Unique Multi-Directional Shoulder Instability in a Collegiate Hockey

Player: A Case Study

Johnson BZ*, Public JQ: *Weber State University
Background: This report deals with the treatment of a 21 YO male
collegiate hockey forward, dislocated his left shoulder in 2007 by getting
checked and landing on it. Immediate pain was noted in the anterior surface
of the shoulder, but no swelling. Differential Diagnosis: In this case,
possible injuries included an acromioclavicular sprain, a labral tear, a glenohumeral dislocation, and strains of the musculature surrounding the shoulder
Treatment: Following additional dislocations in 2009, the subject went in for
x-rays, which turned up negative. In 2011, the subject began his own selfprescribed rehabilitation protocol bases around strengthening the
musculature of the shoulder, no immobilization was done. No further
treatment was reported Uniqueness: After the x-rays in 2009, the subject
sought no further medical attention, despite several recurrent dislocations to
each shoulder. The laxity in the left shoulder is so great, dislocations are
experienced while performing the arm-swing of the box jump exercise. The
subject can dislocate upon command. The subject also performed his own
rehabilitation protocol, which did not progress or change from 2011 to
present. Conclusions: Early joint mobility and non-progressive resistance
training rehabilitation have minimal effect in preventing recurrent glenohumeral dislocations. Word Count: 214

Bo Johnson
Dr. Herzog
MSAT 6541
10-19-14
Unique Multi-Directional Shoulder Instability in a Collegiate Hockey Player: A
Case Study
Hockey is a sport that sees a lot of injuries due to its collision-like
nature.1 Over 50% of all injuries in hockey happen as a result of contact with
another player.2,3 Gleno-humeral dislocations are one of the most common
shoulder injuries in hockey as well.1-3 As a forward for Weber State
Universitys hockey team, the subject of this case report (height of 1.79cm,
weight of 96kg at 21 years old) has suffered recurrent left and right glenohumeral dislocations over the span of several years, all the while seeking no
medical attention and performing self-prescribed rehabilitation. The purpose
of this case study is to review the literature surrounding gleno-humeral
dislocations and compare the efficacy of traditional rehabilitation protocols
with the subjects self-prescribed protocol. The controversy and uniqueness is
that the subjects gleno-humeral joint is so loose that is dislocates during
swinging motions of exercises such as the box jump

The gleno-humeral joint is the most unstable joint in the body and
therefore is the most commonly dislocated joint.4-6 Anterior dislocations
account for over 90% of all dislocations of the gleno-humeral joint.4,7 Once an
initial dislocation takes place, the chances of additional dislocations increase
to over 50%.5,7 Several conditions exist that can predispose an individual to
recurrent gleno-humeral dislocations, including capsular laxity, labral
detachment, and bony defects.7-9 Dislocations most often occur from falling
or impact in which the arm is flexed and abducted.4 If significant tearing
occurs, arthroscopic surgery has been shown to be a valid and effective
method of repair for any significant damage that may occur.8-17 After
dislocation, common rehabilitation protocols dictate that the affected
shoulder be immobilized for a period of 3-6 weeks, followed by multidirection resistance training in order to strengthen the musculature
surrounding the gleno-humeral joint.4,18 This rehabilitation process begins
with isometric exercises and progresses into sports specific exercises. The
rehabilitation process usually lasts a few months.4,18
In September of 2007, a 14 year old male high school athlete dislocated
his left gleno-humeral joint in a hockey game. The subject reported getting
checked into the glass and falling awkwardly onto his horizontally adducted
shoulder. The subject reported feeling immense pain as the gleno-humeral
joint dislocated in an anterior direction. The gleno-humeral joint was
immediately relocated and pain ceased. Two years later, at the age of 16,
the subject reported dislocating his shoulder 2-3 more times, this time

resulting from impact and hitting other players, once more all dislocating in
an anterior direction. Between the ages of 16 and 18, the left gleno-humeral
joint would dislocate occasionally from getting checked in hockey or from
falling. At the age of 18, the subject reported his left gleno-humeral joint
being very loose, to the point of dislocating in multiple directions just from
swinging his arms, like in counter-arm movement of a box-jump. During the
age of 18, the subject reported also dislocating his right gleno-humeral joint,
although it was self reported as not as severe as the left one. Between the
ages of 18 to 21, the subject reported dislocating each gleno-humeral joint
dozens of times.
The chief complaint was pain in the gleno-humeral joint since the initial
dislocation at the age of 14. Currently, the gleno-humeral joint only becomes
painful immediately after a dislocation and remains sore through the next
24-48 hours. Occasionally, it is reported that the subject cannot sleep in a
side-lying position on the affected side due to soreness. This phenomenon
increases in occurrence immediately after a dislocation. The subject also
reported a sensation of both gleno-humeral joints (but mainly the left glenohumeral joint) being stuck when going from horizontal abduction to
horizontal adduction, and vice-versa.
After the initial dislocation of the right gleno-humeral joint at the age of
16, the subject went to the hospital for medical attention. The left and right
gleno-humeral joints were x-rayed and revealed that no fracture were

present. The subject sought no further medical attention after the initial xrays. There was no corrective surgery and no consultation with a medical
professional, until September of 2014.
Upon examination in September of 2014 by a certified athletic trainer, the
subjects musculature was at full strength. Manual muscle testing revealed
full strength (5/5) of the subscapularis, supra and infraspinatus, teres minor,
latissimus dorsi, pectoralis major, and the posterior, middle and anterior
deltoids. Instability testing of the gleno-humeral joint revealed hypermobility
(3/4) in the anterior direction. The subject also had a positive finding with the
apprehension test. Differential diagnoses that were ruled out were acromioclavicular sprain (no drop-step deformity, negative piano sign) strained
musculature (manual muscle testing) and a torn labrum ( negative clunk,
negative crank, no clicking or popping with pain).
Because no further consultation with a medical care professional took
place, no course of treatment was prescribed. At the age of 18, the subject
performed his own self-prescribed rehabilitation program with the goal of
increasing the strength of the musculature that surrounded the glenohumeral joint. Since 2011, his rehabilitation program has stayed the same.
With approximately 15-20 pounds of resistance, he performed 3 sets of 15
repetitions of the following directions: internal rotation, external rotation,
flexion, extension, abduction and adduction of the gleno-humeral joint. He
performed this rehabilitation protocol 3-4 times per week before resistance

training. Since beginning this rehabilitation protocol, the subject reported

that he feels stronger and more stable, though the dislocation phenomenon
still occurs frequently and during exercises such as box jumps. It was also
self-reported that when this rehabilitation protocol is not followed for 2-3
weeks, the gleno-humeral joint felt significantly weaker. In order to prevent
further dislocations during hockey games, kinesio tape was applied in order
to stabilize the head of the humerus within the glenoid fossae.
What makes this case study unique is the fact that after the initial x-rays
was taken, no further medical care was sought out. The subject has been
performing the same rehabilitation routine since 2011 and continues to
experience frequent anterior and inferior dislocations of the gleno-humeral
joint. This multi-directional instability has also led to dislocations occurring
during the swinging motion of the arms during the box jump.
Literature suggests that the most effective nonoperative means of
preventing future dislocations after the initial occurrence follow a specific 3step protocol. The first step involves immobilizing the affected shoulder for a
period of 2-6 weeks in order to prevent further trauma to the site. Once this
immobilization period is over, protocols usually shift to step 2, which
revolves around restoring range of motion and isometric strength of the
musculature surrounding the shoulder. This step 2 usually lasts from week 46 to weeks 8-12. Step three is when the rehabilitation protocol focuses on
returning to play by focusing the rehabilitation on strength through a full

range of motion, power, etc. This last step can last up to 4 months,
depending upon the demands of the sports. Individuals who follow this
protocol report fewer dislocation phenomenon.
In conclusion, the subjects gleno-humeral instability could have been
managed better so that fewer dislocations took place. While the selfprescribed rehabilitation protocol might have been effective in preventing
further dislocation phenomenon, a period of immobilization followed by a
more progressive rehabilitation protocol has been shown to have excellent
efficacy in preventing further trauma. From this case study, we can take
away that shoulder dislocations should be more diligently cared for so that
repeat trauma to the gleno-humeral joint happens less often.

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