Shoulder Instability Case Study: Real-World Expert Tips

When a young woman walked into expert shoulder physio Ellie Richardson’s clinic after years of shoulder instability, she wasn’t just dealing with functional issues, she was carrying frustration, fear, and a sense that her shoulder couldn’t be trusted anymore.

In this comprehensive Case Study, Ellie opens the doors to her clinic and shares exactly how she tackles one of physio’s trickiest challenges – chronic shoulder instability. From treatment decision making and carefully planned prehab to post-surgical recovery, you’ll see how she used smart assessment, thoughtful progressions, and a whole lot of clinical reasoning to guide her patient back to control and confidence. This blog gives you a sneak peek into Ellie’s invaluable insights, focusing on the initial assessment and prehabilitation.

If you’d like to see exactly how Ellie managed her patient, from treatment decisions to tailored post-surgical rehabilitation, watch her full Case Study HERE.

Initial assessment and decision making

Subjective assessment

Firstly, Ellie emphasises that understanding the patient’s clinical history is essential, not just for understanding the problem, but for shaping communication, goal setting, and clinical decision-making. In this case, the patient had experienced more than one episode of anterior dislocation, and felt her surgical management had been “incomplete” in the past.

A useful tool in the subjective assessment is the ICE framework – exploring the patient’s Ideas, Concerns, and Expectations about her condition and recovery. This is especially valuable in instability cases where fear and hesitation often play a large role in function.

Another important part of the subjective is identifying the type of instability using the Polar Classification:

• Type I (traumatic structural)
• Type II (atraumatic structural)
• Type III (muscle patterning/neurological dysfunction)

Recognising the likely category can help tailor treatment pathways and even influence expectations around surgical outcomes.

Objective assessment

Given the depth of the subjective history, Ellie’s objective assessment in the first appointment was brief, and prioritised only a few assessments to understand the patient’s baseline. This included:

• Beighton score: borderline hypermobility (4/9).
• Apprehension signs: during external rotation (ER) and ER with abduction (ER/ABD).
• Range of Motion (ROM): Passive range exceeded active, indicating no true stiffness.
• Supine internal rotation (IR) and hand-behind-back (HBB) tests, both showing restricted mobility.
• Isometric strength testing (ER and abduction): Ellie notes that in the first assessment, these are unlikely to be a true measure of peak force, but rather a measure of how comfortable the patient is with producing force.
• Prone capacity assessment. Watch Ellie demonstrate in this clip from her Case Study:

Altogether, this initial assessment helped Ellie pinpoint not only the mechanical impairments, but also the patient’s functional limitations and apprehension, all of which shaped her early treatment decisions.

Initial prehabilitation

With the assessment complete, Ellie began a carefully structured prehabilitation program designed to address both the physical impairments and the patient’s high level of apprehension. The early phase of rehab focused on restoring confidence in movement. The key areas Ellie identified which needed to be addressed were:

• Apprehension in ER/ABD: Building tolerance and confidence in these provocative positions was Ellie’s top priority. This was done progressively, with low-load isometrics and controlled movement exposure.
• Through-range IR: Improving IR mobility, especially in positions like hand-behind-back, helped restore daily function.
• Isometric ER: Targeted isometric loading of the rotator cuff provided a safe entry point for building strength in unstable ranges.
• Prone shoulder capacity work: Continued from her assessment findings, this helped isolate and work required muscle groups to improve shoulder stability and mobility.
• WOSI (Western Ontario Shoulder Instability Index): Special focus was placed on the emotional domain, acknowledging the significant fear and frustration that can come with failed surgeries and chronic instability.

Watch Ellie demonstrate some great initial ER exercises she prescribed, and what she progressed to in the intermediate prehab stage in the below videos from her Case Study:

Additionally, Ellie used clinical checkpoints throughout prehab to make sure the patient was improving, and to guide decisions about rehab progression, what she used was:

• WOSI
• Strength (hand held dynamometry)
• ROM

This prehab phase wasn’t just about movement, it was about re-establishing the patient’s trust in her shoulder. By focusing on achievable, measurable goals and progressing load sensibly, Ellie laid a strong foundation ahead of surgery.

Wrapping up

By the end of prehabilitation, the patient had already made measurable gains in confidence, strength, and movement control, all important factors heading into surgery. Through thoughtful loading, clear communication, and frequent checkpoints, Ellie created a rehab environment that felt safe, empowering, and effective. The result? A stronger, more resilient patient heading into surgery – physically and mentally prepared for the next stage of recovery.

But of course, prehab is only half the story… You’ll definitely want to see how Ellie guided her patient through post-surgical rehabilitation, from early protection and progressive loading to restoring full function. Watch Ellie’s full Case Study HERE.