Casey D. Taber, M.D.

Total Joint Replacement & Sports Medicine

Metropolitan Methodist Plaza Westover Hills Medical Plaza I

1200 Brooklyn Ave., #320 11212 Hwy 151, #150
San Antonio, Texas 78212 San Antonio, Texas 78251
210.804.5460 210.804.5461
www.tsaog.com

Acute Anterior Shoulder Dislocation

Physical Therapy Protocol
The intent of this protocol is to provide guidelines for rehabilitation following an acute anterior
dislocation. It is not intended to serve as a substitute for clinical decision making. Progression
through each phase of rehabilitation is based on clinical criteria and time frames as appropriate.

Risk of recurrence following first time dislocation:

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• For those 21-30 years old, the main published risk of recurrence is 67%. Some authors
have reported reoccurrence as high as 90%. The most significant risk factors for
recurrent dislocations noted in these studies are age and level of sports participation.
• For those over 30 years old; the risk of published recurrence is 9-14%.
• For adolescents; the recurrence rate is as high as 92%-100%.
• Initial research has shown that external rotation bracing significantly reduces the risk of
recurrent dislocation.
• Research is currently being done to compare recurrent dislocation rates following
immobilization in external rotation, immediate surgery, and conservative rehabilitation.
These options should be discussed thoroughly with your orthopedic physician.
• Traumatic recurrence can further damage cartilage, bone and the rotator cuff.

Physical Therapy :
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• Initiate PT immediately for bracing & instruction in a home exercise program to optimize
return to full function and for prevention of recurrence.

• The following conditions should be ruled out following shoulder dislocation:

• Glenoid bone erosion caused by recurrent dislocations

• Bankart or bony Bankart

• Large Hill-Sachs lesion

• Rotator cuff tear

• Fractures associated with injury

• Axillary nerve or brachial plexopathy

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Bracing & Rehab progression:
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First Time Acute Anterior Dislocation:

• Under 30 years old:
o Donjoy ER brace x 3 weeks to reduce the labrum.
o Sling x 3 weeks if Donjoy ER is not practical.
o Sully brace if patient is returning to immediate activity/skiing.

• Over 30 years old:

o Sling for comfort x 1-2 weeks.
o Sully brace if patient is returning to immediate activity/skiing.
o Progress as tolerated through each phase of rehabilitation. No time restrictions.

Recurrent Dislocation:
• Sling for comfort x 1-2 weeks
• Sully brace if returning to immediate activity/skiing

Phase I – Initial:
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Goals:
• Protect integrity of healing capsular tissue
• Diminish pain and inflammation
• Restore non-painful Range Of Motion (ROM)
• Prevent muscular inhibition / atrophy
• Improve proprioception and dynamic stability

Precautions:
• Sling/brace per above guidelines
• ROM limits
o Avoid “throwing position” for 8 weeks for anterior dislocation
(abduction/ER)

Exercises:
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ROM
• Active Elbow, wrist and hand ROM (no resistance)
• Pendulums
• Active Assisted/Active ROM
o Flexion
o External rotation in scapular plane or at side
o Internal rotation – no limits
o Gentle Isometrics: IR, ER, Flexion, Extension (submax/painfree)

Strength
• Progress Dynamic Resistive Exercises (resistive tubing, light free weights)
o UBEE as tolerated – no hiking of shoulder allowed
o External Rotation
o Internal Rotation
o Forward Punch
o Rows
o Standing Shoulder Extension
o Biceps Curls
o Triceps

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 o Prone Rows, horizontal adduction, extension
o Push-ups with a plus on to table

Proprioception
• Initial Proprioception Exercises
• Rhythmic stabilization drills
• ER/IR with arm at 90° of abduction limiting ER

Criteria for progression to next phase:

• Full AROM and PROM
• Dynamic rotator cuff strength 80% of uninvolved side
• Able to perform all strengthening exercises with proper form and minimal pain
• Demonstrates proper muscle firing patterns of scapular and shoulder stabilizers
• Demonstrates proprioceptive control

Phase III – Advanced Strengthening:

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Goals:
• Prepare for return to activity
• Restoration of dynamic muscle strength
• Optimize neuromuscular control and proprioception
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Precautions:
• Avoid the throwing position (abduction/ER)

Exercises:
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ROM
o Continue stretching where limitations exist except in throwing position

STRENGTHENING
• Progress Resistive Exercises
o ER/IR at varying elevations
o Timed bouts 30-90 seconds
o Eccentric ER training
o PNF D2 pattern with rhythmic stabilization
o Strengthening at end ranges allowed
o Push-up progression
• Kneeling
• Full push-up
• Push-up on swiss ball
• Begin throwing progression
• Weights (if rotator cuff strength is sufficient)
o Keep arms and elbows in site at all times
o No wide arm pressing
o No behind the head lateral pulls or military press

Plyometric Drills
• Controlled trampoline ball toss
• Wall dribbles
• Chest pass throw
• Soccer throws
• Deceleration drill

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Criteria for progression to the next phase (IV):
• Full pain free ROM
• Satisfactory clinical exam
• Strength 100% in all directions

Phase IV – Return to Activity:

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Goals/Criteria for full return to sports:

• Maintain optimal level of strength/endurance/dynamic stability
• Progress activity level to prepare for sports

Continue all exercises from phase III

Consider bracing for return to contact sport
No contact sports until 8 weeks post-injury
Return to practice with interval program

References:
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Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents. J Shoulder Elbow Surg
2000;9:470-474

Hoelen MA, Burgers AMJ, Rozing PM. Prognosis of primary anterior dislocation in young adults. Arch
Orthop Trauma Surg 1990; 110:51-54.

Hovelius L, Anterior dislocation of the shoulder in teen-agers and young adults. Five-year prognosis. J
Bone Joint Surg 1987m,69:393-399.

Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A
ten-year prospective study. J Bone Joint Surg 1996;78:1677-1684.

Hovelius L, Eriksson K, Fredin H et al. Recurrence after initial dislocation of the shoulder. Results of a
prospective stud of treatment. J Bone Joint Surg 1983;65:343-349.

Itoi E, Hatakeyama Y, Kido T. A new method of immobilization after traumatic anterior dislocation of the
shoulder: a preliminary study. J Shoulder Elbow Surg 2003;84:12:413-415.

Marans HJ, Angel KR, Schmeitsch EH et al. The fate of traumatic anterior shoulder dislocation of the
shoulder in children. J Bone Joint Surg 1992; 74: 1242-1244

Simonet WT,Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;12:19-24

Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and
physical examination findings in first-time, traumatic anterior dislocations. Am J sports Med 1997;25:306-
311.

Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic
glenohumeral instability. North American J sports Phys Ther 2006;1:16-31.