What is the recommended rehabilitation protocol after shoulder hemiarthroscopy for an adult patient with a history of shoulder pain or injury and no significant comorbidities?

Rehabilitation Protocol After Shoulder Hemiarthroplasty

Begin immediate mobilization without immobilization—accelerated rehabilitation protocols demonstrate superior outcomes with fewer complications compared to traditional sling immobilization approaches. 1

Immediate Post-Operative Phase (Weeks 0-2)

Start active-assisted and passive range of motion exercises immediately post-operatively without any period of immobilization. 1 This accelerated approach has been validated in reverse total shoulder arthroplasty with excellent outcomes and is applicable to hemiarthroplasty.

Initial Movement Protocol

• Position the arm in safe positions within the patient's visual field during all exercises to prevent inadvertent trauma 2, 3
• Focus specifically on external rotation and abduction movements as these address the most common post-operative limitations 2, 3
• Apply ice before each exercise session for symptomatic pain relief 2
• Perform gentle passive range of motion in all planes, avoiding any overhead pulley devices which encourage uncontrolled abduction and increase complication risk 4

Pain Management

• Prescribe ibuprofen taken before bedtime as it is superior to acetaminophen for shoulder pain and improves sleep quality 2
• Consider acetaminophen as an alternative if NSAIDs are contraindicated 5, 3
• Never allow the patient to sleep on the affected shoulder—proper positioning during sleep is crucial for recovery 2

Early Strengthening Phase (Weeks 2-6)

Progress to active range of motion exercises gradually while simultaneously restoring proper shoulder alignment. 5, 2, 3

Exercise Progression

• Increase active range of motion incrementally in conjunction with strengthening weak muscles of the shoulder girdle 5, 2, 3
• Target rotator cuff and scapular stabilizer muscles with progressive resistance exercises 2
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 2
• Continue focusing on external rotation and abduction as these movements remain critical throughout rehabilitation 2, 3

Monitoring Response

• Assess pain levels, range of motion, and functional capacity at 2-week intervals to track progress 6
• Expect significant functional improvements by week 6 based on validated rehabilitation protocols 6

Advanced Strengthening Phase (Weeks 6-12)

Advance to intensive strengthening exercises and graduated return to overhead activities. 2, 6

Functional Training

• Implement sport-specific or occupation-specific exercises tailored to the patient's activity goals 7
• Incorporate full-body training to prevent undue stress on the surgical repair during return to activity 7
• Progress resistance training systematically while maintaining proper mechanics 2, 7

Expected Outcomes

• Anticipate large effect sizes in flexion, abduction, and external rotation range of motion by 12 weeks 6
• Expect substantial improvements in shoulder function scores with continued gains through this phase 6, 8

Critical Pitfalls to Avoid

Immobilization Errors

• Avoid any prolonged immobilization or sling use—accelerated protocols without immobilization demonstrate fewer postoperative complications, particularly fall-related injuries 1
• Never use static positioning or strapping of the upper extremity as evidence does not support these interventions for preventing pain or loss of motion 5, 4

Exercise Technique Errors

• Strictly prohibit overhead pulley exercises as they encourage uncontrolled abduction and dramatically increase the risk of shoulder complications 4
• Ensure early mobilization is mandatory to prevent development of adhesive capsulitis (frozen shoulder) 2

Monitoring Failures

• If no improvement occurs after 3-4 weeks of rehabilitation, obtain imaging and consider specialist referral for potential structural complications 2
• Reassess equipment needs regularly with the aim of discontinuing adaptive devices as independent function returns 5

Adjunctive Interventions When Indicated

For Persistent Pain

• Consider subacromial corticosteroid injection if pain is clearly related to bursal inflammation or rotator cuff pathology 5, 2
• Evaluate with ultrasound to assess for structural complications if progress plateaus 2

For Spasticity-Related Pain (if applicable)

• Botulinum toxin injections into subscapularis and pectoralis muscles can be used for spasticity-related shoulder pain 5, 3

Emerging Adjuncts

• Transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) may be considered as adjuncts to upper extremity therapy 5, 3

Duration and Return to Activity

The rehabilitation program should extend at least 3 months to achieve optimal outcomes, though young active patients may progress more rapidly 5, 7

• Ensure complete resolution of symptoms before returning to full overhead activities 2
• Continue monitoring functional outcomes and range of motion at regular intervals through 12 months post-operatively 1, 8
• Expect continued improvements in pain scores and subjective shoulder value throughout the first year 1, 8