Shoulder Instability Repair (Anterior or Posterior Procedures)

Phase 1 · 0–6 weeks after surgery

NOTE: Initial PT eval 1–3 days after surgery

Goals

• Control pain and swelling
• Protect the surgical repair
• Achieve UE stages of ROM goals (DO NOT exceed)
• Initiate scapular control and motion
• Educate patient about post-operative precautions
  • Monitor patient's use of arm for ADLs and school/work activities that may cause increased pain
  • Hypersensitivity in axillary nerve distribution is common
  • Educate about environmental/fall risks while wearing sling

Precautions

• Sling full-time for 4 weeks, then wean by 6 weeks post-surgery

Range of motion goals

Week	Forward Flexion	ER / Scaption	IR / Scaption	ABD
Week 1–2	< 90°	15°–20° @ 30°	45° @ 0°	30°
Week 3–4	< 90°	30° @ 40°	60° @ 0°	60°–80°
Week 5–6	< 90° (120° with increasing hypomobility)	45° @ 50°	45° @ 0°	≤ 90°

NOTE: If posterior surgical procedures performed, refer to included addendum for Phases 1–3

Wound care

• Post-op dressing removed at PT eval
• Shower at post-op day #3
• Submerge in water after wound is fully healed
• Suture removal @ 7–14 days post-op by Ortho

Modalities

• Cryotherapy
  • Hourly for 15 minutes for the first 24 hours after sensation is restored from nerve block
  • Continue use until acute inflammation is controlled
  • Once controlled, use 3x per day for 15 minutes or longer as tolerated
• Soft tissue mobilization and other integrative medicine techniques
  • Soft tissues/trigger point work to the kinetic chain (i.e. cervical spine, scapular, and forearm)

Rehabilitation

• Frequent use of cryotherapy and/or ice
• Begin scar massage after incision site has healed and scar is formed
• Consider dry needling with avoidance of incision sites (discuss with Ortho)
• Consider blood flow restriction (BFR) on uninvolved arm or LE for physiological benefits at 1–2 weeks from surgery
• As tolerated, progress rehabilitation exercises as wound healing occurs and the inflammatory response decreases
• ~Weeks 1–2 – ROM exercises:
  • Shoulder PROM/AAROM within above ROM guidelines in non-impingement position (i.e. hammer grip)
  • Scapular mobilizations
  • Modified pendulums in sling; progress to full pendulums after 3–5 days
• Strengthening:
  • Hand squeezing exercises
  • Elbow/wrist AROM and grip strengthening with shoulder in neutral position at side
  • Gentle submaximal ("2-finger") shoulder isometrics
  • BFR (elbow FLEX/EXT) on uninvolved arm or LE
• Cardiovascular training:
  • Recumbent bike while wearing sling
  • No running or high-impact activity for aerobic training
• ~Weeks 4–6 – UE strength training: BFR (elbow FLEX/EXT)
• Opposite extremity progressive resistance exercises (PREs)
• LE progressive resistance training
• Cardiovascular training: continue recumbent bike

Follow-up

• Supervised rehab: 1–2x per week
• PT re-eval: ~10–14 days
• Ortho re-eval: ~2 weeks and ~6 weeks

Criteria for progression

• Minimal pain 6 weeks from surgery
• Pain-free ROM:
  • FLEX 90°
  • ER: 45° in scaption
  • ABD: 90°

Phase 2 · 7 to 10–12 weeks after surgery

Goals

• D/C sling
• Achieve staged ROM goals
  • ER at 45° ABD
• Minimize shoulder pain
• Begin to increase strength and endurance
• Increase functional activities

Range of motion goals

Week	Forward Flexion	ER	IR
By 12 weeks	160° or symmetric	60°/90° ABD or symmetric	Full at 90° or symmetric

Precautions

• DO NOT perform stretching significantly beyond staged ROM goals during this phase
• NO push-ups, bench press, pec flys, throwing, or overhead activities
• NO running or high-impact activity for aerobic training

Rehabilitation

• ROM exercises
• Trunk stabilization (NWB)
• Scapular strengthening emphasizing scapular retractors and upward rotators
• Shoulder strength and endurance progression
  • Continue base strengthening/isometrics as needed
  • PREs
  • Increase functional activities
• Modalities PRN
• Cardiovascular training: continue recumbent bike; progress to elliptical (no push/pull with surgical arm) and/or treadmill walking
• Adjunct treatments to consider: BFR on involved arm for AROM and isometric activities, dry needling, cervicothoracic manual therapy, aquatic walking with water at chest level or below (no UE movement or resistance; no swimming)

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: ~10–14 days
• Ortho re-eval: ~12 weeks post-op

Criteria for progression

• Pain-free ROM within stated goals
• Achieve ROM goals to normalize AROM/PROM
• Normal/near-normal scapular stabilization and coordination

Phase 3 · 10–12 weeks to 4–6 months after surgery

Goals

• Normalize AROM/PROM
• Normalize strength, endurance, neuromuscular control, and power
• Gradual increase of stress to capsulo-labral tissues
• Return to sport-specific training/practice
• Perform functional and kinesiological assessment (i.e. FMS)
• Perform initial functional testing (i.e. Closed Kinetic Chain Upper Extremity Stability Test [CKCUEST] and Upper Quarter Y-Balance Test)

Precautions

• No independent or unsupervised overhead, dynamic, resisted, or repetitive activities
• If ROM is severely limited, consideration for surgically assisted release should be addressed at this time

Rehabilitation

• Normalize ROM
• Pain management
• Trunk stabilization (progress to FWB)
• Scapular strengthening emphasizing scapula control in overhead motions
• Shoulder strengthening: continue PREs
• Begin push-up and pull-up progression; progress as symptoms allow
• Cardiovascular training: running progression initiated with pain-free shoulder motion
  • Adjunct treatments to consider: dry needling, cervicothoracic manual therapy, and A/P GH joint mobilizations as indicated (not P/A)

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: 1–3 weeks
• Ortho re-eval: after completion of Phase 3 goals

Testing

• Normalized functional assessment
• Achieve passing score for push-ups
• Consider baseline 90% on Upper Quarter Y-Balance Test and/or 20+ reps on CKCUEST

Phase 4 · 4–6 months after surgery

Goals

• Meet occupational requirements at 4–6 months
• Initiate/continue return to weight training program
• Begin sport-specific training; include initiation of throwing program for overhead athletes

Precautions

• Avoid the following:
  • Wide grip pull downs
  • Behind the neck shoulder press
  • Wide grip bench press
  • Standing lateral deltoid raises
  • Overhead triceps press
• Clearance based upon strength, neuromuscular control/coordination, and functional ROM

Rehabilitation

• Advanced specific, functional, and individualized training to achieve Phase 4 goals (i.e. lift, pull, carry, and climb in unloaded/loaded conditions)
  • Modifications to PREs and base strengthening (manual resistance) as needed
  • Stretching
  • Soft tissue work
  • Interval throwing program (overhead athletes)
  • Return to weight room and strength training
  • Full, pain-free ROM
  • Normal strength in RC and scapular muscles
  • 2–3x per week
  • High repetitions
  • Not to "muscle failure"
  • Gradual increase of stress to capsulo-labral tissues

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: 2–4 weeks
• Ortho re-eval: Upon completion of Phase 4 goals

Testing

• Repeat CKCUEST and/or Upper Quarter Y-Balance Test with > 90% Limb Symmetry Index before returning to unrestricted sport activity

Miscellaneous

• Pass a return-to-sport / fitness test at 6–9 months
• Progress activities for return to sport/collision sports or aggressive physical training (e.g. tactical or military training) based on the patient's functional performance and endurance. This time period will be directed by the Ortho Surgeon and the Physical Therapist. This may require between 6–12 months before cleared without restrictions.

Addendum · posterior procedures

Addendum to Shoulder Instability Rehabilitation (Posterior Surgical Procedures)

Posterior · Phase 1 · 0–6 weeks after surgery

NOTE: Initial PT eval 1–3 days after surgery

Goals

• Control pain and swelling
• Protect the surgical repair
• Achieve UE stages of ROM goals (DO NOT exceed)
• Initiate scapular control and motion
• Educate patient about post-operative precautions
  • Monitor patient's use of arm for ADLs and school/work activities that may cause increased pain
  • Hypersensitivity in axillary nerve distribution is common
  • Educate about environmental/fall risks while wearing sling

Precautions

• Sling full-time for 4 weeks, then wean by 6 weeks post-surgery

Range of motion goals

Week	Forward Flexion	ER / Scaption	IR / Scaption	ABD
Week 1–2	< 90°	15°–20° @ 30°	0°	30°
Week 3–4	< 90°	30° @ 40°	0°	60°–80°
Week 5–6	< 90° (120° with increasing hypomobility)	45° @ 50°	0°	≤ 90°

Wound care

• Post-op dressing removed at PT eval
• Shower at post-op day #3
• Submerge in water after wound is fully healed
• Suture removal @ 7–14 days post-op by Ortho

Modalities

• Cryotherapy
  • Hourly for 15 minutes for the first 24 hours after sensation is restored from nerve block
  • Continue use until acute inflammation is controlled
  • Once controlled, use 3x per day for 15 minutes or longer as tolerated
• Soft tissue mobilization and other integrative medicine techniques
  • Soft tissue/trigger point work to the kinetic chain (i.e. cervical spine, scapular, and forearm)

Rehabilitation

• Frequent use of cryotherapy and/or ice
• Begin scar massage after incision has healed and scar is formed
• Consider dry needling with avoidance of incision sites (discuss with Ortho)
• Consider blood flow restriction (BFR) on uninvolved arm or LE for physiological benefits at 1–2 weeks from surgery
• As tolerated, progress rehabilitation exercises as wound healing occurs and the inflammatory response decreases
• ~Weeks 1–2 – ROM exercises:
  • Shoulder PROM/AAROM within above ROM guidelines in non-impingement position (i.e. hammer grip)
  • Scapular mobilizations
  • Modified pendulums in sling; progress to full pendulums after 3–5 days
• Strengthening:
  • Hand squeezing exercises
  • Elbow/wrist AROM and grip strengthening with shoulder in neutral position at side
  • Gentle submaximal ("2-finger") shoulder isometrics
• BFR (elbow FLEX/EXT) on uninvolved arm or LE
• Cardiovascular training:
  • Recumbent bike while wearing sling
  • No running or high-impact activity for aerobic training
• ~Weeks 4–6 – UE strength training: BFR (elbow FLEX/EXT)
• Opposite extremity progressive resistance exercises (PREs)
• LE progressive resistance training
• Cardiovascular training: continue recumbent bike

Follow-up

• Supervised rehab: 1–2x per week
• PT re-eval: ~10–14 days
• Ortho re-eval: ~2 weeks and ~6 weeks

Criteria for progression

• Minimal pain 6 weeks from surgery
• Pain-free ROM:
  • FLEX 90°
  • ER: 45° in scaption
  • ABD: 90°

Posterior · Phase 2 · 7 to 10–12 weeks after surgery

Goals

• D/C sling
• Achieve staged ROM goals
  • ER at 45° ABD
• Minimize shoulder pain
• Begin to increase strength and endurance
• Increase functional activities

Range of motion goals

Week	Forward Flexion	ER	IR
Weeks 7–9	135°	45°/90° ABD	30°–45°/45° ABD
By 12 weeks	160° or symmetric	60°/90° ABD or symmetric	60°/90° ABD or symmetric

Precautions

• DO NOT perform stretching significantly beyond staged ROM goals during this phase
• NO push-ups, bench press, pec flys, throwing, or overhead activities
• NO running or high-impact activity for aerobic training

Rehabilitation

• ROM exercises
• Trunk stabilization (NWB)
• Scapular strengthening emphasizing scapular retractors and upward rotators
• Shoulder strength and endurance progression
  • Continue base strengthening/isometrics as needed
  • PREs
  • Increase functional activities
• Modalities PRN
• Cardiovascular training: continue recumbent bike; progress to elliptical (no push/pull with surgical arm) and/or treadmill walking
• Adjunct treatments to consider: BFR on involved arm for AROM and isometric activities, dry needling, cervicothoracic manual therapy, aquatic walking with water at chest level or below (no UE movement or resistance; no swimming)

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: 10–14 days
• Ortho re-eval: ~12 weeks post-op

Criteria for progression

• Pain-free ROM within stated goals
• Achieve ROM goals to normalize AROM/PROM
• Normal/near-normal scapular stabilization and coordination

Posterior · Phase 3 · 10–12 weeks to 4–6 months after surgery

SAME AS ABOVE FOR ANTERIOR SURGICAL PROCEDURES

NOTE: With the following changes for REHABILITATION

Rehabilitation

• P/A GH joint mobilizations only as indicated (not A/P)
• Initiate push-up progression at 16 weeks

References

• Chmielewski TL, Martin C, Lentz TA, Tillman SM, Moser MW, Farmer KW, Jaric S. Normalization considerations for using the unilateral seated shot put test in rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(7): 518-24.
• Damkjær L, Petersen T, Juul-Kristensen B. Is the American Society of Shoulder and Elbow Therapists' rehabilitation guideline better than standard care when applied to Bankart-operated patients? A controlled study. Clinical Rehabilitation. 2015; 29(2): 154-64.
• DeFroda SF, Mehta N, Owens BD. Physical therapy protocols for arthroscopic bankart repair. Sports Health. 2018; 10(3): 250-258.
• Gaunt BW, Shaffer MA, Sauers EL, Michener LA, McCluskey III GM, Thigpen CA. The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder. Journal of Orthopaedic & Sports Physical Therapy. 2010; 40(3): 155-68.
• Gibson J, Kerss J, Morgan C, Brownson P. Accelerated rehabilitation after arthroscopic Bankart repair in professional footballers. Shoulder & Elbow. 2016; 8(4): 279-286.
• Ismail MM, El Shorbagy KM. Motions and functional performance after supervised physical therapy program versus home-based program after arthroscopic anterior shoulder stabilization: a randomized clinical trial. Annals of Physical and Rehabilitation Medicine. 2014; 57(6): 353-72.
• Roush JR, Kitamura J, Waits MC. Reference values for the closed kinetic chain upper extremity stability test (CKCUEST) for collegiate baseball players. N Am J Sports Phys Ther. 2007; 2(3): 159–163.
• Shah KM, Baker T, Dingle A, et al. Early development and reliability of the timed functional arm and shoulder test. Journal of Orthopaedic & Sports Physical Therapy. 2017; 47(6): 420-431.
• Tucci, HT, Jaqueline M, Sposito G, Camarini MF, Oliveira AS. Closed kinetic chain upper extremity stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC Musculoskeletal Disorders. 2014; 15(1): 1-9.
• Westrick RB, Miller JM, Carow SD, Gerber JP. Exploration of the y-balance test for assessment of upper quarter closed kinetic chain performance. International Journal of Sports Physical Therapy. 2012; 7(2): 139-47.

Abbreviations

AROM / AAROM / PROM: active / active-assisted / passive range of motion. ROM: range of motion. ER / IR: external / internal rotation. ABD / ADD: abduction / adduction. FLEX / EXT: flexion / extension. WBAT / PWB / TTWB / NWB: weight bearing as tolerated / partial / toe-touch / non-weight bearing. SLR: straight leg raise. HS: hamstrings. ITB: iliotibial band. UE / LE: upper / lower extremity. UBE: upper body ergometer (arm bike). BAPS: balance board. BFR: blood flow restriction training. PREs: progressive resistance exercises. D/C: discontinue. prn: as needed. POD: post-operative day. TENS: transcutaneous electrical nerve stimulation. ADLs: activities of daily living.

Source

Adapted from Defense Health Agency, Tri-Service Post-Operative Rehabilitation Guidelines, "DHA Shoulder Instability Rehab", May 2020, published by William Beaumont Army Medical Center (a work of the U.S. Government in the public domain). Original: DHA Shoulder Instability Rehab.pdf. Army-specific wording in the original (Service fitness test, military training, airborne school) was replaced with civilian equivalents.

This protocol is general guidance for the rehabilitation team and does not replace the specific plan, restrictions and follow-up we set together. Your own situation may differ: if anything here does not match what we talked about, what we talked about wins, so please ask me.

Current version and every other protocol: aaronweymd.com/post-op-protocols