In the battle between chronic shoulder dislocation and cup final, cup final wins every time.

In the battle between chronic shoulder dislocation and cup final, cup final wins every time.

The first thing that should come to mind when anyone mentions chronic shoulder dislocations is Mel Gibson throwing himself against a wall after escaping from a straitjacket in Lethal Weapon 2. TOTALLY REALISTIC (not really). While Nathan Horton hasn’t escaped from a straitjacket and nobody has seen him launching himself into walls, the Bruins have admitted he has a “chronic shoulder issue.”

Horton’s problems began April 20th when a fight with Jarome Iginla ended with him skating off holding his left arm awkwardly. The fight itself wasn’t much to see – A few punches, and Iginla dumped Horton to the ice. They were holding each other’s jerseys when he went down, which could explain the injury – the weight of one’s body on an outstretched arm is a great way to dislocate a shoulder. It’s also a great way to suffer a shoulder subluxation, a similar injury in which the shoulder comes partway out of the socket, and pops back in. The problem of course is that once you’ve had one injury in which you’ve dislocated (or subluxed) your shoulder, you’re very likely to do it again. The other problem is that nonsurgical management isn’t a great solution for someone who needs a working shoulder and uses it for hockey things like slamming into people and taking shots. The other other problem is if you’re a UFA you probably don’t have time for a six month recovery unless you’ve kicked so much playoff ass that your team can’t help but re-sign you.

Shoulder Anatomy

There's a lot going on here.

There’s a lot going on here.

The shoulder is an incredibly mobile joint, and looks like it has a million components. It’s actually made up of just three bones – the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade). The whole deal is held together by a variety of ligaments, and moves thanks to an assortment of muscles in the chest, arm, back, and in the shoulder itself (say hello to your rotator cuff – a group of four muscles). The head of the humerus sits in a socket on the scapula called the glenoid fossa. The rim of the glenoid is made up of a ring of stiff cartilage called the labrum, which helps keep the humerus seated in the shallow socket. The area labeled “capsular ligament” above is actually a group of ligaments that also assist in holding the joint together by connecting the humerus to the glenoid. Those ligaments and that labrum are the jerks responsible for chronic shoulder dislocations/subluxations in most cases.


Shoulder Dislocations

While there are technically three types of dislocations classified by where the humeral head goes when it pops out of the socket, the most common is anterior, accounting for up to 97%. In an anterior dislocation, the humeral head sits in front of the scapula, the patient generally holds their arm bent and cradled in the other arm, and they give you a very distinct “I’m going to kick you in the face” look when you try to touch it. Note the cozy humeral head in the x-ray on the right, snuggled into the glenoid fossa where it belongs. On the left is a face-kick waiting to happen.

This is self-explanatory.

This is self-explanatory.


How do you fix that without getting kicked in the face?

Drugs. While some doctors prefer the do-it-quickly-and-get-it-over-with method, relocating a shoulder hurts, and doesn’t always work on the first try. In the interest of maintaining an environment free of screaming patients and facekicked doctors,  pain medication and sedation is administered first. Once the patient is (mostly) unconscious and (very) relaxed, gentle traction is applied to the arm, almost recreating the mechanism that dislocated the shoulder in the first place. A loud, satisfying clunk indicates that the shoulder is back where it belongs. The patient goes in a sling, and after a few weeks of pain medication, physical therapy, and not being able to comb their own hair they’re back to using their arm. There are several methods of applying traction to relocate a shoulder, and everyone has their own preference. They can be anything from gently rotating the bent arm away from the body to hanging weights off the arm with the patient lying facedown on the bed to literally sticking your foot in their armpit while you yank on their arm (a terrible method nobody should ever use).


Chronic Instability

On average, 50% of people who dislocate a shoulder once will do it again. In younger people the incidence is even higher – up to 80% in some studies. A shoulder doesn’t dislocate without causing some damage, and that damage is to the structures that keep it where it belongs. Almost every anterior dislocation causes damage to the labrum – the structure that’s responsible for deepening the socket the humeral head sits in. This is called a Bankart Lesion, and consists of the labrum tearing away from the bone. It’s usually (but not always) accompanied by a Hill-Sachs Lesion, which is a dent in the humeral head caused by it smacking against the rim of the glenoid as it pops out of joint.

All of this could in part explain why Horton left game one against Chicago after he barely touched Niklas Hjalmarsson with his shoulder. This could also explain why he’s shooting less, since the shoulder is a pretty big part of swinging a stick to hit a puck. Supposedly Horton has been getting intra-articular injections (translation: a shot into the joint) before every game. But shots of what? While steroid shots into a messed up joint are an amazing thing sent straight from god’s own medicine cabinet, you can’t shouldn’t do them more than three to four times a year. They provide amazing short-term pain relief (two to three months), but any time you stick a needle in a joint you risk infection and damage to the joint itself. And although there’s disagreement in the literature, convention holds that too-frequent steroid injections can cause tendon rupture.


Fixing It

A nonsurgical approach can work for some patients, but generally not competitive athletes. Physical therapy, NSAIDs and the occasional shot into the joint just isn’t enough to quickly produce a stable shoulder joint capable of performing under the extreme demands of, say, an NHL game.

Shoulder repair is most commonly arthroscopic (through tiny incisions), and consists of reattaching the labrum to the glenoid and tightening it to keep the humerus in place. Anchors are drilled into the bone, and suture holds the labrum in place. The reason it takes so long to heal is that you can’t rely on a few bone anchors and a bit of suture to take the punishment a shoulder joint can dish out. The anchors are just there to hold everything in place while it heals back together. Waiting for everything to heal is the truly unpleasant part of this surgery, because this is generally a six-month rehab process.

A sling stays on for about a month, and you’re not allowed to start moving the joint until about three weeks out. Even then there’s a very strict schedule of what sort of movements you’re allowed to do at what stage in the healing process so as not to put undue stress on the repaired area. After about six weeks strengthening exercises begin, but true weightlifting doesn’t start until about twelve weeks, and it takes up to six months to regain full strength and range of motion. Obviously everyone heals differently, every orthopedic surgeon has different preferences on rehab algorithms, and every physical therapist has a different capacity for bullying their clients into compliance. The upshot is that it takes a really, really long time for a repaired shoulder to get better.

Waiting six months for a shoulder to heal isn’t a career risk for guys like Ryan Kesler or Taylor Hall – Kesler was in the middle of a six year contract when he had his done, and while Hall was in the middle of his entry-level contract there was no doubt in anyone’s mind that the Oilers were going to re-sign him for a long time and a lot of money. Nathan Horton is in a far different situation – he’s a UFA at the end of this season. Whether or not the Bruins are going to re-sign Horton seems to be a matter up for debate, but considering he’s been perched at number two in playoff scoring with a screwed up shoulder has to be a huge vote in favour of keeping him. In the meantime, keep an eye out for dressing room shots of him throwing himself against walls.