Most people hear “shoulder replacement” and picture one operation. There are actually two very different versions, and which one you get depends less on how much your shoulder hurts than on the condition of one structure: your rotator cuff. If a surgeon has just told you the word “reverse” and you nodded along without quite following, you're in good company. This is the explanation we wish every patient got before they walked into our North Palm Beach clinic for their first post-op visit.
On a recent episode of our Pain 2 Power radio show, Dr. Dave Kashuba and Mike McGann sat down with Dr. Ryan Simovitch, an orthopedic shoulder surgeon who helped build HSS's orthopedic program in Florida from a core group of five people to nearly seventeen surgeons and physicians. He trained at Duke, with a shoulder fellowship split between Harvard and Zurich, and has been in practice about twenty years. The following week, Dr. Vani Sabesan, MD, an orthopaedic shoulder surgeon and the Florida Orthopaedic Society's first female president, picked up the same thread and pushed it further. Between the two of them, you get a pretty complete picture of how replacement surgery works now, and what happens to your shoulder afterward.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
Two buckets of patients
Dr. Simovitch described his evaluation as sorting patients into two groups. He was quick to add that no two of them arrive the same way. “Every patient has a different story,” he said. “And every MRI looks a little bit different.” But the first fork in the road is simple enough to explain at a kitchen table.
When the cuff still works
The first group is people with shoulder arthritis whose rotator cuff is still intact. The cartilage is worn, often bone-on-bone, but the cuff muscles and tendons wrapped around the joint are still doing their job. “Historically and even now, I'll still mostly do a regular anatomic replacement” for this group, he said.
When the cuff doesn't, or the bone has other plans
The second group is people whose rotator cuff is not intact, whether or not arthritis is present. That might be a cuff that's deficient, or chronic cuff problems that can't be repaired another way. For them, he does a reverse.
A few situations push toward a reverse even when the cuff is fine: significant bone wear, a revision of a previous replacement, or severely limited function going in. So if you've been told you need a reverse and you've never had a cuff tear in your life, that's not necessarily a contradiction. Ask your surgeon which of those reasons applies to you. It's a fair question, and the answer will matter to your therapist later.
What “reverse” actually reverses
An anatomic total shoulder rebuilds the joint the way it was designed. The ball side gets a metal ball on a stem; the socket side gets a plastic socket. Natural layout, replacement parts.
That design has a requirement: your rotator cuff has to work. The cuff is what compresses the ball into the socket, holds it stable, and drives motion. Without it, the joint has no stability. As Dr. Simovitch explained, even when great therapists push hard to make it function for a while, the implant gets loaded in an unusual way that can cause it to fail in the near term.
The reverse is exactly what it sounds like. The ball goes on the socket side, and the socket goes on the ball side. Flipping the geometry builds stability into the hardware itself. The joint no longer depends on a cuff that can't do the job, and it's protected from the wear pattern that would eventually destroy an anatomic replacement in that shoulder. Here's the side-by-side.
| Anatomic total shoulder | Reverse total shoulder | |
|---|---|---|
| Layout | Ball on the ball side, socket on the socket side, like the original joint | Ball on the socket side, socket on the ball side |
| Who it's usually for | Arthritis with an intact rotator cuff | A deficient or irreparable cuff, with or without arthritis |
| Where stability comes from | The rotator cuff holding the ball in the socket | The implant's own geometry |
| Other reasons to choose it | Significant bone wear, revision of an earlier replacement, severely limited function beforehand |
Why reverse outcomes got so much better
Dave raised something he's watched change from the therapy side. Fifteen or twenty years ago, patients with a reverse struggled to get external rotation past zero degrees, with limited strength. In plain terms, they couldn't turn the arm outward, which makes combing your hair or reaching for a seatbelt a chore. Now he sees them come back with rotation and strength that look clinically excellent.
Dr. Simovitch credited several things working together. The detail matters, because it's why one surgeon isn't interchangeable with another. “There's right ways, there's wrong ways, there's no between ways,” he said. “And if you do the right way and the right patient, generally you're going to have good outcomes or great outcomes.”
The right patient
Whether the posterior cuff, the back portion, is intact largely determines how much external rotation you'll get. When it isn't, a tendon transfer can improve the odds.
Implant choice and positioning
Implants vary in how far they shift the joint outward. Get that tensioning wrong and the muscle can't perform correctly. It's the same principle behind any muscle's length-tension relationship.
What gets repaired, and what doesn't
Repairing the subscapularis at the front of the shoulder adds stability but can tether external rotation, so he doesn't routinely repair it in patients where he expects that trade-off to cost them motion. Dave's blunter version, on which cuff tendon he'd least mind losing in a reverse: “If they're going to have a tear of a rotator cuff, let it be the subscap.”
Six weeks in a sling, or moving tomorrow?
On Episode 9, Dave opened by describing what he sees with Dr. Sabesan's reverse patients: “she's trying to get you to reach behind and put your hand in your pocket within a couple of weeks.” If you've heard the older story about a long stretch of immobilization after shoulder surgery, that sounds fast. It is.
Dr. Sabesan explained how she got there, and it's personal. Her mother has had two reverses. “Do you want to spend six weeks in a sling or would you rather start moving tomorrow?” she said. “Just because you're 76, not driving for six weeks can really disable you from your life, your lifestyle, your family.” Her mom, as it happens, drives the grandkids to school.
So her practice compared the two approaches head to head: one partner kept patients in the sling for six weeks, and she had people moving within days. She reported no complications and similar outcomes, and added, “in fact, at six weeks, they're doing a ton better.” Her takeaway was aimed at her own profession: “You can't sit and stay the same as a surgeon.”
A word of caution before anyone in a sling reads this and takes it off. Early motion was her protocol, for her patients, built around how she does the operation. Your surgeon sets your protocol, and we follow it exactly. What's changed is that early motion is now on the table, so ask your surgeon where they land on it. Dave's own experience with her patients, for what it's worth: “with her reverse total shoulders, I've had nothing but good ones.”
The newer ideas surgeons are working on
Dr. Sabesan was refreshingly unimpressed by technology for its own sake. Her test is whether a new tool solves a patient's problem. “Tech for tech's sake versus tech, solve your problem,” was how she put it. Less pain, faster recovery, bone that grows better, a cuff that heals. She was equally blunt about robots in shoulder and joint surgery, calling them a great marketing tool without much science yet behind them.
The ideas she is excited about are ones that change what rehab looks like afterward, which is exactly why we pay attention.
| Idea | What she said it is | Why it matters for recovery |
|---|---|---|
| Muscle sparing | Doing the replacement without cutting the subscapularis at the front of the shoulder | She said a cut subscap means a six-week restriction while it heals; leaving it alone means no restrictions to start |
| Stemless implants | Implants, some 3D printed, designed for your bone to heal into | Part of what she called making your bone grow better |
| Pyrocarbon | A different material that lets the surgeon resurface one side of the joint instead of both | She said it won't wear away or cause the same levels of pain as trying to do both sides |
| Personalized implants | Implants 3D printed to the patient's own anatomy and size, from a design team she is part of | Her hope: a better fit and a quicker return to the gym |
Muscle sparing, in her words
The muscle-sparing idea is the one with the most obvious rehab payoff. “The subscap, if you cut into it, needs to heal like any other muscle you do, and that's a restriction for six weeks, and it sometimes can lead to lifelong problems,” Dr. Sabesan said. Notice it's the same tendon Dr. Simovitch talked about from the other direction. One surgeon sometimes chooses not to repair it so it won't tether rotation; another is developing ways to avoid cutting it at all. Either way, the subscapularis is a big part of what your therapist is managing in those first weeks.
When a replacement needs replacing
Revisions came up too, and her answer is one we'd like every worried patient to hear. She said she probably enjoys the complex cases the most, and “no one is at the end of the line to me.” She also described patients back to competitive heavy lifting after shoulder surgery, which drew an honest “That would be terrifying to me” from across the studio table.
What happens on the therapy side
Two people can have “a shoulder replacement” and need different rehab, depending on which implant went in, what was repaired, and which protocol the surgeon follows.
Why we ask for your operative report
Dave's team chases down operative reports specifically to learn what was done; for a rotator cuff repair, even whether it was a double-row technique. “It means a lot to the therapist to know what they're doing,” he said. His argument for choosing a therapist-owned clinic is exactly this: therapists don't perform the surgery, but they need to understand it to rehab it. On Episode 9 he described the other half of that homework: “We have to know what the doctor intends their patients to be able to do.” When they'll be discharged, how far the surgeon trusts the therapist to progress them, how hard is too hard.
He also described the cost of getting it wrong in the reverse era. When external rotation wasn't coming back, therapists would end up working around it, patients drifted into a forward-shoulder position (bad for a reverse), and motion stalled around 80 to 90 degrees. He's seen scapular fractures in patients whose rehab wasn't handled carefully.
Dr. Simovitch put it plainly from the surgical side: “The surgeon matters, the surgery matters, but the therapy matters just as well.” Dr. Sabesan backed it with her own numbers. Her team surveyed their shoulder replacement patients, and nearly all of them said their therapist had a big impact on the result. Her comparison was a good hairdresser: someone who talks to you, listens, and adjusts.
What it looks like here
At First Rehabilitation your first visit runs about an hour, one-on-one with a therapist, and treatment usually begins that day. We take your history, read what your surgeon sent, measure where your motion and strength are, and write a plan of care around your surgeon's protocol. If you're on Medicare, your physician certifies that plan; our front desk handles the paperwork and verifies your benefits before you come in. Our 2026 Medicare guide walks through deductibles and coinsurance.
Then comes the part that's on you. Captain Kerry Titheradge, of Bravo's Below Deck, first came to Dave more than twenty years ago with a rotator cuff injury. “Full motion is very, very important,” he said on Episode 13, since he was working on deck at the time. What he remembers about that rehab: “I remember just following everything you said to the tee.” Dave's warning on the same episode runs the other way. Do the exercises precisely, and don't decide that if ten repetitions are good, fifty must be better.
What you can do before any of this is on the table
Both Dave and Dr. Simovitch spent the back half of Episode 8 on prevention, and none of it is complicated.
Dr. Simovitch’s warning is about what he calls the constant warrior: the person playing pickleball six days a week with no moderation and no preparation, who plays until something tears. (He's watched patients switch from right-handed to left-handed rather than stop.) Dr. Sabesan made the same point about Florida: the weather lets people play all year round, which is wonderful until the shoulder gets a vote.
His simple home routine:
- Wall slides: both arms at 90 degrees against a wall, slide all the way up, three sets of ten
- Cross-body stretch: take your right elbow with your left hand and pull across your body to stretch the posterior capsule
- Shoulder shrugs: up and down, three sets of ten
- Scapular retractions: squeeze your shoulder blades toward each other
Add resistance bands for rows and extensions. His reasoning: nearly everything we do all day is internal rotation, so pulling outward is what balances it. Step-by-step instructions are on our home exercises page. If you already have a replacement, check with your surgeon and therapist before adding any of these, because your protocol comes first.
And the one he repeats most: get out of the chair. “The invention of the chair is one of our demise.” Ten or fifteen minutes of walking a day, sit-to-stands, whatever gets you moving.
His whole goal, in his words: “I do everything I can to let people not ever come to see me.”
If your shoulder is already talking to you
You don't need a diagnosis to start. If reaching overhead or getting your arm behind your back has become a problem, an evaluation tells you which path you're on, and often that path doesn't include surgery at all. If it does, we'll coordinate with your surgeon before and after, and you can hear both full conversations on our podcast page and watch the episodes on our videos page.
Call us at 561-624-4263 or request an appointment. You can read more about how we treat shoulder pain, what post-surgical rehabilitation involves, and what physical therapy looks like here. Our FAQ answers the practical questions about insurance and scheduling.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.