Steven Stamkos has a long way to go after blood clot surgery, experts say

Even if Tampa Bay makes the Stanley Cup final, two Toronto-area experts are doubtful Steven Stamkos will be ready to join the Lightning.

His rehabilitation from a two-hour operation on April 4 to address a blood clot, which reportedly included the removal of a rib, should have started by the time the Lightning take the ice in Detroit against the Red Wings on Tuesday night in Game 4 of their Eastern Conference quarter-final.

Raj Suppiah, a physiotherapist who has helped other athletes recover from blood clots, says it's key for Stamkos to get straight to work on his recovery.

"I try to promote early mobilization right after surgery," said Suppiah, director and owner of Foundation Physiotherapy in Toronto and a professional associate at Hamilton's McMaster University. "We try to make sure people are not immobile, we want to move them right away because we want to get the blood flowing and we want to get the joints moving.

"We want to make sure there's no scarring because we can develop a lot of scar tissue around our surgical sites. The more scar tissue that develops the less mobility that someone will have."

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Dr. Thomas Forbes, a vascular surgeon at Toronto's Peter Munk Cardiac Centre, believes that Stamkos likely developed the blood clot in his right shoulder from repeated trauma to the vein. The affected blood vessel rests between the collar bone and the top rib and would be pinched, even scarred, when Stamkos raises his right arm above his shoulder. It's an action the four-time all-star and two time Rocket Richard Trophy winner has performed countless times by winding up for a slapshot.

"One of my colleagues somewhat facetiously said maybe it's from the goal-scoring celebrations. He's got to score fewer goals," said Forbes. "But hockey players aren't the kind of people you think of when it comes to overhead work. It's baseball pitchers and volleyball players [who usually suffer from blood clots in their shoulders]."

For the less athletically inclined, think of the numbness felt in your arm when sleeping with it raised above your head. Those pins and needles are caused by the collarbone and top rib closing on the vein. By removing the rib, there's nothing for the collarbone to press against.

This particular kind of blood clot differs from those suffered by retired Pittsburgh forward Pascal Dupuis, former Penguins goaltender Tomas Vokoun or Philadelphia Flyers defenceman Kimmo Timonen. Dupuis had to stop playing after complications from major knee surgery led to clotting in his lungs, Vokoun had a genetic condition that worsened with travel and Timonen had a blocked shot combined with a hereditary blood disorder keep him off the ice.

4-stage process of recovery

The standard recovery from an injury like Stamkos's involves a four-stage process.

First, doctors run clot-busting medicine by intravenous directly into the affected vein deep in the armpit, between the collarbone and ribcage, to dissolve the clot. Second, the surgery itself would remove a portion of the top rib, a C-shaped bone about the length of an adult's index fingertip to their thumb removed, to avoid further trauma and clots in the vein.

After that, the patient is put on a blood thinners regimen that can last up to three months. It's highly unlikely that a hockey player would be allowed to play or even practice with blood thinners in his system because it could make any internal bleeding suffered from a body check or even a slip on the ice considerably more dangerous.

Finally, a physiotherapist leads the patient through range of motion movements to prevent scarring and slowly restore strength before moving on to rebuilding the muscles around the surgery site. In Stamkos's case, he might re-learn how to do a slapshot.

"I understand that the shoulder might not be 100 per cent but there's so many other muscles that can replicate that [slapshot] movement," said Suppiah. "A lot of what comes from the slapshot can come from the trunk, the twisting of the body. The upper-back muscles, they're largely involved in that slapshot.

"If we can develop those upper-back muscles to compensate for where his shoulder's lacking he can probably get an even more powerful slapshot."

Showing little or no ill effects after the surgery will be a primary concern for Stamkos, who is set to become an unrestricted free agent on July 1 and has already been named to Canada's roster for the World Cup of Hockey, which starts Sept. 17.