Reverse Total Shoulder Surgery: Movements to Avoid, Recovery, and Care

What movements should you avoid with reverse total shoulder surgery?

Following reverse total shoulder arthroplasty (RTSA), patients must strictly avoid specific movements, primarily a combination of adduction, internal rotation, and extension, to prevent dislocation and protect the surgical repair during the critical healing phase.

Understanding Reverse Total Shoulder Arthroplasty (RTSA)

Reverse total shoulder arthroplasty is a specialized surgical procedure designed to address severe shoulder conditions, particularly those involving irreparable rotator cuff tears with associated arthritis (rotator cuff arthropathy). Unlike conventional total shoulder replacement where the ball is on the humerus and the socket on the scapula, RTSA reverses this anatomy: a ball is affixed to the shoulder blade (glenoid), and a socket is attached to the upper arm bone (humerus).

This anatomical reversal dramatically alters the shoulder's biomechanics. The deltoid muscle, which normally assists with arm elevation, becomes the primary muscle responsible for lifting the arm, compensating for the non-functional rotator cuff. While highly effective for restoring overhead function in specific patient populations, this altered mechanics also introduces unique post-operative considerations and movement precautions.

The Critical Post-Operative Period: Why Movement Restrictions Matter

The immediate post-operative period following RTSA is crucial for the success of the surgery. The new joint components need time to integrate with the surrounding bone, and the soft tissues (capsule, muscles) require protection to heal without undue stress. The primary risk during this phase is dislocation of the prosthetic joint.

Because the deltoid becomes the primary mover and the inherent stability provided by the rotator cuff is diminished, certain positions can create a lever arm that forces the humeral socket off the glenoid sphere. Adhering to movement restrictions is not merely about comfort; it is a critical measure to prevent complications, ensure proper healing, and optimize long-term functional outcomes.

Specific Movements to Strictly Avoid

Understanding the biomechanics of RTSA helps clarify why certain movements are contraindicated. The most dangerous position for a reverse shoulder replacement is typically a combination of:

• Shoulder Adduction: Bringing the arm across the body towards the midline.
• Shoulder Internal Rotation: Rotating the arm inward, such that the thumb points towards the body.
• Shoulder Extension: Moving the arm backward behind the plane of the body.

When these three movements are combined, particularly with the elbow bent, they create a lever that can cause the humeral component to dislocate. This combination is often referred to as the "dislocation position" or "impingement position" for RTSA.

Specific activities that involve this dangerous combination include:

• Reaching behind your back: Such as tucking in a shirt, reaching for a wallet in a back pocket, or using a back scratcher.
• Reaching across your body to the opposite armpit or shoulder.
• Forcing the arm into extreme internal rotation.
• Extreme Shoulder Extension: Reaching far behind your body.
• Lifting Heavy Objects: Especially with the affected arm, as this places excessive strain on the healing tissues and joint.
• Sudden, Jerking Movements: Any uncontrolled or ballistic motion of the arm.
• Weight-Bearing on the Affected Arm: Pushing up from a chair using the surgical arm, leaning on the arm, or using it to brace yourself during a fall.
• Driving: Until cleared by your surgeon, as it requires quick, often rotational movements and can compromise the surgical site during sudden stops or turns.

Common Activities and Positions to Be Mindful Of

Beyond the strictly forbidden movements, several daily activities require conscious modification to protect the surgical site:

• Sleeping Positions:
  • Avoid sleeping on the affected side.
  • Many surgeons recommend sleeping in a semi-reclined position (e.g., in a recliner or with pillows propped up) for the initial weeks to prevent accidental movements.
  • Avoid sleeping with the arm tucked under the body or reaching across.
• Dressing:
  • Use loose-fitting clothing that can be easily pulled on.
  • Dress the affected arm first, then the unaffected arm.
  • Undress the unaffected arm first, then the affected arm.
  • Avoid reaching behind your back to fasten bras or tuck in shirts.
• Showering and Hygiene:
  • Use long-handled brushes or sponges to reach areas of the back or legs without compromising the shoulder.
  • Avoid reaching behind your head or back for washing hair or drying.
• Reaching:
  • Avoid reaching overhead, especially early in recovery.
  • Avoid reaching far away from your body, particularly into cupboards or shelves.
  • Keep items you use frequently within easy reach.
• Personal Care:
  • Be cautious with toileting and hygiene that requires reaching behind.
  • Avoid sudden movements while drying off after a shower.

The Role of Physical Therapy and Gradual Progression

Adherence to your surgeon's and physical therapist's post-operative protocol is paramount. Rehabilitation after RTSA is typically phased, progressing from:

• Passive Range of Motion (PROM): Where a therapist or gravity moves your arm without muscle activation.
• Active-Assistive Range of Motion (AAROM): You assist the movement, but the therapist or a device still provides support.
• Active Range of Motion (AROM): You move the arm independently.
• Strengthening: Gradual introduction of resistance exercises.

Your physical therapist will guide you through specific exercises designed to restore mobility and strength safely while respecting the necessary precautions. They will teach you how to perform daily activities without putting your shoulder at risk and provide personalized advice based on your individual recovery progress.

Long-Term Considerations and Activity Modification

While the strictest precautions are typically for the first 6-12 weeks, some movement restrictions may be lifelong. Patients with RTSA are often advised to:

• Avoid high-impact activities: Such as contact sports, activities that involve repetitive overhead movements (e.g., throwing, tennis serves), or heavy lifting.
• Limit extreme ranges of motion: Especially the combined adduction, internal rotation, and extension.
• Focus on functional movements: Prioritizing activities that support daily living and light recreation within safe ranges.
• Maintain strength and stability: Continue with a tailored exercise program to support the deltoid and surrounding musculature.

Your surgical team will provide specific guidelines regarding return to sports or physically demanding occupations.

When to Seek Medical Attention

While complications are rare, it's vital to be aware of signs that warrant immediate medical attention:

• Sudden, severe pain in the shoulder.
• A "clunking" or "popping" sensation, possibly accompanied by new pain or instability.
• Inability to move the arm, or a significant change in your ability to move it.
• Signs of infection: Increased redness, swelling, warmth, drainage from the incision, or fever.
• Numbness or tingling in the arm or hand.

Following your post-operative instructions meticulously is the best way to ensure a successful recovery and maximize the long-term benefits of your reverse total shoulder replacement.