Exercises After Reverse Shoulder Replacement: Week-by-Week Protocol

Dr. Jitesh Jain | MBBS, MS Orthopedics, FNB (Sports Medicine & Arthroscopy) | Consultant at Rajasthan Hospital, Jaipur

This phased rehabilitation program is designed to protect the surgical implant while gradually retraining the deltoid muscle to compensate for the absent rotator cuff. Strict adherence to these phases is critical to prevent dislocation and ensure long-term functional success.

If you are still deciding on surgery, first read what reverse shoulder replacement is and who needs it. Do these exercises only as advised by me or your physiotherapist.

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General Guidelines

• Passive range of motion (ROM, where someone else or your healthy arm moves the operated arm) only for 4 weeks. Active assisted ROM at 6 weeks, active ROM at 8 weeks. No strengthening for 8 weeks.
• Avoid external rotation (ER, turning the arm outwards) for the first 2 weeks. No passive ER beyond 30 degrees in 4 weeks.
• Avoid excessive extension beyond 0 degrees and end-range adduction/internal rotation (IR) for 4 weeks.
• Sling/immobilizer to be worn at all times except while doing exercises for 4–6 weeks.
• Expect return to moderate functional activities gradually at 3 months post-op.
• Lifetime restrictions: no lifting over 20 pounds (about 9 kg) out from the body or overhead, and no overhead throwing.

Phase 1: Healing & Passive Motion (Weeks 0–4)

Sling dependency and joint protection. The primary goal is to protect the surgical repair, minimize pain, and prevent extreme stiffness without stressing the new joint.

Immobilization: Wear the sling with abduction pillow continuously, day and night. Remove it only for showering, dressing, and approved exercises.

Sling with abduction pillow, worn day and night in the first weeks

Precautions:

• No active movement of the operated shoulder. Strictly avoid combined extension and internal rotation (e.g., reaching behind your back to tuck in a shirt or hook a bra), as this position poses the highest risk of implant dislocation.
• No active ROM.
• No submersion in pool/water for 4 weeks.
• No weight bearing through the operative arm (as in transfers, walker use, etc.).

First 2 weeks: exercises (3–4 times daily)

1. Neck, elbow, wrist and hand active range of motion (AROM): Gently bend and rotate your neck, elbow, and wrist in all possible directions, as shown in the picture. Do these exercises for 1–2 minutes, and repeat them 3 to 4 times a day.

Neck, elbow, wrist and hand movements

2. Supine passive forward elevation up to 90 degrees (performed by a physiotherapist or using the healthy arm to lift the operated arm): Lie flat on your back (supine) on a bed or floor. Using your healthy, non-operated arm, grasp the wrist or forearm of your operated arm. Let the operated arm remain completely relaxed (passive). Use only the strength of your healthy arm to slowly lift the operated arm straight up toward the ceiling. Stop when the arm is pointing straight up at the ceiling (90 degrees). Do not push past this point. Slowly lower the arm back down to resting position on your stomach or side, again using only the healthy arm to control the weight. Do 10 repetitions morning and evening.

Passive forward elevation up to 90 degrees, lying on your back

3. Scapular retraction: Stand tall with your arms relaxed at your sides. Keep your shoulders down (do not shrug toward your ears) and slowly squeeze your shoulder blades tightly together, as if trying to hold a pencil between them. Hold the squeeze for 5 seconds, then slowly release. Aim for 2 sets of 10–12 repetitions.

Scapular retraction: squeeze the shoulder blades together

Weeks 2–4: continue previous exercises and start these

Now you may use the arm for light activities of daily living (such as feeding, brushing teeth, dressing) with the elbow near the side of the body and the arm in front of the body.

4. Gentle pendulum exercises: Lean forward and let the arm dangle, using body momentum to gently swing the arm in small circles. Do 10 repetitions morning and evening.

Pendulum exercise

5. Passive supine external rotation (start after 2 weeks): The patient lies supine and relaxes. The arm is kept by the side of the body with the elbow bent at 90 degrees and fingers facing upwards. The patient should relax and should not contract any muscles while the therapist or a family member pulls the forearm so your arm rotates out, away from your body, up to 30 degrees, and then brings it back to the starting position. Do 10 repetitions morning and evening.

Passive external rotation up to 30 degrees

6. Passive forward elevation in the scapular plane, 90–120 degrees maximum (starts 2 weeks after surgery):

• When to start: This specific exercise should only be started after 2 weeks of your surgery.
• The position (scapular plane): Instead of lifting your arm straight in front of you or straight out to the side, the arm is lifted midway between the two (about 30 to 45 degrees outward). Imagine lifting your arms to give someone a hug or forming a slight "V" shape.
• The movement (passive): Your operated arm must remain completely relaxed and limp. A helper (or your healthy arm) will do all the work to slowly lift the operated arm in this angled direction.
• The limit: The helper should lift the arm up to shoulder height (90 degrees) or just slightly above it (up to 120 degrees maximum). Stop immediately if you feel pain, and do not push past this limit. Do 10 repetitions morning and evening.

Passive forward elevation in the scapular plane

7. Passive abduction up to 120 degrees maximum. Do 10 repetitions morning and evening.

Passive abduction up to 120 degrees

Phase 2: Transitioning Off the Sling (Weeks 4–8)

In this phase, we begin waking up the deltoid muscle and gradually weaning off the sling in a safe, controlled environment.

Immobilization: Gradually discontinue the sling for daily activities over weeks 4 to 6.

Precautions: No lifting objects heavier than a cup of tea. Continue to avoid reaching behind the back.

Weeks 4–6: exercises

Avoid reaching across the chest (adduction + internal rotation) and hand behind the back (till 6 weeks).

1. Pulley exercises: Using a door pulley to assist with forward elevation. Sit or stand near a door where the pulley is attached. Hold one handle in each hand. Slowly pull down with your good (healthy) arm. This action will automatically lift your operated arm upward. Keep the operated arm completely relaxed and let the healthy arm do all the work. Do 10 repetitions morning and evening.

Pulley exercise

2. Table slides: Sliding the hand forward on a smooth table surface to improve flexion. Sit on a chair facing a table. Place both hands on a small folded towel on the table. Slowly slide the towel forward across the table, away from your body. As the towel moves forward, let your chest drop lower towards the table to gently stretch the shoulder. Slowly slide it back. Do 10 repetitions morning and evening.

Table slide exercise

3. Sub-maximal, pain-free deltoid isometric contractions (pressing gently against a wall without moving the joint): Add sub-maximal isometrics, with pain-free effort, for all functional heads of the deltoid (anterior, posterior, middle). Ensure that with the posterior deltoid isometric the shoulder does not move into extension and the arm remains in front of the body (the elbow does not go behind your body).

Isometric push and pull exercises: Without moving the shoulder, push a pillow against the wall with your fist. Hold for 15 seconds, and then relax for 15 seconds. Do 10 repetitions. The same exercise is repeated, but this time you push the pillow against the wall with your elbow.

Isometric push against a pillow with the fist and with the elbow

Isometric external and internal rotations: With a pillow against a wall, and the arm tucked close to the body, push the pillow with the back of the hand for external rotation and with the palm of the hand for internal rotation. Hold for 15 seconds, and then relax for 15 seconds. Do 10 repetitions.

Isometric external and internal rotation

4. Supine active-assisted forward elevation, progressing to a sitting position: Lie flat on your back on a bed. Hold a light stick (like a walking cane or broomstick) with both hands. Use your healthy arm to push the stick up, lifting the operated arm straight up towards the ceiling. Sitting (progression): once you can do this easily without pain while lying down, try performing the exact same stick exercise while sitting upright in a chair. Do 10 repetitions morning and evening.

Active-assisted forward elevation with a stick

5. Supine active-assisted external rotation: Lying on your back, keep your arms by your side. Now hold a cane between your hands and push the operated hand away from your body until you feel a gentle stretch in your shoulder, as shown in the picture. Gradually increase the range. Do it morning and evening with 10 repetitions every time.

Active-assisted external rotation with a cane

6. Active-assisted abduction: You can do it in a standing or supine position. Do not shrug your shoulder or tilt your body while doing this exercise. Using a stick to assist (as shown), raise your operated arm out to the side with the elbow straight and palm facing upwards. Slowly increase the elevation of your arm as the days progress, using pain as your guide. Repeat 10–20 times.

Active-assisted abduction with a stick

7. Increase external rotation up to 60 degrees between 4 and 6 weeks. Do 10 repetitions morning and evening.

External rotation, now up to 60 degrees

Phase 3: Weeks 6–8

You can start internal rotation (palm on the belly) and continue the previous exercises. You can take the brace off now.

Internal rotation: palm on the belly

Phase 4: Active Motion & Early Strengthening (Weeks 8–12)

The focus shifts to achieving full, unassisted movement against gravity and beginning light resistance training.

Precautions: Avoid sudden, forceful pushing or pulling movements.

Exercises:

• Standing active forward elevation (using a mirror to ensure the shoulder doesn't "shrug" to compensate).
• Scapular strengthening: rows and shrugs using light resistance bands.
• Light Theraband exercises for forward flexion and abduction.
• Begin gradual external rotation stretching to restore functional reaching.

While continuing to work on active assisted range of motion, the patient now begins active range of motion in forward elevation, external rotation and abduction.

Forward elevation: Do 10 repetitions morning and evening.

Active forward elevation

Abduction: Do 10 repetitions morning and evening.

Active abduction

External and internal rotation: Do 10 repetitions morning and evening.

Active external and internal rotation

Theraband exercises

Rowing exercises: Use the muscles around your shoulder blades and pull your shoulder blades back and down. At the same time, as shown in the picture, perform a rowing motion keeping your elbows close to your body. Return to the start position (elbow straight). Do 10 repetitions.

Theraband rowing

Triceps exercises: Straighten your arm as shown in the picture against resistance. Do 10 repetitions.

Theraband triceps exercise

Elbow flexion exercises: Hold the Theraband by looping it around your feet. Then pull it against resistance by flexing the elbow. Do 10 repetitions.

Theraband elbow flexion

Phase 5: Advanced Strengthening (Months 3–6+)

Returning to normal life. This final phase focuses on endurance, functional task simulation, and returning to recreational activities. Functional gains typically plateau between 6 to 12 months.

Precautions: Avoid heavy, repetitive overhead lifting. Avoid high-impact contact sports indefinitely.

Exercises: Progressive resistive exercises (light dumbbells, 2–5 lbs, about 1 to 2 kg, maximum overhead; advanced Theraband exercises).

Resisted internal rotation: Make a 3-feet-long Theraband loop around a doorknob and internally rotate the arm against resistance, as shown in the picture, by moving the hand towards the body. Keep the elbow tucked by the side of the body. Do 10 repetitions.

Resisted internal rotation with a Theraband

Resisted external rotation: Do the same as above, but this time move the hand away from your body. Do 10 repetitions.

Resisted external rotation with a Theraband

Bent-over horizontal abduction: Lie down on your stomach with the arm hanging at the edge. Hold a 1 kg weight and slowly raise it up to shoulder level. Slowly lower it back to the starting position. Do 10 repetitions.

Bent-over horizontal abduction

Forward flexion: Have the Theraband secured around your foot. Start at waist height and raise your arm against the resistance of the band. Raise your arm as far as is comfortable plus a bit more, hold for several seconds, then slowly lower. Do 10 repetitions.

Theraband forward flexion

Abduction: Again, the Theraband is secured at foot level. Raise your arm straight out to the side against the resistance of the band. Raise your arm as far as is comfortable plus a bit more, hold for several seconds, then slowly lower it down. Do 10 repetitions.

Theraband abduction

Need Help With Your Recovery?

Every shoulder heals at its own pace. If you have pain, swelling or doubt about any exercise, send us a message before you push further. For the full picture of the surgery itself, read my complete guide to reverse shoulder replacement, or see shoulder replacement surgery in Jaipur.

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