Adam Seidl, MD - Board Certified Orthopaedic Surgeon - Shoulder and Elbow Specialist

Adam Seidl, MDBoard Certified Orthopaedic SurgeonShoulder and Elbow Specialist

Multidirectional Instability Reconstruction

Phase I: Protect Repair (0 to 6 weeks)

  • May remove dressing and shower postop day # 3.
  • Sutures are all underneath the skin and will dissolve on their own
  • Ice or cold flow systems encouraged for the first week at a minimum: should be used 3-4 times per day.
  • Sling should be in place when not performing exercises.
  • May start active scapular mobility exercises at 4 weeks – Must keep the shoulder musculature relaxed.
  • Strict ROM restrictions
  • Initiate exercise program 3 times per day:
    1. Immediate elbow, forearm and hand range of motion out of sling Pendulum exercises
    2. Emphasize home program (instruct family member with ROM)
    3. Passive and active assistive ER at the side to 30, flexion and scapular plane elevation to 90 only

Phase II: Progress ROM & Protect Repair (6 to 12 weeks)

  • May discontinue sling.
  • Lifting restriction of 5 pounds with the involved extremity.
  • Initiate gentle rotator cuff strengthening and scapular stabilizer strengthening.
  • Avoid ROM above stated limits.
  • Advance active and passive ROM:
    1. ER at the side and flexion to tolerance
    2. Scapular plane elevation to 130
    3. IR and extension to tolerance

Phase III: Full Function (>3 months)

  • Begin combined abduction with ER and IR ROM and advance capsular mobility (gently).
  • Discontinue lifting restrictions.
  • Advance rotator cuff and scapular stabilizer strengthening.
  • Initiate functional progression to sports specific activities at 4 months.

Multidirectional Instability: Nonoperative Protocol


  • Many patients will have a component of impingement due to improper scapular mechanics and cuff weakness resulting in poor humeral depression
  • All patients will have some degree of scapular dyskinesia


  • Assess patients for impingement type symptoms and scapular dyskinesis.
  • If impingement present then exercises must start in pain free range and progress toward increasing scaption as time progresses
  • Cannot progress through stages until scapula is stable on chest wall

General Principles and Guidelines


  • Restore normal proprioception and movement patterns (especially scapulothoracic)


  • Should be pain free
  • Train muscle groups (force couples) rather than individual muscles
  • Incorporate contralateral therapy Scapula Based Rehabilitation Program
  • Evaluate and correct postural alignment (lumbopelvic, thoracolumbar, scapulothoracic)
  • Clear soft tissue restrictions
  • Establish scapulothoracic stability focusing on scapular position and control

Outpatient Phase 1: (Weeks 1 - 6)


  • Joint mobilization of, AC joint, and scapulothoracic junction
  • Correct any capsular asymmetry through PROM and AROM


  • Correct postural abnormalities and scapular position through muscle reeducation including lumbopelvic and scapulothoracic stability
  • Include anterior chest wall stretching
  • Isometric scapular retraction and depression
  • Trunk extension/scapular retraction
  • Emphasize lower trapezius activation (elbow in back pocket)



  • Begin with closed-chain static and short arc isometrics in pain free range including flexion, abduction, extension, ER and IR
  • Facilitate muscular co-contraction to improve dynamic joint stabilization
  • Progress to isotonic cuff strengthening through wider range of motion
  • Rubber tubing for sidelying internal rotation, sidelying external rotation, prone posterior deltoid, internal rotation and external rotation at 90° abduction, biceps, and triceps
  • Supraspinatus program: flexion, scaption in IR, prone horizontal abduction and press-ups


  • Isometric and eccentric scapular stabilization
  • Rubber tubing for shrugs, retraction, depression, D2 flexion, D2 extension, prone and seated rows, chair press-ups, supine serratus anterior, lat pull downs, push-ups with a plus
  • Scapular clocks with hand stabilized on wall at 90° (elevation, depression, protraction, retraction)
  • Closed chain axial load (ball rolls on table top) to emphasize scapular positioning
  • As healing progresses and ROM


  • Core body strengthening exercises to emphasize lumbopelvic and thoracolumbar stability


  • Decrease pain and inflammation and muscles guarding
  • Teach icing techniques
  • Home exercise program

Functional Phase: (Weeks 7 - 12)


  • Improve strength, power and dynamic stability
  • Advance concentric and stress eccentric cuff strengthening per upper extremity strengthening program
    • Muscle Ratios
    • ER/IR: 65-70%
    • ER/Deltoid: 65-70%
    • Scapular retractor/protractor: 100%
  • Advance eccentric and concentric scapular stabilization
  • Reverse corner pushups, wall angels
  • Lat pull downs with free weights,
  • Push-up plus
  • Scapular punches with various weights and positions
  • Shoulder dumps and diagonal punches with light hand weights
  • Dynamic strengthening at 90-90 position for external and internal rotation
  • Core based muscle synergy
  • Progress PNF patterns
  • Start upper extremity plyometric program


  • Begin upper body ergometers at low resistance and height below 90° and slowly progress to height at 140° flexion

Return to Activity: (Weeks 13 -)

  • Develop sport or work specific ROM
  • Plyometric, neuromuscular control and dynamic stabilization drills
  • Initiate isokinetic rotator cuff strengthening at high speeds for muscular endurance; i.e. 240°/second X 30 second bout with 30 second rest, 300°/second X 30 second bout with 30 second rest, etc.
  • Sport or work specific kinematics and exercises
  • Sport or work specific drills for quickness and agility, endurance and power
  • Return to play

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Location Map

  • Orthopedics - University of Colorado Hospital

    1635 Aurora Ct,4th Floor
    Aurora, CO 80045

  • Highlands Ranch Hospital

    1500 Park Central Dr #401,
    Highlands Ranch,CO 80129

  • UCHealth Steadman Hawkins Clinic Denver

    175 Inverness Drive West, Suite 200,
    Englewood, CO 80112

Credibility Logos

  • The American Board of Orthopaedic Surgery logo
  • American Academy of Orthopedic Surgeons logo
  • American Shoulder And Elbow Surgeons logo
  • Western Orthopaedic Association logo
  • Alpha Omega Alpha
  • Moon Shoulder