3 Common Mistakes in Shoulder Instability Rehab

Strength gains don’t always equal confidence and control in atraumatic shoulder instability, which can leave patients and physios feeling stuck.

What do you do when the patient does the exercises, strength improves, yet the shoulder still feels unreliable? Anju Jaggi’s Case Study gives us valuable insight into effective rehab and shows how easily progress can stall when key details in rehab aren’t considered. This blog outlines some takeaways from the case, with 3 mistakes to avoid in your rehab of atraumatic shoulder instability.

If you want to see exactly how an expert physio assessed and managed her patient with atraumatic shoulder instability, check out Anju Jaggi’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

Background

The case involved a 16-year-old female dancer with atraumatic anterior–inferior shoulder instability.

Her first dislocation occurred while reaching for a light switch, followed by a second episode during a double cartwheel. Between episodes, there was an ongoing ache and she became increasingly cautious in how she used her arm. Previous physiotherapy had focused on band-based exercises and electrotherapy, with little benefit.

Classification was the first step in guiding management. Identifying the direction of instability and the presence of hyperlaxity helped inform exercise selection, progression, and patient education. For atraumatic instability, conservative management is recommended. See Anju describe the classification of shoulder instability in the clip below from her Case Study:

Mistake #1: Not considering the impact of positioning on exercise prescription

Many shoulder exercises target the right muscles, but the way they are positioned can dramatically change how those muscles behave. In atraumatic shoulder instability, this detail matters.

Exercise prescription in this case focused on balancing the strength of the shoulder girdle, including the rotator cuff, deltoid, scapular, and thoracic muscles. However, simply selecting these exercises was not enough.

The position of the limb and the plane of movement influenced not only the demands on certain muscle groups (for example, the posterior cuff acting as a stabiliser or a mover) but also the patient’s apprehension. By adjusting exercise positioning, the same movement can work the musculature in different ways. See Anju break this down in this video from her Case Study:

Mistake #2: Not properly addressing the impact of apprehension and fear

Apprehension in shoulder instability is not just a psychological add-on. It directly influences how the shoulder moves and how muscles are recruited.

This patient was understandably wary of using her arm following repeated dislocations. That caution shaped her movement strategies, often more than pain did. Rehabilitation therefore needed to address fear and confidence alongside physical capacity.

To address this in exercise prescription, Anju suggests some practical strategies such as de-weighting or supporting the limb, starting in a prone position (for anterior apprehension), and using distracting tasks (particularly for those with muscle patterning and over-guarding issues). See Anju demonstrate the effectiveness of adding support in this clip from her Case Study:

Anju also highlights the importance of patient education and reassurance. For her, it’s not just an adjunct; it forms the foundation of treatment – and the patient herself noted the utility of the education that had been provided in her rehab.

Education included reviewing imaging and explaining why conservative care was the preferred approach, helping to reduce fear and build confidence. This foundation allowed the patient to engage more fully in graded exposure exercises, progressing toward positions of instability with a sense of control rather than avoidance.

Mistake #3: Too many sessions

This may not be something your clinic director wants to hear, but it’s the way the research is heading!

Sometimes patients with atraumatic shoulder instability end up attending numerous physiotherapy sessions without meaningful progress. This can happen when treatment becomes focused on simply “doing more” rather than progressing exercises in a way that challenges instability safely and builds confidence and self-efficacy.

Overreliance on repeated sessions without clear milestones can reinforce fear and avoidance rather than reduce it. Anju notes that patients typically need around 4–6 sessions but some patients can be more self-led. In this case, the patient only needed 2 supervised sessions because she was able to be self-led using the Derby Shoulder Instability Program – a tool Anju frequently uses and adjusts according to each patient. If you’ve never seen it, make sure you check it out!

The focus should be on purposeful graded exposure to positions of instability, gradually increasing speed and load as confidence grows, all while encouraging patients to stay engaged in their meaningful activities rather than relying solely on the clinic.

Wrapping up

Many people with atraumatic shoulder instability can achieve good clinical outcomes within six months when conservative management is applied thoughtfully.

For physiotherapists, the key message is that effective rehab is rarely about adding more exercises. It’s about understanding the type of instability you’re dealing with, paying close attention to how exercises are performed and prioritising quality over quantity in treatment.

See exactly how Anju managed this case from beginning to discharge, watch her full Case Study here.