthesis.
 Later rehabilitation focuses on rehabilitation of the Deltoid
with static and dynamic shoulder control through progressive
AAROM ,then AROM.
 Must address any abnormal previously learned movement
patterns and any scapula dyskinesis.

26. Summary Continued.
 Expected elevation is increased with a functioning Teres Minor
or the posterior cuff. Increased external rotation movement to
30° and control has been linked with improved stability and
function of the rTSR.
 Latissimus transfer /cuff repair can be additional procedures to
deal with. They will expand the timeframe of recovery.
 Some patients will still have a poor outcome. Having strategies
to deal with this are necessary.
 Research studies have still shown this procedure to have great
benefits in terms of pain control, movement and function.
 Strategies for rehabilitation of the rTSR are changing and
evolving. There are differences in rehabilitation regimens which
need evaluation.
 Longer term studies for the rTSR are required.