Minimal improvements in objective shoulder strength following shoulder arthroplasty: a systematic review

Patients with degenerative shoulder conditions indicated for shoulder arthroplasty frequently present with weakness due to disuse, pain, or their underlying pathology. However, it is unclear whether shoulder arthroplasty results in improvements in strength postoperatively. The purpose of this systematic review was to evaluate changes in objective strength following both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).

A systematic review was conducted in April 2024 using the keywords "shoulder arthroplasty," "outcomes," and "strength" in the PubMed, Web of Science, OVID, and Embase databases. Studies were included if they reported on patients who underwent aTSA or rTSA with preoperative and postoperative strength measurements (in lbs, kg, or N-m) assessed at a mean follow-up of 2 years postoperatively. Proximal humerus fractures, tendon transfers, revisions, axillary nerve injuries, level V evidence, reviews, and biomechanical studies were excluded.

The search identified 2,070 studies, of which 11 met the inclusion criteria: 4 for aTSA, 5 for rTSA, and 2 for both. Among 5 studies evaluating rTSA abduction strength, improvements ranged from 0.4-4.9 kg, with each demonstrating objective strength gains, although 2 did not include statistical analysis of preoperative and postoperative differences. Only one study assessed abduction strength in aTSA, also finding significant improvements. Two rTSA studies and 3 aTSA studies each also demonstrated significant improvements in supraspinatus or forward elevation strength, while one study showed significant improvement in forward flexion strength (3-6 N-m) for both rTSA and aTSA. Three of 4 studies reporting postoperative external rotation strength improvements following rTSA found significant increases, ranging from 1.0-1.8 kg. In aTSA, all 3 studies demonstrated significant improvements in external rotation strength. Three studies also assessed internal rotation strength post-aTSA, demonstrating improvement ranging from 1.4-2.5 kg, with 2 randomized clinical trials finding no significant strength difference between subscapularis peel and lesser tuberosity osteotomy or tenotomy.

While shoulder arthroplasty leads to some degree of strength improvement across all planes of motion, the magnitude is modest and may not be perceptible to patients. Although these improvements may facilitate active shoulder range of motion, postoperative strength remains well below normative shoulder values.