Table 1

Inclusion and exclusion criteria

Inclusion criteriaExclusion criteria
Initial phone screening
Reports of shoulder region discomfort, pain or apprehension/guarding with movement
Willingness to participate in a 12-week exercise programme
Age between 12 and 35 years inclusive		History of significant trauma*
History of glenohumeral dislocation that requires relocation†
Prior surgical history of the affected shoulder(s)
Unable to understand and follow instructions in English
MRI
Normal MRI
Normal anatomical variant accepted: labral deficiency, labral recess, glenoid dysplasia
Minor pathologies accepted: bursitis, small rotator cuff tears, labral ‘fraying’		Bony lesion (bony Bankart, Hill Sach's) or fracture
Labral lesions (SLAP, labral Bankart)
Full thickness rotator cuff tears
Full thickness bicep tear
Frank labral tears
Contraindications to MRI (eg, pacemaker, claustrophobia, pregnancy)
Clinical examination screening
Clinically diagnosed MDI, with symptomatic instability in at least 2 directions. The diagnosis of MDI must be defined by apprehension or guarding with the following tests:

  •  A positive‡ sulcus sign

  •  AND

  •  For one direction, at least 2 out of 3 positive for the following tests:

    • Draw test adducted

    • Draw test abducted

    • Apprehension test

The ‘effect of manual correction on scapula biomechanics’ MUST symptomatically improve a participant's abduction range of motion by a minimum of 20°, significantly reduce a participant's pain or guarding in abduction, or improve a participant's strength on an isometric test21 (table 2 and online supplementary appendix 1).		Non-correctable volitional instability
Non-compliance
Neurological motor deficit
Instability due to UMN or LMN lesion
Ehlers-Danlos syndrome/Marfan's syndrome
Shoulder pain that is predominantly due to cervical dysfunction including:

  •  Cervical spine somatic referred pain

  •  Cervical spine radicular pain

  •  Cervical spine radiculopathy

TOS

  • *Significant trauma defined as contact with an external object (such as a fall, impact with another body or surface) with lock out of the glenohumeral joint and conscious awareness by the patient of a sudden onset of pain.

  • †Relocation defined as MUA by a health professional or force applied externally by patient or other person at the time of injury to relocate the glenohumeral joint.

  • ‡To be positive for instability the participant must have apprehension (which may include muscles spasm or guarding) on testing and not just pain or signs of laxity.

  • LMN, lower motor neuron lesion; MUA, manipulation under anesthetic; TOS, thoracic outlet syndrome; UMN, upper motor neuron lesion.