Rehabilitation guidelines following Proximal Humeral
Replacement Surgery
Much of the surgery carried out on the Sarcoma Unit at RNOHT is unusual.
We have therefore devised guidelines which outline the goals patients should
be aiming to achieve during their rehabilitation. These are guidelines and
every patient should be assessed and treated as an individual, therefore,
there may be variation in timing and outcome but the restrictions MUST
remain the same.
Patients who have been diagnosed with a tumour and then undergone
orthopaedic surgery are, if appropriate, referred for pre/post op chemotherapy
or radiotherapy. (Not all tumours are malignant and not all tumours are
chemotherapy/radiotherapy sensitive). These treatments will impact on their
rehabilitation. (refer to the Appendix for further details)
Proximal Humeral Replacement
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Physiotherapy rehabilitation guidelines
Proximal Humeral Replacement
Up to two thirds of the proximal humerus is removed via an anterolateral
approach and replaced with an endoprosthetic replacement.
Indications:
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Bone tumour of the proximal humerus
Possible complications:
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Wound healing/infection
Neuropraxia
Aseptic loosening
Recurrence
Dislocation
Humeral shaft or glenoid fracture
Oedema/ haematoma
Reduced shoulder ROM
Expected outcome

A stable pain free shoulder enabling light upper limb activities at waist
height and within the functional triangle. It may take 9 months to a year
to achieve this.
Muscles affected

Rotator cuff, deltoid, pectoralis major, latissimus dorsi, lateral and
medial head of triceps, teres major
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Initial Rehabilitation Phase
0 - 6 weeks
Goals:
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Optimise tissue healing
Ensure adequate pain control
Restrictions:
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Patient to wear a polysling at all times. To remove sling for elbow and
hand exercises only when in supine. For washing, patient will be
instructed on a suitable position.
Post Operative Precautions:
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No external rotation, beyond neutral for the first six weeks.
Polysling to support the arm for six weeks.
No shoulder movement for six weeks.
Collar & cuff to be worn for showering, if appropriate.
Orthotic appliances:
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Polysling at all times with waist strap. Sling can be worn over clothes.
Pain relief:
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Adequate analgesia
Patient education:
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Post operative restrictions; outline the rehabilitation guidelines and
importance of complying with the programme set down.
Advice regarding functional activities while in sling.
Ensure independence with exercise programme before discharge.
Physiotherapy rehabilitation:
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Hand and elbow exercises taught in supine
Balance re-education
Prior to hospital discharge patients must be referred for outpatient
physiotherapy outlining that they will require a physiotherapy
appointment once they have been reviewed in clinic at 6 weeks post
op. If patients are also going to receive chemotherapy or radiotherapy
then a transfer summary must be sent to the centre that will be carrying
out adjunctive therapy.
Occupational Therapy rehabilitation:
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Enhance outcome of surgical intervention and reduce risk of dislocation
by teaching safe management of ADLs i.e. within the post operative
precautions.
Optimise function.
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Discuss safe options for return to driving and work/ leisure activities.
Refer to community occupational therapist, if appropriate, for review of
function once they have been reviewed at 6 weeks at the outpatient
clinic.
In instances where independence is not achieved, ensure there is
adequate support to optimise safety in the home during the postoperative period.
Intermediate Treatment Phase
6 weeks to 4 months
Goals:
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Increase passive range of movement moving to AAROM
Optimise normal movement pattern of shoulder complex
Restrictions:
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No exercises that increase pain
No external rotation beyond neutral
No unassisted elevation
No hand behind back or across body
Orthotic appliances:
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Sling can be weaned as comfort allows and when adequate control is
achieved
Pain relief:
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Adequate analgesia
Resting positions
Patient education:
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Weaning from sling
Postural awareness
Pacing activities
Light use of arm at waist level – towards last half of this phase
Continue to take care with exercises to optimise healing
Physiotherapy rehabilitation:
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PROM moving to AAROM - shoulder flexion in neutral rotation; external
rotation to neutral
Active elbow and hand ROM
Active shoulder girdle ROM – elevation, protraction, retraction
Balance work including core stability
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If deltoid has not been sacrificed commence eccentric deltoid
strengthening towards the latter third of this phase. Patients should not
initiate elevation with scapula-thoracic movement but they may not be
able to eliminate it completely.
Hydrotherapy can be useful at this stage if immune status allows
Occupational Therapy rehabilitation
(seen if referred and appropriate for rehabilitation at this stage.)
 Re-assess personal care management, transfers and domestic ADLs
and advise re: techniques and adaptive equipment that may further
enhance independent living, within the restrictions.
 Discussion re: driving and work including ergonomics if relevant.
Final Rehabilitation Phase
5 months and beyond
Goals:
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Increase strength and endurance
Increase ROM with good control and patterning.
Increase function and independence.
Restrictions:
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No activities or exercises that increase pain
No heavy activities e.g. lifting
Patient education:
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Encourage return to normal function.
Physiotherapy rehabilitation:
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AROM at waist height and up to shoulder level where able with good
dynamic scapula control
Scapula stability and core stability
Proprioception and balance work
If deltoid present, continue eccentric deltoid strengthening
Occupational Therapy rehabilitation
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To review if required and work upon any difficulties the patient may still
be experiencing.
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Appendix
Some chemotherapy and radiotherapy side effects and
implications for treatment:
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Bone marrow toxicity, ↓white cell count, ↓platelets, ↓Hb and ↓rate of
healing. White cell count will be at its lowest approximately 10 days
post chemotherapy and signs of wound infection should be watched
for. Hydrotherapy should not be undertaken at this point
Nausea, vomiting, diarrhoea, ↓appetite, lethargy and ↓exercise
tolerance. Physiotherapy will be particularly important during and
immediately after chemo and radiotherapy, as patients often lose ROM
and strength after a cycle. Community physiotherapy may need to be
arranged after discharge if the patient is too unwell to attend for
outpatient treatment. The occupational therapist may need to advise on
the practical implications of the symptoms such as meal and drink
preparation, laundry and hygiene. Relaxation techniques may also be
used to reduce nausea and vomiting in addition to reducing anxiety
levels associated with food and meal times.
Anxiety and depression – these can diminish people’s concentration,
ability to assimilate information and motivation to carry out activities.
The therapists, among other treatment, will identify goals which
increase a person’s sense of control.
Fatigue – needs to be addressed / acknowledged as it can affect a
person’s physical and cognitive ability to carry out normal activities.
The therapists will need to take this into consideration and tailor the
rehabilitation accordingly.
Anaemia which can lead to tiredness, lethargy and breathlessness)
Radiotherapy only:

Fibrosis of soft tissues – Can continue for up to 2 years and may lead
to contractures. Passive exercise is very important during and
immediately post radiotherapy to prevent loss of ROM.
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Demineralisation of bone – increases risk of fracture
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Redness, soreness and sensitivity of the skin to heat – care of the skin
is important.
Heat modalities are contraindicated post DXT.
Application of lotions and manual treatments are contraindicated during
DXT, but can be used with caution post DXT. Electrical modalities e.g.
TNS and FES can be used with caution.
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