ARTICLE IN PRESS

J Shoulder Elbow Surg (2016) ■■, ■■–■■

www.elsevier.com/locate/ymse

Immediate versus delayed passive range of motion

following total shoulder arthroplasty
Patrick J. Denard, MDa,b,*, Alexandre Lädermann, MDc

a
Southern Oregon Orthopedics, Medford, OR, USA
b
Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
c
Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland

Background: The goal of this study was to compare immediate with delayed range of motion (ROM)
following total shoulder arthroplasty (TSA). The hypothesis was that ROM gains would occur earlier with
immediate motion but that there would be no difference in ultimate ROM or functional outcome.
Methods: Sixty patients were randomized to immediate motion (IM) or delayed motion (DM) following
TSA. A lesser tuberosity osteotomy was performed in all cases. ROM and functional outcome were com-
pared at 4 weeks, 8 weeks, 3 months, 6 months, and 1 year postoperatively.
Results: Compared with preoperative values, in the IM group, forward flexion improved from 106° to
141° at 1 year postoperatively, external rotation improved from 21° to 65°, and internal rotation im-
proved by 2 spinal levels (P < .05). In the DM group, forward flexion improved from 104° to 144°, external
rotation improved from 20° to 53°, and internal rotation improved by 4 spinal levels (P < .05). The 2 groups
regained motion differently, but there were no significant differences in final ROM or functional outcome
scores between the 2 groups. The IM group had higher functional outcome scores initially, but by 3 months
postoperatively, there was no difference. The rate of osteotomy healing was 81% in the IM group com-
pared with 96% in the DM group (P = .101).
Conclusion: Immediate ROM provides a more rapid return of function compared with a delayed ROM
protocol following TSA. However, there are no differences in ultimate ROM or functional outcome between
the 2 groups. Moreover, immediate ROM may lower the healing rate of a lesser tuberosity osteotomy.
Level of evidence: Level I; Randomized Controlled Trial; Treatment Study
© 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Shoulder arthroplasty; rehabilitation; lesser tuberosity osteotomy; delayed motion; passive motion;
functional outcome

Total shoulder arthroplasty (TSA) is commonly used to
treat primary glenohumeral arthritis and in most cases leads
to substantial improvement in pain and function.9 The number
Institutional Review Board approval was obtained prior to initiation of the
study.
*Reprint requests: Patrick J. Denard, MD, 2780 E Barnett Rd, Ste 200,
Medford, OR 97504, USA.
E-mail address: pjdenard@gmail.com (P.J. Denard).
of shoulder arthroplasties is rapidly growing and expected to
continue to increase in the years to come.3 It is therefore im-
portant to optimize factors that contribute to a successful
outcome.
Although there is consensus that rehabilitation is impor-
tant following TSA, the ideal rehabilitation protocol has not
been established. Many authors recommend immediate passive
range of motion (ROM).16 This protocol is typically based
on the belief that immediate motion will decrease the chance

1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
http://dx.doi.org/10.1016/j.jse.2016.07.032
 ARTICLE IN PRESS
2 P.J. Denard, A. Lädermann
of postoperative stiffness. However, there is little evidence
to support this protocol. Moreover, there may be downsides
to early passive ROM such as subscapularis failure. To date,
only one study has evaluated different rehabilitation proto-
cols following TSA.7 In this retrospective evaluation, patients
who were immobilized in a sling for 6 weeks achieved higher
forward flexion and abduction than patients who partici-
pated in immediate passive ROM.
The goal of our study was to evaluate 2 different rehabil-
itation protocols following TSA. The hypothesis was that ROM
gains would occur earlier with immediate ROM but that there
would be no difference in ultimate ROM or functional
outcome.
Methods
Study design
A prospective, randomized controlled trial of patients undergoing
anatomic (unconstrained) TSA was performed. The study was con-
ducted by 2 surgeons (P.J.D. and A.L.). The inclusion criteria included
primary glenohumeral arthritis treated with an anatomic TSA, age
40 to 85 years, and minimum follow-up of 1 year. The exclusion
criteria included a full-thickness rotator cuff tear, a type C glenoid,
concomitant glenoid bone grafting, previous surgery on the affect-
ed shoulder, and incomplete follow-up. Patients were prospectively
randomized by a random number generator.
A power analysis was performed prior to enrollment and deter-
mined that a total of 34 patients were necessary to detect a 10°
difference in ROM based on an SD of 10°. In addition, a total of
52 patients were necessary to detect a minimal clinically impor-
tant difference of 6.4 points in the American Shoulder and Elbow
Surgeons (ASES) score based on an SD of 8.15 On the basis of this
analysis, we enrolled 60 patients. Patients scheduled for a TSA
who met the study criteria were invited to participate. Four pa-
tients refused to participate. Three patients in the immediate motion
(IM) group and 2 in the delayed motion (DM) group were lost to
follow-up, leaving 27 patients and 28 patients, respectively,
available for analysis. Baseline characteristics of the patients are
Table I Baseline characteristics
Immediate ROM (n = 27)
Mean age, y 69.1 (range, 52-85)
Sex, n
M 12 (44%)
F 15 (56%)
Dominant arm, n 16 (59%)
Mean forward flexion (SD), ° 106 (± 34)
Mean external rotation (SD), ° 21 (± 16)
Mean internal rotation (SD) L5
Mean VAS pain score (SD) 6.5 (± 1.5)
Mean ASES score (SD) 34.0 (± 11.3)
Mean SST (SD) 3.1 (± 2.2)
Mean SANE score (SD) 32.7 (± 23.5)
ASES, American Shoulder and Elbow Surgeons; F, female; M, male; ROM, range of motion; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoul-
der Test; VAS, visual analog scale.
presented in Table I. There were no differences between the groups
at baseline (P > .05).
Surgical technique
TSAs were performed by 2 surgeons using a consistent technique.
A deltopectoral approach was used to expose the shoulder. The biceps
underwent tenodesis to the pectoralis major tendon. A lesser tuber-
osity osteotomy was used to access the glenohumeral joint. The
osteotomy was initiated at the bicipital groove with a saw blade and
then completed with a curved osteotome. A 5-mm fleck of lesser
tuberosity was taken such that the osteotomy entered the joint me-
dially without violating the humeral head.10,13 A complete release
of the subscapularis tendon was performed, and then the humeral
head was resected with a free-handed anatomic cut respecting native
humeral head version and inclination. The humerus was prepared
for placement of a short-stem press-fit component. The glenoid was
then exposed, and an all-polyethylene glenoid was cemented into
place (50 pegged components and 10 keeled components). Prior to
placement of the humeral component, a 2-mm drill was used to create
3 holes in the bicipital groove and 2 holes at the medial aspect of
the lesser tuberosity. Three No. 2 FiberWire sutures (Arthrex, Naples,
FL, USA) were then passed through these holes; the superior suture
passed only through the superior hole in the bicipital groove, whereas
the middle and inferior sutures passed through both a medial hole
and a hole in the bicipital groove. The humeral prosthesis was then
impacted with the sutures passing posterior to the stem so as to en-
circle the prosthesis.10 The osteotomy was repaired to native bone
with these sutures. The repair was augmented with 1 to 2 sutures
passing through the superolateral corner of the subscapularis tendon
and the anterior supraspinatus, and the rotator interval was closed
with 2 to 3 simple sutures.
Rehabilitation protocol
Postoperatively, patients were randomized to an immediate or delayed
ROM protocol as follows: In the immediate ROM group (IM), a
sling was worn for 4 weeks following surgery. On the first postop-
erative day, patients began passive forward flexion as tolerated with
an overhead rope and pulley and passive external rotation to 30°
Delayed ROM (n = 28) P value
66.9 (range, 42-82) .361
.227
17 (61%)
11 (39%)
15 (54%) .671
104 (± 28) .728
20 (± 16) .824
L5 .713
6.4 (± 2.2) .679
39.4 (± 18.2) .183
3.7 (± 2.6) .518
38.2 (± 24.9) .532
 ARTICLE IN PRESS
Immediate versus delayed motion after TSA
with a stick. Active hand, wrist, and elbow exercises and active scap-
ular retraction were also allowed immediately. At 4 weeks
postoperatively, the sling was discontinued, passive external rota-
tion was allowed as tolerated, and forward flexion was progressed
from active to assist to active motion as tolerated. Strengthening was
initiated routinely at 8 weeks postoperatively. Activities were allowed
as tolerated at 12 weeks postoperatively with a lifetime recommen-
dation for no repetitive lifting over 25 lb (11.3 kg).
In the delayed ROM group (DM), a sling was worn for 4 weeks
following surgery. During the first 4 weeks, these patients only per-
formed active hand, wrist, and elbow exercises, as well as active
scapular retraction exercises. At 4 weeks postoperatively, the sling
was discontinued and passive forward elevation with a rope and pulley
and passive external rotation with a stick were initiated as toler-
ated. At 8 weeks postoperatively, active assisted progression to active
ROM was allowed as tolerated. Strengthening was also routinely
started at 8 weeks postoperatively. Activities were allowed as tol-
erated at 16 weeks postoperatively with a lifetime recommendation
for no repetitive lifting over 25 lb (11.3 kg).
Patient evaluation
Function and ROM were assessed preoperatively and postopera-
tively at 4 weeks, 8 weeks, 3 months, 6 months, and 12 months.
Function was determined with the Simple Shoulder Test (SST), Single
Assessment Numeric Evaluation (SANE) score, ASES score, and
visual analog scale (VAS) pain score at each time point. ROM was
assessed by an independent examiner using a goniometer to deter-
mine forward flexion and external rotation with the patient’s arm
at the side. Internal rotation was estimated to the nearest spinal level.
Finally, the belly-press test (graded as positive, negative, or inter-
mediate) was performed at 3 months, 6 months, and 1 year.
Radiographic evaluation
Grashey (true glenohumeral anteroposterior view) and axillary ra-
diographs were obtained preoperatively; immediately postoperatively;
and at 4 weeks, 3 months, 6 months, and 1 year postoperatively.
The integrity of the lesser tuberosity osteotomy on postoperative ra-
diographs was graded as healed if there was bony union or a
nondisplaced fibrous union. The osteotomy was considered un-
healed if it was completely displaced (ie, no contact with the proximal
humerus).
Table II Postoperative outcome
Immediate ROM
(n = 27)
Forward flexion, ° 142 (± 20)
External rotation, ° 62 (± 16)
Internal rotation L3
VAS pain score 0.7 (± 0.9)
ASES score 89.0 (± 10.9)
SST 9.9 (± 2.5)
SANE score 85.8 (± 20.6)
Data are presented as mean (standard deviation).
ASES, American Shoulder and Elbow Surgeons; ROM, range of motion; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoulder Test; VAS, visual
analog scale.
3
Statistical analysis
Continuous data were described by means and standard devia-
tions. The paired t test, sign test, or Wilcoxon rank sum test was
performed (depending on variable distribution) to analyze the dif-
ference in preoperative and postoperative ROM and functional
outcome scores. We conducted χ2 tests for return to activity, satis-
faction, and osteotomy healing at 1 year. A repeated-measures analysis
was performed to evaluate the change in ROM over time in each
group. Statistical analyses were conducted using SAS (version 9.4;
SAS Institute, Cary, NC, USA). Two-tailed P values < .05 were con-
sidered significant.
Results
There was no difference in ROM at 1 year postoperatively
between the 2 groups (P > .05) (Table II). Compared with
preoperative values, in the IM group, forward flexion im-
proved from 106° to 141° at 1 year postoperatively, external
rotation improved from 21° to 65°, and internal rotation
improved by 2 spinal levels (P < .05). In the DM group,
forward flexion improved from 104° to 144°, external
rotation improved from 20° to 53°, and internal rotation
improved by 4 spinal levels (P < .05). Similar to ROM,
there was no difference between the 2 groups in pain or
functional outcome at 1 year postoperatively (P > .05). The
VAS pain score decreased to 0.7 in the IM group versus 1.0
in the DM group, the ASES score improved to 89 versus
89, the SST improved to 10.0 versus 9.8, and the SANE
score improved to 86 versus 88.
There was no statistically significant difference between
the IM and DM groups in any plane of ROM at any time point.
However, in terms of forward flexion, the groups changed dif-
ferently over time as noted by differences in the slopes of the
curves (P = .029) (Fig. 1). External rotation did not change
differently over time (P = .957) (Fig. 2). There were find-
ings of improved functional outcome earlier in the IM group:
The VAS pain score (P = .019) and SANE score (P = .012)
were more improved at 8 weeks postoperatively and the ASES
score was more improved at 4 weeks (P = .025) and 8 weeks
Delayed ROM P value
(n = 28)
146 (± 20) .886
57 (± 12) .209
L1 .685
1.0 (± 1.4) .535
88.9 (± 13.1) .394
9.8 (± 2.4) .376
88.2 (± 12.4) .940
 ARTICLE IN PRESS
4 P.J. Denard, A. Lädermann

Figure 1 Improvement in forward flexion according to follow-up. Preop, preoperatively.

Figure 2 Improvement in external rotation according to follow-up. Preop, preoperatively.

(P = .010) in the IM group. There were no differences in any
variables at 3 months or 6 months postoperatively (Fig. 3).
The lesser tuberosity osteotomy healed in 81.5% of cases
in the IM group (22 of 27) compared with 96.4% in the DM
group (27 of 28) (P = .101). A separate analysis of healed
versus unhealed osteotomies was performed. The belly-
press test was more likely to be negative when the osteotomy
was healed (P < .001). In the IM group, the belly-press test
was negative in 95.5% of cases when the osteotomy was healed
(21 of 22) and positive in 80% of cases when the osteotomy
was not healed (4 of 5). In the DM group, the belly-press test
was negative in 88.9% of cases when the osteotomy was healed
(24 of 27) and positive in the 1 unhealed case. There was no
difference between the 2 groups in the change in ROM from
preoperatively to 1 year postoperatively (P > .05). In terms
of functional outcome scores, improvement in the ASES score
was greater in the healed group and there were trends toward
greater improvement in the SST and SANE score that did not
reach statistical significance (Table III).
There were 2 complications in the IM group (7.4%). One
patient had a brachial plexus injury from an interscalene block;
the symptoms resolved by 2 months postoperatively. Another
 ARTICLE IN PRESS
Immediate versus delayed motion after TSA 5

Figure 3 Comparison of American Shoulder and Elbow Surgeons (ASES) scores between groups according to time. There were signif-
icant differences between the 2 groups at 4 weeks and 8 weeks postoperatively.

Table III Change in outcome from preoperatively to 1 year postoperatively by osteotomy healing
Healed Not healed P value
Preoperative Postoperative Preoperative Postoperative
Forward flexion, ° 105 ± 31 146 ± 18 109 ± 27 131 ± 25 .214
External rotation, ° 20 ± 16 58 ± 14 29 ± 22 64 ± 17 .814
VAS pain score 6.7 ± 1.8 0.7 ± 1.1 4.9 ± 2.3 1.5 ± 1.8 .175
ASES score 35.6 ± 15.5 90.2 ± 10.3 45.0 ± 10.8 81.1 ± 18.4 .008
SST 3.5 ± 2.4 10.2 ± 2.1 2.9 ± 2.2 8.0 ± 3.6 .096
SANE score 34.8 ± 24.6 87.9 ± 16.2 35.4 ± 24.5 80.9 ± 21.2 .092
Data are presented as mean ± standard deviation.
ASES, American Shoulder and Elbow Surgeons; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoulder Test; VAS, visual analog scale.

patient in the IM group, a 59-year-old man, underwent an
attempt at revision repair of a displaced osteotomy seen at
8 weeks postoperatively. The osteotomy remained dis-
placed at final follow-up, and his final SANE score was 20.
There was 1 complication in the DM group (3.6%) consist-
ing of a hematoma that did not require surgery. There were
no infections in either group.
Discussion
This study provides several considerations for rehabilitation
following anatomic TSA. Our results support the hypothe-
sis that immediate passive ROM provides earlier gains in ROM
but does not affect final ROM or functional outcome. In ad-
dition, the rate of lesser tuberosity healing may be lower with
an immediate passive ROM protocol.
Early ROM has been a major tenet of rehabilitation fol-
lowing TSA for many years, with most protocols emphasizing
immediate passive ROM. 16 Neer et al, 8 for instance,
recommended beginning passive ROM on the sixth postop-
erative day following an anatomic TSA performed with a
subscapularis tenotomy approach. Matsen et al4 recom-
mended immediate passive ROM and strengthening at 6 weeks
following TSA with a subscapularis peel approach.
Recently, the concept of immediate passive ROM follow-
ing TSA was challenged by Mulieri et al.7 They retrospectively
reviewed 81 patients who underwent TSA with a subscapu-
laris tenotomy approach followed by either immediate passive
ROM supervised by a therapist or use of a sling for 6 weeks
with only pendulum exercises, followed by a home exercise
program. At final follow-up (mean, 52 months in immedi-
ate ROM group vs 39 months in delayed ROM group), forward
flexion was 154° in the group immobilized for 6 weeks com-
pared with 119° in the group with immediate passive ROM
(P = .024). No difference was seen in internal rotation between
the 2 groups. Mulieri et al did not report external rotation and
did not assess tendon healing. Our study provides further ev-
idence that immediate passive ROM does not improve the final
 ARTICLE IN PRESS
6 P.J. Denard, A. Lädermann
outcome following TSA. Although patients who started im-
mediate ROM had a higher functional outcome initially, these
differences were absent by 3 months postoperatively. There-
fore, it appears that immediate motion does not affect the final
outcome of TSA. However, these early gains may come at
the cost of decreased subscapularis healing.
In recent years, there has been increased attention placed
on the management of the subscapularis during TSA. Several
studies have shown that failure of healing is common fol-
lowing tenotomy for TSA.2,6 Jackson et al2 reported that 7
of 15 tenotomies failed to heal following TSA. This rate is
alarming considering that failure of subscapularis healing may
be a cause for failure of TSA.5 On the basis of the poor healing
following tenotomy, several authors have sought alternative
methods for subscapularis detachment including a lesser tu-
berosity osteotomy.11,12 Scalise et al12 reported that the
subscapularis healed in 53% of cases following a tenotomy
(8 of 15) and 90% of cases following an osteotomy (18 of
20). They also noted improved functional outcomes when the
subscapularis was healed, regardless of repair technique.
In addition to technique, the rehabilitation protocol may
influence subscapularis healing following TSA. Caplan et al1
suggested that passive mobilization be limited in the early
postoperative period to facilitate subscapularis healing. They
performed a tenotomy for TSA in 45 cases and limited passive
forward flexion to 90° and external rotation to neutral for
4 weeks, followed by strengthening at 12 weeks postopera-
tively. Although they did not assess healing, they noted a
negative belly-press test in all patients and attributed this to
their rehabilitation protocol. Our study shows that the reha-
bilitation protocol may also influence lesser tuberosity
osteotomy healing. Our lesser tuberosity osteotomies healed
in 81% of cases with immediate passive ROM compared with
96% of cases in which shoulder ROM was delayed for 4
weeks. Given the lower ASES scores observed in patients in
whom the osteotomy did not heal, this difference appears to
be clinically important. Moreover, on the basis of our finding
that there is little downside to delaying ROM for 4 weeks,
we believe that the ideal rehabilitation protocol following TSA
should emphasize subscapularis healing before initiating
passive ROM.
The major strengths of this study are the prospective
randomized design and evaluation of ROM at multiple time
points. The latter allowed an assessment of the timing for
improvement in ROM following a TSA. However, several
limitations exist. First, the results are limited to an oste-
otomy technique and cannot necessarily be generalized to
other types of repair of the subscapularis tendon such as
tenotomy or a subscapularis peel. Second, the osteotomy
healing rates are specific to the repair technique. We used 3
No. 2 sutures to repair the osteotomy and reinforced this
with multiple soft-tissue sutures. It is possible that addition-
al sutures or higher-strength suture (ie, No. 5 suture) would
decrease the chance of displacement with immediate ROM.
However, our healing rate of 81% in the immediate group
is comparable to healing rates in the literature.14 Third, we
did not assess other protocols. It is unknown, for instance,
if a 2-week period of immobilization as opposed to a 4-week
period would optimize healing and early progression of
ROM. Further study is needed to define the optimal rehabil-
itation protocol following TSA.
Conclusion
Immediate passive ROM provides a more rapid return of
function compared with a delayed ROM protocol follow-
ing TSA. However, there are no differences in ultimate
ROM or functional outcome between the 2 groups. More-
over, immediate ROM may lower the healing rate of a
lesser tuberosity osteotomy with functional consequences.
Acknowledgment
The authors thank Shannon Hiratzka, MPH, for her as-
sistance in the statistics with this project.
Disclaimer
Patrick J. Denard is a consultant for Arthrex. The other
author, his immediate family, and any research founda-
tions with which he is affiliated have not received any
financial payments or other benefits from any commer-
cial entity related to the subject of this article.
References
1. Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary
tendon to tendon repair in patients after replacement arthroplasty of the
shoulder. J Shoulder Elbow Surg 2009;18:193-6. http://dx.doi.org/10
.1016/j.jse.2008.10.019
2. Jackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of
the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg
2010;19:1085-90. http://dx.doi.org/10.1016/j.jse.2010.04.001
3. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of
shoulder arthroplasty in the United States. J Bone Joint Surg Am
2011;93:2249-54. http://dx.doi.org/10.2106/JBJS.J.01994
4. Matsen FA, Clinton J, Rockwood CA, Wirth MA, Lippitt SB.
Glenohumeral arthritis and its management. In: Matsen FA, Rockwood
CA, editors. The shoulder. Philadelphia, PA: Elsevier; 2009. p. 879-88
5. Melis B, Bonnevialle N, Neyton L, Lévigne C, Favard L, Walch G, et al.
Glenoid loosening and failure in anatomical total shoulder arthroplasty:
is revision with a reverse shoulder arthroplasty a reliable option?
J Shoulder Elbow Surg 2012;21:342-9. http://dx.doi.org/10.1016/j.jse
.2011.05.021
6. Miller SL, Hazrati Y, Klepps S, Chiang A, Flatow EL. Loss of
subscapularis function after total shoulder replacement: a seldom
recognized problem. J Shoulder Elbow Surg 2003;12:29-34.
http://dx.doi.org/10.1067/mse.2003.128195
7. Mulieri PJ, Holcomb JO, Dunning P, Pliner M, Bogle RK, Pupello D,
et al. Is a formal physical therapy program necessary after total shoulder
arthroplasty for osteoarthritis? J Shoulder Elbow Surg 2010;19:570-9.
http://dx.doi.org/10.1016/j.jse.2009.07.012
 ARTICLE IN PRESS
Immediate versus delayed motion after TSA
8. Neer CS II, Watson KC, Stanton FJ. Recent experience in total shoulder
replacement. J Bone Joint Surg Am 1982;64:319-37.
9. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty
for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg
2002;11:130-5. http://dx.doi.org/10.1067/mse.2002.121146
10. Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett
PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity
repair technique in total shoulder arthroplasty. J Bone Joint Surg Am
2005;87(Suppl 2):1-8. http://dx.doi.org/10.2106/JBJS.E.00441
11. Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL.
Subscapularis function after total shoulder replacement: results with lesser
tuberosity osteotomy. J Shoulder Elbow Surg 2008;17:68-72.
http://dx.doi.org/10.1016/j.jse.2007.04.018
12. Scalise JJ, Ciccone J, Iannotti JP. Clinical, radiographic, and
ultrasonographic comparison of subscapularis tenotomy and lesser
tuberosity osteotomy for total shoulder arthroplasty. J Bone Joint Surg
Am 2010;92:1627-34. http://dx.doi.org/10.2106/JBJS.G.01461
7
13. Schmidt CC, Jarrett CD, Brown BT, DeGravelle M Jr, Sawardeker P,
Weir DM, et al. Effect of lesser tuberosity osteotomy size and
repair construct during total shoulder arthroplasty. J Shoulder
Elbow Surg 2014;23:117-27. http://dx.doi.org/10.1016/j.jse.2013.03
.018
14. Small KM, Siegel EJ, Miller LR, Higgins LD. Imaging characteristics
of lesser tuberosity osteotomy after total shoulder replacement: a study
of 220 patients. J Shoulder Elbow Surg 2014;23:1318-26.
http://dx.doi.org/10.1016/j.jse.2013.12.010
15. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal
clinically important differences in ASES and Simple Shoulder Test
scores after nonoperative treatment of rotator cuff disease. J Bone
Joint Surg Am 2010;92:296-303. http://dx.doi.org/10.2106/JBJS
.H.01296
16. Wilcox RB, Arslanian LE, Millett P. Rehabilitation following total
shoulder arthroplasty. J Orthop Sports Phys Ther 2005;35:821-36.
http://dx.doi.org/10.2519/jospt.2005.35.12.821