Conservative Anterior Shoulder Instability

The programme contains example exercises. Not every exercise has to be completed
and the program will vary in length for each individual based on:
1. Severity of symptoms
2. Chronicity of instability symptoms
3. Age and activity levels of the patient
4. ROM / Strength status
5. Desired goals and activities

Phase 1: Acute Motion Phase

Goals:

Protect the joint (Consider sling immobilisation for Acute Dislocation)

Decrease pain/ inflammation
Re-establish non-painful ROM
Retard muscular atrophy/ Establish voluntary muscle activity
Re-establish muscle balance
Improve proprioception

**Note: During the early stages of rehabilitation, caution must be applied in placing the
capsule under stress (i.e. stretching into ABD, ER) until dynamic joint stability is restored.
It is important to refrain from activities in extreme range of motion early in the rehabilitation
process.

Decrease Pain/ Inflammation:

Sling for comfort as needed
Therapeutic modalities (ice, electrotherapy etc)
NSAIDs
Gentle mobilizations (grade I-II) for pain neuromodulation
** Do not stretch anterior capsule

Range of Motion exercises:

Gentle ROM only, no stretching of the anterior capsule
Pendulums
 Rope and Pulley Elevation in scapula plane to tolerance

Active-assisted ROM to tolerance

o Flexion
o IR with arm in scapula plane at 30 abduction
o ER with arm in scapula plane at 30 abduction
Stretching of posterior capsule if indicated
o Manual techniques
o Home stretches
o Active-assisted (e.g. Mulligan technique)

** DO NOT PUSH INTO ER OR HORIZONTAL ABDUCTION**

Strengthening/ Proprioception Exercises:

Isometrics (performed with arm at side)
o Flexion
o Abduction
o IR (multi-angles)
o ER (scapula plane)
o Biceps / triceps
o Scapula retract/ protract; elevate/depress
Rhythmic Stabilisations (small range oscillation movements)
o ER/ IR/ Flexion/ Extension in mid range positions
o Education of normal scapula position
Weight Shifts (CKC Exercises) Scapula plane
Early Stage proprioceptive drills
Consider EMG Biofeedback for posterior cuff muscles.

Phase 2: Intermediate Phase

Goals:

Regain and improve muscular strength

Full ROM
Enhance popriception and kinaesthesia
Improve neuromuscular control of the shoulder complex
Consider neck and thorax in relation to shoulder function

Criteria to progress to Phase 2:

Full Passive ROM (except ER)
 Minimal pain or tenderness
Good strength tests of IR, ER, flexion and abduction
Baseline proprioception and dynamic stability

Consider referral to Physical Coach for whole body maintenance

Initiate Isotonic Strengthening

** PRECAUTION IS AVOIDING EXCESSIVE STRESS ON ANTERIOR CAPSULE

Emphasis on External Rotation and Scapula Strengthening with control of

GHJ position. Sample exercise include:
o ER/ IR Tubing emphasis on eccentric muscle training
o Consider Isokinetic training for Eccentric External Rotators
o Scaption with ER (Full Can)
o Abduction to 90
o Side lying ER to 45
o Shoulder Shrugs
o Prone Extension to Neutral
o Prone Horizontal Abduction to neutral
o Prone Rowing
o Lower Trapezius
o Biceps & Triceps
o Table push-ups

Improve neuromuscular control of shoulder complex

Initiation of proprioceptive neuromuscular facilitation
Rhythmic stabilisation drills (small range oscillation movements)
o ER/ IR at 90 abduction
o Flexion/ Extension at 100 flexion
o Progress to oscillations at mid and end range of motion positions
Progress OKC programme
o PNF
o Manual resistance ER (Supine Side lying), prone row
o ER/ IR tubing with stabilization
Progress CKC exercise with rhythmic stabilisations
o Wall stabilization on ball
o Static holds in push-up position on ball
o Push-ups on tilt board

Phase 3: Advanced Strengthening Phase

Goals:
 Improve strength, power and endurance
Improve neuromuscular control
Enhance dynamic stabilizations
Prepare patient/ athlete for activity

Criteria to progress to Phase 3:

Full non-painful range of motion

No palpable tenderness
Continued progression of resistive exercises
Good normal muscle strength

Continue isotonic strengthening (PREs)

o Continue all exercises listed above
o Progress to end range stabilization
o Progress to full ROM strengthening

Consider isokinetic strengthening

o Eccentric external rotation
o High speed IR / ER :start in the scapular plan and progress to 90 /90
position

Emphasize PNF

Advanced neuromuscular control drills (for athletes)

o End range RS with tubing
o Push-ups on ball/ rocker boards with rhythmic stabilizations
o Manual scapula control drills

Endurance Training
o Timed bouts of exercise 30-60 seconds
o Increase number of repetitions
o Multiple bouts throughout the day

Initiate Plyometric training

2-hand drills:
o Chest pass
o Side to side
o Overhead
Progress to 1-hand drills:
 o 90/90 throws
o Wall dribbles

Sport Specific Drills

Criteria to return to Sport:

Full pain free ROM

No pain or palpable tenderness
L = R Strength
Satisfactory clinical exam and sport specific tests
Isokinetic tests L = R