Alex Tuch’s Shoulder Surgery Mystery

What procedure did the new Sabre require?

The trade is complete!! After months of waiting, speculating, and false alarms, the Buffalo Sabres finally completed the difficult transaction of moving former franchise savior Jack Eichel.

The details of the trade can be found here, but one of the main pieces that come back to Buffalo is RW Alex Tuch who is rehabbing through a shoulder injury that required surgery. GM Kevyn Adams ships off Eichel and receives what could be perceived as damaged goods in Tuch.

While the details of Eichel’s expected surgery are well-known along with the risks, virtually nothing is known regarding the specifics of Tuch’s surgery and recovery as he heads east.

Hockey is notoriously secretive with the specifics of an injury, usually giving no more than upper or lower body designations. The exception always appears to be if there is a season-ending injury where details of the injury are sometimes released.

What we know:

  • Alex Tuch required offseason shoulder surgery in Las Vegas in late July, specifically, the week of July 18th. The playoffs ended for Vegas on June 24th.
  • General Manager Kelly McCrimmon noted that the injury did not limit him during the playoffs.
  • McCrimmon also noted that this injury was not related to one specific incident, the shoulder was giving him trouble throughout the year.
  • McCrimmon went on further to note that no one felt that the injury was really serious or would need surgery.
  • He only missed one game between the regular season and playoffs due to the injury.
  • This is an injury that is not uncommon to hockey players./

Identifying the injury timeline:

  • Digging in further, the timeline for his injury did suggest that this was a season-long issue. An undisclosed injury that was termed day-to-day first appeared on January 10th, days prior to the opening of the season.
  • The next instance came up in March where he would be a game-time decision on March 19th. This comes after he missed the only game of the season on March 17th against San Jose.
  • In May, he began to miss some practices as the playoffs began and had missed the 3rd period of the regular-season finale for “maintenance”.
  • In June, several players including Tuch were considered game-time decisions.
  • Those were the last instances of injury reporting for Tuch until it was announced that he would require shoulder surgery in July./

This leaves the question of what type of injury did he suffer that required surgery?

There are context clues within the reports that help narrow it down.

Possible Shoulder Injuries

While labral tears are the most common injury seen in hockey players according to the research, I don’t believe that he suffered this injury as there is pain and instability within the joint following an event such as this. There would also be weakness during basic movements which would make a quick return to elite level hockey very difficult without rest and rehab. He was only ever termed “day-to-day” with an injury this season and only missed 1 game.

Players such as Jack Hughes, Ryan Callahan, and Derek Stepan all missed several weeks or the season with subluxation or dislocation of the shoulder. Callahan even suffered the same injury again in 2017 again and missed 8 games. There was also the risk of a Hill-Sachs lesion that wouldn’t require surgery or a Bankart lesion that does require surgery, both occurring as the result of repeated dislocations.

There is a possibility that he could have suffered an AC joint sprain or a separated shoulder. However, like the labrum tear, there would also be instability within the area and he would have difficulty with taking hits against the boards and would have likely missed more time in between instances where the injury occurred.

The timeline to return from an AC joint reconstruction is about 4-to-6 months which fits the timeline, but the wording that no one felt the injury was serious or that would require surgery suggests that this may not be the case. He would have had a visible deformity of the shoulder with the clavicle elevated with the joint irreducible. If the injury was so severe that it required surgery, that would have been known at the time of injury or shortly afterward. He would have also missed some time initially. In a lot of instances, the AC joint does not need to be reconstructed and can heal on its own.

This leaves a partial-thickness rotator cuff tear with loose bodies as the likely culprit.

Rotator Cuff Anatomy

The rotator cuff is made up of 4 muscles that include the supraspinatus, infraspinatus, teres minor, & subscapularis. These muscles assist in shoulder abduction, internal & external rotation. These motions are vital for a variety of activities that we perform daily.

The rotator cuff also helps keep the humeral head depressed and against the labrum so that it can create enough space within the joint for the humerus to move & not ram into the acromion during elevation.

What likely happened was that Tuch suffered a shoulder injury, had pain and weakness in the shoulder initially but played through. In 2012, Marian Gaborik suffered a rotator cuff tear prior to the playoffs and struggled through the injury, but required a similar timeline for recovery. It’s important to note that he did not miss any games. There are likely more instances of the injury, but remember, hockey injury details are guarded like Fort Knox.

Mechanism of Injury

The mechanism for injury to the rotator cuff can happen in a number of ways. It can occur as a result of landing on your arm outstretched, jamming the head of the humerus into the scapula. It can occur with a fall directly onto the shoulder area, throwing an object either with increased frequency or if the object is too heavy.

It can also occur from an overload of the area such as a sudden pull on the area. Finally, it can occur over a period of time with impingement due to weakness in the area with altered biomechanics leading to a wearing down on the tendon insertion.

Types of Rotator Cuff Tears

There are two types of rotator cuff tears that can affect any of the muscles in the cuff area: Partial-thickness and full-thickness. Based on the names, the partial-thickness is a partial tear to the tendon that can be small & can even heal on its own at times.

Full-thickness is when the tendon tears completely through & there is a significant loss of function noted in the area. Any of the muscles in the rotator cuff can tear but the supraspinatus is the most commonly torn muscle. It is anchored at the top of the humerus head & is more likely to bear the brunt of an injury or become worn down.

There are also varying grades of partial vs full-thickness tears which further indicate the severity as seen above. The tear is measured in both size & depth. So it’s possible that there could be a big superficial tear that could be managed conservatively or there could be a tear that is deep that requires surgery. Most surgeries are indicated for tears medium & above.

He likely continued to occasionally aggravate the shoulder with further hits, leading to fraying of the tendons that connect the muscle to the bone. This happens often with chronic tears with one specific incident not leading to the injury, but a culmination of events that lead to this. Hockey players are known to be tough and Tuch played through the injury. At some point, the team likely did some sort of imaging to rule out major issues but an MRI may not have been performed right away.

Tuch finished the season and possibly looked to see if the shoulder would calm down once the constant playing stopped. When he realized that the pain was not going away, they likely looked at the shoulder with further imaging and saw a tear. Considering his age, they went in to repair the damage and clean out any loose bodies or any possible bone spurs that developed over the course of the season. He may have required a subacromial decompression which requires the surgeon to trim back a portion of the acromion to create more space for the humerus to move.

Considering Tuch does not play a sport that involves a lot of overhead activity, this is why he can return to playing sooner than baseball players with a rotator cuff tear. Once he returns, he will likely require some time to get re-acclimated to playing and may have a slow start with even a dip in his production but should return to his pre-playing levels in 2022 considering his age.

Re-Injury Risks

There is a chance he could re-tear the rotator cuff if the original tear was big enough. Think of a hole in your pants. If it’s small, then a quick fix to the area usually does not cause further problems. If there is a big hole, it can be fixed, but that places stress on the surrounding fabric and could cause either a re-tear of the original hole, or this could place stress on the stretched fabric and cause failure elsewhere.

Re-tear rates can be anywhere from 21-to-27 percent and in some cases even more severe cases. If Tuch had a serious tear, he would not have been able to play through the injury, no matter how tough he was. He likely suffered a small tear in the cuff initially, played through it, and intermittently injured it as he went along before realizing the pain wasn’t going away once he stopped playing. I have little concern that he will re-tear the area though new injuries to the area can’t be ruled out or necessarily prevented.

The long-term concerns for Tuch are far less than what Eichel will be dealing with his disc-replacement surgery. Even though the Sabres traded for an injured player, they still won by getting a more predictable injury and one that will have fewer issues moving forward. I expect to see Tuch get on the ice if he hasn’t already to work on his conditioning so when he is cleared to initiate contact, he can be slotted back into the lineup.

Return to Play

Based on the timeline for a rotator cuff repair and the NHL schedule, it was expected that Tuch was to return sometime in late January. However, the NHL All-Star game is scheduled for February 4th with a break for the Olympics from the 1st to the 25th. This could allow Tuch to return to play a few games before the break and if he has issues, then he could rehab during the break. The other option is to have him return after the break and allow him to get in practice time with his new team and hit the ice with a smoother return.

The Sabres held fast with the trade and won not only with assets and players, but won on the injury front as well. Hopefully, this is a new chapter in Buffalo Sabres history that leads to long-term success that has been missing for over a decade.