Multidirection Instability (MDI) Protocol

Multidirectional instability (MDI) of the shoulder is characterized by symptomatic subluxation or dislocation in more than one direction (anterior, posterior, or inferior). When conservative management fails, surgical intervention—typically an arthroscopic capsular shift or plication—is performed to reduce capsular volume and tighten the joint. This post-operative rehabilitation protocol is designed to protect the repair while systematically restoring range of motion, strength, and neuromuscular control to ensure long-term shoulder stability.

Phase I: Protection & Early Range of Motion (Weeks 0-6)

The primary focus of this phase is to protect the capsular repair and allow the tightened tissue to heal while preventing joint stiffness and muscle atrophy.

• Goals:
  • Protect the capsular shift/plication repair
  • Minimize post-operative pain and inflammation
  • Initiate early, protected range of motion (ROM) within safe limits
  • Maintain distal extremity mobility and initiate light scapular activation
• Precautions & Restrictions:
  • Sling with abduction pillow must be worn at all times (including sleep) except during hygiene and physical therapy exercises.
  • Strictly avoid active shoulder elevation (flexion or abduction).
  • Limit external rotation (ER) to neutral or 20 degrees in the scapular plane to prevent anterior capsular stress.
  • Avoid extension past neutral to protect the anterior capsule.
  • No lifting, pushing, or pulling with the surgical arm.
• Suggested Exercises:
  • Active range of motion (AROM) of the elbow, wrist, and hand.
  • Pendulum exercises (gentle circles) for joint lubrication.
  • Passive and active-assisted range of motion (PROM/AAROM) in the scapular plane: Flexion limited to 90 degrees, Abduction limited to 90 degrees, and External Rotation limited to 0–20 degrees.
  • Scapular shrugs, retractions, and depression in the sling.
  • Submaximal, pain-free shoulder isometric exercises in neutral rotation (flexion, extension, abduction, adduction, internal/external rotation).
• Criteria to Progress:
  • Minimal resting pain and well-controlled inflammation.
  • Passive shoulder flexion to 90 degrees.
  • Passive external rotation to 20 degrees.
  • Demonstrated compliance with sling wear and motion restrictions.

Phase II: Progressive ROM & Core Stabilization (Weeks 6-12)

During this phase, the sling is discontinued, active range of motion is introduced, and progressive scapulothoracic and rotator cuff stabilization is initiated.

• Goals:
  • Gradually discontinue sling use (usually completed by week 6-8).
  • Restore full active and passive range of motion by week 12.
  • Establish proper scapulohumeral rhythm during active movement.
  • Initiate light, progressive rotator cuff and scapular strengthening.
• Precautions & Restrictions:
  • Avoid sudden, jerky movements or lifting objects heavier than 5 pounds.
  • Avoid aggressive terminal stretching, especially into combined abduction and external rotation (the "high-five" position).
  • Do not push past the point of pain or fatigue to prevent capsular stretching.
• Suggested Exercises:
  • Discontinue sling use under supervision; transition to active-assisted and then active range of motion (AROM) in all planes.
  • Active-assisted shoulder flexion and abduction using a wand or pulleys, progressing to active motion as tolerated.
  • Rotator cuff strengthening: submaximal internal and external rotation exercises using resistance bands or light dumbbells, performed in the scapular plane.
  • Scapular strengthening: rows, shrugs, punches (serratus anterior press), and extension exercises.
  • Closed-chain stabilization exercises: wall slides, table-top weight shifts, and quadruped rocking to stimulate proprioceptors.
• Criteria to Progress:
  • Full, pain-free active range of motion (AROM) in flexion and abduction.
  • Normal scapulohumeral rhythm without compensatory shoulder shrugging.
  • Pain-free execution of light resistance exercises.
  • Stable shoulder during daily activities without sensation of subluxation.

Phase III: Dynamic Strengthening & Neuromuscular Control (Weeks 12-18+)

This phase emphasizes restoring maximum strength, dynamic stability, and neuromuscular control to prepare the patient for a return to sports or demanding manual labor.

• Goals:
  • Restore normal shoulder strength and endurance in all planes.
  • Optimize dynamic stability of the rotator cuff and scapular stabilizers.
  • Enhance proprioception and joint position sense.
  • Prepare for a safe, gradual return to recreational activities and manual tasks.
• Precautions & Restrictions:
  • Avoid overhead activities or heavy lifting if poor mechanics are present.
  • Monitor closely for any signs of fatigue-induced subluxation or instability.
  • Avoid high-stress positions (e.g., heavy bench press, deep dips, behind-the-neck pulldowns).
• Suggested Exercises:
  • Progressive resistance exercises (PREs) for the rotator cuff and scapular stabilizers (e.g., resisted internal/external rotation, lateral raises, front raises, rows, and lat pulldowns modified to stay in front of the head).
  • Dynamic stabilization and neuromuscular control drills: perturbation training (holding a ball or stick while the therapist applies resistance), PNF (proprioceptive neuromuscular facilitation) patterns.
  • Advanced closed-chain exercises: plank variations, light push-up plus (on wall or incline, progressing to floor).
  • Proprioceptive exercises: ball tosses against a wall, balloon tapping, and bodyweight weight-bearing exercises.
  • Introduction of light, sport-specific or work-specific activities at the end of this phase (e.g., light throwing, swimming strokes, or tool handling).
• Criteria to Progress:
  • Full, pain-free range of motion with excellent stability.
  • Shoulder strength of at least 80-90% compared to the uninvolved side.
  • No subjective reports of instability, subluxation, or apprehension.
  • Surgeon clearance for discharge to independent home program or return to sport.

These guidelines represent a standard rehabilitation protocol. Individual recovery rates vary significantly depending on the size of the repair, bone/tissue quality, and general patient health. Your surgeon 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.