Preventing Recurrence: Physiotherapy Strategies for Anterior Shoulder Instability

Shoulder Instability refers to the inability of the shoulder joint (glenohumeral joint) to maintain the humeral head securely within the glenoid fossa. This can result from damage to the soft tissues or bony structures, leading to excessive movement or dislocation of the joint.

Anterior glenohumeral instability is a condition where the head of the humerus tends to dislocate or subluxate from the glenoid cavity, predominantly in an anterior direction. This condition can range from a single traumatic dislocation to recurrent episodes of instability due to structural or functional deficiencies

Types of Shoulder Instability

• Anterior Instability
• Posterior Instability
• Multidirectional Instability (MDI)
• Inferior Instability

 

Types of Anterior Shoulder Instability

Symptoms

• Recurrent dislocations or subluxations.
• Pain due to impingement or rotator cuff tendinopathy.
• "Dead arm" sensation during activity.
• A detached labrum may result in a "catching" or clicking sensation.

 

Examination

• Assess for generalized ligamentous laxity, such as the sulcus sign.
• Evaluate movements like external rotation and abduction along with muscle strength testing to identify neurological involvement.

Special Tests

• Load and Shift Test - evaluates anterior-posterior translation of the humeral head.
• Apprehension-Relocation Test - detects apprehension and instability during movement.

 

Imaging Studies

Imaging is essential to identify associated lesions and guide management:

• X-rays or CT

It is useful for detecting bony abnormalities like Hill-Sachs and Bankart lesions. X-rays are often sufficient for traumatic anterior instability cases.

• MRI

Identifies soft tissue damage, including labral tears, capsule injuries and rotator cuff involvement.

 

Differential Diagnosis

• Rotator Cuff Tear
• Labral Tear (e.g., SLAP Lesion)
• Glenohumeral Osteoarthritis
• Subacromial Impingement Syndrome
• Biceps Tendon Pathology
• Multidirectional Shoulder Instability
• Acromioclavicular Joint Pathology
• Suprascapular Nerve Entrapment
• Adhesive Capsulitis (Frozen Shoulder)
• Fracture (e.g., Proximal Humerus, Glenoid Rim)
• Cervical Radiculopathy
• Posterior Shoulder Instability
• Scapular Dyskinesis
• Thoracic Outlet Syndrome

 

Physiotherapy Management of Anterior Shoulder Instability

Commonly Used Exercises for Shoulder Instability Rehabilitation

Phase I: Acute Phase

The focus of physiotherapy for anterior shoulder instability should include effective pain management, strategies to improve range of motion (ROM) and exercises aimed at enhancing muscle activation to stabilize the shoulder joint.

ROM Exercises

• Pendulum exercises
• Rope and pulley exercises

Strengthening Exercises

• Isometric flexion, abduction and extension

Proprioception Exercises

• External rotation (ER) active joint repositioning drill
• Internal rotation (IR) active joint repositioning drill

 

Phase II: Intermediate Phase

In Phase II, the focus shifts to strengthening the shoulder muscles, enhancing neuromuscular control and improving proprioception to promote joint stability and functional recovery.

Isotonic Strengthening

• Sidelying dumbbell exercises for IR/ER
• Abduction to 90°

Eccentric Strengthening (IR/ER at 0° abduction)

• Eccentric strengthening for internal rotation (IR) and external rotation (ER) at 0° abduction targets the rotator cuff muscles, specifically the subscapularis (for IR) and infraspinatus/teres minor (for ER). This exercise focuses on the controlled lengthening of these muscles under load,

Neuromuscular Control Drills

• Rhythmic stabilization drills which focuses on inner, mid, and outer ROM
• Scapulothoracic and glenohumeral musculature training
• Proprioceptive neuromuscular facilitation (PNF) patterns
• Weight shifts with hand on a ball or wall stabilization drills

 

Phase III: Advanced Strengthening Phase

Phase III, the advanced strengthening phase, emphasizes dynamic stabilization, building strength and endurance, and refining neuromuscular control to prepare the shoulder for higher levels of activity and functional demands.

Strengthening

• Continue isotonic and eccentric strengthening exercises

PNF with Rhythmic Stabilization

• Incorporate rhythmic stabilization holds

Advanced Neuromuscular Control Drills

• Push-ups with rhythmic stabilization (progress to unsteady surfaces)
• Rocker board drills

Endurance Training

• Timed sessions are performed (30-60 seconds) with increasing repetitions

 

Phase IV: Return to Activity Phase

Focus is on maintaining functional strength, endurance and sport-specific preparation.

Advanced Strengthening and Neuromuscular Control

• Continue Phase III exercises

Interval Sport Program

• Gradually introduce sport-specific movements and activities

Endurance Maintenance

• Timed endurance drills tailored to the patient’s activity demands
• This structured exercise progression ensures safe recovery and optimizes functional return to activity or sport.

 

Commonly Used Exercises for Traumatic Shoulder Instability Rehabilitation

Phase I: Acute Motion Phase

Phase I, focuses on achieving pain-free range of motion (ROM), promoting dynamic stability and initiating early muscle activation to support the healing process and prevent further injury.

Range of Motion (ROM) Exercises

• Pendulums
• Rope and pulley
• Active-assisted ROM - flexion (F), Internal Rotation (IR), External Rotation (ER)

Strengthening/Proprioception

• Isometric exercises - flexion, abduction, extension, IR, ER (performed with arm at the side)

Rhythmic Stabilization

• Scapular plane: ER/IR/F/E
• Weight shifts with hands on a table
• Proprioception training: Active joint reproduction (F/IR/ER)

Caution: Avoid external rotation and horizontal abduction to minimize stress on the anterior capsule.

 

Phase II: Intermediate Phase

The focus during this phase is on strengthening the shoulder muscles, improving proprioception, and enhancing neuromuscular control to increase stability and function, laying the groundwork for more advanced rehabilitation.

ROM Progression

• Gradual ER ROM at 90° abduction (within pain-free limits)

Strengthening Exercises

Isotonic strengthening

• Side-lying ER to 45°
• Abduction to 90°
• Push-ups onto a table
• Biceps curls, triceps pushdowns
• Prone rowing

Neuromuscular Control Drills

• Proprioceptive Neuromuscular Facilitation (PNF) patterns
• Wall stabilization using a ball
• Static holds in push-up position on ball

 

Phase III: Advanced Strengthening Phase

Focus is on strength, endurance, neuromuscular control and dynamic stabilization.

Strengthening Exercises

• Full ROM isotonic strengthening (progress resistance)
• Bench press in restricted ROM
• Flat and incline chest press

Neuromuscular Control Drills

• Ball flips on a table
• Push-ups on a ball with rhythmic stabilizations
• Manual scapular neuromuscular control drills
• Perturbation activities

Endurance Training

• Timed exercise bouts (30-60s)
• Increased repetitions and multiple sets throughout the day

Plyometric Training

• Two-hand drills: Chest pass throw, side-to-side throw, overhead soccer throw
• One-hand drills: Wall dribbles, 90/90 baseball throws

 

Phase IV: Return to Activity Phase

Focus is on full strength, endurance and functional return to activity/sport.

Strength and Maintenance

• Continue Phase III strengthening exercises
• Progress isotonic exercises and resume normal lifting

Sport-Specific Training

• Initiate interval sport program
• Follow isokinetic testing (ER/IR/Abd/Add)
• Maintain a consistent exercise program for long-term stability

These exercises ensure a progressive return to activity, addressing strength, proprioception and functional needs at each phase.