Pre and Post Shoulder Surgery

Planning ahead for the challenges of surgery and recovery will help ensure a more successful outcome.

Total Shoulder Replacement Protocol

Shoulder replacement can help relieve pain and enable you to live a fuller, more active life. If you are deemed a good candidate for shoulder replacement and decide to have surgery, it is good to be prepared, both mentally and physically before surgery. Planning ahead for the challenges of surgery and recovery will help ensure a more successful outcome.

Patient Forms - Pre Surgery

To help expedite the check-in process for your appointment, we would ask that you please print and complete the following forms and bring them with you to your appointment. If you have any questions, please call our office at (801) 355-6468, we’re happy to help. Thank you!

Please see the pre-surgery packet for more detailed information.

  • Wash the shoulder area well with Hibiclens for 3 days leading up to surgery. Please apply Hibiclens (you can find this at CVS, Walgreens… etc) to the entire shoulder and armpit area for 3 days leading up to your surgery.
  • Be careful to avoid sunburns, poison ivy, etc.
  • Check with Dr. Hofmann’s office for your time to report to the Surgical Center.
  • Nothing to eat or drink after midnight. If surgery is to be performed in the afternoon, you may have CLEAR LIQUIDS ONLY up to six hours before surgery.
  • Please set up your physical therapy appointments to begin the 1-2 weeks after surgery.
  • The sling on the arm will be used continuously 4 weeks. This includes sleeping and no driving while in the sling.
  • Apply cold packs to the operated shoulder to reduce pain. Move your fingers, hand, and elbow to increase circulation.
  • As the nerve block in your shoulder wears off you may need pain medication – you will receive a prescription for when you go home. This includes both oxycodone and When Celebrex runs out you may switch to ibuprofen/Aleve. As your pain improves, take Ibuprofen/Aleve sparingly.
  • You may be instructed to take a 325 mg Aspirin for the purpose of protection against blood clots.
  • Initial post-op bandages should stay on until follow-up These bandages are water-tight and you may shower with them on.
  • The bandage will be removed at your first clinic visit. If the bandage falls off before then, apply a dry sterile dressing to the area. When showering please cover the area with plastic wrap or another watertight bandage to keep it dry for the next 7-10 days.
  • The steri-strips (thin white bandages directly over the incision) should remain on the incision until they fall off on their own.
  • Start passive motion on day 4 (upon discharge from the hospital). Passive ROM only.
    • Limitations: No external rotation beyond 30 degrees.

Please arrange for a post-operative appointment with Dr. Hofmann or the Physician Assistant for follow-up 2-3 days post-op for additional instructions and schedule your PT to begin at 14 days postoperatively.

  • All motion with the affected/surgical arm must remain PASSIVE. Do not raise your arm or elbow away from your body.
  • No lifting, excessive stretching, supporting body weight, or motion behind the back.
  • You should remove your arm from the sling and PASSIVELY stretch several times per day (ask your physical therapist for appropriate stretches).
  • If possible we strongly advise pool therapy starting at week 3 for increased passive range of motion. (This will be reviewed with you at your first pre-operative visit)
  • Once discontinuing the use of the sling, you may begin to use your arm for activities of daily living in front of your body (eating, bathing, shaking ..etc). Limitations include:
    • No lifting of objects heavier than 1 lb.
    • No excessive stretching or sudden movements.
    • No supporting body weight
  • The sling should only be used for sleeping and removed gradually over the course of the next 2 weeks.
  • Stretch your shoulder regularly throughout the day.
  • Schedule a follow-up visit at 6-8 weeks after your surgery for follow-up/monitoring.
  • IF APPROVED by Dr. Hofmann, you will begin strengthening with the guidance of your physical therapist 8 weeks after your surgery.
    • Continue to avoid lifting heavy objects.
    • You may use your affected arm for normal daily activities involved with dressing, bathing, and self-care. Any forceful pushing or pulling activities are to be avoided.
  • At this point, you may continue to progress through strengthening with your physical therapist. Gradually return to normal activity.

Please keep in mind this schedule/protocol is patient-dependent. Your timeline may be altered to assure appropriate progressions through rehab. Should you have any questions please feel free to call the office at (801) 355-6468.

Total Shoulder Replacement Rehab Protocol

Passive Range of Motion (PROM)

PROM is NOT stretching. PROM for all patients having undergone a TSA/HHR should be defined as ROM that is provided by an external source (therapist, instructed family member, or other qualified personnel) with the intent to gain ROM without placing undue stress on either soft tissue structures and/or the surgical repair.

Goals:

  • Allow healing of soft tissue
  • Maintain integrity of replaced joint
  • Gradually increase passive range of motion (PROM) of shoulder; restore active range of motion (AROM) of elbow/wrist/hand
  • Reduce pain and inflammation
  • Reduce muscular inhibition
  • Independent with activities of daily living (ADLs) with modifications while maintaining the integrity of the replaced joint.

Precautions:

  • Sling should be worn continuously for 4 weeks
  • While lying supine, a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch / subscapularis stretch. (When lying supine patient should be instructed to always be able to visualize their elbow. This ensures they are not extending their shoulder past neutral.) – This should be maintained for 6-8 weeks post-surgically.
  • Avoid shoulder AROM
  • No lifting of objects
  • No excessive shoulder motion behind back, especially into internal rotation (IR)
  • No excessive stretching or sudden movements (particularly external rotation (ER))
  • No supporting of body weight by hand on involved side
  • Keep incision clean and dry (no soaking for 2 weeks)
  • No driving for 3 weeks
  • Passive forward flexion in supine to no greater than 90 degrees.
  • Gentle ER in scapular plane to available PROM (as documented inoperative note) – usually around 30°

ATTENTION: DO NOT produce undue stress on the anterior joint capsule, particularly with the shoulder in extension)

  • Passive IR to chest
  • Active distal extremity exercise (elbow, wrist, hand)
  • Pendulum exercises
  • Frequent cryotherapy for pain, swelling, and inflammation management
  • Patient education regarding proper positioning and joint protection techniques
  • Continue above exercises
  • Begin scapula musculature isometrics/sets (primarily retraction)
  • Continue active elbow ROM
  • Continue cryotherapy as much as able for pain and inflammation management
  • Continue previous exercises
  • Continue to progress PROM as motion allows
  • Begin assisted flexion, elevation in the plane of the scapula, ER, IR in the scapular plane
  • Progress active distal extremity exercise to strengthening as appropriate

 

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation are not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.

  • Tolerates PROM program
  • Has achieved at least 90° PROM forward flexion and elevation in the scapular
  • Has achieved at least 45° PROM ER in plane of scapula
  • Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction.

Not to begin before 4-6 Weeks post-surgery to allow for appropriate soft tissue healing.

Goals:

  • Restore full passive ROM
  • Gradually restore active motion
  • Control pain and inflammation
  • Allow continue healing of soft tissue
  • Do not overstress healing tissue
  • Re-establish dynamic shoulder stability

 

Precautions:

  • Sling should only be used for sleeping and removed gradually over the course of the next 2 weeks, for periods throughout the
  • While lying supine a small pillow or towel should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule
  • In the presence of poor shoulder mechanics, avoid repetitive shoulder AROM exercises/activity against gravity in
  • No heavy lifting of objects (no heavier than a coffee cup)
  • No supporting of body weight by hand on the involved side
  • No sudden jerking motions
  • Continue with PROM, active-assisted range of motion (AAROM).
  • Begin active flexion, IR, ER, elevation in the plane of the scapula pain-free ROM.
  • AAROM pulleys (flexion and elevation in the plane of the scapula) – as long as greater than 90° of PROM.
  • Begin shoulder sub-maximal pain-free shoulder isometrics in neutral.
  • Scapular strengthening exercises as appropriate.
  • Begin assisted horizontal adduction.
  • Progress distal extremity exercises with light resistance as appropriate.
  • Gentle glenohumeral and scapulothoracic joint mobilizations as indicated.
  • Initiate glenohumeral and scapulothoracic rhythmic stabilization.
  • Continue use of cryotherapy for pain and inflammation.

Progress scapular strengthening exercises.

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.

  • Tolerates P/AAROM, isometric program.
  • Has achieved at least 140° PROM forward flexion and elevation in the scapular.
  • Has achieved at least 60+° PROM ER in plane of scapula.
  • Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction.
  • Able to actively elevate shoulder against gravity with good mechanics to 100°.

Not to begin before 6 Weeks post-surgery to allow for appropriate soft tissue healing and to ensure adequate ROM.

Goals:

  • Gradual restoration of shoulder strength, power, and endurance
  • Optimize neuromuscular control
  • Gradual return to functional activities with involved upper extremity

Precautions:

  • No heavy lifting of objects (no heavier than 3 )
  • No sudden lifting or pushing activities
  • No sudden jerking motions
  • Progress AROM exercise/activity as appropriate
  • Advance PROM to stretching as appropriate
  • Continue PROM as needed to maintain ROM
  • Initiate assisted shoulder IR behind back stretch
  • Resisted shoulder IR, ER in scapular plan
  • Begin light functional activities
  • Wean from sling completely
  • Begin progressive supine active elevation strengthening (anterior deltoid) with light weights (0.5-1.5 kg.) at variable degrees of elevation
  • Resisted flexion, elevation in the plane of the scapula, extension (therabands / sport cords)
  • Continue progressing IR, ER strengthening

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints. 

  • Tolerates AA/AROM/strengthening
  • Has achieved at least 140° AROM forward flexion and elevation in the scapular plane
  • Has achieved at least 60+° AROM ER in plane of scapula supine
  • Has achieved at least 70° AROM IR in plane of scapula supine in 30° of abduction
  • Able to actively elevate shoulder against gravity with good mechanics to at least 120°

NOTE: (If above ROM are not met then patient is ready to progress if their ROM is consistent with outcomes for patients with the given underlying pathology).

Not to begin before 12 Weeks to allow for appropriate soft tissue healing and to ensure adequate ROM, and initial strength.

Goals:

  • Maintain non-painful AROM
  • Enhance functional use of the upper extremity
  • Improve muscular strength, power, and endurance
  • Gradual return to more advanced functional activities
  • Progress weight-bearing exercises as appropriate

Precautions:

  • Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures. (Example: no combined ER and abduction above 80° of )
  • Ensure gradual progression of strengthening

Typically the patient is on a home exercise program by this point to be performed 3-4 times per

  • Gradually progress strengthening program
  • Gradual return to moderately challenging functional

Return to recreational hobbies, gardening, sports, golf, doubles tennis… etc.

  • Patient able to maintain non-painful AROM
  • Maximized functional use of the upper extremity
  • Maximized muscular strength, power, and endurance
  • The patient has returned to advanced functional activities