 Sports Rehabilitation & Performance Center 
 Total Shoulder Arthroplasty Guidelines© * 
 
 
 
The following total shoulder arthroplasty guidelines were developed by the Sports 
Rehabilitation and Performance Center staff at Hospital for Special Surgery. Progression is 
both criteria-based and patient specific. Phases and time frames are designed to give 
the clinician a general sense of progression.  The rehabilitation program following total 
shoulder arthroplasty emphasizes pain management in the early days and weeks following the 
procedure.  Early mobilization is encouraged as per surgeon’s direction.  Each patient is 
treated individually as preoperative ROM, bone quality, and soft tissue integrity will have an 
influence on the progression of the program.   
 
Follow physician’s modifications as prescribed 
 
POST – OPERATIVE PHASE I (WEEKS 0-4) 
MAXIMUM PROTECTION PHASE  
 
 
 
 
 
 
GOALS:  
- Control post-op pain and swelling 
- ROM: Elevation in plane of scapula: to 120°, 
      External Rotation to 30° 
- Independent with light activities of daily living, dressing 
- Independent home exercise program 
 
PRECAUTIONS: 
- Avoid unnecessary lifting beyond normal ADLs  
- Avoid ROM beyond surgeon’s direction 
 
TREATMENT RECOMMENDATIONS: 
- Sling immobilization except for light ADLs, and therapeutic exercise; Codman’s/ pendulums; PROM to 
AAROM exercises (MD directed): elevation in plane of scapula, cane ER in plane of scapula; scapulothoracic 
mobilization; scapular stability (sidelying AROM progressing to manual resistance, and scapular retraction In 
sitting); distal strengthening; modalities for pain and edema; Emphasize patient compliance to HEP and 
protection during ADLs 
- Other: _________________________________________________________________________ 
MINIMUM CRITERIA FOR ADVANCEMENT: 
- Controlled pain 
- ROM: Elevation in plane of scapula to 120°, External rotation to 30° 
- Independent home exercise program 
- Independent light ADLs 
 
 
 
 
 
 
 
Patient Name: _______________________________________________ 
 
Physician’s Signature: ________________________________________ M.D. 
Date: ___ /___ / _____ 
Emphasize: 
- Controlling pain and inflammation 
- ROM as per surgeon’s guidelines 
- Sling immobilization 
 
MODIFICATIONS TO PHASE I: 
 
 
POST – OPERATIVE PHASE II (WEEKS 4-10) 
GOALS:  
 
- Pain control 0/10 with ADLs 
- PROM: elevation in plane of scapula to 150°;  
      ER to 45° 
- Independent home exercise program 
 
PRECAUTIONS: 
- Avoid pain during ADLs 
- Avoid ROM beyond surgeon’s direction 
 
TREATMENT RECOMMENDATIONS: 
- PROM to AAROM exercises in plane of scapula:  ER with cane; advance elevation to using cane in neutral 
rotation with adequate humeral head control, pulleys when ROM >120° and good humeral head control; 
AROM: elevation in supine, internal rotation at 6 weeks (towel pass); Humeral head control exercises: ER/ IR 
(supine/ scapular plane), elevation at 100°; Hydrotherapy: elevation in plane of scapula, horizontal abduction/ 
adduction; Isometrics: deltoid in neutral, ER in modified neutral when ROM >30°, IR (modified neutral) at 6 
weeks; Closed kinetic chain exercises: ball stabilization,weight shifting; scapular retraction with elastic bands, 
extension with elastic bands; Airdyne or upper body ergometry; modalities as needed, modify home exercise 
program, as appropriate. 
- Other: _________________________________________________________________________ 
 
MINIMUM CRITERIA FOR ADVANCEMENT: 
- 0/10 pain with ADLs 
- ROM: 150° elevation; 45° elevation 
- Good humeral head control 
- Independent home exercise control 
 
 
Patient Name: _______________________________________________ 
 
Physician’s Signature: ________________________________________ M.D. 
Date: ___ /___ / _____ 
 
 
 
 
 
Emphasize: 
- Avoiding ROM beyond surgeon’s direction  
- Pain control 
- Overusing the shoulder 
- Avoiding heavy lifting 
 
MODIFICATIONS TO PHASE II: 
 
POST – OPERATIVE PHASE III (WEEKS 10-16) 
GOALS:  
- Pain control 0/10 with advanced ADL 
- PROM: elevation to 160°, ER to 60° 
- AROM: IR to T12 
- Restore normal scapulohumeral rhythm below horizontal 
- Improve muscle strength to 4/5 
- Independent in current HEP 
 
PRECAUTIONS: 
- Avoid pain with therapeutic exercise and ADLs 
- Avoid AROM that encourage scapular hiking, poor biomechanics. 
 
TREATMENT RECOMMENDATIONS: 
- Progress ROM activities as tolerated; Flexibility exercises: towel stretch, posterior capsule stretch; 
Hydrotherapy; Isometrics: deltoid away from neutral; Scapular stabilization; Rhythmic stabilization; PREs for 
scapula, biceps, triceps; Elevation in plane of scapula; Airdyne/ UBE for endurance; Progressive resistive 
equipment (lightweight) for chest press, row; modalities prn, modify and advance HEP 
- Other: _________________________________________________________________________ 
 
MINIMUM CRITERIA FOR ADVANCEMENT: 
- Pain control 0/10 with advanced ADL 
- PROM: elevation to 160°, ER to 60° 
- IR to T12 
- Muscle strength 4/5 throughout upper extremity 
- Normal scapulohumeral below horizontal 
- Independent in current HEP 
 
 
Patient Name: _______________________________________________ 
     
Physician’s Signature: ________________________________________ M.D. 
Date: ___ /___ / _____ 
 
 
 
 
Emphasize: 
- Avoiding inflammation of rotator cuff 
- Establishing normal strength base and 
scapulohumeral control 
 
MODIFICATIONS TO PHASE III: 
 
POST – OPERATIVE PHASE IV (WEEKS 16-22) 
GOALS:  
 
- Maximize ROM 
- Adequate strength and flexibility to meet demands of ADLs 
- Normal scapulohumeral rhythm >100° elevation 
- Functional muscle strength throughout involved upper extremity 
- Independence in home and gym therapeutic exercise programs 
 
PRECAUTIONS: 
- Avoid pain with therapeutic exercise and functional ADLs 
- Avoid lifting heavy objects 
 
TREATMENT RECOMMENDATIONS: 
- Assess and address any remaining deficits in ROM, strength, and flexibility; AROM, AAROM, PROM 
exercise; Flexibility program: posterior capsule stretching, towel stretch IR; PREs to include dumbbells; elastic 
bands for IR/ER; Rythmic stabilization; proprioceptive neuromuscular facilitation patterns; modalities, PRN; 
Modify home exercise program; Discharge planning for maintenance and advancement of gains achieved 
during rehabilitation. 
 
CRITERIA FOR DISCHARGE/ RETURN TO SPORT: 
- Maximize ROM 
- Full independence in ADLs 
- Normal scapulohumeral rhythm >100° elevation 
- Functional muscle strength throughout the involved upper extremity 
 
 
 
Patient Name: _______________________________________________ 
 
Physician’s Signature: ________________________________________ M.D. Date: ___ /___ / _____ 