Reverse Shoulder Replacement
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The rotator cuff plays an important role in shoulder movement and stability. When these tendons are severely damaged or no longer able to support the joint, a traditional shoulder replacement may not be appropriate. Reverse Shoulder Replacement may be considered because it changes the mechanics of the shoulder and relies more on the deltoid muscle.
Dr. Thomas Freeman is a board-certified orthopedic surgeon with fellowship training in sports medicine and shoulder surgery. He evaluates the rotator cuff, bones, joint surfaces, symptoms, medical history, and previous treatments to determine which treatment options may be considered.
Dr. Freeman sees patients from Traverse City, Northern Michigan, and communities throughout the Great Lakes region.
What Is Reverse Shoulder Replacement?
Reverse Shoulder Replacement is a surgical procedure that replaces damaged portions of the shoulder joint while changing the position of the ball and socket.
In a natural shoulder, the ball is located at the top of the upper arm bone and the socket is part of the shoulder blade. During Reverse Shoulder Replacement, a ball-shaped component is attached to the socket side of the joint. A cup-shaped component is placed on the upper arm side.
This reversed arrangement changes how the muscles move and support the shoulder. Rather than relying mainly on the rotator cuff to center the joint and raise the arm, the reconstructed shoulder allows the deltoid muscle to contribute more to arm movement.
Reverse Shoulder Replacement may be considered for certain patients with severe rotator cuff damage, rotator cuff tear arthropathy, complex fractures, failed previous shoulder surgery, or other conditions. It is not appropriate for every patient with shoulder pain or a rotator cuff tear.
Understanding Shoulder Anatomy
The shoulder joint is called the glenohumeral joint. It is formed by two main structures:
- The humeral head, which forms the ball at the top of the upper arm bone
- The glenoid, which forms the socket in the shoulder blade
The humeral head is much larger than the glenoid. This shallow ball-and-socket arrangement allows the shoulder to move in many directions, but it provides limited stability through bone alone.
Several muscles, tendons, ligaments, and cartilage structures help support the joint.
The rotator cuff includes four muscles and their tendons:
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
These tissues help keep the humeral head centered against the glenoid as the arm moves. They also assist with lifting and rotating the arm.
A large or long-standing rotator cuff tear may prevent the tendons from performing these functions. The humeral head may begin to move upward rather than remaining centered in the socket. Over time, this altered movement can contribute to cartilage damage, bone changes, pain, weakness, and limited motion.
The deltoid is the large muscle that covers the outside of the shoulder. It helps lift the arm away from the body.
Reverse Shoulder Replacement changes the joint’s center of rotation so the deltoid can contribute more to arm elevation. A functioning deltoid is generally important for this procedure.
Conditions That May Lead to Reverse Shoulder Replacement
Reverse Shoulder Replacement may be considered when the rotator cuff cannot adequately support an anatomic shoulder replacement or when other shoulder damage makes a reversed joint arrangement more appropriate.
Rotator Cuff Tear Arthropathy
Rotator cuff tear arthropathy develops when a severe, long-standing rotator cuff tear occurs along with arthritis in the shoulder joint.
Without adequate rotator cuff support, the humeral head may shift upward in the socket. This can change how the joint moves and cause wear on the cartilage and bone.
Possible symptoms include:
- Shoulder pain
- Weakness
- Difficulty raising the arm
- Grinding or catching
- Reduced shoulder motion
- Pain at rest or during sleep
Because Total Shoulder Replacement generally relies on a functioning rotator cuff, Reverse Shoulder Replacement may be considered when both arthritis and severe rotator cuff damage are present.
Severe Rotator Cuff Tears
Some rotator cuff tears cannot be repaired. This may occur when a tear is very large, has been present for a long time, or is associated with substantial changes in the tendon and muscle.
An irreparable rotator cuff tear does not automatically require shoulder replacement. Treatment depends on pain, motion, arthritis, age, activity needs, and previous treatment.
Reverse Shoulder Replacement may be discussed when an irreparable tear causes significant symptoms and other treatment options are unlikely to address the condition adequately.
Shoulder Arthritis With Rotator Cuff Damage
Shoulder arthritis can occur at the same time as a rotator cuff tear. When the rotator cuff is not functioning adequately, Total Shoulder Replacement may not have the soft tissue support it typically requires.
In this situation, Reverse Shoulder Replacement may be considered. Imaging and a physical examination help evaluate both the joint surfaces and the rotator cuff.
Complex Proximal Humerus Fractures
A proximal humerus fracture affects the upper portion of the arm bone near the shoulder joint. Some fractures separate the bone into several pieces and may affect the joint surface or the areas where the rotator cuff attaches.
Treatment options depend on:
- The fracture pattern
- The position of the bone fragments
- Bone quality
- Rotator cuff attachments
- Age and overall health
- Previous shoulder function
Some fractures can be treated without surgery. Others may be repaired with plates, screws, sutures, or other methods. Reverse Shoulder Replacement may be considered when reconstruction is not appropriate or when the fracture and surrounding tissue damage make another approach less suitable.
Failed Previous Shoulder Surgery
Reverse Shoulder Replacement may be considered after certain previous shoulder procedures that have not provided an acceptable result. Examples may include a failed rotator cuff repair, failed fracture treatment, or a previous shoulder replacement with complications.
Revision procedures are planned according to the existing implants, available bone, rotator cuff, deltoid muscle, infection risk, and reason for the previous procedure’s failure.
Other Complex Shoulder Conditions
Reverse Shoulder Replacement may also be considered for selected patients with:
- Significant glenoid bone loss
- Chronic shoulder dislocation
- Certain tumors affecting the shoulder
- Instability after a previous shoulder replacement
- Severe joint damage following trauma
These conditions require individual evaluation. Reverse Shoulder Replacement is one possible treatment and is not automatically recommended.
When May Reverse Shoulder Replacement Be Considered?
A shoulder evaluation may include a medical history, physical examination, X-rays, and additional imaging when appropriate.
Factors that may be considered include:
- The condition of the rotator cuff
- The presence and extent of arthritis
- Ability to raise the arm
- Shoulder strength and stability
- Bone quality
- Condition of the deltoid muscle
- Previous shoulder injuries or operations
- Response to nonsurgical treatment
- Overall health
- Activity needs
- Personal goals and expectations
The decision is not based on age or imaging alone. Dr. Freeman considers the full clinical picture when discussing treatment options.
Reverse Shoulder Replacement vs Total Shoulder Replacement
Both procedures replace damaged surfaces within the shoulder, but they use different joint arrangements.
Total Shoulder Replacement
Total Shoulder Replacement follows the natural anatomy of the shoulder. The ball remains on the upper arm side, and the socket remains on the shoulder blade side.
This arrangement generally relies on a functioning rotator cuff to center and move the joint.
Reverse Shoulder Replacement
Reverse Shoulder Replacement switches the position of the ball and socket components. This changes the mechanics of the shoulder and allows the deltoid muscle to contribute more to lifting the arm.
It may be considered when the rotator cuff is severely damaged or for certain fractures, revision procedures, and other complex conditions.
Neither procedure is appropriate for every patient. The recommendation depends on the diagnosis, condition of the rotator cuff, bone quality, shoulder anatomy, and previous treatment.
Preparing for Reverse Shoulder Replacement
Preparation may include a medical evaluation, imaging, laboratory testing, and a review of medications.
Patients may also be asked to:
- Arrange transportation after surgery
- Plan for help with certain daily activities
- Prepare loose or front-opening clothing
- Set up a comfortable sleeping area
- Review sling instructions
- Discuss postoperative physical therapy
- Follow instructions about food, drink, and medication before surgery
Patients should not stop prescription medication unless directed by the appropriate medical professional.
What Happens During Reverse Shoulder Replacement?
The exact procedure varies according to the patient’s anatomy and shoulder condition.
In general, the damaged humeral head is removed. A stem or other support is placed within the upper arm bone, and a cup-shaped component is attached on the humeral side. A base component is secured to the glenoid, and a ball-shaped component is attached to it.
This arrangement changes the center of rotation of the shoulder. The deltoid muscle can then contribute more to raising the arm.
The incision is closed, and the arm is typically placed in a sling. Surgical technique, component positioning, fixation, and soft tissue management vary based on individual factors.
Risks of Reverse Shoulder Replacement
All surgical procedures involve risk. Possible risks associated with Reverse Shoulder Replacement include:
- Infection
- Bleeding
- Blood clots
- Nerve or blood vessel injury
- Fracture
- Stiffness
- Instability or dislocation
- Implant loosening or wear
- Changes in the bone around the implant
- Deltoid muscle problems
- Continued or recurring pain
- Limited strength or motion
- A difference between expected and actual function
- Need for additional surgery
- Medical or anesthesia-related complications
This list does not include every possible complication. Individual risks depend on overall health, bone quality, previous procedures, and the condition of the shoulder.
Recovery After Reverse Shoulder Replacement
Recovery occurs in stages. The timeline varies based on the reason for surgery, surgical technique, bone quality, previous procedures, and individual healing.
A Reverse Shoulder Replacement performed for arthritis may have a different recovery plan from one performed for a fracture or revision procedure.
Early Recovery
A sling is commonly used during the early recovery period. The length of sling use depends on the procedure and the condition of the repaired tissues.
Patients receive instructions regarding:
- Wound care
- Bathing
- Medication
- Sleeping positions
- Sling use
- Safe hand, wrist, and elbow movement
- Shoulder restrictions
- Signs that should be reported to the surgical team
Lifting, pushing, pulling, and using the arm to rise from a chair may be restricted.
Shoulder Movement
The timing of shoulder motion depends on the procedure. Some patients may begin guided motion relatively early, while others require a longer period of protection.
Patients should follow the rehabilitation plan provided by Dr. Freeman rather than advancing movement based on a general timeline.
Physical Therapy
Physical therapy may begin with protected or assisted movement. Active motion and strengthening may be added as healing progresses.
Rehabilitation may focus on:
- Shoulder mobility
- Deltoid function
- Shoulder blade control
- Safe use of the arm
- Gradual return to daily activities
The amount of motion and strength regained varies. Reverse Shoulder Replacement does not recreate a normal shoulder or normal rotator cuff.
Returning to Activities
The timing for driving, working, lifting, sports, and household activities varies. Clearance depends on healing, comfort, coordination, motion, strength, and the physical demands of the activity.
Some lifting or high-impact activities may remain restricted after recovery. Patients should discuss their work and recreational goals before surgery.
Reverse Shoulder Replacement Based on Your Diagnosis
Reverse Shoulder Replacement may be considered when severe rotator cuff damage or another complex condition prevents the shoulder from functioning normally. The procedure changes the mechanics of the joint so the deltoid can contribute more to arm movement.
It is not appropriate for every rotator cuff tear, fracture, or case of shoulder arthritis. Dr. Freeman evaluates the rotator cuff, joint surfaces, bone, deltoid muscle, symptoms, medical history, and previous treatment before making a recommendation.