Total Shoulder Replacement: Safely Returning to Swimming After Surgery

Can you swim with a replaced shoulder?

Yes, many individuals can successfully return to swimming after a total shoulder replacement, but it requires significant patience, a diligent rehabilitation program, and explicit clearance from your orthopedic surgeon and physical therapist.

Understanding Total Shoulder Arthroplasty (TSA)

Total Shoulder Arthroplasty (TSA), commonly known as shoulder replacement surgery, involves replacing damaged parts of the shoulder joint with prosthetic components. This procedure is typically performed to alleviate severe pain and improve function in cases of advanced arthritis or severe injury.

• Anatomy of the Replacement: In a traditional (anatomic) TSA, the damaged head of the humerus (upper arm bone) is replaced with a metal ball, and the glenoid (socket of the shoulder blade) is resurfaced with a plastic component.
• Reverse Total Shoulder Arthroplasty (rTSA): In a reverse TSA, the ball and socket positions are switched. A metal ball is affixed to the shoulder blade, and a plastic socket is placed on the humerus. This design is often used when the rotator cuff tendons are severely damaged or irreparable, relying more on the deltoid muscle for arm elevation. The biomechanics of rTSA impose different movement precautions, particularly limiting internal rotation and extension.

The Road to Recovery: Rehabilitation Phases

Returning to activities like swimming after TSA is a gradual process, guided by a structured rehabilitation program. Attempting to rush this process can jeopardize the surgical outcome and lead to complications.

• Phase 1: Initial Post-Operative (Weeks 0-6)
  • Focus: Protection of the healing tissues, pain management, and gentle passive range of motion (ROM), where the arm is moved by a therapist or the non-operative hand.
  • Swimming: Absolutely contraindicated. The shoulder is fragile, and any active movement or weight-bearing could disrupt healing or dislocate the implant.
• Phase 2: Early Mobility (Weeks 6-12)
  • Focus: Gradual introduction of active-assisted and active ROM, light isometric strengthening (muscle contraction without joint movement), and regaining basic functional movements.
  • Swimming: Still generally not advised. The joint is not yet stable enough for the repetitive, multi-directional forces involved in swimming strokes, nor is the incision fully healed for water immersion.
• Phase 3: Intermediate Strengthening (Months 3-6)
  • Focus: Progressive strengthening of the rotator cuff, deltoid, and scapular stabilizers. Emphasis on improving endurance and functional strength.
  • Swimming: With explicit medical clearance, some individuals might begin gentle water exercises or very modified strokes in a controlled environment, often with a physical therapist present.
• Phase 4: Advanced Activity and Return to Sport (Months 6+)
  • Focus: Advanced strengthening, power, agility, and sport-specific training.
  • Swimming: If all previous milestones are met, and ROM, strength, and pain-free movement are optimal, a gradual return to swimming strokes can be considered under professional guidance.

Key Considerations Before Returning to Swimming

Before you even contemplate getting back in the pool, several critical factors must be addressed.

• Surgeon's Clearance: This is non-negotiable. Your surgeon will assess your implant stability, bone healing, and overall recovery to determine if your shoulder is ready.
• Physical Therapist's Guidance: A physical therapist is crucial for assessing your readiness, guiding your progression, and ensuring proper technique to protect your new joint.
• Achieved Range of Motion (ROM): Swimming requires significant, pain-free ROM in all planes, especially:
  • Flexion: Reaching arms overhead (e.g., freestyle recovery).
  • Abduction: Moving arms away from the body (e.g., breaststroke pull).
  • Internal and External Rotation: Essential for various stroke phases (e.g., hand entry in freestyle, sculling).
• Adequate Strength and Endurance: You need sufficient strength in your:
  • Rotator Cuff: For stability and controlled movement.
  • Deltoid: For arm elevation.
  • Scapular Stabilizers: To provide a stable base for arm movement.
• Pain-Free Movement: Any pain during movement is a red flag and indicates that the shoulder is not ready or the activity is too strenuous.
• Incision Healing: The surgical incision must be completely closed and healed to prevent infection from water exposure.

Gradual Reintroduction to Swimming

Once cleared by your medical team, the return to swimming should be approached with extreme caution and a structured, progressive plan.

• Start with Water Acclimatization:
  • Kicking with a Kickboard: Focus on lower body propulsion, allowing the shoulders to simply rest on the board and get used to the water's resistance without active movement.
  • Water Walking or Jogging: Provides a low-impact way to move in the water and get accustomed to the buoyancy and pressure.
  • Gentle Water Exercises: Perform the exercises you did in physical therapy (e.g., shoulder flexion, abduction, internal/external rotation) in the water without resistance, focusing on control.
• Introduce Modified Strokes:
  • Breaststroke: Often the first stroke considered due to less overhead reach compared to freestyle. Focus on a shorter, controlled pull and recovery, avoiding extreme external rotation or extension.
  • Backstroke: Can be beneficial for maintaining ROM, but requires significant external rotation and overhead movement. Start slowly, focusing on a smooth, controlled arm entry and exit.
  • Freestyle (Crawl): This is typically the most challenging stroke to return to due to the repetitive overhead reach, internal rotation, and propulsive forces. Begin with a very short stroke, focusing on a high elbow and gentle hand entry, avoiding forceful pulls or extreme rotation.
  • Butterfly: Generally discouraged or significantly modified due to its high impact, extreme ROM requirements, and potential for excessive stress on the shoulder joint.
• Focus on Technique: Work with a swim coach or physical therapist to refine your stroke mechanics. Poor technique can place undue stress on the new joint.
• Listen to Your Body: This is paramount. Stop immediately if you experience any pain, clicking, grinding, or instability.

Potential Risks and How to Mitigate Them

While swimming can be a fantastic low-impact exercise, it carries specific risks for a replaced shoulder if not managed properly.

• Dislocation or Subluxation: Especially a concern with reverse TSA, which has different stability characteristics. Certain movements, particularly combinations of internal rotation and extension, can put the implant at risk.
• Implant Loosening: Repetitive, high-force movements or poor technique can put excessive stress on the implant, potentially leading to loosening over time.
• Tendonitis or Bursitis: Overuse or improper mechanics can inflame the remaining soft tissues around the shoulder.
• Infection: While rare, if the incision is not fully healed, water exposure can introduce bacteria.

Mitigation Strategies:

• Strict Adherence to Medical Advice: Never deviate from your surgeon's or physical therapist's recommendations.
• Gradual Progression: Increase duration, intensity, and stroke complexity very slowly.
• Proper Technique: Prioritize form over speed or distance.
• Warm-up and Cool-down: Always prepare your muscles and joints before and after swimming.
• Regular Monitoring: Report any new or worsening symptoms to your medical team immediately.

Long-Term Management and Maintenance

Returning to swimming is not the end of the journey; it's the beginning of a new way to manage your shoulder health.

• Continue Strength Training: Maintain the strength of your rotator cuff, deltoid, and scapular stabilizers through land-based exercises.
• Maintain Flexibility: Regularly perform gentle stretching to preserve your gained range of motion.
• Vigilance: Always listen to your body. If a particular stroke or intensity causes discomfort, modify it or take a break.
• Regular Check-ups: Continue with scheduled follow-ups with your orthopedic surgeon to monitor the health of your implant.

Conclusion: A Measured Return to the Water

Swimming with a replaced shoulder is a realistic and achievable goal for many, offering excellent cardiovascular benefits and a low-impact way to exercise. However, it demands an unwavering commitment to your rehabilitation, strict adherence to medical guidance, and a patient, methodical approach to reintroducing activity. By respecting the healing process, diligently following your professional team's advice, and listening carefully to your body, you can safely and effectively enjoy the water once again.