Reverse total shoulder replacement · Dr Joe Coory

Type: Major joint arthroplasty
Designed for: Cuff-deficient shoulder
Hospital stay: 1 night
Sling: 1 week
Driving: ~2 weeks
Implant survival: >95% at 10 years

What it is.

The reverse total shoulder replacement (rTSA) was developed by Paul Grammont in the 1980s and reached widespread clinical use in the 2000s. Its design addresses a long-standing problem in shoulder surgery: how to restore active elevation in a shoulder where the rotator cuff is irreparably damaged.

The geometry is reversed. A metal ball is fixed to the scapula side, and a polyethylene socket is fixed to the humeral side. This change in mechanics moves the centre of rotation downward and medially, giving the deltoid muscle a powerful mechanical advantage to elevate the arm without the help of the cuff.

The rTSA is now used for several indications:

Cuff tear arthropathy — the end-stage state of a massive irreparable cuff tear, with secondary glenohumeral arthritis. This is the original and primary indication.
Massive irreparable rotator cuff tears — even without arthritis, in older patients with significant functional loss.
Glenohumeral osteoarthritis with a borderline cuff — increasingly used in this setting in older patients to insure against late cuff failure.
Complex proximal humerus fractures — in older patients with comminuted three- and four-part fractures.
Revision arthroplasty — where a failed anatomic replacement is converted to reverse.

How it is performed.

Under general anaesthesia with a regional block, a deltopectoral approach is used. The worn humeral head is removed. The glenoid is exposed and prepared — robotic or CT-navigated guidance is used to optimise baseplate position, which is the most consequential single technical step in determining long-term outcome. A metal baseplate is fixed to the scapula with screws, and a hemispherical metal glenosphere is attached. The humeral side is then prepared and a stemmed or stemless humeral component is implanted with a polyethylene cup. The shoulder is reduced and the soft-tissue tension is checked carefully — tensioning is the second critical technical step.

Recovery timeline.

Dr Coory uses an accelerated post-operative protocol for reverse shoulder arthroplasty — one night in hospital and one week in a sling, with early active-assisted motion under the supervision of your treating physiotherapist.

Day 0–1

Regional block lasting 12–18 hours.
Inpatient physiotherapy with pendulum exercises and gentle passive range.
Sling fitted; discharge home usually the next morning.

Week 1 (sling phase)

Sling worn for one week post-operatively.
Pendulum and passive elevation daily.
No driving, no lifting.

Weeks 1–6

Sling discontinued at the end of the first week.
Active-assisted range of motion under your physiotherapist.
Active range progressing from weeks 2–4.
Deltoid-led elevation exercises commence early.
Driving resumed at approximately 2 weeks once off opioid analgesia.

Weeks 6–12

Strengthening focused on deltoid and scapular control.
Most daily activities resumed.

Month 3–12

Return to most recreational activity.
Final outcome at 9–12 months.

Outcomes.

In well-selected patients, the reverse total shoulder replacement produces reliable pain relief and meaningful restoration of active forward elevation. Active rotation (the deltoid cannot rotate the arm) is less predictably restored. Patients with intact teres minor function tend to do better. Australian registry data show survivorship of greater than 95% at 10 years.¹

Rehabilitation protocol.

A written copy of this protocol is provided to your physiotherapist on the day of surgery. The timeline below is a guide — progression is based on clinical milestones, not the calendar alone.

Weeks 0–1 — immediate post-operative

Sling at all times except during prescribed exercises.
Ice and heat as directed for pain and swelling management.
Pendular (Codman’s) exercises to maintain gentle movement.
Hand-to-mouth movements permitted.
Active range of motion for elbow, wrist and hand.

Weeks 1–6 — early rehabilitation

Active-assisted forward flexion using pulleys.
Progress toward full active forward flexion if scapula control is adequate.
Hand behind back (HBB) stretching with a stick.
External rotation with a stick in adduction.
Wall walking in the shower for overhead range.
Continue sling use between exercise sessions.

Weeks 6–14 — strengthening

Wean off sling.
Strengthening with emphasis on scapula stabilisers, external rotation and abduction at 90/90.
Encourage full active range of motion in all planes.
Proprioceptive and functional rehabilitation.

Week 14 onwards — unrestricted activity

Full unrestricted activities permitted.
Continue strengthening as required.
No specific limitations from this point.

View the recovery roadmap for the full five-phase journey, or visit For Physiotherapists to request protocols directly.

Frequently asked questions.

Why is it called “reverse”?

Because the ball-and-socket geometry of the natural shoulder is reversed. A metal ball is fixed to the scapula and a polyethylene socket is fixed to the humerus — the opposite of the natural arrangement and of an anatomic replacement.

Why is reverse used instead of anatomic in some patients?

An anatomic replacement relies on a functioning rotator cuff to lift and rotate the arm. If the cuff is torn or deficient, the anatomic replacement won't lift the arm and the operation will fail. The reverse design lets the deltoid muscle do the lifting, bypassing the cuff.

Will I be able to lift my arm again?

In well-selected patients, yes — active forward elevation to or near horizontal is the typical result. Active external rotation is less reliably restored and depends on the residual teres minor function.

How long is the recovery?

An accelerated protocol: one night in hospital, sling for one week, active-assisted range from week 1, driving from approximately 2 weeks once off opioid analgesia, most daily activities by 6 weeks, final outcome at 9–12 months.

Is it covered by Medicare and private health?

Yes — total shoulder replacement is covered under MBS item numbers and most private health funds at appropriate hospital cover tiers. Dr Coory's reception team will provide a written estimate before surgery.

References.

Bacle G, et al. Long-term outcomes of reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(6):454–461.
Boileau P. Complications and revision of reverse total shoulder arthroplasty. Orthop Traumatol Surg Res. 2016;102(1):S33–S43.
Australian Orthopaedic Association National Joint Replacement Registry. Shoulder Arthroplasty Annual Report. Adelaide: AOA; 2024.

Reverse total shoulder replacement.