Wednesday, July 17, 2013

Nathan Horton's shoulder surgery, monstrous contract, and injury history: Should Blue Jackets fans be worried?

The Player

Nathan Horton is a 6 ft. 2 inch, 229 pound winger formerly of the Boston Bruins and Florida Panthers, who just signed a 7-year, $37.1 million contract with the Columbus Blue Jackets. Horton is an established top-six power forward in the NHL, however, Horton is also established as one of the more injury-prone forwards in the league. With a history of shoulder and concussion problems, the Blue Jackets certainly took a risk signing Horton to a long-term contract.

The Welland, Ontario native was drafted 3rd overall by the Florida Panthers in 2003 after two impressive seasons with the Oshawa Generals in the OHL. Horton stuck with the Panthers until he was traded to the Boston Bruins (along with Gregory Campbell) before the 2010 NHL season for Dennis Wideman, the 15th overall pick in the 2010 NHL Entry Draft and a 3rd round pick in the 2011 NHL Draft.

The Injury

During the Stanley Cup Finals, it was revealed (via a report from D.J. Bean of WEEI in Boston) that Horton has been dealing with a chronic shoulder injury. More specifically, Horton's injury is chronic left shoulder subluxation.

Horton originally suffered his injury when he fought Jarome Iginla on April 20th, causing him to miss the final five games of the regular season. The fight can be seen on the video below; Iginla pulls Horton to the ice by grabbing onto his left shoulder pad and Horton flips over, putting his arm in an awkward position. He immediately comes up after the linesmen clear the scuffle favoring one of his arms as Jack Edwards mentions.



Horton eventually returned for the Bruins' Stanley Cup Playoff run where he "received shots prior to each game to deal with the pain." Presumably, Horton received something like a cortisone shot which provides short-term pain relief and reduces joint swelling caused by inflammation. However, in Game One of the Stanley Cup Final, Horton suffered another subluxation or dislocation of his left shoulder when he bumped into Niklas Hjalmarsson as shown below:



Horton seems to just extend his left arm to create space in front of the net but immediately backs away, clearly in pain. Despite the injury not looking like much there, it shows the severity of chronic shoulder instability and how painful it is.

What exactly is a shoulder subluxation? 

A shoulder subluxation is quite similar to a dislocation. However, the difference between a subluxation and dislocation is that a subluxation is temporary and partial. By definition, a shoulder subluxation is "the separation of the humeral head from the glenoid cavity, resulting in strain on the soft tissues surrounding the shoulder joint."




To clarify, we must look at the shoulder's anatomy as shown above. The shoulder is a highly mobile joint that is only made up of three bones – the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade). The joint is formed by the connection of the rounded end of the humerus and the concave surface of the scapula called the glenoid fossa. The ball-and-socket joint is stabilized and essentially held together by ligaments and tendons known as the rotator cuff, as well as an assortment of muscles in the chest, arm, and back. 

Unfortunately, the joint is fundamentally unstable due to its flexibility and the shallowness of the glenoid cavity. Because of this, trauma (such as a fall, heavy blow to the shoulder, or a severe twist) can cause the humerus to be pushed out of its place in the glenoid fossa. If the humerus spontaneously returns to its position in the cavity, it is a subluxation. A dislocation is when the humerus comes all the way out of the socket and does not return on its own. When a subluxation occurs, tissues in the shoulder (muscles, ligaments and tendons) can be damaged, stretched or torn. 

Chronic Shoulder Instability due to Subluxation

The main significance of subluxation is that after the first incident, recurrence is very likely. When a shoulder dislocates or undergoes a subluxation, it causes damage to the structure, most notably the [glenoid] labrum which deepens the socket which the head of the humerus sits in. When the labrum is damaged due to subluxation, it actually tears away from the bone and is called a Bankart Lesion. This type of injury also can cause other associated ligaments, tendons and muscles in the shoulder to become loose or torn. Chronic shoulder instability occurs when these tissues are unable to keep the humerus in the shoulder socket.

When a shoulder is instable, the slightest amount of contact can cause another subluxation. This explains why Horton left after barely touching Hjalmarsson as shown above. Horton's injury was so severe, it requires surgery to tighten the socket so the shoulder will stop popping out of place.

Surgery to fix Chronic Shoulder Instability 

Each shoulder injury is unique, and it is up to the patient's physician to determine a specific surgical treatment for shoulder instability. Washington University Orthopedics offers a great summation on their website of the three main surgical treatments: capsular shift, labral/bankart repair, and latarjet procedure. The information can be found here: WUSTL Ortho: Surgical Treatment for Shoulder Instability

In summation, most shoulder surgeries are done using a minimally invasive technique known as arthroscopy. Arthroscopy involved a surgeon making small incisions called portals in the shoulder. A tiny camera is then placed in the portal to visualize the interior of the shoulder. This allows the surgeon to evaluate the shoulder injury and determine what surgical treatment would be best to treat the cause of instability. Essentially, the surgery then consists of reattaching and tightening the labrum to the glenoid to keep the humerus in place.

Recovery

Horton's recovery timeframe after surgery is 4-6 months and involves the shoulder healing and rehabilitating back to its original strength. The surgery involves drilling anchors into the bone and using a suture to hold the labrum in place. These just hold the labrum in place while it heals. During this time, the arm is temporarily immobilized in a sling. Once the sling is removed, Horton will have a series of exercises assigned by his physician or physical therapist to rehabilitate his shoulder ligaments. The exercises will improve his shoulder's range of motion and prevent scarring. The exercises are very limited to start out with in order to not put too much stress on the recovering shoulder which could cause scarring. Eventually, exercises to strengthen the shoulder will be added gradually to the rehab plan (usually about six weeks in). Horton will probably not be allowed to start weightlifting until twelve weeks and will probably not regain full strength or range of motion in his shoulder until six months post-surgery.

UPDATE: Horton undergoes surgery today (putting him at a mid-November to January return date) according to an ESPN report.

Injury History

Unfortunately, left shoulder injuries are not uncommon for Horton. During his rookie season, Horton was forced to undergo surgery after suffering a torn rotator cuff and labrum ending his rookie campaign at just 55 games. The following season, Horton suffered a shoulder injury in December during a fight and had to undergo surgery to repair it. In fact, that injury in 2005 was the same exact injury he has been suffering from this past season (a left shoulder subluxation). Horton underwent surgery and recovered well, coming back feeling "better and stronger." The following news article outlines Horton's 2005 injury and surgery: SunSentinel: "Once Again, Shoulder Surgery Ends Horton's Year"

Additionally, Horton has had several concussion issues. During the 2011 Stanley Cup Finals while a member of the Bruins, Horton was hit with a late check to the head by Canucks defenceman Aaron Rome. Horton was unresponsive and was carried off the ice on a stretcher and later diagnosed with a severe concussion. Less than a year later, Horton sustained another concussion due to a hit from Tom Sestito on January 22, 2012. Horton missed the final 36 regular season games as well as 7 playoff games and didn't return to hockey until the 2013 opening night in January.

Conclusion

After just signing a huge deal with the Blue Jackets, Horton has a long road ahead of him before he dons his new sweater. Blue Jackets fans have to hope he does not rush back and fully recovers after his third left shoulder surgery. The organization has made a commitment to a great player, but it can definitely be seen as a very risky move considering Horton's injury history.