Physical Therapy for the

Tre a t m e n t o f S h o u l d e r
Instability
Daniel J. Stokes, MD, Timothy P. McCarthy, MD,
Rachel M. Frank, MD*

KEYWORDS
 Rehabilitation  Glenohumeral joint  Instability  Physical therapy

KEY POINTS
 The glenohumeral joint is the joint most prone to instability in the body.
 Shoulder instability is the separation of the humeral head from the glenoid fossa.
 The goal of rehabilitation is to restore pain-free mobility, strength, and functioning.
 Rehabilitation improves functional status, strength, and scapular positioning.

INTRODUCTION

Glenohumeral joint (GHJ) instability is the separation of the humeral head from the gle-
noid fossa. The unique anatomy of the shoulder allows for the most range of motion
(ROM) of any joint in the body.1 However, this wide ROM increases the susceptibility
to instability.
The GHJ is the most dislocated joint in the body, representing 50% of all major joint
dislocations,2 with an incidence rate of 23.9 cases per 100,000.3 The incidence of shoul-
der instability in college and high school athletes makes up 0.12 and .22 instability events
per 1000 athlete exposures, respectively.4 The highest risk demographic for GHJ insta-
bility are young athletes in their second and third decades of life.5 It is essential to under-
stand the mechanism and the appropriate management to ensure a return of full
shoulder function, prevention of recurrence, and a quick return to play (RTP).

ANATOMY

Shoulder instability severity ranges from subluxation to dislocation.5 Knowing the

anatomy of the GHJ is imperative for understanding the causes of shoulder instability.
Laxity is classified as anterior, posterior, or multidirectional shoulder instability.

Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora,

CO, USA
* Corresponding author. Department of Orthopaedic Surgery, UCHealth CU Sports Medicine -
Colorado Center, 2000 South Colorado Boulevard, Tower 1, Suite 4500, Denver, CO 80222.
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 34 (2023) 393–408

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394 Stokes et al

Table 1
Functions of static stabilizers

Structure Function
Rotator interval Restrains posteroinferior translation in adduction
Joint capsule Encloses the GHJ and creates a seal providing
negative intra-articular pressure (suction effect)
Coracohumeral ligament Extra-articular; restraint against posterior
translation (FF, IR) and inferior translation
(adduction, ER)
Superior glenohumeral ligament Primary restraint against inferior translation in
adduction; acts as a pulley for the LHBT
Middle glenohumeral ligament Resists anterior translation in ER with 45 of
abduction
Inferior glenohumeral ligament Primary restraint against anteroinferior translation
Anterior band Primary restraint against anterior translation in 90
abduction and ER
Posterior band Primary restraint against posterior translation in 90
abduction

Abbreviations: ER, external rotation; FF, forward flexion; IR, internal rotation; LHBT, long head of
the bicep tendon.

The unique bony articulation between the humeral head and the glenoid fossa pro-
vides a wide degree of motion and inherent instability. The glenoid fossa is pear-
shaped, retroverted, and shallow.6 The size of the humeral head compared with the
glenoid is incongruent, commonly equated to a golf ball sitting on a golf tee. This
4:1 ratio in surface area between the humeral head and glenoid provides minimal
bony constraint and unrestricted movement throughout the joint.7 Though there is a
discrepancy in bone surfaces between the glenoid and humerus, the articulating carti-
lage surface area is congruent, creating an inherently stable GHJ where small trans-
lations of the humeral head on the glenoid are considered normal.8 Damage to the
articulating surfaces results in more extensive pathologic translations.
The GHJ receives stabilization from both static and dynamic stabilizers. Table 1 de-
scribes the role of the rotator interval, the glenohumeral ligaments, and the glenoid
labrum.1 Each structure is critical in providing passive stabilization to the GHJ.
The coordination of dynamic muscle forces further stabilizes the shoulder. The del-
toid, biceps brachii, rotator cuff, and periscapular muscles provide dynamic stabiliza-
tion by maintaining contact between the humeral head and the center of the glenoid
surface.9 Each component contributes to maintaining proper shoulder stability and
overall function.

PATHOPHYSIOLOGICAL MECHANISMS
Anterior Shoulder Instability
Anterior shoulder instability (ASI) is the pathologic laxity of the GHJ in the anterior di-
rection. It is the most common shoulder instability, accounting for over 90% of
cases.10 The most common mechanism of injury resulting in ASI is a force on an
abducted, flexed, and externally rotated arm.
When the humeral head is displaced anteriorly, the natural tendency is to retract,
resulting in impaction of the posterior humeral head on the anteroinferior glenoid. A

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 Treatment of Shoulder Instability 395

Bankart lesion is an avulsion of the anteroinferior labrum from the glenoid rim. A bony
Bankart lesion, or anteroinferior glenoid rim fracture, can occur.11 A Hill-Sachs lesion
is a chondral impaction of the posterosuperior humeral head secondary to contact
with the anterior glenoid rim. Bankart lesions often result in recurrent instability.

Posterior Shoulder Instability

Posterior shoulder instability (PSI) is dysfunctional laxity posteriorly and is the second
most prevalent, accounting for approximately 2% to 5% of cases.12 PSI typically has a
subtle onset, with pain being the primary complaint.13 Partially attributed to this
discrepancy are the differences in ligamentous support provided by the IGHL.
The anterior band of the IGHL is a strong band of tissue that is the primary restraint
against the humerus displacing forward.14 The posterior band of the IGHL limits pos-
terior displacement but is significantly thinner in comparison. In a healthy shoulder,
this band is sufficient. However, repetitive micro-trauma to the posterior band, primar-
ily in a forward flexed, adducted, and internally rotated arm, causes PSI.15
Articulating surfaces play a vital role in posterior stability. Therefore, glenoid hypo-
plasia and excessive retroversion predispose an individual to recurrent PSI.16 Retro-
version of the glenoid increases humerus external rotation (ER).15 The average
retroversion of the glenoid is 1  3 .17 There is a strong correlation between the
amount of glenoid retroversion and the risk of recurrent PSI.18,19
Table 2 highlights labral and humeral head characteristic lesions found in PSI.

Multidirectional Shoulder Instability

Multidirectional instability (MDI) of the shoulder is symptomatic laxity of the GHJ in
more than one direction.20 MDI can occur in the setting of connective tissue disorders,
a single traumatic event, or repetitive microtrauma.
Hyperlaxity alone does not meet the requirements for MDI but can increase the risk.
Instability requires the presence of symptoms commonly reported as nonspecific
pain, weakness, or declining athletic performance, in addition to an abnormal transla-
tion of the shoulder.21 Owing to the hypermobile nature of connective tissue disorders,
individuals with Marfan and Ehlers-Danlos syndromes are at increased risk of devel-
oping MDI.22
The most common etiology is microtrauma caused by repetitive movements. Over-
head athletes such as volleyball players, gymnasts, climbers, and weightlifters sustain
repetitive microtrauma resulting in structural damage to the static and dynamic stabi-
lizers. These patients present with an insidious onset. However, a sizable labral tear
may be present when the injury is a single traumatic event.
Characteristic findings shown on imaging can support an MDI diagnosis. The pres-
ence of a patulous or redundant inferior capsule on MRI may be indicative of MDI.

Table 2
Posterior shoulder instability characteristic lesions

Lesion Description
Reverse Hill-Sachs Erosion of the anteromedial aspect of the humeral head
Reverse Bankart Posteroinferior labral detachment
Reverse Bony Bankart Bony avulsion of the posterior glenoid rim
Kim Posterior labral tear between an intact superficial labrum and
glenoid articular cartilage

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396 Stokes et al

EVALUATION/INDICATIONS FOR TREATMENT

Physical Examination
A detailed history can help guide the physical examination. The interview should
address the mechanism of injury, location of pain, first-time dislocation, frequency
of instability events, avoidance of provocative positions, and any repetitive move-
ments or overhead activities. Regardless of suspected ASI, PSI, or MDI, every shoul-
der examination should include bilateral inspection, palpation, active/passive ROM,
strength, and neurovascular testing. It is also important to evaluate the cervical spine
during shoulder examination.

SPECIAL TESTING FOR INSTABILITY

Anterior Shoulder Instability Special Tests
 Anterior drawer: With the patient sitting upright and the arm relaxed by the side,
the examiner will place an index finger on the coracoid process with the thumb at
the scapular spine. While grasping the humeral head, an anterior force is applied.
This test is positive if greater than 50% of the humeral head translates anteriorly
beyond the glenoid rim.17
 Anterior load and shift: With the patient supine and the shoulder at 40 to 60 of
abduction and forward flexion, the examiner will put an axial load on the humer-
us, centering it within the glenoid. An anterior force to the humeral head is
applied, causing an anterior shift. Increased translation compared with the
contralateral side suggests ASI.23
 Apprehension/Relocation/Release test:
 With the patient supine on the edge of the examination bed and the shoulder at
90 of abduction, the examiner will gently externally rotate the arm to 90 . If the
patient reports pain or apprehension, the test is positive.
 With the shoulder at 90 of abduction and ER, the examiner will apply a pos-
terior force to the humerus. If positive, the patient will report decreased
apprehension.
 The examiner withdraws the posterior force on the proximal humerus from the
relocation position. This test is positive if the patient reports a return of pain or
apprehension24 (Figs. 1 and 2).
Posterior Shoulder Instability Special Tests
 Posterior drawer: This is the same maneuver as the anterior drawer, but a pos-
terior force is applied.17
 Posterior load and shift: This is the same maneuver as anterior load and shift, but
a posterior force to the humeral head is applied, causing it to shift posteriorly.23
 Jerk test: With the patient sitting upright and the arm at 90 of forward flexion and
internal rotation with full adduction, the examiner will apply a posterior force at
the elbow while looking for subluxation. The examiner will then abduct the arm
while maintaining the posterior load. As the humeral head relocates, a clunk in-
dicates a posterior labral tear.16
 Kim test: With the patient sitting upright and the shoulder at 90 of abduction and
w45 of forward flexion, the examiner will apply an axial load on the elbow while
simultaneously applying a posterior force on the humerus, looking for subluxa-
tion. Pain or a clunk indicates a positive test16 (Fig. 3).
Multidirectional Instability Special Tests
 Sulcus sign: With the patient in a standing position and the arm relaxed by the
side, the examiner will apply a downward force on the arm while observing the

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 Treatment of Shoulder Instability 397

Fig. 1. Apprehension test.

superior aspect of the humeral head for an interval of >1 to 2 cm. When the sulcus
sign remains positive in ER, this indicates rotator interval incompetence.20
 Gagey/hyperabduction test: With the patient sitting upright and the arm relaxed
by the side, the examiner will stabilize the shoulder by placing an index finger on
the clavicle with the thumb at the scapular spine. The examiner will then passively
abduct the arm while preventing shoulder elevation. This test is positive if the end
range is > 105 abduction and indicates laxity of the IGHL (Fig. 4).
 Beighton score: Components of screening for hyperlaxity include:
 Passive apposition of the thumb to the forearm (2 points)
 Passive hyperextension of the fifth metacarpophalangeal joint greater than 90
(2 points)
 Passive hyperextension of the elbow greater than 10 (2 points)
 Active hyperextension of the knee greater than 10 (2 points)
 Active forward flexion at the waist, placing the palms of the hand on the floor
with the knees fully extended (1 point)

Fig. 2. Relocation test.

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398 Stokes et al

Fig. 3. Variation of Kim test in a supine position.

Values > 4 indicate a positive Beighton score suggesting joint hyperlaxity.25

Instability can show positive findings from each subset. For this reason, it is essen-
tial to manage each patient on a case-by-case basis. If surgery is elected, each phys-
ical examination finding should be confirmed and compared with the contralateral side
under anesthesia before the operation.17

IMAGING

The first imaging modality for a patient with suspected GHJ instability should be plain
film radiographs. The standard series should include an anteroposterior (AP), a true AP
(Grashey view), axillary, and modified scapular Y views. Specialty views, such as the
Stryker notch and West Point view, provide insight into Hill-Sachs defect and anteroin-
ferior glenoid rim fracture.
MRI assesses soft-tissue damage in all patients. Magnetic resonance arthrography
(MRA), or an MRI with contrast enhancement, can increase the sensitivity to the cap-
suloligamentous complex. This study can be helpful in PSI to evaluate a Kim lesion or
in MDI to check for a patulous capsule.16 Computed tomography should measure gle-
noid bone loss and assess the glenoid version and bony lesion irregularities.26

Fig. 4. Gagey/hyperabduction test.

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 Treatment of Shoulder Instability 399

Although shoulder instability is a clinical diagnosis, imaging can contribute to and

enhance subsequent management options.26 Managing shoulder instability should
encompass subjective considerations and patient preference. A physical rehabilitation
program has proven to improve outcomes, regardless of conservative or surgical
management.

TREATMENT

Treatment of shoulder instability is multi-faceted. Patient-specific goals and risk strat-

ification of adverse outcomes require a collaborative effort between medical special-
ists and the patient to provide comprehensive options and informed decision-
making.27 Options for treatment can include an initial course of physical therapy
versus early surgical intervention. Surgical intervention followed by physical therapy
should be considered with risk factors associated with a high recurrence rate or pre-
viously failed conservative management. Risk factors that might prompt the decision
for surgical intervention include:
Age: A patient’s age upon the initial subluxation/dislocation is predictive of recurrent
instability. Compared with arthroscopic stabilization, conservative management in a
population less than 26 years of age leads to failure rates as high as 60% to
75%.28–30 In a study comparing recurrence rate, RTP, and patient-perceived improve-
ment, acute surgical stabilization of first-time shoulder dislocation was found to be
more effective than conservative treatment in patients 15 to 25 years of age.31
Trauma: Most first-time shoulder dislocations have a traumatic etiology. Repetitive
trauma, especially in overhead athletes or high-impact sports, increases the risk for
recurrent instability events. Arthroscopic management has resulted in a lower recur-
rence rate than conservative management and a significantly higher rate of RTP.32
Therefore, surgery is effective and may be desirable, especially in young male athletes,
to reduce the recurrence rate and increase RTP.28,31–33
Structural deficit: Bankart lesions are the most common injury following primary
shoulder dislocation. Evidence reveals satisfactory subjective function and surgical
success rates for isolated Bankart repair.34 A fracture following primary dislocation
or bone erosion changes the normal shoulder biomechanics and decreases articulat-
ing surface area. With recurrent instability, glenoid and humeral defects either enlarge
or develop at a significantly higher rate.35 Identifying bipolar bone defects is critical as
they strongly predict postoperative failure when unaddressed.6

PHYSICAL REHABILITATION

Rehabilitation plays a fundamental role in successful outcomes following shoulder

instability. Most first-time shoulder dislocations are treated nonoperatively.36 The pri-
mary goal of rehabilitation is to restore pain-free mobility, strength, control, and
activity-specific functioning.37

REHABILITATION APPROACH

A patient with an acute shoulder instability event typically presents with pain and
guarding. Commonly, the shoulder is internally rotated, subduing the provocative po-
sition. Self-limiting activity is implemented to prevent further pain and injury. The initial
goal for rehabilitation should focus on reducing pain and inflammation through a
period of immobilization.
Immobilization is consistently agreed upon, but the position and duration have been
debated. The immobilization period should be limited, typically one to 3 weeks.

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400 Stokes et al

Immobilization allows for patient comfort rather than a decreased risk for recurrence,
as the evidence fails to show a significant difference.38 Likewise, immobilization in ER
compared with internal rotation is theorized to provide better soft-tissue positioning
relative to the glenoid, thereby decreasing the risk of recurrent instability. However,
repeated inconsistencies across these studies have failed to show any substantial
benefit of ER.38
Early passive motion is encouraged and may contribute to healing while decreasing
pain. Early movements are restricted to the scapular plane and less than 90 of abduc-
tion with rotational movements.36 Dynamic GHJ stability begins with gentle isometrics
and rhythmic closed kinetic chain exercises.39 Closed kinetic chain exercises ensure
shoulder support through hand fixation on a stable surface, facilitating deltoid, rotator
cuff, and scapular muscle coactivation, as well as proprioceptive control.37
After 4 to 6 weeks, full ROM and strengthening exercises are implemented. Return
of full active ROM is expected in this phase through a gradual progression of flexion,
ER, and IR exercises with escalating degrees of abduction.36 Strengthening exercises
are introduced, mainly focusing on the rotator cuff and scapular stabilizers. Rotator
cuff activation is maximized primarily through resisted flexion, abduction, and ER.
Activation of the supraspinatus and infraspinatus through ER helps anteriorly balance
the GHJ against pectoralis major forces. Internal rotation can strengthen the subsca-
pularis, but there is equal activation in the pectoralis major.27 Therefore, it is essential
to find the balance of subscapularis strengthening while promoting GHJ stability.
Periscapular strengthening further increases stability. Scapular dyskinesis needs to
be addressed early in rehabilitation as it contributes to shoulder pain, decreased mus-
cle strength, and limited ROM.39 These patients often have a discrepancy in muscle
strength across the scapula resulting in an imbalance. Scapular strengthening exer-
cises restore balance through the activation of the weaker muscles. Once balance
returns, advanced scapular strength exercises integrate activity-dependent move-
ments and control.40
Resistance, movement complexity, and endurance continue to intensify as the pa-
tient progresses. A deliberate rehabilitation program with attention to scapular posi-
tioning, dynamic strengthening, and GHJ motion requires a dedicated patient and
attentive medical team but ultimately provides optimal outcomes and sustainability
with nonoperative management. Jaggi and Alexander37 outline an exercise-specific
rehabilitation protocol for shoulder instability.

POSTERIOR SHOULDER INSTABILITY REHABILITATION

The most common etiology for PSI is subtle onset with pain. Conservative manage-
ment is typically the primary option in an atraumatic presentation, as bony deformity
is often absent.
The insidious onset of pain without an acute trauma does not warrant an immobili-
zation period. Posterior shoulder rehabilitation emphasizes rotator cuff and scapular
musculature strengthening, similar to ASI, as these are the primary dynamic stabi-
lizers. A common finding in PSI is downward scapular rotation improved through
elevation maneuvers. Though subscapularis strengthening has limited utility in ASI,
it is a key dynamic stabilizer for PSI.13 The subscapularis, along with the infraspinatus
and teres minor, counterbalances the superior directed force of the deltoid. Further-
more, strengthening these muscles compresses the humeral head, maintaining stabil-
ity within the glenoid.
There are poor prognostic indicators for conservative management, as seen with
ASI. A painful jerk test is notable for poor response to rehabilitation and will likely

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 Treatment of Shoulder Instability 401

need surgical intervention.16 More consistent with traumatic etiology, surgical stabili-
zation with an osseous repair is recommended for glenoid or humeral bone loss.
Furthermore, a positive Kim test or evidence of labral or other soft-tissue pathology
may experience unsatisfactory results with conservative management.15
Symptom persistence despite appropriate rehabilitation is an indication of surgical
intervention. Although it is more common in individuals with traumatic etiology, soft-
tissue defects can be present without trauma and is a common cause of conservative
management failure. However, without evidence of significant bone loss, aggressive
rehabilitation is the preferred primary option.

MULTIDIRECTIONAL INSTABILITY REHABILITATION

First-line treatment of MDI is rehabilitation.20,21,41 These patients typically present with

a subtle onset of pain due to the microtrauma endured from repetitive movements or
hyperlaxity.
Scapular dyskinesia is a widely recognized manifestation of MDI denoted by a
drooping scapula.37 Of the limited protocols available, scapular kinematics is a heavy
focus.42,43 Strengthening the rotator cuff and periscapular muscles is the mainstay of
treatment. The goal of therapy is to improve humeral head centering with the glenoid
through compressional forces conducted by the rotator cuff and proprioceptive con-
trol of the scapular stabilizers.21 A two-part series developed by Watson and col-
leagues42,43 offers a detailed 6-stage rehabilitation program for MDI.
MDI rehabilitation has shown immediate subjective improvement in atraumatic
instability.44,45 Long-term outcomes are less definitive, but unsuccessful rehabilitation
is more predictive in young, athletic patients or those with traumatic etiology.44,46
Though rehabilitation efforts have shown improvements in functional status, strength,
and scapular positioning,45 not all patients respond favorably.
Before consideration of surgical intervention, a patient generally needs to have
failed at least 6 months of extensive therapy. A psychological component has a role
in MDI. It is imperative to distinguish between patients that voluntarily dislocate the
GHJ from those that avoid positional instability despite the ability to reproduce dislo-
cation. Voluntary dislocation has a poor prognosis with surgical treatment, whereas
patients who avoid positional instability have a favorable response to operative stabi-
lization.21 MDI presents challenging scenarios that require collaborative decision-
making. Surgical treatment has progressed substantially in recent years, and it is a
viable option for those with debilitating symptoms despite rehabilitation.

RETURN TO PLAY FOR ATHLETES

In athletes, RTP is naturally the most influential consideration in determining how to

proceed with management. Despite the acceptable RTP percentages following in-
season rehabilitation, evidence suggests surgical intervention results in a lower recur-
rence rate and more successful RTP without recurrence.27,47 In the National Football
League (NFL), surgical stabilization after an instability event reduces the recurrence
rate.48 Nonetheless, an athlete may forego surgical stabilization and RTP. Therefore,
it is imperative to fully educate the athlete on potential risks and complications for
both surgical and nonsurgical management.
Athletes need to prove they can perform sport-specific requirements before return-
ing. Therefore, rehabilitation focuses on activities that comprise these movements. Fa-
tigue is a significant contributor to primary and recurrent injury. In addition to sport-
specific actions, endurance is essential to meet RTP criteria. When strength, motion,
endurance, and sport-specific tasks are performed equivalent to the contralateral side

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402 Stokes et al

without pain or apprehension, an athlete may receive clearance for RTP by medical
personnel.27
Subjective considerations are essential, as everyone progresses at different rates,
but generally, RTP has a quick turnaround for the mid-season athlete and can be
achieved within 3 weeks.29,49 Dislocation, compared with subluxation, will typically in-
crease the amount of time for RTP.48,50 Collision sports should also be considered as
this significantly increases the risk for recurrence. Failure to RTP, instability after RTP,
or even successful RTP patients should be reevaluated following the season to
discuss the best steps forward.

ADJUNCTIVE TREATMENT DURING REHABILITATION

Adjunctive treatment options may contribute toward therapeutic efforts during rehabil-
itation. If elected, these modalities are in conjunction with the previous rehabilitation
protocol.
Patients may benefit from using cryotherapy in the immediate post-injury phase by
decreasing inflammation.49 Heating before, icing after, and using ultrasound during
physical therapy can reduce pain and muscle spasms.
Extra support can be gained through therapeutic tape or bracing. Though there is a
lack of evidence supporting functional improvement or decreased risk of recurrence,
there is subjective improvement in security, posturing, and proprioception.37 Bracing,
especially in athletes, is a viable option for improvement and confidence while restrict-
ing provocative movements.27,49 However, athletes may decline to brace as they tend
to be restrictive.
Posterior shoulder stiffness is a perpetuating factor for abnormal shoulder kine-
matics in ASI.27 Posterior capsular and anterior shoulder stiffness contribute similarly
to PSI.13 Joint mobilization stretches to improve flexibility are important adjunctive ex-
ercises to regain full mobility.39

SHOULDER INSTABILITY POSTOPERATIVE REHABILITATION PROTOCOL

Postoperative rehabilitation maintains the same primary objective as nonoperative

management with one fundamental exception: protect the repair. Implementing a
rehabilitation program following shoulder stabilization is essential to restore optimum
functionality.
The Multicenter Orthopedic Outcomes Network (MOON) shoulder instability study
began in 2012 to identify outcome predictors following shoulder stabilization.51 The
MOON shoulder instability postoperative rehabilitation protocol is based on their find-
ings and clinical expertise (Table 3).52

SUMMARY

The shoulder is the most mobile joint in the body. However, the wide ROM through
minimal articulation increases the risk for instability. A complex network of static
and dynamic stabilizers maintains proper shoulder alignment and overall function.
Injury of the GHJ stabilizers is a common feature of subluxation, dislocation, and re-
petitive microtrauma.
Owing to the complexity of the shoulder, a detailed history and physical examination
are essential. Plain film radiographs and MRI further evaluate bony and soft-tissue
damage. CT is used to quantify the degree of bone loss.
ASI is the predominant form of instability. It is usually a result of trauma in an
abducted, flexed, and externally rotated arm. Identification of structural deficits,

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Table 3
Multicenter Orthopedic Outcomes Network shoulder stabilization rehabilitation protocol

Timeline Stage Goal Activity Anterior Stabilization Posterior Stabilization

Limitations Limitations
Phase I 0–2 wk Protection Protect repair; reduce pain Immobilization (sling with No shoulder ROM No shoulder ROM
and inflammation ABD pillow)
ROM––elbow, wrist
Phase II 2–6 wk ROM Pain free and symmetric No combined ABD and ER No combined ABD and IR
motion bilaterally
2–4 wk PROM/AAROM Submaximal isometrics 90 FF, ER-S to neutral; No 90 FF; No combined ABD
isometric IR/ER and IR
4–6 wk PROM/AAROM Submaximal isometrics 120 FF, 90 ABD, 20 ER-S 120 FF, 90 ABD; No
isometric ER
Scapular protraction/
retraction
Phase III 6–12 wk Strength Full active ROM, improve Discontinue sling No anterior glides No posterior glides
muscular strength

Treatment of Shoulder Instability

6–8 wk AROM Resisted isometrics No resisted IR No resisted ER/IR
8–10 wk Strength Theraband resistance 30 IR-S, 45 IR with 30 ABD
10–12 wk Strength Theraband resistance No IR limitations
Phase IV 12–18 wk Sport specific Improve power and Advanced strength/power No limitations No limitations
endurance
Phase V 18–24 wk Return to play Pass functional tests; return Functional test assessment No limitations No limitations
to sport

Abbreviations: AAROM, assisted active ROM; ABD, abduction; AROM, active ROM; ER, external rotation; ER-S, ER-side; FF, forward flexion; IR, internal rotation; IR-
S, IR-side; PROM, passive ROM; ROM, range of motion.

403
404 Stokes et al

including Bankart and Hill-Sachs lesions, is essential in determining the risk for recur-
rent instability and the role of surgical intervention.
PSI often presents with insidious onset of pain rather than instability. Repetitive
microtrauma to the thin posterior band of the IGHL appears to require less force for
disruption and subsequent PSI. Patients with an atraumatic etiology are typically
managed conservatively. Surgical stabilization is recommended for glenoid or humeral
bone loss with traumatic injuries.
MDI is symptomatic laxity in more than one plane of motion. MDI can occur in the
setting of connective tissue disorders, a single traumatic event, or repetitive micro-
trauma. Overhead activities can result in microtrauma to the shoulder stabilizers
and consequential incompetence. First-line treatment of MDI is rehabilitation. A pa-
tient that has failed at least 6 months of therapy should undergo surgical evaluation.
Voluntary dislocation has a poor prognosis with surgical treatment and should be
considered a last resort. Surgery is a viable option for those with debilitating symp-
toms despite rehabilitation or evidence of a patulous inferior capsule.
The primary goal of rehabilitation is to restore pain-free mobility, strength, and func-
tioning. Brief immobilization followed by early passive motion is encouraged to further
aid healing and pain control. Dynamic GHJ stability through gentle isometrics and
rhythmic closed kinetic chain exercises restore proprioceptive control. After 4 to
6 weeks, full ROM and strengthening exercises are implemented. Rotator cuff and
periscapular muscle strengthening exercises follow. Resistance and endurance exer-
cises can be intensified as the patient progresses.
Postoperative rehabilitation maintains the same primary objective as nonoperative
management while protecting the repair. After shoulder stabilization surgery, the pa-
tient is kept in a sling for at least 6 weeks. Passive ROM (PROM) and assisted active
ROM (AAROM) exercises are initiated during this time. Active ROM (AROM) is started
around 6 weeks and is expected to be restored at 8 weeks. Focus is shifted to mobility
maintenance and strengthening with resisted isometrics and TheraBand exercises
through week 12. Advanced strengthening and power exercises are performed during
week 12. At this time, athletes can perform sport-specific activities. Finally, functional
testing for RTP can be considered after 18 weeks.

CLINICS CARE POINTS

 The glenohumeral joint is the most dislocated joint in the body.

 Excessive retroversion of the glenoid increases the susceptibility to recurrent posterior
instability.
 Conservative management in a population less than 26 years of age leads to high failure
rates.
 Arthroscopic management of first-time shoulder dislocation results in a lower recurrence
rate and a significantly higher rate of return to play (RTP)
 Subjective function and surgery success rates for isolated Bankart repair are satisfactory.
 Glenoid and humeral defects either enlarge or develop at a significantly higher rate with
recurrent instability.
 A painful jerk test and a positive Kim test have a poor response to rehabilitation.
 Immobilization does not decrease the risk for recurrence.
 Immobilization in external rotation does not provide substantial benefit.

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 Treatment of Shoulder Instability 405

 Multidirectional instability rehabilitation has immediate subjective improvement in

atraumatic instability.
 Rehabilitation improves functional status, strength, and scapular positioning.
 Dislocation, compared with subluxation, increases the amount of time for RTP.
 Collision sports significantly increase the risk for recurrence.

DISCLOSURE

The authors have nothing to disclose.

ACKNOWLEDGMENTS

The authors thank and acknowledge Dave Daniels MD, and Kevin Shinsako PA-C, for
their assistance with photographs for this article.

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