Anterior Instability (Non-Operative) Protocol

Following a first-time anterior shoulder dislocation, a structured non-operative rehabilitation program is essential. When a dislocation occurs, the ligaments and capsule at the front of the joint are stretched or torn. Instead of relying on surgical repair, this protocol focuses on training the dynamic stabilizers of the shoulder (the rotator cuff and periscapular muscles) and restoring proprioception (the body's awareness of joint position) to prevent future instability and support long-term joint health.

Phase I: Protection and Joint Calming (Weeks 0 to 3)

The primary focus of this phase is protecting the healing anterior joint capsule and labrum while managing pain and swelling from the initial injury.

• Goals: Protect healing tissues, control pain and inflammation, prevent muscle shutdown, and maintain safe passive range of motion.
• Precautions & Restrictions: Avoid the combined abduction and external rotation position (the "apprehension position"). Avoid forced extension of the arm behind the body. Wear the sling for comfort as directed, typically weaning off within 1 to 2 weeks.
• Suggested Exercises: Pendulum exercises, submaximal pain-free shoulder isometrics (flexion, abduction, internal rotation, and external rotation with the arm at the side), active range of motion for the elbow, wrist, and hand, and gentle active scapular movements (shrugs, squeezes, and elevation).
• Criteria to Progress: Minimal pain and swelling at rest, passive flexion to 120 degrees tolerated, external rotation to neutral (0 degrees) tolerated with the arm at the side, and pain-free isometric contractions.

Phase II: Restoring ROM and Early Stabilization (Weeks 3 to 6)

During this phase, the sling is discontinued, and the emphasis shifts to restoring active movement and initiating early strengthening of the rotator cuff and scapular muscles.

• Goals: Achieve full non-painful active range of motion, initiate dynamic stabilization of the glenohumeral joint, and re-establish basic scapular control.
• Precautions & Restrictions: Still strictly avoid placing the arm in combined abduction and external rotation. Do not push through sharp pain, catching, or feelings of joint instability.
• Suggested Exercises: Active-assisted and active range of motion (AAROM/AROM) in flexion and abduction within comfortable ranges, resisted rotator cuff strengthening (internal and external rotation using resistance bands, keeping the elbow tucked at the side), scapular strengthening (rows, wall slides), and closed kinetic chain exercises (wall push-ups, quadruped weight shifts) to stimulate joint receptors and proprioception.
• Criteria to Progress: Full pain-free active flexion and internal rotation, active external rotation to 45 degrees (arm at side) without pain, good control of the shoulder blade during active movements, and minimal pain with light resistance exercises.

Phase III: Dynamic Stabilization and Proprioception (Weeks 6 to 12)

This phase focuses on rebuilding muscular strength, endurance, and advanced neuromuscular coordination to stabilize the shoulder during more challenging movements.

• Goals: Restore full range of motion, maximize rotator cuff and scapular muscle strength and endurance, and enhance dynamic stabilization in elevated positions.
• Precautions & Restrictions: Monitor for apprehension or feelings of instability, particularly as the arm approaches the 90/90 position (90 degrees of abduction and 90 degrees of external rotation). Avoid sudden, uncontrolled loads on the front of the shoulder.
• Suggested Exercises: Progressively resisted rotator cuff and scapular strengthening, rhythmic stabilization (gentle manual perturbations or self-applied resistance at various angles of elevation), proprioceptive training (plank variations, push-up plus, dynamic stabilization on unstable surfaces), eccentric rotator cuff training, and light plyometrics (two-handed medicine ball chest passes and ball drops).
• Criteria to Progress: Complete pain-free range of motion, rotator cuff and scapular strength at least 80% to 85% compared to the uninjured side, and no feelings of apprehension or instability in functional ranges.

Phase IV: Advanced Strengthening and Return to Activity (Weeks 12 to 18+)

The final phase focuses on optimizing strength, power, and coordination to prepare the patient for a safe return to sports, recreational activities, or physically demanding work.

• Goals: Maximize shoulder strength, power, and muscle endurance; restore advanced dynamic stability in vulnerable or athletic positions; and achieve a safe transition to full activity.
• Precautions & Restrictions: Ensure a thorough warm-up before any heavy or high-speed activity, avoid exercising to the point of extreme fatigue (which degrades stabilizers), and systematically progress athletic and high-demand tasks.
• Suggested Exercises: Advanced resistance training (dumbbells, kettlebells, or bands in functional movement patterns), sport- or work-specific drill progression (interval throwing programs, overhead sport drills, contact training preparation), and advanced single-arm plyometrics (ball throws, rebounder tosses, and wall dribbles).
• Criteria to Progress/Return to Play: Clear clinical assessment and approval from Dr. Veillette, shoulder strength and endurance matching the uninjured side, no pain or instability symptoms during sport-specific testing, and negative apprehension and relocation signs during clinical exams.

These guidelines represent a standard non-operative rehabilitation protocol. Individual recovery rates vary significantly depending on the severity of the dislocation, any associated tissue injury, and general patient health. Your surgeon or physical therapist may modify this protocol specifically for you.

Disclaimer: This protocol is for educational purposes and is not a substitute for professional medical advice. Always consult your surgeon or physical therapist before performing any exercises or modifying activity restrictions.