Non-Operative — Posterior Shoulder Instability (Non-Operative)

Orthopedic & Sports Medicine Specialists (OSMS)

Weight-Bearing

Not brace/immobilizer-based; progression is criterion-based across 5 phases and may overlap between adjacent phases depending on individual progress

Key Restrictions

Caution against undue stress on posterior joint capsule during Phase I-II dynamic stability exercises; limit degrees of IR during prone/side-lying ER work to protect posterior capsule; isokinetic testing prerequisite strength (5-10 lbs ER, 15-20 lbs IR) required before Phase II testing; avoid excessive stress on anterior capsule during military press Phase IV

Timeline & Phases

Phase I: modalities as needed (heat/ice/e-stim), PROM/AAROM for flexion/abduction/horizontal abduction/ER/IR, anterior cuff/capsule stretch, joint mobilization (anterior glide emphasis), active ER 0 to full ROM with tubing (isometrics if painful, progressing to free weights prone at 90 deg abduction or side-lying), active IR full ER to 0 with tubing (limiting IR degrees to protect posterior capsule), supraspinatus exercise in scapular plane if 0-90 deg ROM available, active flexion through available ROM, active abduction to 90 deg, shoulder shrug (avoiding traction between reps), active horizontal abduction prone (45 deg horizontal adduction to full horizontal abduction), forearm strengthening; Phase II: continue anterior cuff/capsule stretch/mobilization/ROM, continue RTC/posterior deltoid strengthening with tubing/free weights (eccentric emphasis), arm ergometer endurance, push-ups (wall progressing to floor, 80-90 deg abduction, caution on ascent phase), isokinetic strength/endurance test (ER/IR at side, horizontal abduction, abduction/adduction) once prerequisite strength met, active IR with free weights supine, horizontal abduction through increased range, total body conditioning with flexibility; Phase III (criteria: full nonpainful ROM, no tenderness, continued resistive progression): continue anterior capsule stretching and eccentric RTC emphasis, continue arm ergometer, add military press, isokinetic strengthening/endurance at high speeds (200+ deg/sec) for IR/ER at side, isokinetic horizontal abduction/adduction and flexion/extension/abduction/adduction as needed, second isokinetic test requiring >=80% strength/endurance vs. uninvolved side before activity-specific exercises, total body conditioning emphasizing RTC/posterior deltoid, PNF initiation, rhythmic stabilization drills, continued modalities; Phase IV, Advanced Strengthening (criteria: full ROM, no pain/tenderness, satisfactory isokinetic test/clinical exam): improve strength/power/endurance and neuromuscular control, capsular stretches for joint imbalances, continued modalities, continued isotonic/eccentric strengthening, PNF emphasis, initial isokinetics (flexion-extension, abduction-adduction, IR-ER, horizontal abduction/adduction), initiate plyometric training (tubing, wall push-ups, medicine ball, boxes), initiate military press (avoiding excessive anterior capsule stress); Phase V, Return to Activity (criteria met from Phase IV): maintain strength/power/endurance, progressively increase activity level for full functional return, continue Phase IV exercises and capsular stretches, initiate interval program, continue modalities, follow-up isokinetic testing and interval program progression, exercise maintenance

Notes

OSMS Rehabilitation Guidelines; for nonsurgical or in-season rehabilitation of multidirectional glenohumeral instability; rehabilitation length varies by instability degree/laxity, acute vs. chronic presentation, immobilization duration, strength/ROM status, and activity demands; visit frequency determined jointly by patient/therapist/athletic trainer; persistent instability may warrant surgical evaluation