Glenohumeral Instability Part III: Non-Operative Management

MDI

What are the types of atraumatic, multidirectional cases of shoulder instability that can be treated non-operatively

- Male

- Participation in sport

- Hypermobility in males

- Increased glenoid index (height to width ratio)

What are moderate to large risk factors associated with first time occurrence of shoulder instability

- Male

- Younger than 30 y.o.

- History of GH instability with concomitant injury (e.g., RTC injury)

What are moderate to large risk factors associated with recurrent cases of shoulder instability

Emergency closed reduction with traction and anesthesia (if necessary)

What does Acute Anterior Dislocation Treatment entail

Likely in sling for specified timeframe

What does immobilization for Acute Traumatic Dislocation Management Include

- Sling use

- Activity mod

- HEP

What does education for Acute Traumatic Dislocation Management Include

- Adjacent regions (if necessary)

- PROM if needed

What does manual therapy for Acute Traumatic Dislocation Management Include

Protected ROM & mobility

What does exercise for Acute Traumatic Dislocation Management Include

Out of sling

What does immobilization for Sub-Acute Traumatic Dislocation Management Include

Recurrence and avoidance of 'at-risk' position

What does education for Sub-Acute Traumatic Dislocation Management Include

Impairment based (will not need much at GH)

What does manual therapy for Sub-Acute Traumatic Dislocation Management Include

- Motor control

- strength and endurance of scapula

- RTC

What does exercise for Sub-Acute Traumatic Dislocation Management Include

None

What does immobilization for post Sub-Acute Traumatic Dislocation Management Include

- Recurrence

- At-risk position

What does education for post Sub-Acute Traumatic Dislocation Management Include

Impairment based (will not need much at GH)

What does manual therapy for post Sub-Acute Traumatic Dislocation Management Include

Continue previous and potentially move to more sport/work specific demands

What does exercise for post Sub-Acute Traumatic Dislocation Management Include

Similar approach to management as anterior dislocation, except avoid flexion with ADD and IR in acute phase

What is a key point about the management of Posterior Dislocation as compared to anterior dislocation

- Post reduction shoulder is immobilized for 3-6 weeks

- Education, activity modification

- Initiate strengthening program for RTC, periscapular musculature

what are important considerations about the early management of posterior shoulder dislocations

- Progressive loading of RTC

- periscapular musculature

- work/sport specific composite motions

what are important intervention approaches to include in the late management of posterior shoulder dislocations

3x/wk, postural exercise

Isometric → isotonic using yellow TB

RTC+periscapular exercises

What is included in the exercise recommendation for low load management of Multidirectional Atraumatic Shoulder Instability

3x/wk, 50% → 90% of 10RM (Week 1-9)

8RM (Week 10-15)

RTC+periscapular exercises using dumbbells

What is included in the exercise recommendation for heavy load management of Multidirectional Atraumatic Shoulder Instability

- Progressing from more to less stable positions

- Scapular muscle strength and control

- RTC strength and control

- UE weight bearing exercise (encourages co-contraction)

- Perturbation activities

- Consideration of incorporating the LE kinetic chain into shoulder exercises

What are the key elements to include in the Exercise prescription for atraumatic MDI

Retraining specific scapular motor control before any rotator cuff/deltoid strengthening. Exercises progress into functional/sports specific ranges.

What is the focus of the Watson program for the management of MDI

Sport/occupation specific

What is included in stage 6 of the Watson Program for MDI

8-12 weeks

How long would you attempt rehabilitation prior to considering sending the patient for a surgical opinion?

- failure to improve

- worsening pain/symptoms

- new clinical findings

What factors would sway your decision to continue rehabilitation versus referring on for surgery?

Reduce the shoulder as needed, usually in the ED or on the sideline

How is an acutely unstable shoulder typically managed?

Typically 1–4 weeks

How long is a sling typically worn after instability?

Regain ROM and begin initial strengthening

What are the goals of early rehabilitation

Progressive strengthening into less stable positions

What is emphasized in sub-acute/late-stage rehab

The patient and injury characteristics

What determines surgical vs. non-surgical management

Young (<25) and highly active individuals

Who has high recurrence rates after shoulder instability

No preferred position has been shown to reduce recurrence

Does sling position (IR vs. ER) reduce recurrence

as tolerated

When should a patient wean from the sling

Recurrence does not appear to increase based on duration

Does immobilization duration clearly affect recurrence risk?

It may protect the anterior glenoid labrum during healing, especially with Bankart lesions

Why might an ABD/ER sling be used

Strengthen muscles to improve dynamic stability

What is the main PT goal for shoulder instability

Rotator cuff (RTC) and scapular muscles

Which muscles are targeted for dynamic shoulder stability

Composite movements within the patient's range of confidence

What movement approach is used early in rehab

As needed to improve joint awareness and control

When is GH proprioceptive re-education used

Provocative positions that increase instability or apprehension

What positions should initially be avoided

Gradually work toward them as strength and confidence improve

How should apprehensive positions be addressed later

Avoid shoulder ABD with ER and positions that place stress on the anterior shoulder

For acute, traumatic anterior dislocations, what positions should patients avoid?

Educate them about tissue healing and gradually progress activity to reduce the risk of reinjury

How should you address a patient who is overzealous about returning to pre-injury activities?

Use education, graded exposure, and progressive exercise to build confidence

How should you address a patient who is highly fear-avoidant about returning to activities?

Rotator cuff and scapular muscles, focusing on strength and neuromuscular control

What muscles should be strengthened for shoulder instability?

UE weight-bearing

LE kinetic-chain exercises

Perturbations

Stability exercises

What types of exercises should be included for shoulder instability

Progress from positions of greater stability to positions of less stability

How should exercise positions progress for shoulder instability

Gradual exposure to feared or apprehensive movements and positions

What should be included for kinesiophobia and apprehension

Supervised progressive strengthening and neuromuscular control was slightly more effective than a home program

What did Eshoj et al. (2020) find regarding supervised exercise?

No significant difference in self-reported function or dislocation recurrence between advice/materials alone and a PT program

What did the ARTISAN study (2024) find

82/97 athletes returned to the same sport without reinjury for at least one full season with conservative management

What did Shanley et al. (2019) find in scholastic athletes

Arm-across-body activities

What should be limited during the acute/irritable phase of posterior shoulder dislocations

Scapular, rotator cuff, and sport/occupation-specific strength training

What strength training may be needed of posterior shoulder dislocations

At least 12 weeks of individualized exercise progression

What is the minimum exercise progression duration of posterior shoulder dislocations

Scapular and/or humeral head position

What positions should PT assess and manage for posterior shoulder dislocations

Both local and global muscles

What muscles should exercise progression target for posterior shoulder dislocations

Motor control and strength, anatomy/pathomechanics, and pain coping strategies

What should patient education emphasize for posterior shoulder dislocations

Build motivation and knowledge to perform exercises independently at home

What is the key goal of a home-based exercise program for posterior shoulder dislocations

With low exercise efficacy, poor home support, limited exercise insight, or need for verbal/tactile feedback

When is a clinician-supervised exercise program especially helpful for posterior dislocations

6-12 weeks

What is the typical timeline for pain and ADL recovery for posterior dislocations

1-3 weeks

What is the typical immobilization period for posterior dislocations

After 3–6 months of PT, based on individualized discussion with the patient

When may patients return to high-risk sport/work after immobilization from posterior dislocation

After 6–12 months of PT, based on individualized discussion with the patient

When may patients return to high-risk sport/work after surgery for posterior dislocations

low quality evidence

What is the quality of evidence supporting exercise for MDI

low grade evidence

What is the evidence comparing conservative treatment vs. surgery for MDI

High-load exercise produces better self-reported function

How does high-load exercise compare to low-load exercise at 16 weeks (MDI)

No significant difference in self-reported function

How does high-load exercise compare to low-load exercise at 1 year (MDI)

Retrain scapular motor control

What is the main focus of Stage 1a of the Watson Program for MDI

0-1 kg

What is the load for Stage 1a for MDI?

Scapular upward rotation/elevation drills in standing

What exercises are used in Stage 1a for MDI

Controlling arcs of motion from 0°–45° elevation

What is the main focus of Stage 1b for MDI

yellow-red theraband

What is the load for Stage 1b for MDI

Standing extension rows from 45° flexion to neutral

What is one Stage 1b exercise for extension for MDI

Standing ER from 0°–45° ER at 0° ABD

What is the Stage 1b ER exercise for MDI

Standing IR from 0°–45° IR at 0° abduction

What is the Stage 1b IR exercise for MDI

Building posterior GHJ muscle bulk

What is the main focus of Stage 2 for MDI

Green Theraband or 1–2 kg

What is the load for Stage 2 for MDI

Standing bent-over rows

What row exercise is used in Stage 2 for MDI

Side-lying ER

What ER exercise is used in Stage 2 for MDI

Standing Theraband rows

What other row exercise is used in Stage 2 for MDI

Sagittal plane flexion motor control

What is the main focus of Stage 3 for MDI

Yellow–green Therabands or 1–3 kg

What is the load for Stage 3 for MDI

Standing shoulder flexion with Therabands and weights

What is the main Stage 3 exercise for MDI

Controlling arcs of motion

What is Stage 4 of the Watson Program for MDI

45°–90° elevation

What is the elevation range for Stage 4 for MDI

standing

What position is the patient in for all Stage 4 exercises

Yellow-green Therabands / 2–5 kg

What is the load for Stage 4 exercises for MDI

External rotation (ER) at 90°

What is the Stage 4 ER exercise for MDI

Internal rotation (IR) at 90°

What is the Stage 4 IR exercise for MDI

Flexion at 90°

What is the Stage 4 flexion exercise for MDI

Specific deltoid strengthening

What is Stage 5 of the Watson Program for MDI?

1–4 kg+

What is the load for Stage 5 exercises for MDI

bent over rows

What rowing exercise is performed in Stage 5 for MDI

Supine and sitting flexion

What flexion exercises are performed in Stage 5 for MDI

Short-lever abduction at 45°–60°

What abduction exercise is performed in Stage 5 for MDI

ER 90°, IR 90°, and flexion 90°

What are the key exercises in Stage 4 for MDI

Bent-over rows, flexion, and short-lever abduction

What are the key exercises in Stage 5 for MDI