Recurring Subluxation Of An Unstable Shoulder In A Collegiate Football

Player: A Case Study

Corey Hall, ATS; Beth Funkhouser, MEd, VATL, ATC, CSCS
Athletic Training Education Program, Emory & Henry College, Emory, Virginia

Abstract
Objective: To present the case of conservative treatment and
rehabilitation of an unstable shoulder with recurrent subluxations
in a National Collegiate Athletic Association Division III football
quarterback.
Background: While attempting to run the football down the field
during a scramble, the athlete switched direction to the left and
landed on his left shoulder. Although the athlete reported that his
shoulder was dislocated, on-field and sideline evaluations led to
the diagnosis of a subluxation. The history of the athlete shows
chronic instability in the injured shoulder.
Differential Diagnosis: Dislocated shoulder.
Setting: Edgar V. Wheeler Athletic Training Room on the campus
of Emory & Henry College.
Treatment: Initially, the shoulder was immobilized in a sling.
Conservative rehabilitation was performed on the injured shoulder.
Uniqueness: Chronic instability is a common issue in overhead
throwing athletes. Many rehabilitation protocols exist for this
condition. There is not one standard rehabilitation protocol for
chronic instability. This condition is often treated properly;
however, more focus should be placed on preventing it.
Conclusions: More research should be done on proper
preventative methods of chronic instability in overhead athletes.
This condition is the cause of many season and career-ending
injuries.
Key Words: shoulder instability, subluxation, conservative
rehabilitation

Introduction
Shoulder instability is characterized by unwanted
translations of the glenohumeral joint. The glenohumeral
joint gives the greatest amount of motion compared to any
joint found in the body. Instability of this joint may be
present in anterior, posterior, inferior, or multidirectional
planes. Recurrent instabilities of the shoulder may occur
after acute subluxation or dislocation. The muscles of the
shoulder complex provide dynamic stabilization to the joint.
Chronic instability in any plane usually occurs in
individuals under the age of 30. Shoulder instability, for a
long time, has been recognized as a cause for many
symptoms in the shoulder, and is commonly seen in
overhead athletes. Overhead athletes must have a proper
balance of flexibility and stability in order to have the
appropriate mobility needed for their sport.1,2
Shoulder instability may be treated surgically or
conservatively. This decision is dependent upon various
factors, such as the mechanism, chronology, and direction
of instability. The rehabilitation remains the same despite
whether the treatment is surgical or nonsurgical because
the healing process of the tissue is the same.3 Surgical
rehabilitation is indicated when conservative management
is not expected to be successful for the individual.
Common complications after shoulder stabilization surgery
include limited motion, recurrent instability, inability to
return to preinjury level of play, and the development of
osteoarthritis. The ultimate goal of the rehabilitation is to
increase the stability of the shoulder complex.
TEMPLATE DESIGN 2008

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Purpose
The purpose of this case study was to determine a proper
rehabilitation protocol for chronic instability in the throwing
shoulder of a college quarterback. This rehabilitation
protocol must allow for a safe return to participation in
collegiate football.

Methods
My rehabilitation protocol corresponded with the three phases
of the healing process: Inflammatory-Response Phase
(Phase 1), Fibroblastic-Response Phase (Phase 2), and
Maturation-Remodeling Phase (Phase 3). In addition to these
3 phases, I incorporated a fourth phase that focused on the
athletes functional progression. The athletes level of pain,
range of motion, and strength were assessed throughout the
rehabilitation to ensure a proper progression.
Phase 1 lasted for two weeks post injury. During phase 1, the
athlete was immobilized in a sling. The goals of this phase
were to limit the athletes inflammatory process, decrease
pain, and impede muscle atrophy. Example exercises include
Codman pendulum, passive range of motion, isometric
strengthening, and low-grade joint mobilizations. During the
first phase, I used electrical stimulation along with ice after
exercise to limit inflammation and pain. Criteria to progress to
phase 2 included a reduction of pain and tenderness and the
shoulder no longer needed to be immobilized.
The second phase began during the third week of
rehabilitation, when the athlete was removed from the sling.
The primary goal of phase 2 was for the athlete to gain full
normal active range of motion in the injured shoulder.
Example exercises include active-assisted range of motion,
finger walk, and PNF stretching. I applied ice to the shoulder
to manage pain. Criteria to progress to phase 3 included painfree full normal active range of motion in the injured shoulder,
minimal pain or tenderness with strengthening exercises, and
improvement in strength of shoulder muscles.
Phase 3 was entered at week five of the rehabilitation. The
goal of this phase was to restore normal strength and
neuromuscular control in his shoulder. Example exercises
include resistance tube strengthening, dumbbell
strengthening, and push-ups. All exercises were progressed
to more difficult levels throughout the third phase. Progression
to the final phase included the criteria of pain-free full normal
active range of motion in the injured shoulder, pain-free while
performing strength exercises, and continued improvement in
strength of shoulder muscles.
The fourth phase was the athletes functional progression.
The goal of this phase was to progress the athlete to have
adequate shoulder strength and stability to no longer be at risk
for shoulder injuries. The rehabilitation in this phase consisted
of a strengthening program for muscles of the shoulder
complex. Example exercises include lat pull-downs, seated
rows, and military press. My decision to discharge the athlete
from rehabilitation was based on him having full pain-free
range of motion, normal shoulder strength, pain-free sportspecific activities, and the ability to properly protect his
shoulder from reinjury.

Results

Discussion

The athlete presented with very limited range of motion and

strength in his injured shoulder prior to the start of
rehabilitation. He also reported a high level of pain. As the
athlete reached the end of the first phase of rehabilitation, his
range of motion improved, and strength remained about the
same. At the end of the second phase, the athlete obtained a
normal range of motion in the injured shoulder. The athletes
strength also showed some improvement. The athletes
strength continued to gradually improve during the third phase
of rehabilitation. The athlete obtained normal strength in the
injured shoulder upon completion of the fourth phase. As the
athletes range of motion and strength increased, his pain
level decreased from a level of 9/10 to 0/10 over the span of
the rehabilitation.

The rehabilitation protocol set forth by myself was successful

in restoring the athletes shoulder stability. The goals set forth
before the start of the rehabilitation were achieved upon
completion of the protocol. The athlete attained full pain-free
range of motion, normal shoulder strength, pain-free sportspecific activities, and the ability to properly protect his
shoulder from reinjury. The subject gradually reached each
goal as he progressed through the four phases.
I designed the rehabilitation protocol to focus on different
goals to correspond to the different phases of healing. Initially,
the focus was to reduce inflammation, then to increase
mobility, and then finally to increase stability. The athlete
followed the rehabilitation program as expected. The athlete
chose to leave campus each week, which limited the number
of days each week that he was able to rehabilitate his
shoulder. The only other factor that obstructed his goals was
when he suffered a laceration on the thumb of the involved
side. This only set him back a few days in the protocol. I
decided that it would be best for the subject to follow the
strengthening protocol on his own due to time conflicts in our
schedule, and for him to become more responsible. I sent the
athlete with the strengthening routine and instructed him to
stick with it. The athlete now understands the importance of
shoulder stability to his lifestyle activities.

Photos, Tables & Graphs

Glenohumeral Range of Motion in Each Phase
140
120

Flexion

100

Extension

80
Abduction
60
40

Internal
Rotation

20

External
Rotation

0
Phase 1 Phase 2 Phase 3 Phase 4

Glenohumeral Strength in Each Phase

1. Borsa PA, Lephart SM, Kocher MS, Lephart SP. Functional

Assessment and Rehabilitation of Shoulder Proprioception for
Glenohumeral Instability. J Sport Rehabil. February 1994;3:84-104.
2. Downar JM, Sauers EL. Clinical Measures of Shoulder Mobility
in the Professional Baseball Player. J Athl Train. January-March
2005;40(1):23-29.

6
5

Flexion

Extension

Abduction

Internal
Rotation

References

3. Prentice WE. Rehabilitation of Shoulder Injuries. Rehabilitation

Techniques. 5th ed. New York, NY: The McGraw-Hill Companies,
Inc. 2011:395-398.

Acknowledgements

External
Rotation

0
Phase 1 Phase 2 Phase 3 Phase 4

I would like to thank Beth Funkhouser for her assistance with

the preparation and completion of the study.

Level of Pain in the Shoulder in Each Week

Contact Information

Pain Scale
10
8
6

Corey Hall, ATS

DC Cobler, EdD, VATL, ATC, CSCS- Program Director
Beth Funkhouser, MEd, VATL, ATC, CSCS- Clinical Coordinator

4
2
0

Emory & Henry College

Department of Athletic Training
PO Box 947
Emory, Virginia 24327

T: 276.944.6500
F: 276.944.6738
E: dccobler@ehc.edu