What is Posterior Shoulder Instability

Posterior shoulder instability is one of the most commonly misdiagnosed or not-recognized shoulder pathologies due to its variety of clinical presentations.

According to the ABC Classification different types of posterior shoulder instability can be distinguished based on the underlying pathomechanical principle.[1]

There is structural posterior shoulder instability (Type B2) which is caused by a structural defect e.g. due to trauma and there is functional posterior shoulder instability caused by inappropriate muscle activation without any trauma (Type B1). [2]

Posterior Shoulder Instability rehab

Pathology and Treatment

In patients suffering from functional posterior shoulder instability the humeral head translates excessively due to lack of contraction of stabilizing muscles, provoking a posterior subluxation or dislocation every time the shoulder passes a particular phase of movement.

Common symptoms reported include pain during movement of the arm, a loss of range of motion due to weakness or blockage that inhibits any further movement, as well as a strong feeling of instability that extensively limits shoulder function.

While structural posterior shoulder instability can be addressed surgically, in functional posterior shoulder instability operations should be avoided as there are typically no structural defects that can be addressed and therefore surgery often results in additional pain and further limitation of shoulder function.[3-7]

Regular physiotherapy is the current gold- standard of treatment for patients suffering from functional posterior shoulder instability including tactile biofeedback, coordination and strengthening exercises.[5, 7]
Unfortunately, conventional conservative treatment can often be unsuccessful in achieving a satisfying outcome in affected patients.

How to treat Posterior Shoulder Instability with electrical muscle stimulation treatment

Recent studies showed that patients suffering from functional posterior shoulder instability could benefit from electric muscle stimulation which re-activates the previously hypoactive muscles.[8, 9]

The Neuralign System S (formerly Shoulder Pacemaker™) device is a motion activated electrical muscle stimulator developed to retrain the patients’ muscle pattern in order to treat posterior shoulder instability. In a cohort of patients with previously failed conventional physiotherapy

The Neuralign System S (formerly Shoulder Pacemaker™) therapy concept led to a highly significant improvement of stability, function, as well as pain and several patients were able to return to physically demanding and even athletic activities.

Future assessment includes the beneficial effect of the Neuralign System S (formerly Shoulder Pacemaker™) device treatment in patients suffering from structural shoulder instability during the postoperative rehabilitation phase as well as in patients with combined structural and functional deficiencies.

posterior shoulder instability stimulation protocol


What is the Posterior Shoulder Instability Protocol

Neuralign System S (formerly Shoulder Pacemaker™) protocol for posterior shoulder which is available on MySPM App, consists in a sequence of 9 exercises with different duration and 3-levels of increasing intensity.

The aim of the rehabilitation session is to stimulate hypoactive muscle group throughout the motion exercises established in the protocol, and it has been
developed for:

  • Rehabilitation after acute posterior shoulder subluxation (A1)
  • (postoperative) Rehabilitation after acute posterior shoulder dislocation (A2)
  • Treatment for posterior positional functional shoulder instability (B1)
  • (postoperative) treatment for structural posterior shoulder instability (B2)
  • Prevention of progression of constitutional static posterior shoulder subluxation (C1)
  • (postoperative) prevention of progression for acquired static posterior shoulder subluxation (C2)
  • postoperative rehabilitation after anatomical shoulder arthroplasty with B or C glenoids




Electrode positioning for Posterior Scapular instability Protocol

To make sure that the motion exercises will be effective, the electrodes must be positioned correctly in the area of the nerve supplying the hypoactive muscles:

  • The first electrode should be placed inferior to the spina scapulae to stimulate the external rotators (infraspinatus, teres minor and posterior deltoid)


  • The second electrode should be placed medially to the margo medialis scapulae to stimulate the scapula retractors (lower trapezius and rhomboids).

Duration of treatment

A minimum 3 sessions of treatment per week over a period of 3 months is suggested. Longer periods of treatment can be indicated.

Protocol Working

How do the exercises in the protocol work?


The Posterior Shoulder Instability protocol includes 9 exercises of vary intensity and duration. Each level contains different exercise types:

  • Concentric exercises
  • Eccentric exercises
  • Functional exercises


This protocol has been developed in collaboration with:

Prof. Philipp Moroder

Heiko van Vliet | International NMES Expert
Rehabilitation, coaching, medical & sport consultant

Prof. Philipp Moroder

Prof Dr. Philipp Moroder | Department of Shoulder and Elbow Surgery
Center for Musculoskeletal Surgery Charité – University, Berlin, Germany


Other Resources of interest

Find other videos un VuMedi! 

  • Shoulder Pacemaker Treatment of Functional Posterior Shoulder Instability
    This video shows a new concept for treatment of functional posterior shoulder instability.
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  • Functional Shoulder Instability: How to Identify the Type of Shoulder Instability? What Treatment Options Are Recommended?
    Instructional video on functional shoulder instability.
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1. Moroder, P. and M. Scheibel, ABC classification of posterior shoulder instability. Obere Extrem, 2017. 12(2): p. 66-74.

2. Moroder, P., et al., Characteristics of functional shoulder instability. J Shoulder Elbow Surg, 2020. 29(1): p. 68-78.

3. Hawkins, R.J., G. Koppert, and G. Johnston, Recurrent posterior instability (subluxation) of the shoulder. J Bone Joint Surg Am, 1984. 66(2): p. 169-74.

4. Huber, H. and C. Gerber, Voluntary subluxation of the shoulder in children. A long-term follow-up study of 36 shoulders. J Bone Joint Surg Br, 1994. 76(1): p. 118-22.

5. Jaggi, A. and S. Lambert, Rehabilitation for shoulder instability. Br J Sports Med, 2010. 44(5): p. 333-40.

6. Kuroda, S., et al., The natural course of atraumatic shoulder instability. J Shoulder Elbow Surg, 2001. 10(2): p. 100-4.

7. Takwale, V.J., P. Calvert, and H. Rattue, Involuntary positional instability of the shoulder in adolescents and young adults. Is there any benefit from treatment? J Bone Joint Surg Br, 2000. 82(5): p. 719-23.

8. Moroder, P., et al., Use of shoulder pacemaker for treatment of functional shoulder instability: Proof of concept. Obere Extrem, 2017. 12(2): p. 103-108.

9. Moroder, P., et al., The Shoulder Pacemaker treatment concept for posterior positional functional shoulder instability: prospective clinical trial. Am J Sports Med, 2020.

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