Are there any limitations after having a reverse shoulder replacement due to arthritis, rotator cuff tear, rheumatic disease or a fall?
As a diagnostic radiographer, I address this common concern among patients I have seen after having surgery for a reverse shoulder replacement.
I rely on my experiences and medical scientific research to address this concern.
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Any questions? remarks? Let’s meet in the comments section at the end of this article.🙏
Last updated: July 2024. Written by Juliet Semakula a diagnostic radiographer
Disclaimer: no affiliate links.
▶️Before we delve into restrictions of a reverse shoulder replacement let’s view a brief overview of the shoulder anatomy.
Our shoulder is made of a ball and socket joint which is made up of three bones and muscles.
🟢The humerus (upper arm bone)
🟢The scapula (shoulder blade)
🟢The clavicle (collar bone)
🟢Muscles (rotator cuff and bursa sac)
Illustration of a Normal shoulder. The head of the humerus is round (Blue) and fits into the more rounded shoulder blade (glenoid).
The head of the upper arm bone fits into a shallow socket in the shoulder blade and it is kept in by the rotator cuff.
▶️How useful is a rotator cuff to shoulder movement.
Rotator cuff is a group of muscles that come together as tendons to form a covering around the head of the humerus.
It is supported by a lubricating sac called the bursa which lies between the rotator cuff and the acromion.
The rotator cuff helps to lift and rotate your arm while it’s in the shoulder blade and the bursa allows it to glide freely. That’s why you can lift and swing your arm in any direction.
Before you start having problems with your shoulder, the whole anatomy will be in position allowing you to move your arm in almost all directions.
▶️What is a reverse shoulder replacement in simple medical terms.
A reverse shoulder replacement is a special type of shoulder surgery.
During the surgery, a surgeon removes the damaged parts of the shoulder and replaces them with artificial parts.
⏭️Why is this shoulder replacement called ‘reverse’?
In a reverse shoulder replacement, the normal ball and socket structure is reversed.
An artificial ball is attached to the shoulder blade and an artificial socket is attached to the top of the arm bone.
The large deltoid muscle that covers the shoulder is typically able to move the arm with this kind of prosthesis.
Illustration of reverse shoulder replacement in x-rays.
▶️Why would you need a reverse shoulder replacement?
There are several reasons you may need a reverse shoulder replacement.
The common reason being the wear and tear on the rotator cuff tendons. As we have seen these tendons are responsible for moving the shoulder in all directions.
As we age these tendons can potentially become damaged. When they are too damaged, they are not in position to allow proper shoulder movement, instead the deltoid muscle which is less prone to damage takes over the shoulder movement.
The deltoid muscle can move the shoulder effectively with this type of joint hence the choice of replacement.
Picture of a reverse shoulder replacement before it is implanted.
A reverse shoulder replacement is a prosthesis that reverses the normal anatomy of the shoulder, the head of the humerus and the glenoid of the scapula no longer have the same shape.
What leads to wear and tear on the rotator cuff of the shoulder
1️⃣Inflammatory arthritis: When you have inflammatory arthritis, you will frequently develop destructive shoulder arthritis and rotator cuff tearing.
Reconstruction with reverse shoulder prosthesis would lead to early satisfactory results. It can successfully decrease pain and improve function with rotator cuff-deficient shoulders.
(Hattrup 2012).
2️⃣Rheumatic disease.
3️⃣Falls due to ageing.
▶️Why are there some limitations after a reverse shoulder replacement?
When the rotator cuff is no longer functional, you can lose the ability to actively elevate your shoulder to 90°.This loss of motion has been established as pseudo-paresis.
Following a reverse shoulder replacement, you will be able to regain the ability to elevate your shoulder again with minimal discomfort.
However, after surgery of a reverse shoulder replacement, certain movements may be restricted to prevent dislocation of your shoulder joint.
(A) A patient with pseudo paresis of the right shoulder secondarily to a massive rotator cuff tear. Notice her inability to elevate the shoulder pass 90°. (B) A radiograph showing her reverse shoulder prosthesis. (C) A postoperative picture depicting significant improvement in right shoulder elevation following surgery.
The goal is allowing the joint to heal properly and reduce the risk of complications during the early stages of recovery.
▶️The risk of a dislocation after shoulder replacement.
Dislocation of the artificial joint is the most common complication after a reverse total shoulder replacement.
The humerus socket can become dislodged or disconnected from the ball (the shoulder blade). It is important to avoid shoulder movement during the initial weeks after surgery to help with tissues and muscle healing.
However, the risk of dislocation remains very rare, less than 4% of people who have reverse shoulder replacement.
(Hermena 2022).
Safeguard for shoulder dislocation and pain prevention
To minimise pain and the risk of dislocation it is important to gradually reintroduce shoulder movements after a reverse shoulder replacement.
Remember your body needs to recover from surgery and adapt to the new joint.
▶️What movements are restricted after a reverse shoulder replacement.
You will need a structured rehabilitation programme for achieving the best possible outcome in the long term after complete healing from a reverse shoulder replacement.
Due to the nature of your surgery, you will require assistance with washing and dressing when you return home for the first weeks.
Post-Operative Advice
You will be given post-operative instructions which are often personalised to your needs.
▶️Safety measures of Shoulder movement must be restricted after surgery:
Until informed otherwise by your physiotherapist or doctor. You are not allowed (alone or even with your physical therapist) to
🟨Perform internal rotation movements of the shoulder.
🟨Perform any 90 degrees of flexion, which means your elbow must not move above your shoulder.
🟨Perform any 70 degrees of abduction, which is taking your arm out to the side.
These are all movements that, in theory, when performed with extreme amplitudes and quickly, can cause dislocation of the shoulder.
▶️Are there permanent restrictions after reverse shoulder replacement
Regardless of surgical success, some restrictions may persist after shoulder replacement surgery.
Some physical therapists and surgeons will tell you that you can resume everything, even sports, if you do it gradually and listen to your body or avoid for life
or you may find some movements limited for life not because they are forbidden but simply because the replacement may not allow you to be as flexible as before.
🟨Limits on participating in high-impact sports, such as tennis, hooking or weightlifting.
🟨Restrictions on lifting heavier objects than 2-6 lbs above your head.
🟨The inability to reach behind your back (for example putting on a bra). Some patients can reach their low back or same side back pocket, but many are limited to their posterior hip. The biomechanics of the reverse simply do not allow this to happen.
🟨After a reverse shoulder replacement, it is a good sign if you can raise your arm up to 120 degrees or reach things for a height of 2 metres high.
🟨Tying your hair, cleaning or drying your back
🟨Driving a car that requires significant shoulder range of motion.
The limitation you may face is not about poor recovery or inadequate treatment, but the mechanism of the replacement may not provide the same range of motion as before.
What is the normal range of motion after reverse shoulder replacement
Here’s the normal range of motion after reverse shoulder replacement presented in a chart format
A. Flexion of motion backwards 45 to 120 degrees forward.
B. Abduction range of motion 90 to 130 degrees
C. Abduction range of motion 90 to 115 degrees
D. External rotation range of motion 30 to 45 degrees.
Normal range of motion reduces after reverse shoulder replacement projected in yellow.
keep in mind some people may have ranges of motion that fall outside the normal valves mentioned above.
If you happen to perform a forbidden movement, be rest assured a single movement is not likely to cause any major issues.
It is extremely rare for a simple isolated movement to result in a dislocation. If you happen to have a dislocation, it could be due to repetitive and forceful movements overtime.
▶️Recovery stages and timeline after a reverse shoulder replacement
These time-line rely on medical studies and they can differ from individuals sometimes depending on the type of procedure you had.
| Stages | Timeline |
| Numbness and heaviness in your limb after surgery | These symptoms might still be present when you are discharged home. They should resolve within 48 hours, and strength and feeling in your limbs should return to normal |
| Wound care | Keep the wounds dry until they are healed, which is normally within 8 to 10 days |
| If the stitches/clips need removing. | This is usually done at 10 to 14 days after your operation at your GP practice. |
| Bathing or strip wash | strip wash for the first 10 days with your sterile dressing on. After this, you can shower but you must keep your dressing on |
| As with any surgery, you should expect some degree of pain. | Painkillers will be prescribed, and it is advised that you take them regularly so that you can perform your exercises and you are able to use the arm. |
| Swelling of the shoulder | You may experience swelling of your shoulder for up to 6 weeks postoperatively. Ice can be used to help control the pain and reduce this swelling. |
| While sitting down | Rest your arm on a pillow(s) or on the arm of a chair to relax the shoulder |
| Wearing the sling | You will be provided with a sling, which is for your comfort to wear for up to 4 weeks. |
| Sleeping | You will need to keep the sling on whilst sleeping for the first 6 weeks. |
| Progression to daily home activities | You can resume light lifting e.g. a mug of tea, at three weeks following surgery, whereas lifting of heavier items cannot resume till at least six months following surgery. |
| Returning to work is very individual | Generally, you should be able to return to work within 2 to 3 months of the operation |
| Driving | You can drive when you no longer require the sling and have good movement in your shoulder. This is likely to be at least 6 weeks post operatively. You must feel comfortable and be able to safely operate the vehicle before returning to driving |
| Complete recovery | Can take 18 months to 2 years following surgery. |
Conclusion: Below is the estimated progress you should be making following your surgery:
⏭️Three Weeks: At least 50% of your pre-operative active (independent) range of movement has recovered.
⏭️Six Weeks: Passive movement, where someone moves your arm for you, is the same as your pre-operative active movement.
⏭️12 Weeks: You should be able to move your shoulder independently more than you could pre-operatively
We have come to the end of this article, wish you a quick recovery🙋
📚Sources:
Hattrup SJ, Sanchez-Sotelo J, Sperling JW, Cofield RH. Reverse shoulder replacement for patients with inflammatory arthritis. J Hand Surg Am. 2012 Sep;37(9):1888-94. doi: 10.1016/j.jhsa.2012.05.015. Epub 2012 Jun 30. PMID: 22749484.
S.M. Howell, A.M. Imobersteg, D.H. Seger, et al.Clarification of the role of the supraspinatus muscle in shoulder functionJ Bone Joint Surg Am, 68 (1986), pp. 398-404
Hermena S, Rednam M. Reverse Shoulder Arthroplasty. (Updated 2024 March 1). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):389-408, x. doi: 10.1016/j.ocl.2013.03.010. Epub 2013 Apr 29. PMID: 23827841.
Guarrella V, Chelli M, Domos P, Ascione F, Boileau P, Walch G. Risk factors for instability after reverse shoulder arthroplasty. Shoulder Elbow. 2021 Feb;13(1):51-57. doi: 10.1177/1758573219864266. Epub 2019 Jul 27. PMID: 33717218; PMCID: PMC7905521.
Images:https://orthoinfo.aaos.org/en/diseases–conditions/rotator-cuff-tears/