CONDITION CHART: Reverse Total Shoulder Joint Replacement

Gabby Kowalski, s/OT

Epidemiology/histology: As of 2020, incidence of reverse total shoulder arthroplasty (rTSA) was 19.3 cases per 100,000 persons.1 People can get a rTSA – instead
of a standard shoulder arthroplasty - for a few reasons. The two major factors are the quality and function of the rotator cuff muscles, and the bone quality of
the humerus and scapula. Specifically, here’s a few reasons:2
• If a person’s rotator cuff is extensively damaged or missing (this + arthritis = arthropathy)
• If a person – specifically an older adult – has a proximal humerus fracture
• If a person’s glenoid cavity has worn away to such a degree that the installation of a prosthetic cavity would have a high likelihood of failing or complications
• If a person has chronic arthritis
• If a person had a failed standard shoulder replacement

Tissues/Structures involved:
• Rotator Cuff Muscles (Supraspinatus + Subscapularis, plus Teres Minor and Infraspinatus)
• Articular cartilage on head of humerus and inside glenoid fossa (labrum included)
• Long head of the biceps tendon
• Glenoid cavity of scapula
• Proximal end of humerus (head and neck)

The Surgery7: The humeral head is removed, and a hollow is drilled down into the humerus. The hollow is filled with a concrete-like substance. A long shaft with
a concave head is placed and secured into the humerus. This becomes the new “glenoid fossa” (the socket of the joint), just now on the humerus instead of the
scapula. Meanwhile, the long head of the biceps tendon is clipped from its origin of the supraglenoid tubercle and then sewed onto the humerus. On the
scapula, the surgeons remove any remaining cartilage from and shave down the glenoid fossa. They drill a few holes into that surface (a pre-drill for the screws
of the prosthesis). Then, they insert the prosthesis – a sphere with screws attached - into the scapula where the glenoid fossa once existed. This becomes the
“ball” of the joint.

Scenario: Elizebeth Freeman is a 75 yo female 6 weeks s/p a R rTSA surgery. Her surgeon chose a technique (anterosuperior approach)3 that preserved her
subscapularis tendon5 and excised the supraspinatus.6 She was cleared to remove her abduction sling4 at 4 weeks, so she has been out of the sling for 2 weeks.
However, a large snowstorm hit her area right before she was to come to outpatient therapy last week, so hasn’t received much therapy in the past two weeks.
Elizebeth has osteoporosis, and played tennis often until about 7 years ago, when she partially tore her rotator cuff (supraspinatus and infraspinatus). She enjoys
gardening, baking, and word puzzles. She currently lives in a townhome in Plainfield, NJ. Elizebeth is a widow, and lives alone with her dog named Shakespeare.
She is retired but volunteers at the local library 3 times a week and has a social group of friends who are also volunteers there.
MOI: (Pretending it’s winter). She was out walking her dog with thick gloves on when she slipped on a patch of ice. She did a FOOSH maneuver, falling on
her outstretched right hand, which resulted in a proximal humerus fracture due to her osteoporosis, and a complete tear of her supraspinatus and
infraspinatus, due to existing damage from the previous injury.
Posture: Normal (line/segment)
static/ picture/description
dynamic
An ideal posture consists
of several anatomical
landmarks being aligned.
Quite literally, a line can
be drawn through each of
these landmarks, which
are: the mastoid process,
shoulder joint, greater
trochanter of the femur,
midline of the knee joint,
and lateral malleolus.
If the shoulder is shifted
anteriorly or posteriorly
due to muscular
imbalances, the plumb
line is disrupted, and
abnormal posture results.
When seated, the plumb
line from the greater
trochanter and up should
still be intact.19
Static /Dynamic Movement17
What the shoulder needs to be supported:
The shoulder joint’s configuration of bones does not provide much stability by itself.
The head of the femur articulates with the curved but shallow glenoid fossa of the
scapula, which can be visualized by thinking about a ball on a tee. The primary stability –
and thus, posture – of the shoulder comes from the muscles and fibrous capsule
surrounding it. Specifically, the 4 rotator cuff muscles center the humeral head in the
glenoid fossa, with the glenoid labrum providing greater depth for the head. If there is a
weakness or an imbalance in the resting tone of one or more of the muscles (elongated
or shortened muscles, respectively), or an abnormality with the bones, postural
dysfunction can result. The shoulder could be shifted anteriorly or posteriorly,
superiorly or inferiorly, or internally/externally rotated out of its standard position in
the plumb line. This is true of the periscapular muscles that control overall posture, as
well.
The primary ligaments that contribute to shoulder static stability are the
coracoclavicular ligament, anterior/posterior ligaments, coracohumeral ligament, and
superior, inferior, and middle glenohumeral ligaments.
What the shoulder needs to move:
Figure 1. Ideal Posture18 As with stability, an imbalance within the rotator cuff muscles and periscapular muscles
can affect the mobility of the shoulder joint. To have proper movement, antagonists
need to be inhibited when agonists are working (e.g. the latissimus dorsi must be
sufficiently lengthened and not activated when the supraspinatus is trying to abduct the
arm). In addition, those agonists must be able to support the weight of the arm,
especially in a gravity-resisted position.
How the shoulder moves:
The 4 rotator cuff muscles plus surrounding muscles provide the shoulder with 4
degrees of freedom. In the coronal plane, the supraspinatus and middle deltoid abducts
the arm, while the pec minor, latissimus dorsi, and teres major adduct the arm. In the
sagittal plane, the anterior deltoid, coracobrachialis, biceps brachii, and pec major flex
the arm, while the latissimus dorsi, teres major, posterior deltoid, and triceps extend
the arm. In a horizontal plane around a vertical axis, the subscapularis, teres major, pec
major, lat dorsi, and anterior deltoid internally rotate the arm, while the infraspinatus,
teres minor, and posterior deltoid externally rotate the arm.
Note that the primary movers of the shoulder joint are the 4 rotator cuff muscles:
supraspinatus, infraspinatus, teres minor, and subscapularis.
In addition, a muscle especially important in an rTSA is the deltoid, which becomes the
prime mover of the shoulder when the RC muscles are too tattered to be of use.
Client Factor Faults/Imbalance Local Description:
(Body Part)
Limitations

Due to condition
and resulting
In Elizebeth’s case, both her shattered humeral head and fully torn The rTSA moves the center of rotation of the joint distally and medially, which
skeletal imbalance supraspinatus and infraspinatus necessitated an rTSA rather than a increases the moment arm and tension of the deltoid fibers, giving it more leverage
standard shoulder arthroplasty. and thus, more power.8 See Figure 2 below.8
Elizebeth kept her arm in an abduction sling for 4 weeks. The sling
kept her humerus slightly abducted and slightly externally rotated.
Elizebeth is currently in transition from the occupational restriction
phase to the occupational augmentation phase.

How the rTSA itself affected pt’s muscles:

Biceps: long head tendon underwent tenodesis, cut at top of
humeral head, tendon surgically inserted on humerus near inferior
border of pec major.9
Deltoid: split along its anterior and middle divisions, then surgically
repaired3
Rotator Cuff Muscles
Supraspinatus: Excised
Infraspinatus: surgically repaired Figure 2. The red dot indicates the center of rotation (COR) before surgery, and the
Teres minor: left intact blue dot shows the medialization of the COR after surgery. Notice the increase in
Subscapularis: left intact moment arm from the standard anatomy to the post-surgery anatomy.

How the immobilization period affected pt’s muscles: Stages of Rehab10,15-16

Biceps: slightly weaker than before due to tenodesis, possible There is controversy over what the timeline of rehab should be for rTSA. Below is
adaptive shortening from the sling but not much. Weak from non- what I chose for this condition:
use.
Deltoid: slightly weaker due to incision and repair, elongated due to Acute: 0-6 weeks
new difference in bone structure, possible slight adaptive Arm is immobilized in sling for first few weeks
shortening due to slight abducted position from sling. Weak from Inflammation and pain
non-use. Deltoid and remaining RC muscles healing
Subscapularis: slightly elongated (weakened) due to externally Skin incision healing
rotated arm position from sling. Weak from non-use. Restricted movements
Infraspinatus: stronger than post-injury/pre-surgery due to repair Subacute: 6-12
and healing time but still weak. Possibly slightly shortened due to Sling definitely off
repair and externally rotated arm position from sling. Muscles almost healed, now need to be strengthened and elongated if
Teres minor: possibly slightly shortened due to externally rotated shortened
arm position from sling. Reduced PROM and AROM
Chronic: 12+ weeks
Misc. comments: Strengthening continues
Shoulder (scapula) may be rotated upward slightly post-surgery PROM and AROM increases
Functional Kinematics11-12 Detail 11-12
Movement
Affected/
Compensatory

Scapular Humeral Rhythm: Scapular Humeral Rhythm:

Post-surgery, the pt deviates from standard scapulohumeral
rhythm by “showing less glenohumeral motion and more scapular
motion in operated shoulders compared to non-operated,
contralateral shoulders” (Kim et al., 2012). Meaning, the pt is likely
to engage in excessive scapular motion and limit their actual arm
movement, likely due to a fear of pain.
Compensatory Reaching Motion
Pt may flex and/or rotate trunk and elevate shoulder instead of
flexing and abducting/adducting shoulder.
The difference in the post-rTSA SHR might be a result of a “reduced ability of the
deltoid to provide support due to cuff deficiency and altered mechanics” (Lee et al.,
2016).
Compensatory Reaching Motion
Pt may be attempting to compensate in this way due to stiff shoulder flexion and
abduction/adduction muscles.

Occupations Client Occupation Impairments – OTPF20 Activity Task Specific

Affected Client-Centered Detailed, Adaptations

ADLs: UE dressing and washing hair in shower are challenging tasks
(especially fastening bra and tucking in shirt)
IADLs: household chores requiring reaching or lifting such as making
the bed, grabbing items off of high shelves, vacuuming, walking her
dog, pouring dog food out, carrying heavy loads (laundry, getting
dishes out of the oven, cleaning heavy dishes) are challenging tasks
since she is only using her non-dominant arm for reaching
Work: tasks requiring reaching or lifting such as grabbing down or
stocking books on shelves (librarian volunteer)
Leisure: tasks requiring reaching, lifting, or twisting arm such as
digging holes in the garden, lifting flower pots, pulling baking sheets
out of the oven, lifting and pouring bowls of batter for baking
Sleep/Rest: Cannot sleep on her right side like she used to
ADLs: Pt uses a one-handed dressing technique, and uses a long-handled hair
shampoo brush.
IADLs: Using non-dominant arm more than affected arm, balancing dishes on the
counter to wash, scooping instead of pouring out dog food, using a reacher
Work: Uses a reacher or non-affected arm to grab books off the shelf
Leisure: Uses a hand cart dolly to move big pots, uses other non-affected arm to
dig, currently cannot bake due to fear of dropping sheets from the oven
Sleep/Rest: Currently sleeping on back to avoid hurting arm

Specific Performance Skills Affected:

Reaches, Grips, Manipulates, Coordinates, Moves, Lifts,
Transports, Endures
Assessment TYPES Description and Evidence

Impairment based17 Impairment Based17

Goniometry Goniometry assesses range of motion to ensure pt has expected ROM after surgery.
Sensory Testing (Dermatome) Sensory Testing ensures no nerves were damaged during surgery, and provides
MMT updates on sensory feedback recovery.
Postural Assessment MMT assess strength of the extremity against resistance and/or against gravity. Will
be using it to establish a baseline to monitor progress over time.
Performance14 Postural Assessment to identify if/where muscles have been adaptively shortened
ARAT and, especially since periscapular strength is so important in rTSA rehab, to
Constant Murley Score (CS) – also includes SROM determine if there are any muscular imbalances that could be leading to
compensatory movements.
SROM14
Disability of the Arm, Hand, and Shoulder Questionnaire Performance14
(DASH) ARAT measures upper limb functioning (grasp, grip, pinch, gross mvmt) using
Shoulder Pain and Disability Index (SPADI) observation.
Patient-Specific Functional Scale (PSFS) CS measures overall functioning of a pt’s shoulder. Looks at pain, ROM, strength,
ability to perform ADLs, and UE function. Both objective measures and subjective
Special Tests14 included.
Shrug Test
SROM14
DASH assesses symptoms and functioning of entire UE (asks about both unilateral
and bimanual tasks).
SPADI assesses pain and disability with ADLs of the upper arm.
PSFS quantifies activity limitation and measures functional outcomes.

Special Tests14
Shrug Test to ensure pt is not using trunk to compensate for arm mvmts.

Interventions Biomechanical/Remediate15-16 Occupation-based

There are varying opinions on when to start AAROM, isometrics,
and isotonic exercises with rTSA. For the purposes of this
assignment (6 weeks s/p surgery), I’m deferring to the judgement of
Boudreau et al. and several studies in the systematic review of TSA
and rTSA rehab by Bullock et al. According to Boudreau, the three
most important concepts in rTSA rehab are “joint protection,
deltoid function, and establishing appropriate functional and ROM
expectations.”
Restriction w/adaptation (methods, equip etc)
Augmentations to (I)
Executions to promote positive change in performance
Patient education
Use diagrams/X-Rays to show them what the prosthetic looks like to help them
understand why certain motions could cause the device to dislocate
Teaching precautions:15
§ Be mindful of extension, don’t go too far past neutral
 PROM § No “tuck in back of shirt” maneuver (Adduction + Internal Rotation +
Up to 140° shoulder flexion Extension can lead to dislocation)
Up to 30° external rotation § Don’t *actively* raise your arm past 120° quite yet
Up to 30° internal rotation BUT only with at least 60° of abduction
to avoid dislocation
Assistive Technology for Home Use
A/AROM § Encourage use of reacher for items above eye-level, but caution not to
Full motion at elbow, wrist, and hand become dependent on it
Shoulder flexion between 90-120° in supine § Suggest shower chair for now so that she can safely bend at the waist to
Up to 30° external rotation wash her hair with both hands to encourage bimanual use
Gentle pendulum
Other Compensatory Techniques for Home Use
Isometric Exercises, targeting: § When showering, bend forward at the waist and let arm dangle to clean
Deltoid armpit (this allows for a pendulum PROM activity built into client’s daily
§ Because due to rTSA, it becomes a prime mover for abduction, flexion,
routine)
and extension.
§ No extension or full active flexion yet, so when dressing, continue to use
Periscapular muscles
§ Because we want to decrease compensatory movements as much as the one-handed technique when pulling a shirt over head. Be sure to
possible, and having strong periscapular muscles is the key to that. emphasize that we’ll discontinue this technique in a few weeks (don’t
become dependent on it)
Isotonic exercises, to a lesser extent. Only progress to isotonic if pt
tolerates isometric well, and begin with a low weight-high rep Occupation-Based Therapy Activities
program. § Baking cookies/cake or potting a plant to work on bimanual UE use
(making the L UE be the helper hand so the affected arm is doing the
Biofeedback with surface electromyography15 for deltoid majority of activity), and to reinforce mindfulness of precautions during
strengthening. Strengthening the deltoid is of upmost importance in
I/ADL activities [Occupation as means]
rTSA, especially Elizebeth’s surgery because she had her
supraspinatus excised. Biofeedback can assist the pt in increasing § Working on dressing tasks using precautions [Occupation as end]
deltoid muscle fiber recruitment, which will lead to strengthening.

45 min 1-10min: Assess and Prep Notes:

treatment Quick MMT of shoulder flexion, abduction, and ER § If Elizebeth seemed confused by the biofeedback training, we would skip
session15-16 PROM of shoulder flexion, ER, and IR that and add in a different deltoid strengthening activity (possibly using
AROM of elbow, wrist, and hand. the lightest theraband doing abduction exercises with 30 deg abduction).
Then AAROM shoulder flexion, external rotation, and internal
§ I’d provide Elizebeth with a handout for her HEP providing pictures and
rotation in supine (do goniometry to get measurements for
progress reporting too) instructions on how (and how often) to do the exercises
10-20min: Prep à Performance
Biofeedback with surface electromyography for deltoid muscle
fiber recruitment doing an isometric deltoid exercise (pressing
back of hand against wall laterally with a towel for comfort)
 20-35min: HEP review
Review exercises to do at home:
Pendulum for PROM
AAROM with cane
Deltoid isometric strengthening against the wall
Teres Minor isometric strengthening against wall (ER)
Shoulder flexion wall glides, paying attention to keeping
scapulas pinched and shoulders level
35-45min: Assess - DASH Administration
Administer the DASH to gain a better understanding of which
activities Elizebeth is having the most difficulty with and wants
to focus on to use as a baseline and progress report

**Note to Dr. DeMott: Check out the real-life Elizebeth Friedman in her biography, The Woman Who Smashed Codes!

References

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