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The Rotator Cuff: Anatomy, Tears, and Repair

Rotator Cuff

The Rotator Cuff. The Rotary Cuff. The Rotator Cup. The Rotary Cup. I’ve heard them all and they all refer to the same thing: a collection of muscles in the shoulder. In this post, I’m going to tell you what the rotator cuff is, what it means when it gets torn, and how it is repaired surgically. I’m even going to give you some insight into the rehab process for it after surgery.

What is it?

In today’s NFL shoulder injuries are plentiful. One of the more common injuries that we hear about is a torn rotator cuff, especially in QBs. The rotator cuff is a collection of 4 muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) that wrap around the back and top of the shoulder like a hand. See Fig 1. They work together to stabilize the shoulder and to lift the arm overhead from the side. Any time the hand is out from the body, especially overhead, the rotator cuff muscles work together to keep your shoulder stable and in place.

Rotator Cuff
Fig 1: Rotator Cuff diagram

The Dreaded Rotator Cuff Tear

Any muscle can tear, and the Rotator Cuff muscles are no exceptions. See Fig 2. Tears can be traumatic or degenerative. Traumatic tears happen as a result of sudden injury, such as a fall onto the shoulder or outstretched arm. A traumatic tear can also happen while lifting weights with poor form or trying to lift too much weight. Degenerative tears happen over time, typically starting with tendonitis (inflammation or irritation of the tendon) that lasts too long. If the muscle(s) are being pinched between the bones of the shoulder, a condition called impingement, you get inflammation and swelling in the joint every time it gets pinched. Think about biting the inside of your lip. What happens? It hurts and swells, right? Then you tend you bite it again, and then again, making it worse each time. The same process is going on in your shoulder each time the tendon gets pinched. If this continues to happen, gradually, the bone starts to saw through the muscle until, “POP!”, it tears. Bone spurs from arthritis can also saw through the tendon(s) leading to a tear over time.  People who tend to try to “work through the pain” are more prone to degenerative tears stemming from impingement because they make it worse each time they push into and through pain. The old moniker of “No pain, no gain” does not apply in this case.

Torn Rotator Cuff diagram
Fig 2: Torn Rotator Cuff

There are several degrees of tears. A small tear may heal on its own with scar tissue filling in the tear. A partial tear may or may not require surgery, and this is determined by an orthopedic surgeon via MRI. If it isn’t too severe, conservative measures such as rehab, can address the problems of pain and weakness as the tear heals on its own. What the person does for a living plays into this decision as well. Elite athletes who need their shoulders for their job, eg: QBs, are more likely to need surgery to repair a tear than an 80 year old retiree. The only thing that will repair a full tear is surgery. 

The Rotator Cuff Repair

You can look up the surgery for rotator cuff repair on YouTube, but in a nutshell, the surgeon typically cleans out the joint and then anchors the torn muscle back to the bone. See Fig 3. The severity of the tear will dictate how extensive the surgery is. If there is arthritis (which can include bone spurs), the surgeon will smooth out the bone to “clean up” any degenerative changes. If impingement caused the tear, they may perform a bursectomy, which removes the fluid-filled sack, or bursa, in the joint that lubricates the joint and prevents muscles from rubbing over bone. They also might cut out part of the collarbone, which opens up the space where the rotator cuff is, preventing further episodes of pinching. 

Rotator Cuff surgery
Fig 3: Rotator Cuff surgery

Post-repair Rehab

Each orthopedic surgeon has his/her own protocol for rehabilitation after surgery depending on their surgical procedure, the extent of the repair, and what other procedures need to be done. Typically it starts with a period of immobilization in a sling to allow for initial healing. Then there is a period of time during which no active motion is allowed, but passive range of motion is allowed. This is typically done by a Physical Therapist. During these first several periods, exercises can be done to preserve strength and range of motion of the elbow and hand. Then there is a period of active-assistive range of motion, where the person uses their good arm to move the surgically-repaired arm, typically using devices such as over-the-door pulleys, wands (such as long pieces of PVC pipe), or wall wipes with a towel. During this phase, the person starts to activate the repaired muscles but not fully. Then comes the active range of motion phase where the person starts moving the operative arm by itself. This involves activating the muscles fully. Then there’s the strengthening phase with weights and sport-specific activities in preparation for return to play. This whole process is guided by a professional, usually a Physical Therapist, and barring setbacks, takes at least 3 months. Fully strengthening repaired muscles can take more than 6 months and it can take a year to return to pre-tear performance on the field. Even then, endurance can be an issue, and only time and continued hard work will fix that.

Player implications

So, you may be asking, as a fantasy football player, what does all this mean for me? Well, it has huge implications for QBs who are susceptible to and suffer shoulder injuries, such as rotator cuff problems. The most recent example is Cam Newton. He was diagnosed with a partial rotator cuff tear during the 2016 season but played through it. He then waited until March of 2017 to have surgery. This is odd, but apparently, the plan was to see if rest and rehab would fix it. As a Physical Therapist, I can tell you that, except for very small tears, the only thing that will fix a torn rotator cuff is surgery. He was limited for the entire 2017 season. He seemed to be back to his stellar self the first half of the 2018 season, but he had a very different second half in the 2018 season compared to the first half. We saw his ability to throw the deep ball decrease, and this could have been from arm fatigue or weakness, as noted in the Oct 26, 2018 game when he was pulled for Heinicke to throw a Hail Mary. He underwent another procedure in Jan 2019, but this was reported to be just a “clean-up” and not another repair. With clean-up procedures, the recovery time is much less than with a repair, so he was able to rehab much sooner. All indications so far (the sprained foot/ankle he sustained during the preseason this year notwithstanding) is that he is making all his throws well in training camp and the preseason, so there is little concern for him being limited this year because of the shoulder.

Takeaways:

The size of the tear and the position the player plays determine the timeframe of recovery from surgery. QBs are in the spotlight here because they need their shoulders to play their position. You can expect at least 3 months of intense rehab and then another 6 to a year before returning to pre-tear status. Even then you may have some residual muscle endurance issues, so continued exercise is the key to playing a full season unhindered.

So, there you have it: the rotator cuff. What is it, what can go wrong with it, and how to fix it. Reach out on Twitter @StonePT74 if you have any questions!

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