Shoulder Replacement: Addressing Shoulder Hike and Shrug

How soon is it reasonable to expect shoulder replacement patients to return to sports and other desired activities?

In a study by Katrin Schumann and colleagues, 89 percent of shoulder replacement patients return to their desired activities in three to six months.¹ Today’s baby boomer patients, who are striving to maximize even an above-the-norm recovery, require a more advanced way to rehabilitate the shoulder arthroplasty.

How can rehabilitation clinicians help our shoulder replacement patients reach their goals and get them back to important activities faster while avoiding the dreaded shoulder hike and shrug?

Pre-Operative Impairments

We must approach shoulder replacement rehabilitation with an understanding that the patient has had a long period of pain and disuse pre-operatively. Therefore, addressing pre-operative impairments is our first and foremost goal.

These pre-operative impairments can be improved with manual therapy of the four muscles that, when adaptively shortened, can restrict arm elevation:

• The levator scapular
• The subscapularis
• The pectoralis minor
• The infraspinatus

When the rehab professional directs the rehab process immediately, whether pre-op or post-op, better posture scapular positioning and thoracic alignment will be enhanced. Getting these impairments out of the way allows for a much more efficient facilitation of the phases of rehab that strengthen the shoulder.

Addressing the Kinetic Chain

Shoulder arthroplasty rehabilitation requires attention to the entire kinetic chain. From the acute stage through home care, the clinician needs to prepare the patient for outpatient rehab.

The first 21 days of treatment should focus on those preoperative impairments of posture, scapular mobility, and restrictors to shoulder elevation. This will be the bridge to recovering activities of daily living and, eventually, functional strength.

Shoulder Hike or Shrug

One of the key rehabilitation goals when returning patients to their desired activities is to eliminate and prevent the dreaded “shoulder hike or shrug” following shoulder replacement. We can do a better job of addressing this concern, and it should be every clinician’s goal when rehabbing a shoulder patient.

The biomechanical reason behind shoulder hike and shrug is that most shoulder replacement patients have pre-operative rotator cuff weakness or pathology. If the rotator cuff cannot adequately compress the head of the humerus into the glenoid fossa, the force couple will be absent between the rotator cuff and the deltoid, meaning the head of the humerus will go into a superior direction versus a posterior inferior direction.

Exercises using a short lever deltoid action can result in making the deltoid a two-action muscle (performing both humeral head compression and elevation), thus addressing shoulder hike and shrug.

The acute care clinician can start facilitating deltoid activation with short lever ball squeezes while at the same time performing isometrics of the biceps. This exercise can be added to the typical surgeon-directed therapy of elbow, wrist, and hand range-of-motion-only protocols. Once the patient can start active assistive elevation, the extremity should be once again in a short lever position.

To learn more about how you can best restore function and range of motion to your shoulder replacement patients, watch my MedBridge course, “Shoulder Arthroplasty: Return to Function—An Update.”