It’s awfully hard to write about NHL injuries where there aren’t any. Somehow this year’s playoff season has been fairly uneventful, leading to me staring at my computer for at least an hour willing it to come up with something to write about (it didn’t, but the good news is there’s still funny cat videos on YouTube). Silly me, I completely forgot that when there’s nothing going on and almost everyone is healthy, you can always count on Ryan Kesler to have some body part falling off. This time it’s his shoulder, and for those of you who are keeping track, 75% of Kesler’s limbs have now been repaired.

Last week the Vancouver Canucks announced that Ryan Kesler had shoulder labrum repair surgery, and is expected to be out for six months. They also announced that he’d had the injury since February, which was a surprise to absolutely nobody since he wasn’t playing like the Ryan Kesler of old (remember the one who scored goals?). Kesler is an old hand at offseason surgery, having already had labrum repair surgery in both hips. He’s also a fan of coming back very quickly from injuries, returning after about ten weeks with each hip. Canucks faithful have loudly (and likely correctly) speculated that his return from the most recent hip surgery was too soon, and contributed to his less than stellar season. The hope now is obviously that the shoulder repair isn’t handled the same way. The nature of the injury itself may help keep him sidelined for a more appropriate amount of time, as labrum repairs in the shoulder are notoriously slow to heal. Healing time aside, having one shoulder completely out of action for several weeks immediately post-op puts a sizeable dent in your regular training regimen – good luck lifting weights, running, skating, pulling up your own pants, etc.

 

The Shoulder: It’s complicated, bad tempered, and kind of smug 

The shoulder is a complex joint with a complex range of complex injuries requiring complex repairs. In Kesler’s case, it’s a torn labrum. The labrum is a ring of cartilage that surrounds the socket part of your biggest and best ball-and-socket joints – your hips and shoulders. Its job is to deepen the socket so the ball stays in there better, and to create more surface area to share the load on the joint. In the case of the shoulder it’s particularly important because the glenoid fossa (shoulder socket) is very shallow. Unlike the socket of the hip (aka the acetabulum) which is a nice pocket built into the pelvis, the glenoid fossa is basically just a dent on the outside of the shoulder blade.

 

That's it. Seriously.

 

The glenoid (shoulder) labrum is also the point of attachment for a whole bunch of important ligaments that keep your shoulder joint stable. That’s why if you’ve dislocated your shoulder once you’re inclined to do so again – the ligaments can tear, and can even pull the labrum off the bone leading to an unstable joint (that likes to pop out at the least provocation). As if the socket-deepening-ligament-attaching business weren’t enough, the labrum is also where the biceps tendon attaches. The biceps is that big impressive muscle in your upper arm that as you can well imagine isn’t too terribly useful if it’s not attached at the top end the way it should be.

The clear message here is that the labrum itself can be injured in a variety of ways, most of which lead to a shoulder joint that’s weak, unstable, or weak and unstable. Oh, and painful. Did I forget to mention the pain?

 

So how do you tear your labrum?

Labrum tears can happen in several different ways – a sharp blow to the shoulder, falling onto an outstretched hand (aka the FOOSH – one of my favourite medical acronyms), a sudden tug on the arm, repetitive motion, and simple age or overuse. There’s about as many subtypes of glenoid labrum injuries as there are ways to injure it, but the main two are the SLAP tear and the Bankart lesion. Obviously the SLAP has the cooler name, and I’m sure Bankart is pretty jealous about it. SLAP stands for superior labral anterior-posterior, which is just a fancy way of saying that the upper part of the labrum is injured. The Bankart lesion is damage to the lower part of the labrum (as a result of dislocating the shoulder). I’ve tried to come up with a cool acronym to compete with SLAP, but LLAP is the best I’ve got. Ortho people: Feel free to use that. You’re welcome.

 

SLAP is cooler than Bankart. Sorry, Bankart.

 

Okay, so I tore my labrum. Now what?

You probably figured out your labrum was torn because your shoulder wouldn’t stop hurting and felt weird. You probably had an MRI, and it showed some damage. Chances are you’re going to start out very conservative, with anti-inflammatory medications and exercises to strengthen the muscles around the joint. The reasoning behind that is that labrum repair tends to have about a six month recovery period, and if you’re a professional athlete you probably don’t feel like sitting around for that long.

Remember back in March when the Oilers announced that Taylor Hall was having shoulder labrum repair surgery? Hall stated the injury was actually from his junior days in the OHL, and there were plenty of questions about why he waited so long to have it fixed. The reasoning with athletes is frequently that if it’s tolerable and not affecting how they play, then why not limp it along as long as possible until you finally have no choice but to have it repaired. Hall’s case in particular seems pretty unsurprising – Six months is a long time to miss in your final OHL season or your rookie NHL season. The Oilers were finished early this year, so what better time to finally have a repair that’s going to keep him out until at least the pre-season.

Now that you’ve limped your shoulder along to the point where you’re ready to either rip the arm off or finally get it fixed, odds are you’ll need an arthroscopic repair. You’ll have a few little holes through which your orthopedic surgeon will put a few little instruments and a little camera, and depending on what you’ve done to your labrum they’ll either trim off loose bits, or reattach things that have torn away from where they’re supposed to be, or both. Small anchors will be drilled into the bone of the socket to hold sutures that will keep the labrum in place while it heals back to where it belongs.

 

BAD

GOOD

This labrum isn't where it should be.

This labrum has been tied back in place.

 

That doesn’t sound so bad! Now I just have to heal, right?

And here, ladies and gentlemen, is the problem with shoulder labrum repairs. Once you’ve anchored the cartilage back to the bone, it has to reattach itself. Yes, there’s a fun little anchor and a fun suture holding things in place, but that’s not meant to withstand the amount of pressure the average person puts on their shoulder joint, let alone what an elite athlete can do.

You’ll spend the first month to six weeks in a truly uncomfortable sling with a goofy pillow that holds your arm away from your body. You can actually buy one on Amazon, although they’re expensive and uncomfortable so if this was your brilliant plan for a Halloween costume you might want to go with plan B. You probably won’t be allowed to drive, and you’ll need help showering and dressing because not only are you not supposed to move that shoulder joint, you really, really won’t want to. It takes four to six weeks for the labrum to heal back to the bone, so in that time it’s imperative that there be no stress and minimal movement in the joint. A week to ten days after your procedure you’ll start physical therapy, and it will SUCK. No offense to the PTs out there, you do wonderful work, but we all know your job is to torture and yell and make life generally miserable. And for that we thank you.

After your sling finally comes off, you’ll notice that you have one little goofy skinny arm because you’ve barely moved it in over a month. The good news is your cartilage has healed back where it belongs. The bad news is everything is very weak, and that cartilage isn’t too hard to rip right back off. Physio will continue, you’ll be miserable, and very, very slowly you’ll build strength back. After six months you should be able to go back to your sport, and 75% of the time you’ll be back playing at the same skill level as when you hurt yourself.

 

What’s Kesler’s deal?

If Kesler goes with his usual method of hustling back on the ice as soon as he’s moderately sure his limbs are reasonably well attached, he’s going to be playing with one arm that’s still not as strong as it should be. When you consider the shoulder’s range of motion and the importance of the bicep it’s clear that regardless of what type of labrum tear Kesler had, failure to heal it completely is equivalent to… Say… Coming back from a hip labrum repair too soon. Kesler’s balls-to-the-wall style doesn’t jibe well with what’s required to properly heal a shoulder labrum – patience and time. Maybe the third labrum is the charm, and this time the team will ignore Kesler’s insistence that he’s ready to play when he shows up to practice with one skinny little post-op arm.