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Total shoulder arthroplasty (TSA) is a standard operative treatment for a variety of disorders of the glenohumeral joint. Patients, who have continued shoulder pain and loss of function in the presence of advanced joint pathology, despite conservative management, are often managed by undergoing a TSA. The overall outcomes that are reported after surgical intervention are quite good and appear to be primarily determined by the underlying pathology and the tissue quality of the rotator cuff. The current Neer protocol for postoperative TSA rehabilitation is widely used and based on tradition and the basic science of soft tissue and bone healing. The purpose of this paper is to review the indications for TSA, focusing on the underlying pathologies, and to describe the variables that impact the rehabilitation program of individuals who have had a TSA. A postoperative TSA rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented. J Orthop Sports Phys Ther 2005;35:821-836. Key Words: physical therapy, protocols, shoulder rehabilitation T he first total shoulder arthroplasty (TSA) was performed by Jules Emile Pean in 1893 for the purpose of treating tuberculous arthritis of the shoulder. 68 Neer 81 developed a humeral prosthesis for the treatment of 4-part fractures in 1955, and in the mid-1970s he refined his prosthesis for the treatment of the degenerative humeral head. 82 TSA is a standard treatment intervention for patients with underlying advanced joint pathology who have persistent pain and loss of function despite conservative management. These pathologies include osteoarthritis (OA), 7,13,30,32,39,41,43,44,64,71,74,82,86,88,89,100,101 rheumatoid arthritis (RA), 6,34,35,38,52,61,64,76,91,102,106 cuff tear arthropathy, 5,33,64,94,95,107,111 osteonecrosis, 26,48,49,64,70,79 and fractures of the humeral head. 2,3,6,21,42,62,69,85,90,93 Over the last 25 years, surgical techniques and prostheses have advanced greatly. However, there is still considerable variability in surgical techniques, particularly the use of cement for fixation and the type of prosthesis. Despite these significant variations, the overall reported outcomes for patients that have undergone TSA are good. 31,49,64,99,104 Self-assessed health status reports of individuals who have undergone TSA are comparable to those of individuals who have undergone a total hip arthroplasty or coronary artery bypass graft.

Study Design: Case report. Background: Patients with hyperflexion/hyperabduction injury to the glenohumeral joint are at risk for isolated greater tuberosity fractures, which are often undiagnosed or misdiagnosed. In this case report, we describe the clinical decision-making process that led to the diagnosis of an isolated greater tuberosity fracture and subsequent rotator cuff tear. Case Description: The patient was a 45-year-old male who sustained a shoulder injury as the result of a fall while skiing. After the initiation of physical therapy, he was diagnosed with an isolated greater tuberosity fracture. Little is known regarding the optimal management and overall prognosis of this type of fracture. Conservative nonoperative management and postoperative physical therapy management are discussed. Outcomes: With conservative nonoperative management, the patient was unable to regain high-level functional shoulder use. Suspicion of continued pathology of the greater tuberosity dictated further diagnostic imaging, which led to surgical intervention. Upon completion of postoperative rehabilitation, he was able to resume full recreational activities. Discussion: It is recommended that sound clinical decision-making dictate the management and ongoing evaluation of traumatic shoulder injuries, especially when managing a patient with an injury for which optimal treatment and prognosis is not well established. J Orthop Sports Phys Ther 2005;35:521-530. Key Words: diagnostic imaging, physical therapy, shoulder rehabilitation P roximal humeral fractures are quite common and the type of fracture greatly dictates the appropriate plan of care. The classification of proximal humeral fractures has been established and accepted for over 30 years. Yet, there are few reports describing the management of isolated nondisplaced greater tuberosity fractures of the humerus, which would be classified as a type I fracture using Neer's classification system. 35 Most of the recent published work on proximal humeral fractures deals with the management of 3-and 4-part fractures. 3,6,10,22,33,40,42 There are typically 2 mechanisms of injury for a greater tuberosity fracture: impaction or