Return to sport after shoulder arthroplasty: The role of fast-track rehabilitation in reverse shoulder arthroplasty

Abstract

Introduction

Shoulder arthroplasty, encompassing Total Shoulder Arthroplasty (TSA) and Reverse Shoulder Arthroplasty (RSA), has become an essential treatment for severe glenohumeral arthritis and complex rotator cuff pathologies. This study evaluated and compared clinical outcomes and return-to-sport rates in TSA patients following standard rehabilitation protocol and RSA patients following fast rehabilitation protocol.

Material and Methods

This retrospective study analyzed 44 patients (TSA: 13; RSA: 31) treated between 2020 and 2023 with at least 12 months of follow-up. Participants engaged in regular upper-extremity sports preoperatively. Patients in the TSA group followed a standard rehabilitation protocol, whereas those in the RSA group were assigned a new standardized fast rehabilitation protocol. Clinical outcomes were assessed using the Constant-Murley Score (CS), Visual Analogue Scale (VAS) for pain, and return-to-sport rates.

Results

TSA patients showed a 100% return-to-sport rate, significantly higher than the 54.84% rate for RSA patients (p < 0.05). Functional outcomes were better in TSA (CS: 81 ± 13.18) compared to RSA (CS: 76.54 ± 8.3, p > 0.05). Within the RSA group, those who resumed sports had significantly higher CS scores (79.59 ± 7.41) than non-returners (73.21 ± 8.64, p < 0.05). Postoperative VAS was similarly low in both groups.

Conclusion

TSA patients exhibited superior return-to-sport rates and functional outcomes compared to RSA patients, highlighting TSA's biomechanical advantages.

Introduction

Over the past few decades, shoulder replacement surgeries, including total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), have emerged as effective treatments for end-stage glenohumeral arthritis and post-traumatic sequelae.^1,2 These procedures are primarily aimed at alleviating pain and restoring mobility in the affected shoulder joint. The choice of implant for shoulder arthroplasty is influenced by various critical factors. TSA is typically indicated for patients suffering from arthritis who still have a preserved rotator cuff and adequate glenoid bone stock. TSA is effective in these cases as it relies on the integrity of the rotator cuff muscles to ensure proper joint function post-surgery. ³ Conversely, RSA is preferred when the rotator cuff is compromised. ⁴ This can occur due to several conditions, including irreparable massive rotator cuff tears, ⁵ post-septic conditions, ⁶ rheumatic diseases, ⁷ or fractures that result in comminuted and osteoporotic tuberosities, ⁸ which are essentially bony rotator cuff tears. In these scenarios, RSA is advantageous because it relies on the deltoid muscle, rather than the rotator cuff, to power and stabilize the shoulder joint. ⁴ As surgical techniques and implant designs have advanced, an increasing number of individuals are opting for shoulder replacement to improve their quality of life. ⁹ Between 2011 and 2017, the volume of primary shoulder arthroplasties rose by 103.7%. Notably, RSA procedures experienced a 191.3% increase, reaching a total of 63,845 interventions in 2017. ¹⁰

Traditionally, shoulder replacement surgeries were predominantly performed on elderly patients suffering from degenerative shoulder conditions. However, there is a growing trend of performing these surgeries on younger, more active individuals. ¹¹ This shift is driven by the desire to maintain an active lifestyle and reduce the limitations caused by shoulder issues. Moreover, the evolution in surgical techniques and implant materials has made it possible for younger patients to consider shoulder arthroplasty as a viable option. ¹

One of the most common concerns among patients considering shoulder arthroplasty is the extent to which they can resume their pre-surgery activities. ⁹ Patients often inquire about their ability to return to sports, hobbies, and various work-related tasks post-procedure. This concern is particularly pertinent for younger patients who wish to maintain a high level of physical activity. ¹

While there is a wealth of literature examining activity levels following total hip and knee replacements,^12,13 the body of research focusing on post-operative activity levels after shoulder arthroplasty is comparatively limited. Nonetheless, the available research suggests that many patients can return to a range of activities following shoulder replacement, although the specific outcomes can vary depending on factors such as the type of surgery performed, the patient's overall health, and their adherence to rehabilitation protocols. ¹

Generally, patients undergoing TSA exhibit a higher rate of return to sport compared to those undergoing RSA.^11,14–17 A recent meta-analysis by Liu et al. ¹⁵ revealed an overall return-to-sport rate of 85.1% (95% CI, 76.5–92.3%) independent of the surgical approach employed. Specifically, TSA patients had a significantly higher return rate of 92.6%, in contrast to 74.9% for RSA patients (p = 0.003).

However, the best strategies for post-operative rehabilitation management to ensure optimal patient outcomes are still under debate.^18,19

Many rehabilitation protocols following shoulder arthroplasty are readily available online. These protocols, which are usually internally validated, exhibit considerable variation across several factors, including the duration of initial immobilization, the timeline for brace weaning, the frequency and length of physiotherapy sessions, the setting of rehabilitation (home-based versus supervised by a physiotherapist), and the recommended timeframe for resuming basic activities of daily living such as eating, drinking, or computer use.

In a recent systematic review, Moffat et al. ²⁰ found no differences in patient-reported or clinician-reported outcomes at 12 months post-surgery between early and delayed rehabilitation following shoulder replacement. To date, the impact of early rehabilitation protocols on the rate of return to sport has not yet been analyzed.

The purpose of our study was to evaluate and compare clinical outcomes and return to sport rate in patient undergoing TSA following standard rehabilitation protocol ²¹ and RSA with post-operative fast rehabilitation protocol.

Early rehabilitation primarily emphasizes the initiation timing of therapeutic interventions, whereas fast-track rehabilitation encompasses the broader pace and organization of the entire recovery steps. The latter aims to expedite functional restoration through a more intensive and proactive approach.

We hypothesized that our fast rehabilitation protocol in RSA would positively influence the rate of return to sport without causing an additional increase in complication rates. Additionally, we hypothesized that the RSA cohort would exhibit better outcomes than the TSA cohort compared to existing literature.

Material and methods

Study design

This study involved a retrospective analysis of a monocentric consecutive series of shoulder arthroplasties, including TSA and RSA, performed between 2020 and 2023. All procedures were executed by the senior author. For RSA procedures, the Aequalis Ascend Flex Reverse System 145° (Stryker Corp, Kalamazoo, MI, USA) was selected for small-to-medium sized glenoid or patients with documented nickel allergies, while the Equinoxe Reverse 145° implant (Exactech Inc, Gainesville, FL, USA) was preferred for large glenoid. All TSA procedures were performed utilizing the Aequalis Ascend Flex for the humerus and Aequalis Perform for the glenoid (Stryker Corp, Kalamazoo, MI, USA). Each system was implanted following standardized procedures as outlined in the manufacturer's technical manuals.

To be included in the study, patients were required to engage in regular sports activities, either competitive or non-competitive, at least three times per week prior to TSA and RSA surgery. Only patients whose sports activities involved the upper extremities were included, and each patient needed to have a minimum follow-up period of 12 months. The definition of return to sport varies across the literature. ²² In this study, return to sport is defined as the ability to resume sporting activities, not necessarily at the pre-surgery level, but with the patient reporting good level of satisfaction.

Only patients who confirmed adherence to the prescribed protocols during the follow-up visits, as documented for database compilation, were included in the study. Additionally, a thorough review of the post-operative follow-up reports recorded in the hospital system was conducted to ensure there were no anomalies in the rehabilitation protocol or complications. This review also verified the surgeon's authorization to progress to the next rehabilitation phase until the patient's return to sport.

Several exclusion criteria were applied to ensure the clarity and relevance of the study results. Patients who did not participate in regular sports activities prior to treatment were excluded. Furthermore, patients with incomplete data, follow-up of less than 12 months, sports activities not involving the upper extremities, those undergoing revision surgery or hemiarthroplasty, and patients undergoing additional tendon transposition procedures in RSA surgery were not considered.

Clinical evaluation

At the final follow-up, which had a minimum duration of 12 months, postoperative clinical outcomes were assessed by the same examiner. The evaluation criteria included demographics data, the Constant-Murley Score (CS) to measure shoulder function, a visual analogue scale (VAS) to assess pain during normal activities, return to sport. Return-to-sport was assessed at the 12month postoperative; any return to sporting activity occurring beyond this timeframe was not included in the study analysis.

Statistical analysis

Statistical analyses were conducted using GraphPad Prism 10 V10.2.3 (GraphPad Software, Inc., San Diego, CA, USA). The significance threshold was conventionally set at alpha = 0.05. Variables were summarized using the mean, standard deviation, and 95% Confidence Intervals (95% CI). The normality of distribution was assessed both graphically with QQ Plots and using the Shapiro-Wilk and D’Agostino-Pearson tests. For comparing groups, the Mann-Whitney U test was used for continuous variables that did not follow a normal distribution. For categorical variables, the χ² test with Fisher's correction was applied. Logistic regression analysis was performed to investigate the predictive value of independent variables such as age and Body Mass Index (BMI) on the likelihood of returning to sports.

TSA standard rehabilitation protocol

The rehabilitation protocol for patients following a TSA is divided into four distinct phases, each targeting specific recovery goals and exercises (Table 1). The patient exclusively undergoes physiotherapy at specialized referral centers dedicated to the rehabilitation of individuals recovering from shoulder surgery. A direct and continuous line of communication is maintained between the physiotherapists and the surgical team to address any needs that arise. Orthopedic follow-up evaluations are conducted at 7, 14, 30, 60, 90 and 180 days post-surgery.

Table 1.

Comparison of the four rehabilitation phases for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), including: time frames, focus areas, and phase-specific limitations. (ROM: range of motion; ER: external rotation; ADLs: activities of daily living).

Phase	Time Frame (TSA)	Focus Areas (TSA)	Limitations (TSA)	Time Frame (RSA)	Focus Areas (RSA)	Limitations (RSA)
Phase 1	0–30 days	Immobilization; protect subscapularis repair; initiate passive ROM within limits (90° flexion)	No ER >30°, no extension >0°; wear sling except during exercises	0–15 days	Tissue healing; implant protection; initiate passive ROM; deltoid activation	Use sling for comfort and at night; passive ROM limited to 90° flexion, 45° abduction, 20° ER
Phase 2	30–90 days	Progress to active-assisted and active ROM; initiate isometrics and light strengthening	No internal rotation strengthening; sling for comfort	15–45 days	Begin active-assisted ROM; increase independence in ADLs; continue isometrics	Progressive ROM limits (up to 120° flexion, 90° abduction); possible soreness
Phase 3	90–120 days	Progressive resistance training; full ROM with scapular control	As tolerated ROM; emphasize controlled movements	45–90 days	Restore full active ROM; isotonic strengthening; proprioception	Strengthening only with good control; cryotherapy as needed
Phase 4	Beyond 120 days	Strengthening; dynamic/overhead function; return to sport	Return to sport allowed after 6 months	Beyond 90 days	Functional recovery; sport-specific strengthening; return to activities	Return to sport allowed after 6 months

In the first phase (0–30 days), the shoulder is immobilized with a sling, which is worn at all times except during exercises. The primary focus is on protecting the subscapularis repair and avoiding any excessive external rotation (ER) beyond 30° and shoulder extension beyond 0°. Exercises include pendulum movements, elbow flexion and extension, forearm pronation and supination, and scapular retractions. Gentle passive range of motion (PROM) is introduced as per physician guidance. The goal is to achieve a supine active assist forward elevation of 90° by week 4.

In the second phase (30–90 days), the immobilizer is discontinued, though a simple sling may still be used for comfort. Patients begin supine active assisted ROM, progressing to seated and standing active ROM once they demonstrate good scapular control. Exercises include wand exercises for flexion, abduction, and ER, as well as pulley exercises. Shoulder isometrics, except for internal rotation (IR), and light weight, high repetition rotator cuff retraining exercises start around week 10. The goal is to achieve a supine forward elevation of 140° and standing forward elevation of 120° by week 12.

In the third phase (90–120 days), the focus shifts to progressive resistance training for the rotator cuff and periscapular stabilizers. ROM exercises are advanced as tolerated without limitations, incorporating dynamic exercises such as wall washing. The primary goals are to achieve full, non-painful active ROM with good scapular control and to increase muscular endurance and strength.

The fourth phase (Beyond 120 days) emphasizes further strengthening exercises and improving dynamic and overhead function. The ultimate goal is to return to sport-specific activities and achieve optimal functional performance for desired activities. A return to unrestricted sporting activity is permitted 6 months after the surgical procedure.

RSA fast rehabilitation protocol

The fast rehabilitation protocol was developed by a surgeon specializing in shoulder prostheses (F.F.) and was designed in collaboration with his designated physiotherapists (Table 1).

The standard postoperative rehabilitation protocol following RSA at our institution comprises an initial immobilization phase lasting two weeks, during which a shoulder brace is worn continuously. During this period, only elbow flexion-extension and unrestricted wrist and hand movements are permitted. This is followed by a subsequent two-week phase in which the brace is still worn, but may be temporarily removed to perform progressive passive range-of-motion exercises within the limits of pain tolerance. Beginning in the fourth postoperative week, the brace is progressively abandoned and unrestricted range-of-motion exercises and active muscle strengthening are initiated. From this point onward, patients typically participate in a minimum of three physiotherapy sessions per week, each lasting at least one hour.

The rehabilitation protocol for patients who have undergone a RSA surgery is structured in four phases, each with specific goals and treatments to ensure a comprehensive recovery. The patient initiates independent exercises immediately, complemented by a minimum of four physiotherapy sessions per week with a dedicated physiotherapist during the first 45 days. Thereafter, the patient continues with at least two physiotherapy sessions per week under the supervision of a dedicated physiotherapist until returning to sport. Each physiotherapy session lasts between 60 and 120 min, tailored to the patient's abilities. The patient receives physiotherapy exclusively at specialized referral centers focused on the rehabilitation of shoulder surgery patients. A continuous and direct communication channel is maintained between the physiotherapists and the surgical team to address any emerging concerns. Orthopedic follow-up assessments are scheduled at 7, 14, 30, 60, 90, and 180 days post-surgery.

The rehabilitation protocol implemented in this study involves a relatively high frequency of physiotherapy sessions, especially during the early postoperative period. This increased intensity is intentionally designed to facilitate early functional recovery and to ensure accurate execution of prescribed exercises, particularly given the common challenges related to motor control and scapulohumeral rhythm observed in the initial stages following RSA. We consider close supervision by experienced physiotherapists to be essential during this critical period, as it may reduce the risk of complications and enhance functional outcomes. Furthermore, these sessions offer substantial psychological support, fostering a sense of continuous guidance and encouragement, which may positively influence patient motivation and adherence throughout the recovery process.

In the first phase (0–15 days), the focus is on tissue healing, implant protection, pain and inflammation control, and initiating passive range of motion (ROM) recovery. Patients intermittently use a sling during the day and consistently during nighttime rest.

Patients engage in assisted active mobilization of the elbow, wrist, hand, and cervical spine. Passive shoulder mobilization in a supine position is limited to 90° flexion, 45° abduction, and 20° external rotation. Isometric exercises for the deltoid and scapular stabilizers and cryotherapy are included. Simple activities involving the operated limb, such as eating or using a computer, are encouraged immediately.

The second phase (15–45 days) continues pain control and passive ROM recovery, beginning with assisted active ROM recovery, and achieving autonomy in daily activities. The sling is permanently removed, but the patient may use it for a few hours if experiencing significant soreness following physiotherapy.

Treatments include pendulum exercises, surgical scar massage, active mobilization of the elbow, wrist, hand, and scapulothoracic region, and progressive passive shoulder mobilization—up to 120° flexion, 90° abduction, 30° external rotation, and internal rotation at 60° humeral abduction. Patients start transitioning to assisted active and active shoulder mobilization exercises, maintaining isometric exercises for the scapular stabilizers and deltoid, along with cryotherapy.

In the third phase (45–90 days), the focus is on complete passive and active ROM recovery, dynamic joint stability, improved neuromotor coordination, and maintaining autonomy in daily activities. Patients progress to active shoulder mobilization in sitting or standing positions, transition from isometric to isotonic strengthening exercises for the deltoid and scapular stabilizers and start using resistance bands. Cryotherapy is used as needed, and proprioceptive exercises are introduced.

The fourth phase (beyond 90 days) aims to optimize joint and muscle recovery, increase arm strength and endurance for functional activities, and ensure the optimal use of the arm in daily tasks. Treatments include progressive strengthening exercises in external and internal rotation on the scapular plane, weight training in a supine position, and a gradual return to functional activities. Also for RSA patients, unrestricted sporting activity is allowed 6 months following the surgical procedure.

Results

The initial cohort comprised 52 patients who underwent shoulder arthroplasty, including 13 cases of TSA and 39 cases of RSA. Eight patients from the RSA group were excluded due to non-adherence to the prescribed rehabilitation protocol, specifically failing to attend the required number of physiotherapy sessions. These patients reported an inability to access the rehabilitation facility. Consequently, the final study population consisted of 44 patients: 13 who underwent TSA and 31 who underwent RSA. The mean age of the patients was 68.87 ± 10.2 years (95% CI 65.77–71.97). The mean age of the TSA group was 63.71 ± 12.54 years (95% CI 56.13–71.28), while the mean age of the RSA group was 71.29± 8.42 years (95% CI 68.20–74.38). All patients enrolled in the study were classified as recreational athletes, likely due to age-related considerations. The t-test revealed a significant difference in the mean age of the patients of the two groups (p < 0.05) (Figure 1). The BMI of the patients averaged at 25.2 ± 4 (95% CI 23.98–26.42). The mean BMI of the TSA group was 25.12 ± 3.47 (95% CI 23.02–27.21), while the mean BMI of the RSA group was 25.24± 4.28 (95% CI 23.67–26.81). The t-test revealed no significant difference in the BMI of the patients in the two groups (p > 0.05) (Figure 1). Among the participants, 59% were male, and specifically 71% and 52% male in the TSA and RSA group, respectively. The dominant arm was operated on in 63,6% of the cases, of which 38.5% and 74.2% in the TSA and RSA group, respectively.

Figure 1.

Whiskers plot. A: Comparison of age between groups of patients following RSA and TSA. B: Comparison of BMI between groups of patients following RSA and TSA (BMI: Body Mass Index; RSA: reverse total shoulder arthroplasty; TSA: anatomical total shoulder arthroplasty; *: significant difference; ns: no significant difference).

In the TSA group, 6 patients participated in swimming, 2 in tennis, 2 in sport climbing, 2 in combat sports and 1 in rowing. In the RSA group, 13 patients engaged in swimming, 10 in tennis, 1 in sport climbing, 4 in combat sports, 2 in rowing and 1 in volleyball. Sports distribution is summarized in Table 2.

Table 2.

Sports distribution (RSA: reverse total shoulder arthroplasty; TSA: anatomical total shoulder arthroplasty; RSA-RTS: return to sport in RSA patients).

Sport Activity	TSA	RSA	RSA-RTS
Swimming	6	13	9
Tennis	2	10	6
Combat Sports	2	4	2
Sport Climbing	2	1	0
Rowing	1	2	0
Volleyball	0	1	0

Fisher's Exact Test showed a statistically significant difference in return-to-sport rates, with TSA patients having a 100% return rate compared to 54.84% for RSA patients (p < 0.05) (Figure 2).

Figure 2.

The number of patients who resumed and did not resume post-operative sports activities after undergoing RSA and TSA. (RSA: reverse total shoulder arthroplasty; TSA: anatomical total shoulder arthroplasty).

Welch's t-test revealed no significant difference in CS between TSA (81 ± 13.18 (95% CI 73,04–88.96)) and RSA (76.54 ± 8.3 (95% CI 73.65–79.44)) groups (p > 0.05), with TSA patients exhibiting no statistically significant better functional outcomes. In the RSA group, patients who returned to sporting activity showed a significant difference in CS compared to those who did not return to sport after surgery (sport:79.59 ± 7.41 (95% CI 75.77–83.40); no sport: 73.21 ± 8.64 (95% CI 68.23–78.20)) (p < 0.05). Analyzing patients who returned to sporting activity after surgery, Welch's t-test revealed no significant difference in CS between TSA and RSA groups (p > 0.05) (Figure 3).

Figure 3.

Whiskers plot. A: Comparison of CS between groups of patients following RSA and TSA. B: Comparison of CS between groups of patients who resumed and did not resume post-operative sports activities after undergoing RSA. C: Comparison of CS between groups of patients who resumed post-operative sports activities after undergoing RSA and TSA. (CS: Constant Score; RSA: reverse total shoulder arthroplasty; TSA: anatomical total shoulder arthroplasty; *: significant difference; ns: no significant difference).

The Mann-Whitney U test indicated no significant difference in post-operative VAS between the two groups (TSA group (1.15 ± 2.07 (95% CI −0.1–2.4)); RSA group (1.16 ± 1.88 (95% CI 0.47–1.85)) (p > 0.05). In the RSA group, patients who returned to sporting activity did not show a significant difference in pain compared to those who did not return to sport after surgery (sport:1.06 ± 1.64 (95% CI 0.22–1.9); no sport: 1.29 ± 2.19 (95% CI 0.02–2.55)) (p > 0.05). Analyzing patients who returned to sporting activity after surgery, Welch's t-test revealed no significant difference in pain between TSA and RSA groups (p > 0.05) (Figure 4).

Figure 4.

Whiskers plot. A: Comparison of VAS scores between groups of patients following RSA and TSA. B: Comparison of VAS scores between groups of patients who resumed and did not resume post-operative sports activities after undergoing RSA. C: Comparison of VAS scores between groups of patients who resumed post-operative sports activities after undergoing RSA and TSA. (VAS: Visual Analogue Scale for pain; RSA: reverse total shoulder arthroplasty; TSA: anatomical total shoulder arthroplasty; ns: no significant difference).

Logistic regression analysis, examining the influence of age and BMI on the likelihood of returning to sports in the RSA group, showed no significant predictive value (p > 0.05), with low ROC curve areas indicating no predictive power. The CS showed significant predictive value (p < 0.05) on the likelihood of returning to sports in the RSA group, with low ROC curve areas indicating weak predictive power (AUC 0.72 ± 0.09 (95% CI 0.53–0.9); odds ratio 1.11; Tjur's R² 0.14) (Figure 5).

Figure 5.

ROC curves of patients following RSA. A: Patient's age and return to sport. B: Patient's BMI and return to sport. C: CS and return to sport. (ROC: Receiver Operating Characteristic; RSA: reverse total shoulder arthroplasty; BMI: Body Mass Index; CS: Constant Score).

Discussion

The return-to-sport rate is a crucial consideration nowadays, especially for younger, more active patients. The findings of our study indicate that a fast rehabilitation protocol in RSA does not significantly alter the rate of return to sport or functional outcomes, and TSA consistently results in higher return-to-sport rates compared to RSA. If rehabilitation is to play a game-changer role, our results may suggest the importance of personalized rehabilitation programs for RSA patients, tailored to individual needs for sport activities and the specific surgical procedure performed. RSA patients may require tailored rehabilitation programs that address the unique biomechanical challenges posed by the procedure. Rehabilitation should focus on optimizing deltoid function and compensatory mechanisms to enhance overall shoulder performance and enable patients to engage in desired activities.

Our findings also reflect the influence of the underlying pathology and patient characteristics on postoperative outcomes. Patients undergoing TSA typically present with degenerative conditions and preserved muscular function, which may partially explain their superior results compared to RSA patients, who often have more complex functional deficits. Although our study aimed to determine whether a fast-track rehabilitation protocol could bridge this gap for RSA, the data suggest that the protocol was not sufficient to match the outcomes observed in the TSA group. Nevertheless, the high success rate observed with our TSA rehabilitation protocol represents a strong point of this study and confirms its clinical applicability and effectiveness.

However, it is important to note that the proportion of dominant-arm surgeries differed significantly between the two groups, with 74.2% of RSA procedures involving the dominant arm compared to only 38.5% in the TSA group. This discrepancy is particularly relevant when interpreting return-to-play outcomes, especially in upper-limb–dominant sports such as tennis. In our cohort, 32% of RSA patients attempted to return to tennis, whereas only 15% of TSA patients did. This imbalance may have influenced the return-to-sport results, as returning to sport with the dominant arm involved may present greater functional demands and psychological barriers. Therefore, the higher percentage of dominant-arm surgeries in the RSA group could partially explain the lower return-to-sport rates observed and should be considered when comparing functional recovery between the two cohorts.

Multiple previous studies have documented the superior functional outcomes and higher return-to-sport rates associated with TSA compared to RSA.^9,15,23

In a study published by Johnson et al. ²³ in 2018, the return-to-sport rates for TSA (75%–100%) are slightly higher than those reported for hemiarthroplasty (HA) (67%–76%) and RSA (75%–85%). However, the authors emphasize that the study population is heterogeneous, and the surgical indications vary, suggesting that the findings should be interpreted with appropriate caution.

Johnson et al. ⁹ in 2016 reported that TSA patients have better shoulder function and higher satisfaction levels due to the preservation of the rotator cuff and more natural joint mechanics. Conversely, RSA is often indicated for more complex cases with significant rotator cuff pathology, leading to compromised functional outcomes but still providing substantial pain relief and stability.

Franceschetti et al. ² emphasized the importance of patient selection and surgical indications in determining the outcomes of shoulder arthroplasty. Their review highlighted that while RSA is highly effective in cases of rotator cuff arthropathy and severe glenoid deformities, TSA remains the gold standard for patients with intact rotator cuffs and good bone stock.

The return-to-sport rate observed in our RSA cohort (54.84%) was lower than that reported in several previous studies, which have documented return-to-sport rates ranging from 75% to 85%. ²³ One likely explanation for this discrepancy is the higher proportion of dominant-arm surgeries in our RSA group (74.2%), which may have had a substantial impact on the ability to resume sporting activities, particularly those requiring fine motor control, strength, and precision from the dominant upper limb. Unlike many published studies, our cohort exclusively included recreational athletes, who may be less driven—both physically and psychologically—to return to sport at all costs, especially after surgery on the dominant limb.

Furthermore, it is important to note that some of the studies reporting higher return-to-sport rates include a broader definition of sport, encompassing activities such as cycling or fitness training, where upper-limb function is less critical. In contrast, most of our patients practiced sports with significant upper-limb involvement (e.g., tennis, swimming, combat sports), where the functional demands are higher and surgical side dominance plays a more critical role in the return-to-sport process.

We observed a statistically significant difference in CS values between RSA patients who returned to sports and those who did not. However, the scores were still generally satisfactory, even in the group that did not return-to-sport. Only four patients in this group had CS below 70/100, which is indicative of poor shoulder recovery. In contrast, all patients who returned to sports had scores above 70/100. This suggests that poor shoulder function is a negative predictor for returning to sports. However, a good recovery based on the CS is neither necessary nor sufficient for returning to sports. This highlights that other factors also play a role in influencing the outcome.

The VAS for pain did not show significant differences between TSA and RSA groups, indicating that both procedures effectively alleviate pain in patients. This finding is consistent with other studies^1,11 that report significant pain relief following both TSA and RSA, regardless of the underlying pathology. Therefore, even residual post-surgery pain does not explain the lower rate of return to sport in patients with RSA compared to those with TSA.

Although our study did not explicitly quantify satisfaction levels, the higher return-to-sport rate in TSA patients suggests greater satisfaction with TSA. Previous literature supports this observation, ⁹ noting that TSA patients generally report higher satisfaction due to better functional outcomes and the ability to resume pre-surgery activities.

Our data revealed that neither age nor BMI significantly predicted the likelihood of returning to sports post-surgery. This weak predictive power of age and BMI contrasts with some literature that highlights these factors as significant predictors of post-operative activity levels. ²⁴ A higher BMI is often associated with increased risks of postoperative complications, such as infections and delayed wound healing. This can lengthen the recovery period and potentially limit the ability to resume high-impact sports. Moreover, excess body weight places additional stress on joints and the musculoskeletal system, further complicating the return to sports. Age is a significant determinant in postoperative recovery. Older patients often exhibit prolonged healing times, diminished muscle strength, and limited mobility, all of which may hinder the resumption of previous athletic activities. Conversely, younger individuals typically recover more rapidly and are more likely to return-to-sport at an earlier stage. Although age did not emerge as a statistically significant predictor of return-to-sport within our cohort—likely due to the limited sample size—it remains a clinically relevant variable. Advanced age is frequently associated with lower preoperative activity levels, altered functional priorities, and more conservative postoperative expectations, which may partially account for the absence of return-to-sport observed in some older patients.

However, the type of sport, the patient's level of physical activity before surgery, and the quality of the surgical procedure and rehabilitation are also significant determinants.^18,25,26

Thus, while BMI and age are important, they should be considered alongside other clinical and functional factors to accurately predict return to sport after shoulder replacement.

The psychological aspect also plays a crucial role in the return to sport following shoulder surgery, often influencing outcomes as much as physical rehabilitation. ²⁷ The same considerations can easily be transferred to patients undergoing shoulder replacement surgery. Patients’ confidence in their shoulder's stability, fear of reinjury, and overall motivation are significant determinants of successful return to sports. ²⁷ Addressing these psychological factors through targeted interventions, such as cognitive-behavioral therapy or motivational interviewing, could enhance the effectiveness of rehabilitation protocols. Moreover, incorporating psychological support within the rehabilitation process may help patients overcome mental barriers, leading to improved functional outcomes and higher satisfaction rates, especially in those undergoing more complex procedures like RSA.

Limitations and future research

Our study has several limitations that future research should address. The retrospective design and relatively small patient cohort may introduce selection bias and limit the generalizability of the findings. Furthermore, the relatively short follow-up period might not adequately capture long-term outcomes and complications. This study is limited by its single-center and single-surgeon design, which may restrict the generalizability of the findings. The lack of preoperative clinical scores and range of motion data limited the robustness of the statistical analysis performed. Another limitation of this study is the imbalance between dominant and non-dominant arm surgeries across groups, which may have influenced return-to-sport outcomes, particularly in sports involving the dominant upper limb. Future studies should include larger, multicenter cohorts with longer follow-up periods to validate our findings and provide more comprehensive insights into the outcomes of shoulder arthroplasty. Further research should also explore the role of advanced rehabilitation techniques and technologies in enhancing post-surgical recovery. For instance, incorporating virtual reality, biofeedback, and personalized exercise programs could improve functional outcomes and return-to-sport rates in both TSA and RSA patients. Additionally, investigating the impact of psychological factors and patient motivation on rehabilitation outcomes could provide valuable insights for developing holistic, patient-centered care models.

Conclusion

Patients undergoing TSA continue to exhibit higher rates of return to sport compared to those undergoing RSA, even with a fast post-operative rehabilitation protocol for RSA patients. This underscores TSA's advantages in preserving rotator cuff integrity and joint mechanics. While RSA remains effective for patients with severe rotator cuff deficiencies, the fast-track rehabilitation did not appear to increase the rate of return-to-sport for this group. This outcome points to the possibility that individualized rehabilitation programs, tailored to the specific needs of each patient and the particular demands of their chosen sports, may be more effective in optimizing return to sport outcomes.