What are the Limitations After Reverse Shoulder Replacement?

A brief reminder about the reverse shoulder replacement: definition

There are different types of shoulder replacement.

The reverse replacement is a total shoulder replacement: which means both parts of the shoulder joint are replaced:

1. The upper part of the humerus, the bone of the arm.
2. A part of your shoulder blade (also called the scapula), the glenoid.

Why is this shoulder replacement called “reverse”?

Because the natural anatomy of the shoulder is reversed:

• Instead of using something that is rather round and full to replace the head of the humerus, something slightly concave is used.
• A sphere-shaped component is used at the level of the shoulder blade.

Demonstration in images!

While the shoulder joint usually looks more like this:

Why this choice to reverse the usual mechanics of the shoulder?

This is done because of wear and tear on the rotator cuff tendons. 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 no longer relied upon for shoulder movement. Instead, another muscle called the deltoid, which is less prone to damage, takes over.

Biomechanically, there is a better chance that the deltoid will be able to move the shoulder effectively with this type of joint. Hence the choice of this replacement!

A reverse shoulder replacement is a prosthesis that reverses the natural anatomy of the shoulder: the head of the humerus and the glenoid of the scapula no longer have the same shape.

Why are some limitations after a reverse shoulder replacement?

The shoulder is a highly mobile joint, capable of movement in three planes:

1. Flexion and extension (raising the arm forward or backward).
2. Abduction and adduction (moving the arm away from or toward the body’s side).
3. Internal and external rotation (turning the palm of the hand outward or inward with the elbow extended).

However, after a reverse shoulder replacement, certain movements may be restricted to prevent dislocation.

Dislocation is when the ball of the humerus comes out of the socket of the scapula, causing the joint to become unstable. It can be painful and require medical attention to correct. Therefore, to protect the newly implanted replacement and ensure its stability, specific movements may be limited temporarily after the surgery. The goal is to allow the joint to heal properly and reduce the risk of complications during the early stages of recovery.

The risk of dislocation after shoulder replacement

The same applies when you have a shoulder replacement: the tissues and muscles need time to heal. They provide slightly less protection to the joint during the initial weeks.

However, rest assured that dislocation remains very rare and is becoming even rarer. Less than 4% of people who have a reverse shoulder replacement experience dislocation in the days or weeks following the surgery.

Be reassured that a “false motion” is not among the risk factors identified as increasing the risk of dislocation.

Source: Hermena 2022

Precaution for pain prevention

Your body also needs time to recover from the surgery and adapt to the new joint. Introducing movements too quickly and too intensely can potentially temporarily increase pain.

As you will see later in the article, this applies to any type of large amplitude movement, and not necessarily to a specific movement.

It is essential to find the right balance between inactivity and overactivity!

Hence the importance of gradually reintroducing shoulder movements after a reverse shoulder replacement. This applies to all movements, to minimize pain and the risk of dislocation (which remains very rare).

What movements are restricted after a reverse shoulder replacement?

First, your surgeon should have given you what we call “post-operative instructions.” These instructions are provided orally and in writing, in your operation and consultation or hospitalization report. They are personalized according to your specific case, the type of surgery performed, and the practices of the service in which you were operated.

These instructions are often communicated to your physical therapist and primary care physician. The role of these professionals is to help you understand and integrate these instructions into your daily life, taking into account your progress over the days and weeks. They will readjust them gradually, personalized to your needs.

The level of restriction of movements can vary between these two scenarios that I have observed as physical therapist.

Scenario with more movement restrictions

You may be prescribed an elbow-to-body or abduction brace. You must keep it on until the follow-up appointment, but you can remove it for bathing or rehabilitation.

You are not allowed (alone or even with your physical therapist) to:

• Perform internal rotation movements of the shoulder
• Perform shoulder extensions (moving the arm backward)
• Perform shoulder adduction movements (bringing the arm closer to the opposite side of the flank), particularly if it is associated with internal rotation
• Go beyond 90° of abduction (raising the arm to the side)

These are all movements that, in theory, when performed with extreme amplitudes and quickly, can cause dislocation of the shoulder.

Scenario with fewer movement restrictions

You may be prescribed an elbow-to-body or abduction brace. You must keep it on until the follow-up appointment, but you can remove it for bathing or rehabilitation. As you progress and tolerate it well, the restrictions may be eased gradually.

Regarding movements, you are allowed to perform all tolerable movements, provided that they are done slowly. Initially, you will perform them passively, with the support of yourself or a third person. Then gradually, you can perform them actively, without overloading your arm.In this scenario, all movements are potentially permitted, including rotations and abduction.

The “forbidden” aspect is simply doing things too abruptly, intensely, or quickly.

How to know which approach is the best?

So, you have guidelines that fall between these two scenarios.

Do you feel that you have too many restrictions or contraindications? Or on the contrary, do you think that your protocol is too lenient?

Discuss it with your physical therapist, physician, or surgeon! Sometimes it is possible to readjust things based on your own assessment of the risk-benefit balance.

Restricted movements after a reverse shoulder replacement depend on what is indicated in your postoperative instructions.

When can you gradually resume all movements?

Again, it will depend on your postoperative instructions.

Sometimes, surgeons describe a protocol like this:

• Pendulum exercises for 10 days;
• Then flexion and abduction for 2 weeks;
• Then a progressive reintroduction of other movements at 1 month.

A few words about pendulum exercises. Surgeons often prescribe this exercise. Sometimes, surgical interns even demonstrate it. The idea is to swing your arm simply using the momentum from your trunk, without the brace, of course.

In practice, even people without pain and with good motor control often find it difficult to perform this exercise correctly: they swing the arm instead of generating the momentum only with the body. Not to mention that it can quickly cause back pain. So, I don’t always find it suitable for everyone.

Some surgeons give instructions that remain the same until the follow-up X-ray, which is usually 1 and a half to 2 months after the operation.

If everything looks good on the follow-up X-ray, normally no movement is restricted anymore.

Generally, about 2 months after the reverse shoulder replacement, no movement is strictly prohibited or restricted.

Are there permanent restrictions after reverse shoulder replacement?

Again, depending on the medical teams you encounter, you will probably hear different opinions on this matter.

Some physical therapists and surgeons will tell you that you can resume everything, even sports, as long as you do it gradually and listen to your body.

Others, on the other hand, may recommend avoiding for life:

• Lifting weights heavier than 25 kg;
• Combat sports, team sports, and racket sports that require a lot of shoulder movement and range of motion. However, often these sports were already discontinued long before the operation.

As with knee or hip replacements, the range of motion is more limited than usual.

• Most people without shoulder issues can raise their arm up to 180°.
• After a reverse shoulder replacement, we are pleased if individuals can regain 120°.
• Normally, you will be able to reach for things at height, but not at 2 meters high.

Some movements may also be limited “for life,” not because they are forbidden, but simply because the replacement may not allow you to be as flexible as before. For example:

• Hooking/unhooking a bra;
• Easily threading a belt through the loops;
• Driving a vehicle that requires significant shoulder range of motion;
• Cleaning or drying your back;
• Tying your hair.

This limitation is not necessarily due to poor recovery or inadequate treatment but rather because, mechanically, the replacement may not provide the same range of motion as before.

Resuming Sports after Reverse Shoulder Replacement

Six months after the operation, 67% of the operated people resume the sports they were already practicing before the surgery. Most of them engage in sports at a “hobby” level, while a few participate in clubs, and one at a national level.

Four years after the operation, 48% of the operated individuals are still involved in the sports they were doing before the surgery.

These sports include:

• Sailing
• Tai Chi
• Croquet
• Bowling
• Yoga
• Aquagym
• Gymnastics
• Fishing
• Golf
• Cycling

Source: Housni 2022

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 table format:

Range of Motion	Normal Range after Shoulder Replacement
Flexion	90 to 120 degrees
Extension	40 to 60 degrees
Abduction	90 to 120 degrees
External Rotation	30 to 45 degrees

Keep in mind that these ranges are approximate and can vary: There are people who may have ranges of motion that fall outside the normal values mentioned in the table!

What is the risk if I perform a forbidden movement with my shoulder replacement?

Many patients fear accidentally making a forbidden movement, for example while sleeping or being distracted.

Rest assured, a single small inadvertent movement is not likely to cause any major issues!

It is extremely rare for a simple isolated movement to result in dislocation. If a dislocation occurs, it is usually due to repetitive and forceful movements over time, rather than a one-time accidental motion.

The risk of damaging the shoulder prosthesis comes from frequent and intensive repetition of certain movements, not from an occasional accidental movement!