Are you recovering from a shoulder dislocation? Or do you experience feelings of instability during certain movements or activities?
In this blog, I am going to teach you everything you need to know about how to properly manage these issues.
Be sure to also check out our Shoulder Resilience Program!
Shoulder Anatomy
First, let’s briefly review some basic shoulder anatomy.
The shoulder joint, or glenohumeral joint, is where the glenoid fossa of the scapula, or shoulder blade, meets the head of the humerus, or arm bone. Around the glenoid fossa is the labrum, a fibrocartilaginous ring that increases the depth of the shoulder and improves its stability. A fibrous structure known as the joint capsule surrounds the shoulder joint and labrum.
Due to the shoulder’s shallow socket, it is the most mobile joint in the body.
Shoulder Instability
Shoulder instability occurs when the humeral head cannot maintain its position within the glenoid fossa, resulting in symptoms such as pain or apprehension.
There are 2 main types of shoulder instability.
The first is traumatic which results in a partial or complete separation of the glenohumeral surfaces, commonly known as a subluxation or dislocation.
This is usually the result of falling on an outstretched hand (FOOSH) or from a direct blow to the shoulder.
About 97% of dislocations occur anteriorly, meaning the head of the humerus is forced out of the joint socket in the forward direction. They can also occur posteriorly or inferiorly, but these are rare.
Traumatic injuries typically involve structural damage, most often in the form of a Bankart lesion, which is when the anterior and inferior portions of the labrum separate from the glenoid.
Other associated injuries can include:
- A Hill-Sachs lesion which is a compression fracture of the humeral head
- A glenoid rim fracture, also known as a bony Bankart
- A neurological injury, such as damage to the Axillary nerve
- A rotator cuff tear
Before reducing a dislocation, or putting it back into its normal position, X-rays are performed to determine the direction and if there are any other injuries, like a fracture.
The second type of instability is atraumatic which is defined as an abnormal motion or position of the shoulder that leads to pain, subluxations, dislocations, and functional impairment, but it happens without any history of a significant preceding injury.
An example would be a swimmer who developed pathological laxity from repetitive overuse. There may be structural abnormalities found in the shoulder, but they are not a result of a single traumatic experience.
In an attempt to simplify these types, traumatic and atraumatic instability are sometimes referred to by the acronyms TUBS and AMBRI, respectively. TUBS stands for Traumatic Unidirectional Bankart lesion treated with Surgery. AMBRI stands for Atraumatic Multidirectional Bilateral treated with Rehabilitation and if surgery is required, a n Inferior capsular shift is performed. However, this is sometimes an over simplification, since traumatic injuries may not always be treated surgically, and atraumatic injuries can also present unidirectional and/or unilateral.
It is also worth noting that the presentation of shoulder instability can change over time. For example, someone may have had a traumatic anterior shoulder dislocation, but, years later, they may develop recurrent instability that occurs without a significant preceding injury.
Other classification systems, like the Stanmore Classification, include a third type that is also atraumatic but is defined by a loss of muscle control without structural damage. These are less common, but someone who can voluntarily pop their shoulder out as a “party trick” or people with Ehlers-Danlos Syndrome would fall into this category.
It’s important to understand that shoulder laxity or hyperlaxity by itself is just a sign, while shoulder instability is a term associated with clinical symptoms.
These symptoms can include pain, apprehension, and feelings of instability with various movements or positions, such as when your arm is away from your body or when reaching back behind you. These positions closely resemble clinical tests that your physical therapist might perform to confirm the diagnosis of shoulder instability.
Brownson et al 2015, Lewis et al 2004, Verweij et al 2023, Jaggi et al 2017, Noorani et al 2019
Management of Shoulder Instability
Regardless if you have traumatic or atraumatic instability, management options include surgery and rehabilitation, or rehabilitation alone.
For anterior shoulder dislocations, multiple studies show that younger athletes who received stabilization surgery experienced lower rates of recurrent instability and decreased need for future surgery compared to those who received nonoperative management. Handoll et al 2004, Belk et al 2021, Alkhatib et al 2022, Zaremski et al 2016
For atraumatic instability, a 2023 randomized, placebo-controlled trial found that surgery, where the joint capsule was “tightened”, did not lead to better results than a placebo, or sham, surgery in terms of improvement in pain and functional impairments.
These studies provide some insight, but the decision whether to undergo surgery is nuanced, as it depends on various factors such as age, sport, type of instability, degree of tissue damage, etc.
As an example, for a young athlete who had an anterior shoulder dislocation with a bony bankart and wants to return to a contact sport like rugby, surgery would be recommended. Conversely, for an older person who had an anterior shoulder dislocation without additional structural damage and does not play a sport, nonoperative management may be the preferred choice, at least initially.
In the cases of atraumatic instability, rehabilitation is often the first-line recommendation. However, in some cases, if symptoms do not improve, referral to an orthopedic surgeon might be necessary.
Shoulder Instability Rehab Overview
Whether you have surgery or not, the goal of rehab is to minimize the risk of recurrence, reduce pain, and improve function by incorporating exercises that address deficits seen with shoulder instability.
The comprehensive rehab program that I am going to present will consist of 5 overlapping categories of exercises that will focus on improving your range of motion, strength, stability, and power in all directions.
These exercises will generally follow a continuum. On the left side, movements involve less range of motion, lower intensities, slower speeds, and more stable environments, while exercises toward the right side will move through more range of motion and involve higher intensities, faster speeds, and less stable environments. A plank on a wall and an external rotation isometric with a band would be examples of exercises on the left side, while plyometric push-ups and ball dribbles against a wall are examples of exercises on the right side.
This framework can be helpful when programming exercises based on your current function, tolerance, and goals. For instance, if your only goal is to perform day-to-day tasks, you might stay more toward the left side. In contrast, if you want to return to a contact sport or a sport that involves more repetitive and demanding shoulder movements, you will eventually need to progress toward the right side and include power and reactive exercises.
As I mentioned previously, whether you’ve had surgery or are planning to, your rehab will follow a similar structure, however, there are some differences due to factors like healing timelines and post-surgical precautions.
Following surgery, there are generally range of motion restrictions and limitations against how much you can lift for a set duration of time to protect the surgical repair. Also, restoring your previous range of motion might not be feasible, or at least highly challenging, since the surgery is performed to purposefully limit excessive motion.
If you did not have surgery, when you start these exercises, what exercises you perform, and how fast you progress will be dictated by your tolerance and function.
Immobilization
Before discussing the exercises, I want to quickly discuss the topic of immobilization, as the use of a sling is recommended following a dislocation, and is required for some time after surgery.
There are generally two types: an ordinary sling and an external rotation and abduction sling. To date, there have been no reported advantages of either option in terms of outcomes, but a systematic review and meta-analysis did suggest that “immobilisation in an ordinary arm sling for comfort appears to be preferable…”
If you had surgery, you might wear a sling for up to 4 weeks depending on your surgeon’s protocol, while if you had a first-time dislocation and no surgery, the sling’s purpose is to help manage pain and swelling and is usually not used more than a couple of weeks.
Category #1: Range of Motion Exercises
The first category of exercises involves restoring your shoulder flexion, extension, external rotation, and internal rotation range of motion.
It’s important to know that exercises for shoulder extension and external rotation will involve anterior translation of the humeral head.
This means that if you have anterior shoulder instability, you may feel apprehensive or symptoms when performing these exercises since they involve similar positions or movements to those that caused your injury. Therefore, it might take you longer to start and progress in these directions.
Shoulder Flexion Range of Motion Exercises
For shoulder flexion, a preferred starting point is performing a pullover with a dowel. While lying on your back with knees bent and holding onto a dowel, slowly move your arms overhead as far as comfortable, using as much assistance from your uninvolved side as needed.
To decrease the intensity, move through less range of motion. To increase the intensity, add a light weight to the stick to help move the shoulder further overhead.
Other options for shoulder flexion include supporting your arms against a wall, elevated surface, or the ground in child’s pose, and gently rocking in and out of as much range of motion as tolerated.
Over time, you can include more advanced variations, like a dumbbell pullover on a bench.
Lastly, to help build strength and control at your end ranges, you can perform prone shoulder flexion with a dowel. Lift the dowel as high as possible while keeping your elbows straight. Hold the top for 2-3 seconds before slowly lowering it back down.
Shoulder Extension Range of Motion Exercises
For shoulder extension, hold a stick or dowel and use your non-involved side to gently move your arm behind you, using as much assistance from the uninvolved side as needed.
As your tolerance improves, you can progress by performing lift-offs with a dowel in standing, and over time, you can even try an advanced variation while lying on your stomach.
Shoulder External Rotation Range of Motion Exercises
For external rotation, lie on your back with your knees bent and place your involved shoulder at your side with your elbow bent to 90°. Holding onto a dowel, use your non-involved side to move your shoulder in and out of external rotation, using as much assistance from the uninvolved side as needed.
As your range of motion and tolerance improves, progress by actively rotating your arm outward without a stick, gradually working your way up to shoulder height.
To increase the intensity, you can hold a light weight in your hand. To move through more range of motion, place your arm on a pad or towel.
Once you possess enough range of motion, you can perform prone external rotation to help build strength and control at your end range. Lie on your stomach with your elbow and shoulder at 90°, and lift your wrist as high off the ground as possible. Hold the top for 2-3 seconds before slowly lowering it back down.
Shoulder Internal Rotation Range of Motion Exercises
Finally, for shoulder internal rotation, start by rotating your hand to your stomach, then work up to shoulder height, and then finally hold a light weight as you slowly lower your hand toward the ground.
You can place your other hand on top of your shoulder as a reminder to not let that shoulder come off the floor.
Another option is the sleeper stretch where you lie on your side with your head supported and shoulder and elbow bent to about 90°. Use your top hand to gently push your other hand down toward the ground.
These range of motion exercises can be performed for 2-3 sets of 30-60 seconds or 10-20 repetitions, moving at a slow and controlled speed.
If you had surgery, you might perform these up to 3 times a day once you have been cleared by your surgeon, while in other cases, 2-4 times a week should be sufficient for improving your shoulder range of motion.
Category #2: Weight Bearing Exercises
The next category includes weight-bearing exercises aimed at improving your strength, stability, proprioception, and confidence through gradual loading of the shoulder. These exercises are recommended because they reduce translation and promote compression of the shoulder joint, as well as allow for co-contraction of your shoulder muscles.
Here are a few options:
The first is a bird-dog progression. Start in a quadruped position, or on your hands and knees. Progress by lifting one arm off the ground, then lifting one leg, and finally to a bird dog where you reach one arm and leg out.
A more dynamic option that involves coordination and control is crawling. You can perform these moving forward and backward, or side to side. To make these more challenging on your shoulders, lift your knees higher off the ground.
The next option is a tall plank progression. Begin with your hands on a wall or elevated surface, progress to the floor, then to shoulder taps where you tap your opposite shoulder in an alternating fashion while minimizing trunk movement, and finally to a weighted drag. For each level, think about pushing the floor away from you.
You can also perform a tall plank with shoulder blade movement. Press the ground away from you, separating your shoulder blades, and then slowly lower your chest to the ground, bringing your shoulder blades together. Repeat this movement while keeping your elbows straight.
If you need to make this easier, perform with your hands on a wall or place your hands on a bench or elevated surface.
If you want to incorporate an overhead component, press the ground away from you and transition into a downward dog, moving your shoulder into as much flexion as comfortable.
You can also bias a single arm by performing what is called downward dog toe taps. As you move into downward dog, reach one hand across your body and touch your opposite foot. If you have a hard time reaching your toes, bend your knees as much as needed.
Other challenging plank variations include a plank up-down, plank rotation, plank with arm reaches in various directions, plank with leg lifts, and a tall plank with alternating arm and leg lifts.
You can also perform side planks. Start with a side plank on your knees or with your arm elevated before progressing to a regular side plank. Then if you feel comfortable, try adding a rotation where you reach your arm underneath and behind you, before returning to the starting position.
You can do most of these variations on your forearms or hands, but generally, performing on your hands will be more challenging for your shoulders.
For any of these weight-bearing options, aim for 2-3 sets of 30-60 seconds, 2-3 times per week.
Category #3: Shoulder Accessory Exercises
There are a ton of options in this category, but the principles are the same as the continuum I showed you earlier. You will start with less range of motion and difficulty, and over time, you will want to move through more range of motion and increase the difficulty.
You can then apply these principles to any accessory exercise, with the goal of gradually increasing your range of motion, strength, and confidence in positions or movements that previously gave you feelings of instability or apprehension.
For example, external rotation strengthening exercises can start with an isometric, or static hold variation into a wall or door frame, or by using a band or cable.
You can then progress to repetitions using a band or cable with your arm at your side before eventually progressing to a position with your shoulder and elbow at 90°.
This same progression can be performed for internal rotation strengthening.
In addition to rotation movements, you may also want to include shoulder elevation exercises. You can start with isometrics into a wall or door frame or using a loop band.
Then progress to lateral raises with dumbbells or bands, starting by lifting to shoulder height, progressing to just above shoulder height, and finally to a butterfly lateral raise which moves your arms fully overhead.
Another option is performing what is called As, Ts, and Ys to target the muscles on the back of your shoulder. I like doing these with a cable or band, but if you have minimal equipment, you can also perform isometrics while lying on your stomach on the ground.
To challenge your shoulders at their end ranges, you can eventually progress to standing angels with a band or prone swimmers. Perform these slow and controlled for 2-3 sets of 30-60 seconds.
For all the other accessory exercises, you can aim for 2-3 sets of 10-15 repetitions or 30-45 second holds for the isometrics, 2-3 times per week. Earlier in the rehab process, you can perform the isometrics daily if symptoms allow.
Similar to the shoulder extension and external rotation range of motion exercises, you may feel apprehensive when performing some of these movements, especially if they involve your arm further away from you r body or when reaching back behind you. For instance, if you have anterior shoulder instability, the 90/90 external rotation with a band or cable may seem intimidating and therefore might be one of the last exercises you work on.
Category #4: Compound Pushing & Pulling Exercises
Push-ups are one of the best options for compound pushing exercises initially since these are easily modifiable.
You can make these easier by elevating your hands or reducing the range of motion, or make these harder by elevating your feet or increasing the range of motion.
If you have anterior shoulder instability, it may take time to build up to these deficit push-ups since they require more shoulder extension.
For horizontal pulling, inverted or TRX rows are a good starting point since you can easily manipulate the effort level by adjusting your body position. The more upright you are, the easier it becomes, while the more horizontal you are, the more difficult it becomes.
To progress back to overhead pressing and vertical pulling movements, you can use angled variations to gradually expose yourself to increasing amounts of arm elevation.
If overhead exercises requiring greater amounts of shoulder external rotation, such as a barbell overhead press or wide grip lat pull-down, are uncomfortable or challenging to perform, you can try single-arm variations using a dumbbell for overhead presses or using a handle attachment for lat pull-downs. These alternatives will allow for more variability in your shoulder position.
Once you can tolerate increasing amounts of arm elevation, you can implement advanced exercises like a bottoms-up overhead press, front rack carry, or overhead carry to further challenge your shoulder stability.
For exercises that require a hanging component, like pull-ups, you may need to initially reduce the load placed through the shoulder by performing assisted variations or adjusting your grip.
Generally, a neutral position will be more tolerable since it requires less shoulder range of motion than an overhand or underhand grip.
A simple rule of thumb is that horizontal pushing and pulling movements are going to be less demanding on the shoulder than vertical pushing and pulling movements. Otherwise, you can manipulate variables like volume, intensity, range of motion, and speed, as needed.
There is a wide range of parameters you can implement, but to keep it simple, aim for 2-3 sets of 5-20 repetitions, 2-3 times a week.
Category #5: Power & Reactive Exercises
The last category of exercises will enhance your shoulder strength, coordination, and power, as well as improve your ability to absorb and generate forces. If you plan on returning to a contact sport or a sport involving more repetitive and demanding shoulder movements, consider this category mandatory.
One weight-bearing option you can start with is called a wall catch. Stand a few feet away from a wall with your arms out in front, fall toward the wall, and catch yourself, controlling the deceleration. Slowly push yourself back up to the starting position and repeat.
You can then perform from a kneeling position and fall toward an elevated surface, before finally progressing to the floor.
To increase the intensity of these exercises, you can incorporate a plyometric component by catching yourself and then exploding away from the wall, elevated surface, or ground as quickly as possible.
If you want to challenge your shoulder even more, you can work up to a plyometric push-up. Begin in a push-up position, slowly lower down, then explode away from the ground as quickly as possible. Maintain control as you catch yourself, and then repeat the movement.
For non weight-bearing exercises, you can perform ball drops with a small weighted ball and your shoulder in various positions. Some options include:
Lying on your side with your arm tucked beside you.
Standing or lying on your stomach with your shoulder and elbow at 90°.
Lying face down with your arm in a T, Y, or overhead position.
You can also perform ball dribbles against a wall. Experiment with your shoulder at different angles like a 90/90 position or in an overhead position.
If you have a partner, you can try more coordinated throws with a tennis ball or lacrosse ball from a half-kneeling position. This is a great option for building strength, power, and control at the end range of shoulder external rotation.
Lastly, you can also incorporate the use of a medicine ball by performing variations like a chest pass, shot put throw, rotational throw, or overhead slams.
In terms of programming, for the variations using a small ball, perform for 2-3 sets of 30-60 seconds of total work.
For the deceleration and plyometric push-up variations or medicine ball options, aim for 2-3 sets of 4-8 reps, with an emphasis on moving fast for each repetition.
Individualizing Your Program
I understand that all of this information might be a lot to process, so let me provide a few additional considerations and examples.
First, these categories will have overlap. For instance, even once you begin the power and reactive exercises, you might still be incorporating shoulder range of motion drills to achieve that last 5 degrees of shoulder flexion or external rotation.
Second, timelines and rate of progression vary from person to person. This is influenced by your symptoms, tolerance, and function, however, if you had surgery, you will also have to wait until precautions are lifted by your surgeon or physical therapist.
Third, you don’t have to do every exercise or exercise category. To demonstrate what I mean, let me show you sample programs for two different patients for the later stages of rehab.
The first patient is older without any sport-related goals. Therefore, they might only focus on restoring their shoulder range of motion, building confidence in weight-bearing positions, and incorporating 1-2 accessory exercises, 3 days a week.
On the other hand, a younger, overhead athlete looking to return to sport may incorporate most, if not all, of the exercise categories presented. Since they are doing more volume overall, they may decide to split these exercises across 2-4 days a week.
Return to Sport
The last topic I want to discuss is how to safely return to sport or other activities. You will have to take into account factors such as your injury, goals, and demands of your specific sport, but generally, 3 main criteria are commonly recommended:
- You possess full, or close to full, pain-free shoulder range of motion
- You are psychologically ready
- You demonstrate strength and power >90% in all directions compared to the uninjured side
Additionally, your physical therapist might have you perform certain tests to determine your readiness. One of these tests is called the closed kinetic chain upper extremity stability test. Here, you set up in a tall plank position with your hands 36 inches apart. You then reach one hand across, tap the back of your other hand, return it to the starting position, and then repeat on the other side.
You perform this alternating movement, trying to complete as many repetitions as possible for 3 sets of 15 seconds, resting 45 seconds between sets. There is data from a couple of studies that determined an average between 3 sets of ≥21 touches is considered a passing score.
The purpose of using criteria and various tests for determining your readiness is to make sure you are adequately prepared for your sport, rather than relying solely on the passage of time.
For example, in a 2021 study, researchers found that in a small cohort of 36 athletes who underwent Bankart repair, those who passed a criteria-based return to sport testing protocol had a lower rate of recurrent instability than those cleared to return based on time.
Finally, keep in mind that even after you are cleared to return to sport or activity, you should (1) continue to perform the shoulder exercises I reviewed earlier and (2) expect this process to take time.
It is going to require a gradual increase in the intensity, volume, and complexity of your training until you are back at your preinjury level or higher.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Shoulder Resilience Program!
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