Sunday, October 6, 2013

Is Ryan Nugent-Hopkins being rushed back from his torn labrum?

THE PLAYER

Ryan Nugent-Hopkins, 20, is expected to return to the Edmonton Oilers lineup for their game against the Devils on Monday. The former first-overall pick recently signed a seven-year, $42 million contract extension in September and has been sorely missed by the Oilers.

On April 21st, it was revealed that Nugent-Hopkins would have season-ending shoulder surgery, missing the final five regular season games. Nugent-Hopkins tore his shoulder labrum, just like another former Oilers first-overall pick, Taylor Hall, the previous season.

That flex.


At the time, Oilers fans were not happy because the issue/injury was not addressed sooner. It was quite obvious that Nugent-Hopkins was playing through his injury as evidenced by his affected and negative performances. The organization decided to monitor his condition and fans believe they didn't handle their young star more carefully by ending his season sooner. 

All in all, Nugent-Hopkins underwent surgery and was expected to be out for 6 months, putting him on track for a late October, more likely early November return. Surprisingly, Oilers coach Dallas Eakins announced last Friday that his young center was ready to go and would be in the lineup Monday evening. 

THE INJURY

To understand the injury, we must first take a look at the shoulder's anatomy (as shown below) and understand the function of the labrum. The shoulder is a highly-mobile, ball-and-socket joint that is made up of only three bones - the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). The shoulder joint is formed by where the rounded end of the humerus meets the concave of the scapula (glenoid fossa). The humerus and the scapula are connected and stabilized by tough tissues known as ligaments that form tethers and hold the bones in their proper place. 


The labrum is a type of cartilage found in the shoulder joint. Cartilage is a flexible connective tissue that is not as hard as bone but less flexible than muscle. Cartilage does not contain blood vessels like other connective tissues and thus takes more time to grow and repair. There are two types of cartilage found in the shoulder joint. The first type of cartilage is found on the ends of bones and is called articular cartilage. Articular cartilage allows the bones to glide and move on each other, when this white cartilage begins to wear out (arthritis) it causes the joint to become stiff and this loss in flexibility is very painful. The labrum is the second type of cartilage in the shoulder joint and is quite different than articular cartilage in both function and form. The labrum is a ring of soft fibrous tissue that is found only around the socket where it is attached. The tissue surrounds the glenoid and helps stabilize the shoulder joint. 

The labrum is an important tissue in the shoulder joint that has two distinct functions. The first is to deepen the socket of the shoulder blade to ensure that the ball stays in place. The labrum is attached the the rim of the socket and essentially acts as a bumper which deepens the socket over time and keeps the humerus in place. The second function of the labrum is to act as an area of attachment for other structures and tissues of the joint. Essentially, the labrum creates more surface area to share the load on the joint in order to not create unnecessary stress. 

The labrum can be injured and torn in a variety of ways. The first type of tear is when the labrum is torn completely off of the bone and is usually associate with when the shoulder has subluxated or dislocated (check out my post on subluxation focusing on Nathan Horton here). This is known as a Bankart lesion and occurs in the lower part of the labrum. The second type of labrum tear is when the substance of the labrum is tearing itself. Over time, the edge of the labrum may get frayed and not longer be smooth. This tearing is quite common and doesn't have many symptoms. The third type of tear is when the upper part of the labrum is injured. The labrum can be injured in the area where the biceps tendon attached to the upper end of the socket, the superior end of the joint. This third type of tear is known as a SLAP lesion, which stands for Superior Labrum Anterior and Posterior. The SLAP lesions are divided into four types, classified on the severity of the injury. In a lesser injury, the labrum is only partially detached while in a more severe injury the labrum is pulled completely off the bone along with the biceps tendon. 


TREATMENT AND SURGERY

Diagnosing a labrum tear is not small feat. Since the cartilage is deep in the shoulder, it's difficult for a physician to diagnose based on physical examination and other tests. A physician may ask the patient for an MRI which can show a tear, but it may miss smaller tears and is not always reliable. The only sure way to make a diagnosis is view arthroscopy of the shoulder. A surgeon will make a small incision and view the joint via a tiny camera and make his diagnosis. Usually, the surgeon then proceeds to perform the procedure depending on the injury. 

Tears of the labrum due to subluxation/dislocation require that the labrum be reattached to the rim of the socket. This surgery can be done with arthroscopic techniques but some institutions prefer to perform an open operation with an incision on the front of the shoulder. SLAP lesions or tears of the labrum near the biceps tendon attachment are fixed using arthroscopic surgery since the area is too difficult to reach with an open operation. The surgeon uses an arthroscope and makes small incisions to re-attach the labrum to the rim of the socket using either sutures or tacks. A video example of the procedure is show below.  


RECOVERY 

Once the cartilage is anchored back to the bone, it has to grow back and reattach itself. The suture helps hold the cartilage in place but it can't withstand the normal pressure the joint sustains on its own. Thus, for four to six weeks the patient's arm is in a sling. During the four to six weeks it takes for the labrum to heal itself, it's important that the arm remains in the sling to sustain as little stress as possible so the injury does not become aggravated. Physical therapy is a must in order to recover your full range of motion and strength. 

After the four to six weeks waiting for the labrum to re-attach itself to the rim of the bone, it takes another four to six weeks to regain your strength gradually and carefully. Most doctors recommend a six month timetable to return to sports after your surgery. 

IS RYAN NUGENT-HOPKINS BEING RUSHED BACK? 

It has been less than six months since Ryan Nugent-Hopkins decided to undergo surgery to repair his torn labrum. Dallas Eakins says he is ready to return to the lineup on Monday, a few weeks ahead of schedule (previously Oilers GM Craig MacTavish stated that November 1st was the earliest expectation for his return). 

Labrum repair is a safe and reliable procedure in athletes. Recovery from the repair is not the same for each patient, especially a professional athlete. After the initial sling period of four to six weeks, the patient dictates their recovery with improving physical therapy. Shoulder strengthening and range of motion exercises must be done consistently. 

Is RNH being rushed back? The best bet is no, he's not. Nugent-Hopkins visited his doctors to get an okay on his shoulder and if he feels comfortable and confident enough to play, it is ultimately his decision after he received an OK from his doctors. 

The proper to question to ask is does returning before six months post operation put you at an increased risk for recurrent injury versus returning after six months. Although there are no studies that look to answer this specific question/comparison, several studies do show athletes returning at time points such as 5 months post-operation and sometimes as quick as 4 months. Here is a great resource describing instability of the shoulder: http://www.netorthodoc.org/sport/Shoulder%20Instab.pdf 

Owens et al. describes the sentiment regarding the uncertainty of when to return after surgery. The article states the "Surgical management....reduces the rate of recurrence...." and that recovery and management is up to the physician, stating "the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport and position-specific demands, duration of treatment, and the athlete's motivation." Essentially, once the physician reviews RNH's shoulder history (this is good since it was his first occurrence) and how his shoulder is functioning via testing he can determine if it's safe to return. RNH has demonstrated that he is motivated by his quick recovery which is a good sign for Oilers fans. They just have to hope that his injury does not get aggravated and that he is careful with his play (no fighting obviously, probably no checking with that side of the body) and protective of his shoulder. Oilers fans should also hope he returns to form, since only around 75% of athletes return to their previous skill level post shoulder surgery (Ide et al.)