Adult ReconstructionShoulderHospital

Reverse Shoulder Arthroplasty

Performed by Maryland Orthopedic Specialists' adult reconstruction surgeon, with fellowship training in shoulder arthroplasty, at a regional hospital facility.

Duration: 90–120 minutesAnesthesia: General

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What is reverse shoulder arthroplasty?

Reverse shoulder arthroplasty is a shoulder replacement where the ball and socket positions are switched — the ball is placed on the shoulder blade side and the socket on the arm side. This design lets the deltoid muscle (instead of the rotator cuff) power the arm, making it the right choice when the rotator cuff is irreparably torn.

Why this approach — at MOS

Reverse shoulder arthroplasty outcomes depend critically on proper patient selection and implant positioning. The procedure works because of the deltoid — a patient with a non-functioning deltoid from axillary nerve damage will not gain overhead function no matter how perfect the implant position. Every candidate is evaluated neurologically before surgery.

Our adult reconstruction specialist uses pre-operative CT-based planning with three-dimensional templating to select implant size, glenosphere offset, and humeral stem version before the case begins. This planning reduces intraoperative decision-making and helps achieve consistent biomechanical restoration — specifically, adequate inferior tilt of the glenosphere (to prevent notching) and appropriate humeral height (to avoid overlengthening, which causes deltoid tension problems).

Glenoid baseplate fixation is the most critical technical step. A loose or rocking baseplate is a catastrophic complication. We use a minimum of two peripheral screws in addition to central fixation on every case. If glenoid bone quality is poor or bone loss is present, bone grafting is incorporated into the plan.

Patients who receive a reverse shoulder arthroplasty at Maryland Orthopedic Specialists, serving the Montgomery County region, are followed long-term for implant surveillance. We obtain post-operative X-rays at 6 weeks, 6 months, 1 year, and then annually. Early detection of glenoid notching, baseplate migration, or polyethylene wear allows intervention before catastrophic implant failure occurs.

Who is a candidate?

Indications

Rotator cuff tear arthropathy (massive irreparable rotator cuff tear combined with glenohumeral arthritis or superior migration of the humeral head)
Massive irreparable rotator cuff tear causing severe pseudoparalysis (inability to lift the arm) even without severe arthritis
Severe glenohumeral arthritis with deficient rotator cuff, prior rotator cuff repair with failed healing, or massive fatty infiltration of rotator cuff muscles
Acute proximal humerus fracture in elderly patients when internal fixation is not appropriate
Revision of a failed anatomic shoulder replacement where the rotator cuff is deficient
Tumor surgery requiring proximal humerus reconstruction

Contraindications

Active shoulder or systemic infection
Neurologically intact deltoid is required — axillary nerve palsy causing deltoid dysfunction is a relative contraindication (the deltoid must work for the procedure to succeed)
Severe glenoid bone loss that cannot support baseplate fixation (requires bone grafting)
Young patients with arthritis but an intact rotator cuff (anatomic total shoulder arthroplasty is preferred)
Patients medically unsuitable for general anesthesia or major surgery

Conservative Treatment First

Patients with rotator cuff tear arthropathy typically arrive after a long history of treatment for their rotator cuff disease. Many have undergone physical therapy, injections, and sometimes prior rotator cuff repair surgery. For patients who are elderly, medically fragile, or have low functional demands, non-operative management with activity modification, analgesics, occasional corticosteroid injections, and therapy to maintain whatever range of motion remains is a reasonable path. Surgery is not urgently required in all patients.

For active patients with severe pain, loss of sleep, and inability to perform basic daily activities — reaching overhead, dressing, personal hygiene — the non-operative trajectory is generally poor, and surgery provides substantially better outcomes. The decision is made through a detailed discussion of symptoms, functional goals, medical history, and realistic expectations for what the reverse replacement will and will not be able to do.

The procedure

What Is Reverse Shoulder Arthroplasty?

In a normal shoulder, the ball (humeral head) sits on the arm bone and the socket (glenoid) is part of the shoulder blade. The rotator cuff muscles are what hold the ball centered in the socket and provide the force to lift the arm. When the rotator cuff is massively and irreparably torn, the ball is no longer held in place — it rides up and grinds against the acromion (the bony roof of the shoulder). Over time, this destroys the articular cartilage and causes a specific type of painful, dysfunctional shoulder called rotator cuff tear arthropathy.

In this condition, a conventional (anatomic) shoulder replacement does not work. Without an intact rotator cuff, the ball simply migrates upward and the patient still cannot lift the arm. The reverse shoulder arthroplasty solves this problem by switching the geometry. The metal ball (glenosphere) is screwed into the shoulder blade, and a cup attaches to the arm bone. This shifts the center of rotation downward and medially, which dramatically changes the mechanical advantage of the deltoid muscle. The deltoid — which is intact in most of these patients — can now efficiently power arm elevation without any contribution from the rotator cuff.

The result is a shoulder that may not function like a young, healthy normal shoulder, but can reliably provide a comfortable, functional range of motion that allows patients to reach overhead, perform activities of daily living, and sleep through the night — outcomes that are simply not possible when the condition is left untreated or treated with an anatomic replacement in the wrong indication.

What Happens During Reverse Shoulder Arthroplasty?

Before Surgery

Reverse shoulder arthroplasty is performed in a hospital setting, as it is a major reconstructive procedure. Pre-operative workup includes blood tests, EKG, and medical clearance from your primary care physician or cardiologist. You will meet with the anesthesiologist beforehand.

You arrive at the hospital on the morning of surgery, approximately 2 hours before the scheduled time. An IV is started, and general anesthesia is administered.

Positioning

You are positioned in the beach chair position with the operative shoulder accessible. The shoulder, neck, and upper chest are cleaned and draped. Fluoroscopy (real-time X-ray) is available in the operating room for implant position confirmation.

Deltopectoral Approach

A 10–15 cm incision is made along the deltopectoral groove at the front of the shoulder. The deltoid and pectoralis major are separated (not cut). The subscapularis tendon is carefully taken down from the humerus — this will be repaired at the end of the procedure. The shoulder capsule is opened, and the humeral head is delivered.

Humeral Head Removal

The humeral head is resected at the appropriate angle and height using guides aligned to patient-specific anatomy. The humeral canal is opened and sized for the stem.

Glenoid Preparation and Baseplate Fixation

The glenoid surface is prepared and sized. A central hole is drilled and a metal baseplate is impacted or screwed into the glenoid. The baseplate is secured with two to four additional peripheral screws to ensure rigid fixation. The glenosphere (metal ball) is then locked onto the baseplate.

Humeral Component Insertion

A polyethylene cup liner is assembled onto the humeral stem, which is inserted into the humeral canal and impacted to the correct depth. The cup engages with the glenosphere. Trial components confirm range of motion, stability, and absence of impingement.

Subscapularis Repair and Closure

The subscapularis tendon is repaired back to the humerus with sutures. The deltopectoral interval is loosely closed. Deep and subcutaneous tissues are closed in layers. A drain is sometimes used in the first 24 hours.

Recovery

You are monitored in the recovery room and then transferred to a hospital room. Most patients stay 1–2 nights. The arm is placed in a sling. Ice packs, elevation, and scheduled analgesics manage post-operative discomfort.

Recovery timeline

Days 0–3 (Hospital Recovery)

1–2 night hospital stay. Pain managed with IV and oral analgesics. Physical therapy begins on post-operative day 1 with pendulums and elbow/hand motion.

Weeks 1–4 (Sling and Early Motion)

Arm in sling. Pendulums, elbow flexion/extension, and wrist and hand exercises continue at home. Early passive shoulder elevation exercises with assistance begin at week 2.

Weeks 4–8 (Active-Assisted and Active Motion)

Sling discontinued around week 4–6. Active-assisted elevation progresses. Most patients begin reaching shoulder height by week 6–8.

Months 2–4 (Progressive Strengthening)

Deltoid and periscapular strengthening exercises. Most patients reach functional overhead range of motion in this phase.

Months 4–6 (Full Daily Function)

Return to most activities of daily living, light recreational activity, and driving. Heavy lifting restrictions are permanent (typically 20–25 lb maximum).

Reverse shoulder arthroplasty patients achieve the best outcomes when they understand what to expect: very reliable improvement in pain (90%+ of patients report significant pain relief) and meaningful improvement in function, but not a shoulder that feels or performs like a normal shoulder. Overhead reach typically improves to 120–140 degrees — functional for daily living. External rotation often improves modestly but may remain limited.

Physical therapy is supervised for the first 2–3 months and then transitions to a home program. The subscapularis repair, if performed, takes 6–8 weeks to heal and guides the progression of internal rotation strengthening. Permanent restrictions on lifting more than 20–25 pounds protect the implant from mechanical failure over the long term.

Frequently Asked Questions

What is the difference between reverse and regular (anatomic) shoulder replacement?

In a regular (anatomic) replacement, the ball is placed on the arm bone and the socket on the shoulder blade — matching normal anatomy. This works when the rotator cuff is intact. In a reverse replacement, the positions are switched: the ball attaches to the shoulder blade and the socket to the arm bone. This allows the deltoid muscle alone to power arm elevation, which is necessary when the rotator cuff is gone.

Will I be able to lift my arm overhead after reverse shoulder replacement?

Most patients regain functional overhead range of motion — typically 120–140 degrees of elevation — after reverse shoulder arthroplasty, compared to very limited or no overhead function before surgery. The improvement is reliable and is one of the most dramatic functional gains patients experience.

Do I need to stay in the hospital overnight?

Yes. Reverse shoulder arthroplasty is a major surgery performed in a hospital setting. Most patients stay 1–2 nights. This allows for pain management, early physical therapy, wound monitoring, and medical supervision during the initial recovery period.

Are there permanent restrictions after this surgery?

Most surgeons recommend limiting lifting to 20–25 pounds or less permanently, to protect the implant from mechanical overload. High-impact activities such as heavy manual labor or contact sports are generally not recommended. Activities like swimming, golf, gardening, and light recreational activity are typically achievable and encouraged.

How long do shoulder implants last?

Modern reverse shoulder implants have excellent long-term outcomes. Studies with 10-year follow-up show implant survival rates of 85–90%. The main causes of implant failure over time are glenoid baseplate loosening, polyethylene wear, infection, and instability. Annual X-ray surveillance allows early detection of problems.

I've already had rotator cuff repair — can I still get reverse shoulder replacement?

Yes. Prior rotator cuff repair does not prevent reverse shoulder arthroplasty. In fact, a significant number of patients who ultimately need reverse shoulder replacement have had prior repair surgery that did not fully resolve their symptoms. The surgical approach is more complex in revision settings, but the procedure remains appropriate and effective.

Is this surgery covered by insurance?

Reverse shoulder arthroplasty for documented rotator cuff tear arthropathy or irreparable massive rotator cuff tears is covered by Medicare and most major insurance plans when medical necessity criteria are met. Your surgical coordinator will verify your specific coverage before surgery is scheduled.

Meet the surgeons

Christopher S. Raffo, MD

Orthopedic Surgery · Sports Medicine

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John J. Christoforetti, MD

Orthopedic Surgery · Sports Medicine · Hip Preservation Surgery

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Related conditions

Glenohumeral Osteoarthritis

Medically reviewed by Christopher S. Raffo, MD

Last reviewed May 20, 2026