Total Shoulder Replacement

Educational overview. Not medical advice.

Total shoulder replacement (shoulder arthroplasty) replaces worn shoulder joint surfaces with metal and plastic parts to reduce pain and improve function. Your surgeon may perform:

  • Anatomic total shoulder arthroplasty (aTSA): used when the rotator cuff is working.
  • Reverse total shoulder arthroplasty (rTSA): used when the rotator cuff is severely torn or not functional.

Indications

Common reasons to recommend surgery:

  • Severe shoulder arthritis (osteoarthritis or inflammatory arthritis) with persistent pain and loss of function despite non-surgical care.
  • Night pain or pain at rest affecting sleep and daily activities.
  • Marked stiffness or weakness limiting grooming, dressing, reaching, or lifting.
  • Certain complex fractures, fracture-dislocations, or failed prior shoulder surgery (selected cases).

Common reasons to delay or avoid surgery:

  • Absolute: active infection (skin or deeper), uncontrolled systemic infection.
  • Relative: poorly controlled diabetes, active smoking/nicotine use, severe medical instability (cardiac/pulmonary), untreated dental or skin infections, inadequate social support for early recovery, severe neurologic impairment limiting rehabilitation, or unrealistic expectations. Medical optimization improves safety and outcomes.1

Benefits and alternatives

Benefits:

  • Substantial pain reduction.
  • Improved shoulder motion (often not fully normal).
  • Improved strength and ability to perform daily tasks.
  • Better sleep and quality of life.

Alternatives (depending on diagnosis and cuff status):

  • Activity modification, ice/heat, acetaminophen and/or NSAIDs if safe.
  • Physical therapy (range of motion, scapular mechanics, rotator cuff and deltoid strengthening).
  • Corticosteroid injection (temporary symptom control; timing relative to surgery matters).
  • Image-guided injections or nerve blocks in selected cases.
  • Arthroscopic debridement (limited role; usually temporary).
  • Other surgeries when appropriate: hemiarthroplasty, tendon transfer, reverse vs anatomic replacement selection, or revision procedures.1

Surgical procedure

Typical steps:

  • Incision over the shoulder; careful protection of nerves and blood vessels.
  • Removal of damaged cartilage and reshaping of bone surfaces.
  • Placement of a metal humeral component (stemmed or stemless) and a plastic socket (glenoid) for aTSA, or a reverse ball-and-socket configuration for rTSA.
  • Balancing soft tissues for stability; repair of the subscapularis tendon is common in aTSA.
  • Closure in layers; sterile dressing applied.

Key variants: implant design (stemmed vs stemless, cemented vs press-fit), and anatomic vs reverse configuration based on rotator cuff status and bone quality.

Implant specifics and MRI considerations

  • Typical materials: titanium or cobalt-chromium alloys and polyethylene (plastic) components.
  • Implants are intended to remain permanently; removal is usually only for complications (infection, loosening, instability, fracture, severe wear).
  • Most modern shoulder implants are MRI-conditional; MRI is often possible but may create image artifact near the shoulder. Tell radiology you have a shoulder implant and bring your implant card if available.
  • Metal detectors may be triggered; a medical device card can help, but policies vary.

Typical anesthesia

  • Most patients receive general anesthesia plus a regional nerve block for pain control (commonly an interscalene block).
  • Nerve blocks can reduce early pain and opioid use, but may cause temporary arm numbness/weakness; rare risks include nerve injury or breathing discomfort in susceptible patients.
  • Many patients go home the same day or stay 1 night, depending on medical risk, pain control, and home support.

Recovery timeline

Protocol varies by implant type (anatomic vs reverse), tendon repair, bone quality, and surgeon preference.

Time point Pain and swelling Immobilization/weight-bearing Activity and restrictions Physical therapy
Days 0-3 Moderate pain first 48-72 hrs; swelling/bruising common Sling nearly full time; no lifting Hand, wrist, elbow motion; ice; sleep semi-upright Start gentle home program if prescribed (often pendulums)
14 days Pain improving; incision tenderness Sling most of day; remove for hygiene/exercises No lifting heavier than a coffee cup; protect repaired tissues Often begin or progress passive range of motion
4 weeks Pain mild to moderate with therapy Sling weaning per surgeon (often still outside home) Light daily tasks at waist level; avoid sudden reaching Passive to active-assisted motion goals
8 weeks Pain mostly mild; soreness after PT Usually out of sling No heavy lifting; avoid high-impact use Begin active motion; light strengthening may start in select protocols
12 weeks Pain typically low; endurance still limited No sling Gradual lifting progression; avoid heavy overhead work Progressive strengthening and functional training
6 months Most daily function restored; occasional stiffness None Many return to low-impact sports; heavy labor may still be limited Maintenance program; sport/work-specific conditioning

Risks and complications

Common:

  • Stiffness, prolonged soreness, temporary numbness from positioning or nerve block.
  • Rotator cuff or subscapularis failure (more relevant to anatomic implants).
  • Scapular/acromial stress fracture or instability (more relevant to reverse implants).6

Less common:

  • Infection (often reported around 0.6% to 2% depending on population, follow-up, and definitions).4,5
  • Blood clots (uncommon in upper extremity arthroplasty, but risk increases with prior VTE, cancer, immobility).

Rare but serious:

  • Permanent nerve injury, major bleeding, implant dislocation, periprosthetic fracture, deep infection requiring additional surgery.

Patient-specific risk modifiers (examples):

  • Higher risk with smoking/nicotine use, uncontrolled diabetes, obesity, immunosuppression, inflammatory arthritis, prior shoulder surgery, and certain bleeding or clotting disorders.1,5

Durability and revision risk

  • Expected longevity commonly measured as "implant survival" (not revised).
  • Large registry and long-term case series data suggest about 92% to 95% of shoulder replacements are still in place at 10 years (meaning roughly 5% to 8% undergo revision by 10 years), with variation by implant type, diagnosis, age, and surgeon/hospital volume.2
  • Reverse shoulder replacements in registry data show similar 10-year survival in common indications such as osteoarthritis and cuff tear arthropathy (about 93% to 94% in reported datasets).2
  • Longer-term data are less certain and are influenced strongly by patient age and demand. In patients under 65, pooled estimates suggest about 75% implant survival at 20 years for anatomic TSA.3
  • Common reasons for revision: loosening (especially glenoid), rotator cuff/subscapularis failure (anatomic), instability/dislocation (especially reverse), infection, and periprosthetic fracture.

Practical instructions

  • Pain control: use a multimodal plan (acetaminophen +/- NSAID if safe, ice, nerve block effects, short course opioid only if needed). Avoid alcohol and sedatives with opioids. Use a bowel regimen (hydration, fiber, stool softener +/- osmotic laxative) if taking opioids.
  • Wound care: keep dressing clean/dry; follow your surgeon's timing for showering. Avoid soaking (pool, tub) until cleared.
  • Sling: wear as directed; remove only for hygiene and prescribed exercises.
  • Sleep: recliner or wedge pillow often helps for 1-3 weeks.
  • Driving: do not drive while taking opioids, while in a restrictive sling, or until you can safely control the wheel and perform emergency maneuvers (often 2-6+ weeks; longer for right shoulder).
  • Work return (ranges): desk work 2-4 weeks; light duty 6-12 weeks; heavy labor 3-6+ months (individualized).
  • Travel/flying: discuss timing with your surgeon. If traveling early, stand/walk regularly, hydrate, and do ankle pumps; use VTE prevention as prescribed (mechanical and/or medication based on risk).
  • Dental/skin infections: treat promptly; notify your surgeon before elective procedures.
  • Red flags (call urgently or go to ER): fever with worsening shoulder pain, increasing redness/drainage, chest pain/shortness of breath, calf swelling/pain, sudden severe shoulder pain or deformity, new hand weakness/numbness that is worsening, uncontrolled bleeding.

FAQ

  • How much pain is normal? Most pain is highest in the first 2-3 days, then improves; therapy can cause temporary soreness.
  • When can I shower? Follow your surgeon's dressing and shower instructions; avoid soaking until cleared.
  • Why the sling? It protects repaired tissues and improves healing in the first weeks.
  • When can I drive? Only when off opioids, safe arm control is restored, and sling restrictions allow.
  • Will I set off metal detectors? Sometimes; carry your implant card if you have one.
  • Can I get an MRI? Often yes (MRI-conditional implants), but tell radiology and expect artifact near the shoulder.
  • Do I need PT? Yes in most cases; adherence strongly affects motion and function.
  • What are infection or clot warning signs? Increasing redness/drainage/fever, or new leg swelling/pain, chest pain, or shortness of breath.

Educational information only; not individualized medical advice. Follow your surgeon's specific instructions, which may differ based on implant type and your anatomy.

Bibliography

  1. American Academy of Orthopaedic Surgeons. Management of Glenohumeral Joint Osteoarthritis: Evidence-Based Clinical Practice Guideline. Rosemont (IL): AAOS; 2020.
  2. Evans JP, Evans JT, Craig RS, Mohammad HR, Sayers A, Blom AW, et al. How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up. Lancet Rheumatol. 2020;2(9):e539-e548. doi:10.1016/S2665-9913(20)30226-5.
  3. Davies A, Lloyd T, Sabharwal S, Liddle AD, Reilly P. Anatomical shoulder replacements in young patients: a systematic review and meta-analysis. Shoulder Elbow. 2022;15(1 Suppl):4-14. doi:10.1177/17585732221075037.
  4. Schick S, Elphingstone J, Murali S, Carter K, Davis W, McGwin G, et al. The incidence of shoulder arthroplasty infection presents a substantial economic burden in the United States: a predictive model. JSES Int. 2023;7(4):636-641. doi:10.1016/j.jseint.2023.03.013.
  5. Kunutsor SK, Barrett MC, Whitehouse MR, Craig RS, Lenguerrand E, Beswick AD, et al. Incidence, temporal trends and potential risk factors for prosthetic joint infection after primary total shoulder and elbow replacement: systematic review and meta-analysis. J Infect. 2020;80(4):426-436. doi:10.1016/j.jinf.2020.01.008.
  6. Parada SA, Flurin PH, Wright TW, Zuckerman JD, Elwell JA, Roche CP, et al. Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2021;30(4):811-818. doi:10.1016/j.jse.2020.07.028.
  7. American Academy of Orthopaedic Surgeons. Shoulder Joint Replacement (OrthoInfo).
  8. American Academy of Orthopaedic Surgeons. Reverse Total Shoulder Replacement (OrthoInfo).
  9. National Joint Registry (England, Wales, Northern Ireland and Isle of Man). 22nd Annual Report 2025. Surgical data to 31 December 2024.
  10. Australian Orthopaedic Association National Joint Replacement Registry. Annual Report 2025.