Surgical Information - Reverse Shoulder

WELCOME Welcome________________________!

Your ___________________@@@@@@@@@by Dr._____________________ is scheduled for_______________________________@@@@@@@@@@ at Lincoln Surgical Hospital @ 1710 S. 70th Street, Lincoln, NE 68506.

Please arrive at _____________ at Entrance C and proceed to the Admissions desk as you walk in – we will be expecting you.

Please bring your driver’s license, insurance card(s), prescription card(s) and your medications.

Between class and your surgery if you have any questions please feel free to call .POEBZ 'SJEBZ GSPN BN UP QN BU 402-484-0884 and leave a message – we will get back to you within 24 hours during business hours.

We look forward to taking care of you and your family! >ŝŶĐŽůŶ ^ƵƌŐŝĐĂů ,ŽƐƉŝƚĂů ŚĂƐ ĨƌĞĞ t/&/͘ >ŽŽŬ ĨŽƌ >^,ŐƵĞƐƚ͖ ŶŽ ƉĂƐƐǁŽƌĚ ŶĞĞĚĞĚ͘

Make PT appointment: _________________________________ Things to do: ______________________ _________________________________ _________________________________ _________________________________

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NIGHT BEFORE SURGERY Medications: t #MPPE UIJOOFST PS TMJDLFST *G ZPV BSF PO BOZ UZQF PG CMPPE UIJOOFST UBML UP UIF QIZTJDJBO UIBU QSFTDSJCFT UIBU NFEJDBUJPO GPS JOTUSVDUJPOT PO TUPQQJOH JU JG OFFEFE QSJPS UP ZPVS TVSHFSZ EBUF t 0UIFS @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ t %JBCFUJD NFEJDBUJPO %P /05 UBLF PSBM EJBCFUJD NFEJDBUJPO UIF NPSOJOH PG TVSHFSZ *G ZPV UBLF JOTVMJO JO UIF NPSOJOH QMFBTF DPOUBDU ZPVS QIZTJDJBO GPS JOTUSVDUJPOT t %JVSFUJDT XBUFS QJMMT %P /05 UBLF XBUFS QJMMT EJVSFUJDT UIF NPSOJOH PG ZPVS TVSHFSZ t EBZT XFFL CFGPSF TVSHFSZ TUPQ v IFSCBM TVQQMFNFOUT NFEJDBUJPOT v XFJHIU MPTT NFEJDBUJPOT v PWFS UIF DPVOUFS NFEJDBUJPOT 05$hT v *CVQSPGFO QSPEVDUT t 0UIFS @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ t 5BLF NPSOJOH PG TVSHFSZ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

8IFO UP TUPQ FBUJOH BOE ESJOLJOH CFGPSF TVSHFSZ:

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Other Instructions:

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DAY OF SURGERY *Please enter through Entrance C and proceed to the front desk Here are the items you need to do/bring with you on the day of your surgery: _____Bring medication(s) in original container(s) _____ Drivers license or other ID card _____ Insurance card(s) _____ Prescription card(s) _____ Comfortable clothes for 1-2 days (drawstring or elastic waist pants/shorts), personal items (toiletry bag) and shoes (slip on with back, no sandals) _____ $BOF JG OFFEFE _____ Your joint book should come back with you _____ If applicable: your home CPAP/Bipap @@@@@ *G ZPV IBWF POF CSJOH ZPVS "EWBODFE EJSFDUJWF QPXFS PG BUUPSOFZ PS MJWJOH XJMM

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WELCOME Welcome to Lincoln Surgical Hospital!

Thank you for choosing us! We will have “exceptional people providing extraordinary care” during your stay with us.

Our goal is to help decrease the anxiety that comes with having surgery by answering your questions, preparing you for what to expect, communicating to your family and getting you home to recover so you can get back to your normal day-to-day life!

OUR RECENT ACCOMPLISHMENTS AND AWARDS INCLUDE: One of America’s 100 BEST HOSPITALS for Joint Replacement, Healthgrades® 5 STAR RECIPIENT for Total Knee Replacement, Healthgrades® 5 STAR RECIPIENT for Total Hip Replacement, Healthgrades® Recipient of the Outstanding Patient Experience Award, Healthgrades® Rated one of the TOP 100 HOSPITALS for Patient Experience, Women’s Choice Award® Recognized as a TOP SMALL HOSPITAL forOverall Inpatient Satisfaction, HealthStream® Named among the TOP 7% of elite facilities in the U.S. to achieve a 5 Star rating from Medicare/Medicaid

Thank you for putting your trust in us!

Robb Linafelter, CEO

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NON-DISCRIMINATION STATEMENT

Lincoln Surgical Hospital complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-297-2266 0018-4960-6554 (TTY: 1-877-248-7836).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-297-2266 0018-5658-6202 (TTY: 1-877-248-7836).

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" '&8 WEEKS BEFORE SURGERY Here are some of the items you can take care of before surgery: _____ Schedule pre-op physical with labs within 2 weeks of your surgery date (has to be within 30 days) with your primary care provider. _____ Pre-op surgery scrub - You will need to do a neck to toe scrub prior to surgery for 3 days – the scrubs can be picked up at your surgeon’s office or we can provide these GPS ZPV @@@@@ %SJOL QMFOUZ PG MJRVJET XFFL CFGPSF TVSHFSZ _____ Do not shave your TVSHJDBM BSFB for at least 48 hours prior to your surgery. @@@@@ 1MFBTF TFF ZPVS EFOUJTU CFGPSF ZPV IBWF TVSHFSZ @@@@@ *G ZPV CFDPNF JMM PS IBWF BOZ UZQF PG JOGFDUJPO DPME GMV EJBSSIFB WPNJUJOH DVUT PS TDSBQFT UIBU NBZ CF JOGFDUFE PS BOZ PUIFS PQFO BSFBT BU UIF TJUF PG TVSHFSZ QMFBTF DPOUBDU ZPVS TVSHFPO T PGGJDF JNNFEJBUFMZ BT ZPVS TVSHFSZ NBZ OFFE UP CF SFTDIFEVMFE _____ Arrange for friends or family members to stay with you for a few days. You will need help with cooking, cleaning, laundry, shopping, and yard work. You may also need help with some self-cares. _____ :PV OFFE B ESJWFS GPS BU MFBTU XFFLT PS BT EJSFDUFE CZ ZPVS TVSHFPO _____ Remove throw rugs, electrical cords and other obstructions from walkways. _____ Install night lights in the bathroom, bedroom, and hallway. @@@@@ 0CUBJO BOZ BEBQUJWF FRVJQNFOU ZPV NBZ OFFE TIPXFS UVC DIBJS DSVUDIFT FUD

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REVERSE SHOULDER &%6$"5*0/ WHAT IS SHOULDER REPLACEMENT? Total Shoulder Replacements were first performed in the 1950s. Then an alternative, a REVERSE total shoulder replacement, was first performed in Europe in the early 1980s. It was later approved by the FDA to be used in the United States in 2003.

A reverse total shoulder replacement is also for the treatment of arthritis, pain, and dysfunction; however, candidates for a reverse total shoulder replacement usually also have a completely torn rotator cuff (that can’t be repaired), or a previous total shoulder arthroQMBTUZ that was unsuccessful.

In a reverse total shoulder replacement the damaged boney surfaces are removed and replaced with artificial components. While doing this, the socket portion is replaced with a ball and the humeral portion (where the ball once was) is replaced with a socket. This allows for the deltoid to become the primary source of strength and power and takes place of the rotator cuff.

After surgery, you can expect to lift your arm just above shoulder height, reach to the top of your head and up into a cupboard. Reverse total shoulder replacement has been shown to provide significant pain relief and patient satisfaction is quite high. It is not expected to regain full motion, and mild weakness may persist due to lack of rotator cuff.

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REVERSE SHOULDER SCHEDULE PHYSICAL THERAPY: The Physical Therapist (PT) will work with you to provide education on exercises to increase your strength, improve range of motion, and to improve balance and safety. The PT will teach you a home exercise program. In addition, the PT will work on getting you in and out of a bed and chair, walking, and going up and down stairs.

OCCUPATIONAL THERAPY: The Occupational Therapist (OT) will work with you to identify strategies to best perform activities of daily living, including bathing, dressing, toileting, and other home tasks. The OT may recommend equipment, such as a reacher, sock-aid, long handled sponge, long-handled shoehorn, or a dressing stick.

DAY OF SURGERY: • You will be able to get up and use the commode or bathroom with assistance.

• Your arm will likely be numb this day due to the type of anesthesia used.

• Your nurse will work with you to take pain medications to keep your pain manageable.

1 DAY AFTER SURGERY • Your shoulder dressing will be changed and you or a caregiver will be taught how to do it.

• If you have a drain, it will typically be removed on this day.

• You will be evaluated by a physical therapist.

• The physical therapist will teach you appropriate exercises and go over your precautions • The occupational therapist will evaluate your ability to complete self-care tasks. The OT will teach you how to put your sling/immobilizer on and off.

GOING HOME • Discharge is specific to your medical needs

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REVERSE TOTAL SHOULDER PRECAUTIONS Do NOT lift your arm straight out to the side.

Do NOT put your arm/hand behind your back (such as to tuck in a shirt, perform hygiene).

Do NOT let your arm fall past the plane of your body (hyperextension) - always keep elbow forward.

Avoid excessive external rotation.

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REVERSE SHOULDER EXERCISES Perform exercises 1-2 sets of 10 reps UJNFT daily.

# - SCAPULAR RETRACTION

# - ELBOW FLEXION

Gently bend and straighten elbow.

With arms at sides (surgical arm can be in sling/immobilizer), pinch shoulder blades together. *Focus on pulling them down and back.

# - TOWEL ROLL SQUEEZE

Gently open and close hand, or squeeze ball or towel roll.

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REVERSE SHOULDER EXERCISES Perform exercises 1-2 sets of 10 reps UJNFT daily. # - WRIST FLEXION/EXTENSION

# - FOREARM SUPINATION

Actively bend wrist forward then back.

Focus on light and gentle mobility and stretching.

Slowly rotate palm down until stretch is felt.

Relax. Then rotate palm up until stretch is felt.

* Copyright® VHI. All rights reserved. Illustrations used with permission from VHI 1-800-356-0709. www.vhikits.com

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UPPER BODY DRESSING PUTTING ON A SHIRT: Dress surgical arm first.

Hold back of neck opening to pull up and over head. Pull shirt down over trunk. %SFTT OPO TVSHJDBM BSN

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CARING FOR YOUR SHOULDER INCISION 1. Self -adhesive wrap is used.

2. Use a smaller piece over the actual incision.

3. Then, place a second piece over top of the first piece.

4. Try to place the second piece as close to the neck as possible.

v :PVS EPDUPS XJMM EFUFSNJOF ZPVS JODJTJPO DBSF OFFET v Keep your incision clean and dry. You will be instructed on how to cover your incision for showering at the hospital. You will want to cover your staples with a light dressing which may be held in place by tape. v Notify your surgeon if you notice redness, warmth, increased swelling or drainage from your incision. v A temperature over 101 degrees Fahrenheit is also to be reported. Any large amount of swelling or bruising may be a sign of a hematoma. Please notify your surgeon if this the case.

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MEDICAL EQUIPMENT DURABLE MEDICAL EQUIPMENT OPTIONS If you have a shower in the tub, you may need to purchase a tub seat for after surgery.

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MEDICAL EQUIPMENT DURABLE MEDICAL EQUIPMENT OPTIONS- You can purchase these at any home health store, pharmacy, or online.

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If you have either of these, you are welcome to bring br them to the hospital.

REACHER BOE 4)0&)03/ • " MPOH TIPFIPSO NBZ CF IFMQGVM GPS HFUUJOH ZPVS TIPFT PO • A reacher is helpful for getting dressed • They can also be useful for picking UIJOHT VQ GSPN UIF GMPPS

ELASTIC LACES DRESSING STICK A dressing stick is helpful for taking off TED hose and socks.

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These allow you to fasten your shoes without having to bend down to tie them.

Reverse Shoulder

HOME INSTRUCTIONS • Sling/immobilizer: Wear your arm sling/immobilizer throughout day and night unless otherwise directed by your doctor or physical therapist.

• Throughout the day, remember to relax your arm and shoulder muscles. 5SZ not UP guard your arm/shoulder. Let your sling support your surgical arm. Practice good posture and do not slouch.

• Bathing: When washing under your arm, bend forward at the waist and let your arm naturally fall forward in order to reach your armpit (you can do the same motion to apply deodorant).

• *O PSEFS UP IFMQ GPMMPX ZPVS QSFDBVUJPOT Qrior to bathing, place either a towel roll in a ziploc bag (comparable to the size of your sling’s pillow) or an empty 2 liter pop bottle under the surgical arm to continue the support provided by your sling’s pillow during the shower.

• Dressing: For easier dressing, 1st bend forward at the waist and let your arm naturally fall forward in order for you to place your surgical arm in your arm sleeve. Next, pull the shirt over your head and then dress your non-surgical arm. When removing your shirt, remove your non-surgical arm from the sleeve first then remove the sleeve from your surgical arm.

For women, it may be more comfortable to keep from wearing a bra for the first 2 weeks.

• Positioning: While seated in the car or in a chair during rest or sleep, place pillows under the arm including the hand and behind the shoulder to increase comfort and control pain.

• Initially, a bed that is flat can be uncomfortable to sleep in and a recliner is recommended.

If you decide to sleep in bed, position a pillow behind the arm to prevent the shoulder from going back toward the bed because this can cause pain and decreased support after your surgery.

Proud to be Physician Owned

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WHILE IN THE HOSPITAL Pain Management: At Lincoln Surgical Hospital, our pain management process begins before your surgery starts, and is tailored to your individual needs throughout your entire length of stay.

• Prior to the start of your surgery, your nurse will administer medications that will help decrease the amount of pain you experience immediately after surgery.

• During ZPVS TVSHJDBM procedure, your surgeon will inject a medication into your surgical site that will help manage your pain after surgery.

• After surgery, a special combination of medications is given to you on a routine schedule to further improve your pain control and enhance your comfort. The medications used are given in low-to-moderate doses. Most patients tolerate these medications very well and experience only some slight drowsiness.

• Stronger medications are available on an as-needed basis to provide additional pain control if necessary.

Our clinical staff is highly skilled in managing postoperative pain. Your nurse will work closely with you, your surgeon, and our clinical pharmacists to tailor your drug therapy to fit your needs. Your comfort is extremely important to us, and we realize that everyone responds differently to medications. Communication with your nurse is important to ensure we are not only meeting your expectations for pain control, but also addressing any side effects caused by the medications. Our goal as your healthcare team is to partner with you to provide exceptional care that exceeds your expectations.

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WHILE IN THE HOSPITAL A member of the front desk will escort you to the pre-op area on Level 2. Here you will be asked to use the bathroom, change into a gown, and be weighed. You will change into a special hospital gown, booties, and hat. Your nurse will complete a surgical consent, You will be connected to monitors to measure your vital signs, an incentive spirometry baseline will be done, an IV will be started and a surgical prep will be completed. You will be measured for support hose and fitted on your non-operative side.

An anesthesia provider will meet you the day of surgery and discuss with you which type of anesthesia is the best option for you- general or spinal.

Surgery generally takes 1 ½ to 2 ½ hours. Some of this time is spent preparing you in the operating room BOE 3FDPWFSZ 1"$6 1PTU "OFTUIFTJB $BSF 6OJU . Family/friends will be asked to wait in B waiting area or cafeteria You will be transferred to B patient care area when awake and stable. Here you will be reunited with family/friends. You will be offered something to drink and eat.

Our private suites have plenty of space for comfort and quiet. Your rest and healing begin!

Your health and recovery are our top priority!!

8F XBOU UP keep you safe during your hospital experience. We ask that you NEVER GET UP WITHOUT ASSISTANCE! Staff will use a gait belt around your waist every time you get up, as well as having at least one or two staff assist you.

A Health Advocate will update your insurance company, as needed, during your stay.

Discharge date depends on medical necessity.

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BREATHING EXERCISES After surgery, you will be less active than normal. Because you are not moving as much as you normally would, you tend to breathe shallow. This could cause portions of your lungs to collapse. If the collapsed areas do not get filled with air, it can cause complications such as pneumonia and bronchitis. Preventing post-operative lung problems is a priority at Lincoln Surgical Hospital. Oxygen is also used to help your body heal. The best way to have a smooth recovery without lung problems is to do these lung exercises. Oxygen is also available to assist with your recovery.

Deep Breathing (to completely fill lungs with air) 1. Breathe in through your nose as deeply as you can. (Your stomach should go out as you breathe in). Hold breath for 5-7 seconds.

2. Let the breath out slowly through your mouth. Try to take twice as long breathing out as breathing in. (Your stomach should go down as you breathe out).

Do this exercise 10 times. Deep breathing exercises can help you relax and relieve pain.

Following the 10 breaths, do the coughing exercise.

Coughing (to help keep lungs clear) 1. Take a slow deep breath in through your nose. (Try to fully expand chest and back.)

2. Breathe out through your mouth. (Your chest should sink down and in.)

3. Take a second breath in the same manner.

4. Take a third breath in, but hold your breath for a moment, then cough hard forcing all of the air out of your lungs.

Do the coughing exercise 3 times. Do the combined deep breathing and coughing every hour while you are awake after surgery. The hospital may give you an incentive spirometer to help you do deep breathing after surgery. Someone will show you how to use it.

Practice these breathing exercises for a week before surgery to help prevent lung problems. Once you are able, following surgery, getting up and walking around will also help prevent lung problems. Remember, never get up on your own while in the hospital.

We will gladly assist you. Also, if you smoke, please try to quit.

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Prevention of Blood Clots v v v v

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FAQS 8IFO DBO * SFTVNF IBWJOH TFYVBM BDUJWJUZ "GUFS TVSHFSZ JU XJMM UBLF UJNF UP SFHBJO ZPVS TUSFOHUI BT XFMM BT DPOGJEFODF JO ZPVS OFX KPJOU .PTU QFPQMF GFFM BCMF QIZTJDBMMZ BOE NFOUBMMZ UP FOHBHF JO TFYVBM BDUJWJUZ GPVS UP TJY XFFLT BGUFS TVSHFSZ %FQFOEJOH PO UIF JOEJWJEVBMT IFBMJOH SBUF BU GPVS UP TJY XFFLT UIF JODJTJPO NVTDMFT BOE MJHBNFOUT BSF VTVBMMZ TVGGJDJFOUMZ IFBMFE UP DPOTJEFS SFTVNJOH TFYVBM BDUJWJUZ 5BML UP ZPVS TVSHFPO JG ZPV IBWF BOZ RVFTUJPOT Will my medications affect my ability to engage in sexual activity?

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WAYS TO MOVE After your total joint replacement, it is important to avoid injury and follow the

instructions provided by your surgeon, nurse, occupational therapist, and physical therapist.

Make sure to follow your movement precautions.

TRANSFER TO BED #BDL VQ UP UIF CFE VOUJM ZPV GFFM UIF CFE Reach back with the unaffected arm, sit down Lean onto your good elbow and bring your legs up into the bed Roll to your back, reposition as needed using only your legs and good arm

TRANSFER TO VEHICLE

Push the seat all the way back and recline it if possible. (Once transferred, make sure to sit the seat back upright).

A plastic trash bag can be used on the seat of the vehicle to help you slide and turn toward the front.

Back up to the car until you feel it touch the back of your legs.

Reach back for the seat and lower yourself down.

Try to avoid cars with lower bucket seats due to the low height.

No driving until your surgeon approves you to drive.

Reverse these steps to get out

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WAYS TO MOVE TRANSFER TO A TOILET

You may need a raised toilet seat PS UPJMFU GSBNF UP IFMQ ZPV HFU PO BOE PGG UIF UPJMFU TBGFMZ XIJMF GPMMPXJOH UIF TIPVMEFS QSFDBVUJPOT When sitting down on the toilet: Take small steps and turn until your back is to the toilet.

Back up to the toilet until you feel it touch the back of your leg.

If using a commode with arm rests, reach back for UIF arm rest and lower yourself onto the toilet.

When getting up from the toilet: If using a commode with arm rests, use the arm rest to push up.

NOTE: Balance yourself before QVMMJOH VQ ZPVS DMPUIJOH BOE grabbing the DBOF JG VTJOH POF

TRANSFER TO THE TUB

Using a bath bench: Place the bench seat in the tub facing the faucets.

Back up to the tub PS CFODI TVSGBDF until you can feel it at the back of your knees. Be sure you are in front of the bath bench.

Reach back with one hand for the bath bench DIBJS. Slowly lower yourself onto the bath bench Move the DBOF out of the way, but keep it within reach.

Lift your legs over the edge of the tub Note: Although bath seats, grab bars, long-handled bath sponges, and hand-held showers make bathing easier and safer, they are typically not covered by insurance or Medicare.

Note: Always use a rubber mat or non-skid adhesive on the floor of the tub or shower.

Getting out of the tub using a bath bench: Lift your legs over the outside of the tub.

Scoot to the edge of the bath CFODI DIBJS. Push up with one hand on the back of the bath CFODI DIBJS Balance yourself before reaching for the DBOF JG VTJOH POF

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ADVANCED DIRECTIVE ADVANCED DIRECTIVE You might have heard of a Living Will or Power of Attorney for Health Care– which Nebraska recognizes.

An Advanced Directive is a document that voices your choice of medical treatment, identifies the people you may want to make these decisions if you are unable to make them for yourself. If you already have this document, please bring a copy with you.

If you do not have one, we have a booklet that we can give you that helps get you started on an Advanced Directive.

If you are from a state other than Nebraska we can discuss your state’s laws.

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/05&4 @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

32

Reverse Shoulder