Rehabilitation after shoulder replacement: sling, exercises and recovery

Replacing the joint surfaces removes the painful, worn ball and socket, but the soft tissues around them have been cut, repaired or re-tensioned and need time before they can take load. Rehabilitation exists to protect those tissues while they heal, keep the elbow, wrist, neck and shoulder blade moving, and then rebuild usable strength. Hospital leaflets consistently frame the programme as a partnership: the physiotherapist sets the stages, but the daily exercises are yours to do.

UK trials of shoulder replacement make the same point from the research side. The RAPSODI-UK protocol, which compares anatomical and reverse replacement for people aged 60 and over with osteoarthritis, specifies that both groups receive the usual post-operative physiotherapy, delivered in person, remotely or as a mix, with timing and frequency following each site's routine practice rather than a fixed national schedule.

You leave theatre with the arm in a supportive sling. West Suffolk guidance says it may come off while sitting down or in bed, with pillows under the arm for support, and for tasks such as washing your face, cleaning your teeth, eating and writing. It must also come off for every exercise session. Keeping the hand above shoulder level in bed with pillows under the whole arm can reduce swelling.

Pain needs to be controlled well enough to let you exercise, so the leaflets ask patients to request or review painkillers rather than put up with discomfort. The same guidance suggests ice wrapped in a damp towel for 20 minutes every two hours, no bath or shower for the first 10 days while the dressing stays dry, and loose clothing that goes on over the operated arm first and comes off from it last.

• Lean forward and let the arm hang to wash the armpit, rather than lifting it sideways.

• Expect to be effectively one-handed for the first few weeks, a point East Kent guidance makes about the first three to four weeks.

• Arrange help at home with washing and dressing, because the shoulder cannot be used actively in the early stage.

A reverse replacement swaps the ball and socket so that the deltoid, rather than the rotator cuff, lifts the arm. The West Suffolk leaflet notes it is indicated when the cuff muscles are deficient. A review of early mobilisation after reverse replacement makes the same biomechanical point: elevation becomes much less dependent on cuff integrity and much more dependent on the deltoid.

Calderdale and Huddersfield publish both protocols side by side. After an anatomical replacement the surgeon cuts and repairs a tendon at the front of the shoulder, so the protocol protects that repair: sling day and night for 6 weeks apart from exercises, no active movement of the shoulder at first, and no resisted internal rotation or forced outward rotation. After a standard reverse replacement the protocol protects the deltoid and the joint stability instead, weaning the sling from 2 weeks and often advising it outdoors until 4 weeks.

Reverse replacements can dislocate if the arm is pushed into certain positions before the soft tissues have settled, so the precautions are specific. The Robert Jones and Agnes Hunt guideline limits movement to no higher than 90 degrees for the first 3 weeks, avoids pendulum exercises for 3 weeks, and avoids placing the hand behind the back for 6 weeks. It also warns against pushing up from a chair with the operated arm, because loading the arm in extension carries a dislocation risk.

Calderdale and Huddersfield give the same warning in their reverse protocol, advising against forcing the hand-behind-back movement and against bearing weight through the arm when getting out of bed or a chair. In practice this means using the other arm and your legs to stand until your physiotherapist says otherwise.

Once the early period has passed, exercises move from assisted to active movement and then to resistance. East Kent guidance says light activities in front of the body can begin about three weeks after surgery, most light activities are usually possible by four to six weeks, and strength starts to improve after six weeks. Calderdale and Huddersfield describe progression to active exercises in all directions with good shoulder-blade control, then strengthening through range once it is pain free.

Do not expect the speed of progress to match another patient's. A guideline from the Robert Jones and Agnes Hunt hospital says it takes approximately three months to get useful active movement, and the same hospital describes improvement continuing for 12 to 24 months. Calderdale and Huddersfield say three to six months is common before daily activities are unrestricted.

East Kent guidance says you will not be able to drive for about eight weeks, subject to how recovery goes, and Calderdale and Huddersfield says to expect a minimum of eight weeks. The same East Kent leaflet places gentle swimming and water exercises at four to six weeks and starting to practise golf at six weeks. Your insurer and your surgeon both have a say, and you should be able to perform an emergency stop confidently.

Lifting limits and return to heavier work are individual and are not set out in the leaflets used here, so ask your own team.

Surgeons worldwide differ on how long to keep the arm in a sling. A global survey of surgeons performing elective shoulder replacement found the great majority recommending a sling for at least 3 to 6 weeks, with range-of-movement restrictions common, and described marked variation in post-operative practice.

A systematic review of six studies of reverse replacement for non-fracture conditions found that earlier mobilisation was associated with slightly greater forward elevation, abduction and lower pain scores, although the gains were smaller than the thresholds usually considered clinically important. It found no extra dislocations or revisions with earlier movement. The authors conclude early rehabilitation appears safe but the benefit is modest, so surgeons keep their own protocols.

Hospital leaflets list infection, nerve injury, bleeding, blood clots, stiffness, fracture and dislocation among the possible complications. Contact the ward or your surgical team, or use NHS 111, for a wound that becomes red, hot or leaks fluid, a high temperature, new numbness or weakness in the hand, or pain that rises despite painkillers and ice. Call 999 or go to A&E for chest pain, breathlessness, or a calf that becomes swollen and painful, which can signal a clot, and for a sudden deformity or severe pain after a fall.