A review of the reverse total shoulder replacement surgery and it's clinical implications for both physical rehabilitation and functional anatomy. Objectives: Understand basic anatomy of the shoulder complex and its implications for shoulder replacement Understand indications for shoulder replacement Understand differences between standard and reverse total shoulder replacements Understand precautions following rTSA Understand important concepts in rehabilitation following rTSA

1. Reverse Total Shoulder
Arthroplasty
Anatomy, Rehabilitation and Clinical Implications
Rafael E. Salazar II, MHS, OTR/L

2. Objectives
Understand basic anatomy of the shoulder
complex and its implications for shoulder
replacement
Understand indications for shoulder replacement
Understand differences between standard and
reverse total shoulder replacements
Understand precautions following rTSA
Understand important concepts in rehabilitation
following rTSA

3. Bony Anatomy
Humerus
Clavicle
Scapula
Sternum
Ribs

4. Anatomy of the Shoulder Complex
4 main
components:
 Glenohumeral (GH) joint
 Acromioclavicular (AC)
joint
 Sternoclavicular joint
 Scapulothoracic joint
(gliding mechanism)
(Peat, 1986)
(Terry & Chopp, 2000)

5. Sternoclavicular Joint &
Acromioclavicular Joint
 SC Joint Functions:
 Acts as only bony attachment of
the upper extremity (UE) to the
axial Skeleton
 Allows for elevation, depression,
protraction and retraction of
clavicle
 Axial rotation with shoulder
elevation (Terry & Chopp, 2000)
 AC Joint Functions:
 Contributes to total arm
movement as well as transmitting
force between clavicle and
acromion (Peat, 1986)
 Elevation/Depression in relation
to scapular movement
 Axial rotation with elevation of the
shoulder (Peat, 1986)
(Terry & Chopp, 2000)

6. Scapulothoracic Mechanism
 Has NO bony attachments
to the axial skeleton other
than through AC and SC
joints (Culham & Pete, 1993)
 Held in place through
axioscapular muscles to
include:
 Trapezius, serratus anterior,
rhomboid major/minor,
levator scapulae
 Function: Allows increased
shoulder mov’ts
 Approx. 1 degree of
scapulothoracic elevation
for every 2 degrees of GH
elevation (Terry & Chopp, 2000)

7. Scapulothoracic Movement

8. Glenohumeral Joint
 Synovial Ball and Socket
Joint
 Large head of humerus on
smaller, shallow glenoid
fossa
 About 25-30% of humeral
head is in contact with
glenoid
 Relies on both static and
dynamic stabilizing forces to
provide stability (Terry & Chopp,
2000)

9. Static Stabilizers of the GH Joint
 Articular Surface
 Glenoid articular cartilage is
thicker at periphery
 Glenoid Labrum
 Dense fibrous tissue; extends
articular surfaces, increasing
stability
 Also acts as an anchor point for
capsuloligamentus structures
 Joint Capsule
 Approximately twice the surface
area of humeral head
 Reciprocally tighten and loosen
with rotation of the arm to limit
translation
 Ligaments
 Coracohumeral ligament
 Glenohumeral ligaments
(Terry & Chopp, 2000)

10. Dynamic Stabilizers of the GH Joint
 Rotator Cuff Muscles:
 Subscapularis
 Infraspiantus
 Supraspinatus
 Teres Minor
 All of the tendons of the RC
muscles blend intricately
with the fibrous capsule (Peat,
1986)
 Contraction of the Rotator
Cuff results in concavity-
compression
 Centers the humeral head;
important stabilizing
mechanism
(Terry & Chopp, 2000)

11. Other Shoulder Muscles
 Deltoid Muscle
 Functions to assist in GH
flexion and abduction and
extension
 Biceps
 2 Heads: long head and
short head
 Long Head is located
between supraspinatus and
subscapularis and functions
as a humeral head
depressor during abduction
(Terry & Chopp, 2000)

12. Indications for TSA:
Total Shoulder Replacement
 Advanced Glenohumeral
pathology (degenerative
changes) caused by:
 Osteoarthritis (OA)
 Rheumatoid Arthritis (RA)
 Osteonecrosis
 Fractures of the Humeral
Head
 RC tear arthropathy
 May be treated with
hemiarthroplasty
(Boudreau, S., Boudreau, E., Higgins, & Wilcox,
2007)

13. TSA vs rTSA
 Total Shoulder Arthroplasty
 Used to treat degenerative
changes of the GH joint
when the RC is intact or
repairable
 Reverse Total Shoulder
Arthroplasty
 Developed in 1980s in
Europe, approved by FDA in
2004
 Used to treat GH arthritis
when it is associated with
irreparable RC damage,
complex fractures, or
revisions of standard TSA
with deficient RC tendons
(Brigham and Women’s Hospital, Inc.
Department of Rehabilitation services, 2011)

14. Indications for Reverse Total
Shoulder Replacement
 Additional Indications for
Reverse Total Shoulder
Replacement:
 Proximal humeral fracture
with malunion/nonunion
 Post traumatic arthritis
 Deficient Rotator Cuff
 Rotator Cuff Tear
Arthropathy
 Severe humeral head
collapse following massive
RC tear
 Revision of previosuly failed
conventional TSA
(Drake, O’Conner, & Edwards, 2010)

15. Rotator Cuff Tear Arthropathy
 3 Critical Features:
 Rotator Cuff Insufficiency
 Superior Migration of the
humeral head
 Degenerative Changes of
the GH joint (Nam et al., 2012)
 End stage glenohumeral
arthritis
 Caused by a high riding
humerus following a RC
tear
(Drake, O’Conner, & Edwards, 2010)

16. Massive and Irreparable RC Tear

17. Contraindications for rTSA
 1. Deltoid Function is
required for active elevation
following a rTSA
 Absence of severe
impairment of the deltoid is
a contraindication
 2. Isolated Supraspinatus
Tear (SST)
 Isolated SST will not
produce an imbalanced
shoulder
 Can be treated by standard
TSA
 3. Massive irreparable RC
tear without arthritis and full
or nearly full active
elevation
 Likely has a balanced
shoulder
 Nonoperative Modalities
indicated
 NSAID and Corticosteroid
Injections
 If continued pain, imaging to
determine presence of Long
head of Biceps tendon
 Tenotomy may decrease pain
and restore function
(Drake, O’Conner, & Edwards, 2010)

18. Precautions
Rehabilitation Following rTSA
 12 wks postoperatively
 No movement in extension,
adduction, & internal
rotation
 No extension beyond
neutral
(Brigham and Women’s Hospital, Inc. Department of
Rehabilitation services, 2011)

19. Important Concepts:
Rehabilitation of rTSA cont.
 1. rTSA Design alters the
center of rotation medially
and inferiorly
 Enhances the torque
produced by deltoid as well
as the line of pull/action of the
deltoid
 2. Deltoid Function
 Stability and mobility of the
shoulder is now dependent
upon the deltoid
 3. Function
 Goal is to maximize overall
upper extremity function while
respecting tissue constraints
 4. ROM
 Normal/full AROM is not
expected following rTSA
(Brigham and Women’s Hospital, Inc. Department of
Rehabilitation services, 2011)

20. Joint Protection
 Higher risk of shoulder
dislocation following rTSA
than standard TSA
 Dislocations occur with
operative arm in IR,
adduction, and extension
 This positions allows
prosthesis to dislocate
anteriorly and inferiorly
 Limit functional activities
such as tucking in a shirt or
reaching behind one’s hip
 At least 12 weeks
postoperatively
(Boudreau, S., Boudreau, E., Higgins, & Wilcox, 2007)

21. Deltoid Function
 Enhancing deltoid function
is the most important
rehabilitation concept in the
strengthening phase of
postoperative rehabilitation.
 Stability and mobility of
shoulder is dependent on
deltoid and periscapular
musculature
 Must assist patients to learn
recruiting strategies to
make deltoid primary
shoulder mover
(Boudreau, S., Boudreau, E., Higgins, & Wilcox, 2007)

22. ROM and Functional Expectations
 Expectation for functional
and ROM gains should be
set on a case-by-case basis
 ROM gains will be
dependent on:
 Underlying pathology
 The status of external rotators
 The extent to which the
deltoid and periscapular
musculature can be
rehabilitated
 Guideline:
 Functional active elevation of
at least 105 degrees should
be expected
 80-120 degrees of elevation
 30 degrees of ER
(Boudreau, S., Boudreau, E., Higgins, & Wilcox, 2007)

23. Rehabilitation Protocol
 Phase I
 Immediate postsurgical/joint
protection
 4-6 weeks post-operatively
 Active elbow, wrist, digit ROM
 PROM to Shoulder
 Submaximal deltoid
isometrics
 Phase II
 Active ROM and early
strengthening
 Approx. 6-12 weeks
 AAROM/AROM gentle
strengthening
 Avoid poor/inappropriate
motor patterns
 Periscapular and deltoid
strengthening should
progress to isotonic between
6-8 wks
 Phase III
 Moderate strengthening
 12+ weeks postoperatively
 Initiate when patient
demonstrates appropriate
PROM/AAROM/AROM while
demonstrating appropriate
shoulder mechanics
 Goal is to advance
strengthening and increase
functional independence
 Phase IV
 Independent and progressive
home exercise program
 Return to light household
work and leisure activities
 Initiated once patient is d/c’d
from rehabilitation services(Boudreau, S., Boudreau, E., Higgins, & Wilcox, 2007)
(Brigham and Women’s Hospital, Inc. Department of Rehabilitation
services, 2011)

24. Summary
 Popularity of rTSA is growing rapidly in the U.S.A.
 To date, optimal postoperative rehab plan/protocol has not
been established
 Minimal research regarding long-term outcomes of patients
following rTSA
 Use of rTSA to treat RC tear arthropathy is clinically sound
 Changes shoulder mechanics and enhances deltoid function in
absence of RC
 Postoperative treatment of clients with rTSA is different than
those following a standard TSA
 Physician, therapist, and client should work together to
develop a postoperative rehab plan (client centered care)
 Further research is required in regards to long-term results of
rTSA and an optimal postoperative rehabilitation plan

25. References
 Brigham and Women's Hospital, Inc. Department of Rehabilitation Services.
(2011). Reverse Total Shoulder Arthroplasty Protocol.
 Brigham and Women's Hospital, Inc. Department of Rehabilitation Services.
(2007). Total Shoulder Arthroplasty/Hemiarthroplasty Protocol.
 Boudreau, S., Boudreau, E., Higgins, L., & Wilcox, R. (2007). Rehabilitation
Following Reverse Total Shoulder Arthroplasty. Ther Journal of Orthopaedic &
Sports Physical Therapy, 734-743. Retrieved August 30, 2015, from www.jospt.org
 Culham, E., & Peat, M. (1993). Functional Anatomy of the Shoulder
Complex. Journal of Orthopaedic & Sports Physical Therapy, 18(1), 342-350.
Retrieved August 30, 2015, from www.jospt.org
 Drake, G., O’Connor, D., & Edwards, T. (2010). Indications for Reverse Total
Shoulder Arthroplasty in Rotator Cuff Disease.Clinical Orthopaedics and Related
Research, 468(6), 1526-1533. doi: http://dx.doi.org/10.1007/s11999-009-1188-9
 Nam, D., Maak, T., Raphael, B., Kepler, C., Cross, M., & Warren, R. (2012). Rotator
Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment. The Journal of Bone
and Joint Surgery (American), 94(6). http://dx.doi.org/10.2106/JBJS.K.00746
 Peat, M. (1986). Functional Anatomy of the Shoulder COmplex. Journal of the
American Physical Therapy Association, 66(12), 1855-1865. Retrieved August 30,
2015, from http://ptjournal.apta.org/content/66/12/1855
 Terry, G., & Chopp, T. (2000). Functional Anatomy of the Shoulder. Journal of
Athletic Training, 35(3), 348-255. Retrieved September 29, 2015, from
www.journalofathletictraining.org
 Wilcox, R., Arslanian, L., & Millett, P. (2005). Rehabilitation Following Total
Shoulder Arthroplasty. Journal of Orthopaedic & Sports Physical Therapy, 35(12),
821-836. Retrieved August 30, 2015, from www.jospt.org
 Images: https://www.google.com/imghp?hl=en&tab=wi&ei=H9rwVe-
VKIe1ggSczqA4&ved=0CBYQqi4oAQ
 https://www.youtube.com/watch?v=l7h2FJnSXyw

26. Questions?