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DISABLEMENT MODEL CASE STUDY 

 

46 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

Conservative Care of a Patient with Initial Anterior Shoulder 
Dislocation Participating in an Intercollegiate Basketball: A 
Disablement Model Case Study 
Lucas Bianco, DAT, ATC, CSCS 
BIOKINETIX, Chicago, IL  

 
ABSTRACT 
A 23-year-old male patient participating in intercollegiate 
basketball, suffered an acute shoulder dislocation. The 
patient was diagnosed with an anterior glenohumeral labral 
tear and was treated with an indirect approach to increase 
range of motion (ROM) and function while decreasing pain. 
Patient-related outcome (PRO) measures were used along 
with clinician related outcome (CRO) measures to discharge 
the patient. The immediate changes in ROM and pain along 
with follow-up assessments of the Disabilities of the Arm, 
Shoulder, Hand (DASH) Scale achieved Minimal Clinically 
Importance Difference (MCID) levels. As rehabilitation 
specialists, athletic trainers have the opportunity to provide 
quality care to patients and recognize the repercussions of 
injury on the patient. The follow-up assessments support that 
the completed conservative indirect treatment for a patient 
with a glenohumeral anterior labral tear was effective at 
reducing pain, improving function, and improving PRO in this 
isolated case. The individual was able to return to basketball 
activities at the same level as before to the diagnosis, within 
a three-week timeframe. The use of Primal Reflex Release 
Technique (PRRT) to restore allostasis in the central nervous 
was effective based on available outcomes for this patient. 
Then the continued re-education of pain-free functional 
movement patterns through Reflexive Neuromuscular 
Stabilization provided the patient the ability to maintain his 
functional gains. Clinically, considering the biopsychosocial 
components of injury can help guide intervention selection to 
provide a patient-centered model of care and ensure an 
optimal outcome. 
 
Key Phrases 
College and university patient population, patient-reported 
outcomes, therapeutic exercise 
 
Correspondence 
Dr. Lucas Bianco, 3205 Street Lynchburg, VA 24501.E-mail: 
lucasbianco4915@gmail.com 
 
Full Citation 
Bianco L. Conservative care of a patient with initial 
anterior shoulder dislocation participating in an 
intercollegiate basketball: A disablement model case 
study. Clin Pract Athl Train. 2022;5(1): 46-52. 
https://doi.org/10.31622/2022/0005.01.7.     
 
Submitted: August 9, 2020 Accepted: April 6, 2021. 

 
INTRODUCTION 

Anterior shoulder dislocations are the most 
common shoulder dislocation. The most 
appropriate treatment for patients following a 

first-time dislocation remains unclear; surgery and 
rehabilitation are the two most common 
treatments. Patients participating in college 
athletics suffer shoulder dislocations at a rate of 
2.58 per 10,000 exposures.1 With 29.6% of 
these patients deciding to have surgery following 
their shoulder dislocation.1 The rehabilitation time 
and return-to-play progression often last longer 
with patients following a surgery shoulder 
stabilization (6-12 weeks) compared to other 
nonoperative management (4-8 weeks).1 

Primal reflex release technique is a treatment 
paradigm that is used to evaluate and release 
nociceptive startle reflexes.2 A clinician begins the 
session with a nociceptive exam to determine 
hypersensitive areas on the body. These 
nociceptive startle reflexes (NSR) could be 
created during a flight, fight, or freeze moment 
that caused the muscle to reflexively react. The 
muscles are then left in the hyperarousal state with 
increased tension in the muscle either effecting the 
involved area and/or another area of the body. 
Like the theory of regional interdependence, 
where seemingly unrelated area of the body may 
contribute or be associated with the patient’s 
primary concern. Through a series of reflexive 
stimulations with manual techniques the NSR and 
central nervous system (CNS) can be 
downregulated to restore an allostasis state in the 
area.2 

Currently, the literature on conservative treatment 
versus surgical intervention does not provide one 
optimal evidence-based practice.3,4 This case 
study shares a scenario where a 
neurophysiological intervention was utilized. The 
treatment plan successfully restored the patient’s 
perceived function as well as improve quality of 
life and alleviated pain. 

https://doi.org/10.31622/2022/0005.01.7


Conservative Care of a Patient with Initial Anterior Shoulder Dislocation Participating in an Intercollegiate Basketball:  
A Disablement Model Case Study 

 

51 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

PATIENT INFORMATION 

The patient in this case is a 23-year-old male 
collegiate basketball player. The patient suffered 
a right shoulder dislocation two weeks before 
returning to campus for preseason workouts. The 
mechanism of injury was a posterior to anterior 
force by an opposing player while reaching to 
intercept a pass. Following a trip to the 
emergency department, the physicians sedated 
the patient to relocate his glenohumeral joint. 
Upon arrival to the Athletic Training Clinic, the 
patient was still using the sling and was very 
apprehensive. Initial evaluation supported the 
diagnosis of sub-acute right anterior shoulder 
dislocation with limited range of motion and 
strength in all shoulder motions. Stress tests 
included a positive empty can, O’Brien’s Test, 
Apprehension Test, and Load and Shift Test; the 
Yergerson’s Test and Speed’s Test were negative. 

During the previous season, the patient did not 
participate fully in games as he was recovering 
from a complication during surgery. The 
complication left him with shortness of breath and 
difficulty catching his breath during strenuous 
exercise. Through the year and a half, following 
this event, the patient worked with breathing 
exercises and neurological resets to retrain his 
breathing and autonomic nervous system to 
prepare for strenuous exercise. The strategies the 
patient learned from the previous interventions 
could have assisted in the current recovery from 
the anterior shoulder dislocation. This example of 
how the patient-centered care for this patient may 
have led to the most optimal outcome.  

Differential Diagnosis and Evaluation 

The patient was not on campus or in the state at 
the time of the incident. The Emergency 
Department Physician who first evaluated the 
patient reported no fractures were present based 
on the x-ray images. The treating clinician 
evaluated the patient six days after the 
dislocation upon his return to the clinic. Following 
the evaluation by the treating clinician the patient 

was referred to the team physician. The team 
physician reported similar instability findings and 
ordered an MRI arthrogram to rule out anterior 
labrum tear. Based on the MRI arthrogram, the 
patient sustained an anterior labrum tear with a 
Hill-Sachs lesion to the humeral head.  

Based on the size and shape of the labrum tear, 
the team physician recommended rest and 
gradual return-to-play. The patient expressed an 
interest in continuing to play as long as he was 
able. The differential diagnosis included fracture, 
contusion, biceps tendon rupture, and rotator cuff 
strain/ tear. The patient supported the two-week 
conservative treatment plan, to determine if 
function could be improved. The next day, the 
patient began an intervention program designed 
to restore the balance of his CNS.  

Body Structure and Function 

Due to the nature of injury, onset, time to the 
season, and the finding from physical examination 
and the MRI arthrogram; it was determined that 
the patient could attempt conservative 
interventions to manage his shoulder pain and lack 
of function. Based on the tissue healing timeframes 
for the structural damage to the cartilage, evident 
on MRI, the plan of care was directed at restoring 
function through balancing the CNS with no 
expectation of tissue healing. Subsequently, a 
secondary evaluation was completed to assess the 
patient perception on his ability to perform 
functional and basketball activities. The Patient 
Specific Functional Scale (PSFS) and DASH were 
completed (Table 1). The patient report zero 
function in his ability to ‘dunk,’ ‘shoot,’ ‘dribble,’ 
and ‘complete one pushup.’ He did report raising 
his arm ‘arm raise’ as a three out of ten on a 
functional scale. Along with the DASH, the DASH 
Sport sub-scale was also completed (Table 1). The 
patient recognized the scores that he entered on 
the DASH Sport sub-section were low and that he 
needed substantial improvements before he 
would play basketball at his desired level.  

Activity and Participation 



Conservative Care of a Patient with Initial Anterior Shoulder Dislocation Participating in an Intercollegiate Basketball:  
A Disablement Model Case Study 

 

52 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

To gather an outcome for the patient’s health-
related quality of life the Disablement in the 
Physically Active Scale (DPAS) was completed. 
The starting point for this DPAS was higher than 
previous measures demonstrating that his health-
related quality of life had improved from the first 
condition that sidelined him for more than a year. 
In his current state, the DPAS was scored at 39. In 
the wellness section, a meaningful finding was the 
perceived lack of support from teammates. This 
finding served as one of the biopsychosocial 
components of injury that helped guide the 
intervention selection. 

Environmental and Personal Factors 

The patient dealt with a significant transition 
period of his life while recovering from this injury. 
After two years of playing college basketball as 
the son of the head coach, he was preparing to 
be on a team with a new head coach. Before the 
injury, the patient was concerned about being 
able to play for the new coach. His environment 
and personal relationships were shifting while he 
was trying to comprehend his college basketball 
career. 

INTERVENTIONS 

The first intervention was PRRT. It was selected to 
down-regulate the nervous system to restore 
allostasis in the CNS of the patient. The reflexive 
muscle inhibition and innervation techniques were 
applied over two treatments. Once the patient 
had decreased NSR and movement began to 
return, Reflexive Neuromuscular Stabilization was 
provided. The arm raise was the movement that 
was addressed. Three treatments of the PRRT and 
RNS were performed with the patient on the first 
three treatment days. Then the next two treatment 
days were focused on upper extremity 
neuromuscular stabilization exercises progressing 
from a closed-chain position to an open-chain 
position. The exercises focused on the areas of 
function that the patient expressed were lacking 
in the PSFS. During these treatment sessions, 
visualization, biofeedback, and acupressure were 

used to help restore the patient’s trust and 
confidence in his shoulder. 

OUTCOMES 

Body Structure and Function 

After the initial treatment of PRRT (Figure 1) the 
patient had improved shoulder abduction. These 
improvements were maintained to the next day 
(Figure 2) then further improvements occurred 
following the second PRRT treatment paired with 
RNS (Figure 3). Pain decreased to zero when at 
rest and two when it was the worst. Over the time 
of three treatments the patient experienced an 
increase of 6.3 for the average of the PSFS 
scores, which meets the MCID (Table 1). 

Activity and Participation 

Upon return to full unrestricted basketball-related 
activities, 13 days following the beginning of the 
initial intervention, the patient had verbalized that 
he was enjoying playing basketball and had a 
good balance with the rest of his life. The DPAS 
score at that time was 5, which was a MCID, from 
the initial score (Table 1). His focus had shifted 
from “can I play, or should I play with my shoulder 
injury” to “I want to play” and “I will control my 
focus and energy every day.” The patient 
reported increased support from this teammates 
and family during this time. 

Environmental and Personal Factors 

After two weeks of completing unrestricted 
basketball related activities the patient began to 
reconsider his position on the team and the 
challenges of play under a new coach. He 
decided it was in his best interest to transfer to 
another college to continue his basketball career. 
After this decision was made, he did not complete 
any on-court basketball-related activities but 
remained physically active during weightlifting 
and conditioning sessions with the team. The 
patient continued to complete upper extremity 
neuromuscular stabilization exercises in the 
athletic training clinic as needed. 



Conservative Care of a Patient with Initial Anterior Shoulder Dislocation Participating in an Intercollegiate Basketball:  
A Disablement Model Case Study 

 

53 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

DISCUSSION 

This case describes the diagnosis and 
management of an intercollegiate basketball 
player following anterior shoulder dislocation and 
subsequent glenoid labrum tear with Hill-Sach 
Lesion treated with neurophysiology interventions 
to decrease pain, improve function, and return to 
full unrestricted basketball activity. The 
interventions used in this case study have been 
used with similar patients, with lower extremity 
dysfunction.5 The physicians involved in this case 
were prepared to surgically repair the patient’s 
shoulder, if the two weeks of conservative care 
did not improve the patient’s outcomes. 
Researchers are divided on the standard of care 
for patients with first-time shoulder dislocations. In 
this case, the innovative treatment plan benefited 
the patient and assisted the patient in reaching his 
goals without surgery. 

To confidently return the patient to unrestricted 
basketball-related activities, the medical team 
assessed the patient’s objective measurements 
(stress tests, range of motion, strength tests, 
functional capabilities, etc.) along with the PRO 
scores (perceived function, pain scores, perceived 
difficulty in ADLs and basketball). Utilizing these 
outcomes as a formal metric is valuable in the 
communication to stakeholders (patient, 
physicians, coaches, etc.). Also, tracking these 
scores can further objectify the return-to-play 
protocol. These outcome measures have been used 
in other disablement case studies to determine the 
best treatment plan for a patient.6 

CLINICAL BOTTOM LINE 

Athletic Trainers often take on the role of care 
provider from the “teams” and patients they work 
with. A portion of the care in this case study was 
rooted in psychological wellness. As the Athletic 
Training Education continues to evolve and 
includes more courses on treating the bio- 

  

Figure 3. Shoulder Abduction One Day Post Intervention 

Figure 3. Shoulder Abduction After Second Intervention 

Figure 3. Shoulder Abduction Post Initial Intervention 



DISABLEMENT MODEL CASE STUDY 

 

50 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

Table 1. Patient-Oriented Outcome Scores 
 Initial Second 

Treatment 
Third 

Treatment 
Fourth 

Treatment Discharge Two Week 
Follow-Up 

Outcome  2 Days 4 Days 9 Days 13 Days  
NRS WB 1 2 0 0 1 0 
NRS NWB 1 2 0 2 0 0 
NRS Best 1 2 0 0 0 0 
NRS Worst 3 3 2 5 2 0 
PSFS Total 0.5 2.3 6.8* 7.3 9 9.6 
PSFS Arm Raise 3 6* 8 8 9 10 
PSFS Carrying Bag 0 8 9 10* 10 10 
PSFS Dunking 0 0 8 4 8 9.5 
PSFS Shooting 0 0 5 6 8* 10 
PSFS Dribbling 0 0 7 9 10* 8 
PSFS Pushup 0 0 4 7* 9 10 
DASH 45 39.4 N/A 33* 17.7 3.8 
DASH Sport 20 20 N/A 15 12 5* 
OMNE (TPs) 10 6 6 2 5 2 
DPAS 39 N/A N/A N/A 5* 12 
GRoC 4 5 N/A 2 3 6 
NRS WB= Numeric Pain Rating Scale in weight-bearing; NRS NWB= Numeric Pain Rating Scale in non-
weight-bearing; NRS Best= Lowest score throughout 24 hour period; NRS Worst= Highest score 
throughout 24 hour period; PSFS Total: Average of Patient-Specific Functional Scale items for that 
session; PSFS Arm Raise, Carrying Bag, Dunking, Shooting, Dribbling, Push-up: Specific item selected and 
scored by the patient as part of the PSFS; DASH: Disabilities of the Arm, Shoulder, and Hand Scale; 
DASH Sport: Sport sub-scale; OMNE (TPs)= One-Minute Nociceptive Exam assessing number of Tender 
Points; DPAS: Disablement in the Physically Active Scale; GRoC: Global Rating of Change Scale; 
MCID=*  

psychosocial component of an injured patient, it 
will be customary for clinicians to explore physical 
interventions that can assist with the traditional 
bio-psychosocial interventions. In this case, the use 
of PRRT helped down-regulate, “calm” the 
patient’s CNS to improve his pain, function, and 
PRO scores. Athletic Trainers are competent in 
recognizing how biopsychosocial elements related 
to injury can navigate patient-centered care and 
intervention strategies that ensure an optimal 
outcome. 

PATIENT PERSPECTIVE 

“As it relates to my shoulder injury specifically, I 
really saw improvements after every training 
session. It all happened fast, and some would say 
my return to basketball was too fast. The results 
were undeniable, and they allowed me to play 
even due to my unusual speedy recovery. 

I know exactly why I got better. I got better due 
to the revelation of the connection your essence 
has between the mind, body and soul that my 
Athletic Trainer very clearly explained to me. My 
Athletic Trainer did a phenomenal job of giving 
me information and communicating the same 
message in multiple different ways. I am a devout 
Christian. With that being said, he was able to 
give me the biblical perspective to my health 
pertaining to my situation while also saying the 
same exact thing behind a physical training lens 
and then tying it all together with science, data, 
and fact. So many different lenses and 
perspectives that he used to tie everything 
together for the same message. He then showed 
me very clearly how all of these things are 
connected and similar along with how these 
elements tie into one another.” 

 



Conservative Care of a Patient with Initial Anterior Shoulder Dislocation Participating in an Intercollegiate Basketball:  
A Disablement Model Case Study 

 

51 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

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Conservative Care of a Patient with Initial Anterior Shoulder Dislocation Participating in an Intercollegiate Basketball:  
A Disablement Model Case Study 

 

52 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

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https://doi.org/10.1177/0363546516660979
https://doi.org/10.1177/0363546516660979
http://dx.doi.org/10.7860/JCDR/2019/42687.13356
http://dx.doi.org/10.7860/JCDR/2019/42687.13356
https://doi.org/10.31622/2019/0003.4

	ABSTRACT

