Boning up on Manny Pacquiao’s rotator cuff injury

The phrase “rotator cuff injury” was not a common expression to most Filipinos unfamiliar with medical terms.  It is a tribute to the popularity of our pambansang kamao, Manny Pacquiao, that when he sustained this shoulder injury, before and during his “fight of the century” with Floyd Mayweather, rotator cuff injury became a household term in the Philippines! 

But what is the rotator cuff?  How is it injured?  How is the injury diagnosed? When should you seek medical attention? And how is it treated? 

BONES, JOINTS, MUSCLES AND TENDONS

The shoulder is a ball-and-socket joint and is made up of three bones: the shoulder blade (scapula), the collarbone (clavicle), and the upper arm bone (humerus). The rotator cuff is a combination of muscles and tendons that form a cuff around the shoulder joint and link your upper arm bone to your shoulder blades. The rotator cuff also holds your upper arm bone in place in your shoulder socket. The four muscles that comprise the rotator cuff are the supraspinatus, infraspinatus, teres minor and the subscapularis.  Each of these muscles is connected to the arm bone by a tendon.   The rotator cuff allows a person to lift his or her arm and reach up. 

A rotator cuff tear is a tear of one or more of the tendons of the four rotator cuff muscles of the shoulder (see illustration). A rotator cuff injury can include any type of irritation or overuse of those muscles or tendons and is among the most common conditions affecting the shoulder.  Thus, the thing to remember is that rotator cuff problems don’t just occur in athletes.  In fact, adults older than age 60 have the highest rate of rotator cuff problems of any age groups.

HOW IS IT INJURED?

You can injure your rotator cuff through wear-and-tear or by poor movement patterns over time.  As a person gets older, calcium deposits in your shoulder area or bone spurs due to arthritis can also irritate or pinch the rotator cuff.  These bony protrusions or bone spurs can irritate tendons by rubbing on them or by narrowing the space in which the tendons have to move (impingement syndrome, see illustration).  Repetitive stress is another culprit.  Sports such as bowling, cricket, swimming, tennis, baseball (especially pitchers), and kayaking, are most frequently implicated. 

The degree of injuries may vary.  Your tendons may be inflammed (tendonitis) from overuse or partially or fully torn.  You may also feel pain in your shoulder from bursitis.  This is a condition where the bursa (a sac filled with fluid that sits between your rotator cuff and your shoulder joint) becomes inflammed and irritated. 

It’s easy to understand how the muscles or tendons of your rotator cuff can be strained, bruised or torn by some sort of trauma.  It can happen when you use an arm to break a fall, fall on your shoulder, or lift or pull something that’s too heavy — particularly if it involves lifting overhead.  When strains or tears occur, they may range from microscopic tears to partial or full-thickness tears. In full tears, the muscle and tendon groups that make up the rotator cuff are ripped apart or separated from the bone.

HOW INJURY IS DIAGNOSED

Clinically, pain is the most common symptom of most rotator cuff problems.  Pain may only occur when you move your shoulder in certain ways, particularly overhead movements such as combing or shampooing your hair, putting on a jacket, or carrying something heavy. You may find that lying or sleeping on the affected shoulder is also painful.  Sometimes, rotator cuff injuries can cause severe or continuous pain.  Additional signs and symptoms of rotator cuff injury include shoulder tenderness or weakness or loss of shoulder range of motion.

The amount of pain you’ll experience isn’t necessarily indicative of the amount of injury you’ve sustained. A full-thickness rotator cuff tear, such as the one Pacquiao sustained, may sometimes cause little pain.  On the other hand, a fairly minor irritation can cause enough pain to substantially affect your quality of life or sports performance. 

X-RAY, MRI SCAN, AND ULTRASOUND

Diagnostic modalities to diagnose rotator cuff injuries include X-ray, MRI, MR arthrography, and ultrasound.  Usually, a tear will be undetectable by x-ray, although bone spurs, which can impinge upon the rotator cuff tendons, may be visible.

The most common diagnostic tool being used now is magnetic resonance imaging (MRI). It enables the detection or exclusion of complete rotator cuff tears with reasonable accuracy and is also suitable to diagnose other pathologies of the shoulder joint.  It can sometimes indicate the size of the tear, as well as its exact location within the tendon.  It may, however, miss certain small, pin-point tears.  In such situations, an MRI, combined with an injection of contrast material, an MR-arthrogram, may help to confirm the diagnosis.  However, its routine use is not advised since it involves entering the joint with a needle with potential risk of infection.  Consequently, this test is reserved for patients whose diagnosis remains unclear.

Musculoskeletal ultrasound has been advocated by experienced practitioners, avoiding the radiation of x-ray and the expense of MRI, while demonstrating comparable accuracy to MRI for identifying and measuring the size of full thickness and partial-thickness rotator cuff tears.  However, MRI provides more information about adjacent structures in the shoulder and these factors should be considered in each case when selecting the appropriate study.

WHEN YOU SHOULD SEEK MEDICAL CARE

It is important to seek medical care for severe or persistent shoulder pain to prevent a permanent loss of motion. Sudden loss of motion after an injury also requires early attention. If pain or limited shoulder motion is bothering you, keeping you awake at night, or interfering with your day-to-day life, there’s probably something that can be done to improve your symptoms. A minor injury or pain from a bout of overuse will often feel better within a few days with proper care.  Self-care tips include:

• Rest. Avoid movements that aggravate your shoulder and cause pain, especially repetitive overhead activities.

• Ice the shoulder. Apply a cold pack wrapped in a cloth for 15-20 minutes at a time, three or four times during daytime.  This can help reduce pain and inflammation.

• Medications, as needed. Nonprescription pain medications such as acetaminophen (Tylenol, others) may help ease the pain for a couple of days. Talk to your doctor if the pain doesn’t improve with normal doses of pain medication or if the pain doesn’t improve after a few days.

Often, the foundation of treatment for rotator cuff pain and injury is exercise therapy.  This may involve working with a physical therapist on specific exercises that will heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced strengthening of shoulder, upper back, and chest muscles. Results of physical therapy may not occur instantly. However, commitment to consistent physical therapy over a few weeks or months is likely to reduce pain and improve shoulder function.

With ongoing pain — especially if it interferes with your ability to do physical therapy — your doctor may recommend injection of an inflammation-suppressing corticosteroid.  This may help reduce pain and inflammation, particularly if inflammation appears to be the root of the problems, such as with bursitis.

SURGERY

If your rotator cuff symptoms are related to a bone spur or calcium deposit that’s pinching or irritating a tendon, certain relatively minor surgical procedures may be helpful.  With calcium deposits in a tendon, ultrasound imaging can be used to guide placement of a needle that’s used to break up the deposit.  Fragments of the calcium deposit can then be suctioned away. With bone spurs that have formed on an arthritic joint, a scoping device and small surgical instruments can be inserted through small incisions near the shoulder.  These instruments can be used to trim away bone spurs and suction debris.

Partial and full-thickness tears may not need to be repaired, depending on how you’re getting along with the injury.  Still, some partial tears can be improved with a trimming and smoothing procedure done using an arthroscope.  Larger partial tears and full-thickness tears (such as the one Pacquiao sustained) are repaired by reconnecting torn muscles and tendons.  This can be done as open surgery with a larger incision.  Either method typically requires at least four to six months or more of rehabilitation before full shoulder function is restored.  For those involved in elite, competitive contact sports, like Manny Pacquiao, he may have to be out of the ring for nine months to a year, or even more, in order to get back to optimum shape, for another boxing bout.

        REHABILITATION

Rehabilitation after surgery consists of three stages:  First, the arm is immobilized so that the muscle can heal. Second, when appropriate, a therapist assists with passive exercises to regain range of motion. Third, the arm is gradually exercised actively, with the goal of regaining and enhancing strength. However, the appropriate timing and intensity of therapy are still subject to debate at this time.

Regardless, most surgeons advocate that the patient’s operated arm remains in a sling or immobilizer for at least six weeks.  This is the stage where Pacquiao is presently.  Theoretically, that gives tissues time to heal. Since patients, especially those recovering from significant large rotator cuff tears, such as the one Pacquiao sustained, are prone to developing new tears, some authorities argue that therapy should be started later and done more cautiously as rehabbing too soon or too strenuously might increase the risk of retear or failure to heal.  No major therapeutic measures are instituted at this time other than oral pain medication and ice.  Some authorities however, advocate early, aggressive rehab.

This is followed by the “proliferative” and “maturation and remodeling” phases of healing which ensues for six to 10 weeks.  Gentle physical therapy guided motion is instituted at this phase, to prevent stiffness of the shoulder as the rotator cuff remains fragile at this time. At about three months after surgery, physical therapy treatments will focus on scapular mobilization and stretching of the operated shoulder joint.  Once full motion is regained (at about four to four and a half months after surgery), strengthening exercises are the focus. Typically, at about six months after surgery, most patients would have made 60 percent of their gains from the surgery.  It will probably take a few more months to regain full strength and start intensive training for an elite sport.

Summing it all up, my estimate therefore is that it will take about nine months for Pacquiao to fully recover from his injury. Add another three months for training, and it will be exactly a year before our boxing hero can go back inside the ring, if and when, he decides to fight again.