Shoulder Repair Surgeries: Rotator Cuff and Labrum Tear

Players who have had a shoulder repair surgery

Quarterbacks

Quarterbacks	# of Weeks From Injury to Return	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Jimmy Garoppolo (2021)	26	15.2	15.7 (+1.5)	11.7 (-3.5)	18.1 (+2.9)
Cam Newton (2017)	23	18.7	13.1 (-5.6)	10 (-8.7)	26.3 (+7.6)
Andrew Luck (2017)	88	21.1	19.5 (1.6)	12.7 (-8.4)	27 (+5.9)
Drew Brees (2005)	35	13.1	8.6 (-4.5)	13.7 (+0.6)	15.6 (+2.5)
Average	43		-2.6	-5	+3.3
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			1/4 (25%)	2/4 (50%)	4/4 (100%)

Running Backs

Running Backs	# of Weeks From Injury to Return	PPG Prior to Injury	PPG in 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Carlos Hyde (2019)	30	7.7	8.3 (+0.6)	3.8 (-3.9)	N/A
Average	30		+0.6	-3.9	N/A
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			1/1 (100%)	1/1 (100%)	N/A

Wide Receivers

Wide Receivers	# of Weeks From Injury to Return	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Tee Higgins (2021)	N/A
Juju Smith-Schuster (2021)	13	10.4	5.1 (-5.3)*ρ	N/A	N/A
Auden Tate (2020)	42	3	1.9 (-1.1)	1.2 (-1.8)	7.2 (+4.2)*
Tyrell Williams (2020)	54	5.2	2.4 (-2.8)	N/A	N/A
Cedrick Wilson (2018)	58	N/A	0	0	2.4
Alshon Jeffery (2017)	32	8.3	20.5 (+12.2)	14.2 (+5.9)	10.2 (+1.9)
Eric Decker (2016)	43	14.9	2.5 (-12.4)	5.8 (-9.1)	6.7 (-8.2)
Plaxico Burress (2013)	N/A	2.6	N/A	N/A	N/A
Wes Welker (2010)	28	16	22.4 (+6.4)	9.7 (-6.3)	8.1 (-7.9)
Average	39		-0.5	-2.8	-2.5
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			2/6 (33%)	2/6 (33%)	3/6 (50%)

tight Ends

Tight Ends	# of Weeks From Injury to Return	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Martellus Bennett (2017)	N/A	4.8	N/A	N/A	N/A
Average	N/A		N/A	N/A	N/A
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			N/A	N/A	N/A

Anatomy of the rotator cuff

The rotator cuff comprises four muscles: the Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. Together these muscles have two distinct functions. They rotate the arm bone (hence the term rotator cuff), and they hold the arm bone in the shoulder socket when the arm is moving (throwing, swinging when running, catching).¹ The shoulder joint is naturally unstable, as it must have a great deal of mobility to perform dynamic motions during athletics. This inherent instability makes the stability function of the rotator cuff so important and is why injury to the cuff muscles can impact an athlete’s performance. Athletes can sometimes function with a partially torn rotator cuff; however, with a full tear, strength is affected, particularly when more than one of the muscles is torn, in which case surgery may be needed.²

Cause of rotator cuff Injury

Rotator cuff tears in athletes occur from a trauma such as falling on an outstretched arm (diving for a catch), in conjunction with a shoulder dislocation, when a quarterback is throwing the ball and a defender blocks his arm, and when the shoulder is hit in such as way that it undergoes excessive motion in any direction beyond what it is typically capable of.

Surgical Procedure for the rotator cuff

Traditionally, factors that would indicate surgery include the tear size (>3cm), significant weakness, significant loss in range of motion, and a full-thickness tear where the entire portion of the tendon has torn.³ Professional athletes, however, are a different breed and in some cases, can play through a tear depending on the severity and their position. Alshon Jeffery is a recent example of a player who tore his rotator cuff early in the 2017 season but continued to play the whole season and underwent surgery after winning Super Bowl LII.

When surgery is indicated, the procedure is performed arthroscopically, meaning only small incisions are made, and the surgical instruments are finessed into the joint to perform the surgery.¹ The patient undergoing surgery is placed in a seated position under anesthesia. The surgeon will create a small incision on the back side of the shoulder where they will feed a camera through to visualize the tissues in the shoulder joint. Other incisions are made around the joint to feed the tools used to perform the surgery. The surgeon will often use a tool called a curette or a burr to shave part of the arm bone where the tendons will be reattached, and this shaving creates bleeding that will help the healing process.  

The torn portions of the tendons are reattached to the bone and anchored with sutures.⁴ In some instances, a part of the shoulder blade called the acromion may be pinching on the rotator cuff tendons contributing to the injury. If this is present, the surgeon may shave this portion of the bone off to stop the pinching. Overall prognosis following a rotator cuff repair is excellent, and athletes typically return to their prior level of performance. 

Rotator cuff tear rehab process – conservative care

Not all rotator cuff injuries require surgery, in fact, many do not! Full-thickness tears, where the entire depth of the tendon is injured, typically require surgery; however, partial tears often don’t.⁵ 30% of the tendon must be torn before a noticeable loss of strength and function occurs.⁶ A positive factor that conservative care may be all the athlete needs is if pain is the primary complaint, but the range of motion and strength is close to normal.

Consider an athlete who suffers a rotator cuff injury in the middle of the season. The surgery will undoubtedly end their season, but with physical therapy, they may be able to get back on the field and perform at a high enough level to help their team.

The early stages of conservative care for a rotator cuff injury must identify the primary issue causing the injury. For some athletes, tightness in the tissues in the back of the shoulder pushes the arm bone forward in the shoulder socket, creating an impingement on the rotator cuff tendons.^7,8 For other athletes, there may be tightness or lack of control of the shoulder blade with motion that leads to pinching the rotator cuff.⁹

Others who are very flexible may have difficulty coordinating overhead motion, leading to pinching the rotator cuff muscles. While each has specific treatments to be utilized, all can benefit from exercises to gently activate the rotator cuff muscles, which will bring more blood flow to the area, and electrical stimulation and ice for pain relief.¹⁰ Initial rehab will be directed by the main issue found, and when this is improved, and pain is lessened, rehab becomes more sport-specific. Often, the athlete can return to playing while continuing to rehab. Sometimes, this can be as soon as the next game, whereas other times can take several weeks.

	Tightness in the Back of the Shoulder	Lack of Control of Shoulder Blade	Too Flexible
Initial Treatments	Joint mobilizations to the shoulder. Stretching of the back of the shoulder muscles and tissues. Rotator cuff activation exercises. Strengthening back muscles that move the shoulder blade. Electical stimulation and ice for pain control.	Manual techniques to help athlete activate shoulder blade muscles. Progress to active exercises to activate shoulder blade muscles. Rotator cuff activation exercises. Electrical stimulation and ice for pain control.	Rotator cuff activation exercises. Overhead exercises using bands to facilitate proper rotator cuff activation.

Rotator cuff tear rehab process – surgical

The return to full activity from a rotator cuff surgery is typically 4-6 months.¹¹ This can be position-specific, however, as a quarterback’s throwing arm will require a much higher level of performance and, therefore, more rehab than a wide receiver. Like most post-surgery rehab, the first six weeks focuses on protecting the surgical site via wearing a sling and avoiding using the arm and passive range of motion with progression to gentle active motion.

After six weeks, the sling is removed, but the shoulder is still protected as the connection of the repaired tendon to the bone is not fully settled until about week 15 after surgery.¹² That being said, the athlete can begin to do gentle activities with their arm, like lifting and weight-bearing through their arm.

By the end of 12 weeks range of motion should be full. At this point, a traditional strength program is started. By week 20, the athlete can begin returning to sport-specific activities such as throwing, sprinting, blocking, catching, etc. 

Timeline11	Goals	Rehab
Post-op Weeks 0-6	Protect surgical site Allow incisions to heal Reduce pain and swelling Passively raise shoulder to 120 degrees	Sling when not at rehab Passive stretching Gentle shoulder retractions and shoulder circles Manual mobility to the shoulder blade and muscles in the area
Post-op Weeks 6-12	Protect surgical site Full passive shoulder range of motion in all directions Begin gentle strengthening	No longer in sling Passive stretching to full ranges Active shoulder motions using the opposite arm or a dowel to help Gentle activation of shoulder muscles
Post-Op Weeks 12-20	Full active range of motion Initiate strengthening program	Continue stretching in all directions Strengthening rotator cuff with bands, dumbells, weight bearing exercises Advance to return to dumbell, barbell, kettlebell workouts
Post-Op Weeks 20+	Return to pre-injury strength and performance	Continue with all rotator cuff specific strength exercises (these become the warmup) Full unrestricted workouts Throwing, catching, sprinting, blocking, ect.

References

1. Lynch B, Christain H, McCrum C, Vyas D. Postoperative Management of Orthopaedic Surgeries; Shoulder. 2016
2. Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5^th ed. Philadelphia, PA: FA Davis Company; 2011.
3. Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589-604.
4. Voos JE, Barnthouse CD, Scott AR. Arthroscopic rotator cuff repair: techniques in 2012. Clin Sports Med. 2012;31(4):633-644.
5. Neer CS 2^nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg Am. 1972;54(1):41-50.
6. Cofield R. Rotator cuff disease of the shoulder. J bone Joint Surg Am. 1985;67(6):974-979.
7. Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brown SW. Glenohumeral joint total rotation range of motion in elite tennis players and baseball pitchers. Med Sci Sports Exerc. 2002;34(12):2052-2056.
8. Burkhart SS, Morgan CD, Kibler WB> The disabled throwing shoulder: spectrum of pathology Part 1: pathoanatomy and biomechanics. Arthroscopy. 2003;19(4):404-420.
9. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26(2):325-337.
10. Jensen BR, Sjogaard G, Bornmyr S, Arborelius M, Jorgensen K. Intramuscular laser-doppler flowmetry in the supraspinatus muscle during isometric contractions. Eur J Appl Physiol Occup Physiol. 1995;71(4):373-378.
11. Thigpen CA, Shaffer MA, Gaunt BW, Leggin BG, Williams GR, Wilcox RB 3^rd. The American Society of Shoulder and Elbow Therapists’ consensus statement on rehabilitation following arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2016;25(4):521-535.
12. Sonnabend DF, Howlett CR, Young AA. Histological evaluation of repair of the rotator cuff in a primate model. J Bone Joint Surg Br. 2010;92(4):586-594.