Shoulder replacement surgery is the third most common joint replacement procedure, following closely being hip and knee replacements. Whether due to severe arthritis, a rotator cuff tear, or degenerative joint changes, replacing the shoulder joint can offer significant pain relief and improved function.
But did you know there are two types of shoulder replacement surgeries? Choosing the right procedure – Total Shoulder Replacement (TSR) or Reverse Total Shoulder Replacement (RTSR) – depends on your individual diagnosis, lifestyle, and the condition of your rotator cuff.
In this blog, we’ll break down the key differences, benefits, and considerations of each procedure, supported by recent research, to help you or a loved one make an informed decision.
Understanding the Anatomy of the Shoulder
The shoulder joint is a complex, highly mobile ball-and-socket joint that allows for a wide range of movement. It involves:
- The humerus (upper arm bone)
- The scapula (shoulder blade)
- The acromion (bony projection of the scapula)
This mobility also make the shoulder vulnerable to wear-and-tear, injuries, and degenerative diseases. When conservative treatments such as physiotherapy, injections, or medications fail, a shoulder replacement may be recommended.
What is a Total Shoulder Replacement (TSR)?
Total Shoulder Replacement (TSR) – also known as anatomic shoulder arthroplasty – is the traditional form of shoulder replacement. In this procedure, the damaged ball (humeral head) and socket (glenoid) are replaced with metal and plastic implants that mimic the normal anatomy of the shoulder.
TSR is typical recommended for:
- Patients with intact rotator cuff tendons
- Individuals with osteoarthritis or rheumatoid arthritis
- Patients experiencing bone-on-bone grinding pain with limited mobility
Because the procedure replicates the natural joint mechanics, it generally leads to good range of motion, particularly in external rotation and overhead movements – provided the rotator cuff is healthy.
What is Reverse Total Shoulder Replacement (RTSR)?
Reverse Total Shoulder Replacement (RTSR) – or reverse shoulder arthroplasty – is the newer surgical technique designed for patients with more complex shoulder issues. In this version, the normal ball-and-socket configuration is reversed:
- The ball component is fixed to the shoulder blade (scapula)
- The socket is attached to the upper arm bone (humerus)
The reverse design shifts the centre of rotation and enables the deltoid muscle to power the arm instead of the damaged rotator cuff.
RTSR is usually recommended for:
- Patients with severe or irreparable rotator cuff tear
- Those with cuff tear arthroplasty (arthritis due to rotator cuff failure)
- Individuals who have had previous failed shoulder surgeries
- Complex fractures in older patients
Because it doesn’t rely on a functioning rotator cuff, RTSR provides a reliable option for restoring arm elevation and reducing pain – even in more advanced cases.
TSR vs RTSR: What Does the Research Say?
Understanding the functional outcomes, recovery timelines, and patient satisfaction levels can help clarify which procedure may be most suitable for your condition
Study 1: Simovitch et al. (2017)
This landmark study evaluated how patients improved after undergoing either TSR or RTSR. The findings were insightful:
- RTSR patients experienced greater improvements in:
- Pain reduction
- Strength
- Function
- Active forward flexion (lifting the arm forward)
- TSR patients had better outcomes in:
- General shoulder range of movement
- Especially external rotation
Recovery Timeline: In both procedures, most improvement occurred within the first 6 months, with further gains up to 2 years post-surgery.
Takeaway: While each surgery has its strengths, both deliver similar long-term functional outcomes, albeit with different movement profiles.
Study 2: Mid- to Long-Term Outcomes (Schoch et al., 2021)
Another study followed patients for a minimum of 8 years after having either a TSR or RTSR. Key insights included:
- TSR patients maintained greater improvements in external rotation (average of 31 degrees) compared to RTSR patients (average of 4 degrees)
- Both procedures showed similar improvements in forward elevation
What the difference in external rotation? The reduced range in RTSR patients is likely due to the underlying rotator cuff damage, which the reverse design cannot fully compensate for in this specific motion.
Patient Preference: One of Each Shoulder
A particularly interesting study followed 19 patients who underwent TSR on one shoulder and RTSR on the other. When asked which shoulder they preferred:
- 68% chose the RTSR shoulder
- RTSR patients reported greater overall satisfaction
- 90% of RTSR patients rated their shoulder as much better or better than before the surgery
- In contrast, only 67% of TSR patients reported the same
- 19% of TSR patients even felt their shoulder was worse post-surgery, compared to just 2% of RTSR patients
Takeaway: Even with reduced external rotation, RTSR was still preferred by the majority of patients for day-to-day comfort and functionality.
TSR vs RTSR: Pros and Cons at a Glance
| Feature | Total Shoulder Replacement (TSR) | Reverse Total Shoulder Replacement (RTSR) |
| Anatomy | Mimics natural shoulder joint | Ball and socket are reversed |
| Muscle Dependence | Requires intact rotator cuff | Powered by deltoid muscle |
| Best For | Arthritis with healthy rotator cuff | Rotator cuff tears, complex arthritis |
| External Rotation | Superior to RTSR | Reduced due to cuff damage |
| Forward Elevation | Comparable | Comparable |
| Recovery | 6-24 months for full improvement | 6-24 months for full improvement |
| Complication Rate | Slightly higher | Lower reoperation and complication rates |
| Patient Satisfaction | Good | Higher overall satisfaction |
Which Shoulder Replacement is Right for You?
The decision between TSR vs RTSR shoulder be made in collaboration with your orthopaedic surgeon, based on:
- Condition of your rotator cuff
- Age and activity level
- Extent of joint degeneration
- Previous surgeries or trauma
At Logan Physio, our team works closely with referring orthopaedic specialists to help patients prepare before surgery, and support their rehabilitation after shoulder replacement, ensuring optimal long-term outcomes.
Physiotherapy After Shoulder Replacement
Regardless of which procedure you undergo, rehabilitation plays a critical role in your recovery. Physiotherapy focuses on:
- Restoring mobility and strength
- Improving functional use of the arm
- Guiding safe movement patterns
- Preventing compensations and stiffness
Our team at Logan Physio will create a tailored rehab program to support your individual recovery goals – whether you’ve had a TSR or RTSR.
Final Thoughts
While Total Shoulder Replacement and Reverse Total Shoulder Replacement serve different patient groups, both have excellent long-term success rates. If you’re struggling with shoulder pain and loss of function, speak to your GP or orthopaedic surgeon about whether one of these procedures is right for you.
At Logan Physio, we’re here to support you every step of the way – from pre-op education to post-op rehab – ensuring your return to pain-free living.
References
Simovitch, R. W (2017). Rate of Improvement in Clinical Outcomes with Anatomic and Reverse Total Shoulder Arthroplasty. The Journal of Bone and Joint Surgery, 99 (21), 1801-1811.
Schoch BS, King JJ, Zuckerman J, Wright TW, Roche C, Flurin PH. (2021). Anatomic versus reverse shoulder arthroplasty: a mid-term follow-up comparison. Shoulder and Elbow, 13 (5), 518-526. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8512971/
