On this episode of the #AskMikeReinold show we talk about how people with irreparable rotator cuff tears can get back to high levels of function, including things like weight training and obstacle courses raises. We’ll cover if that’s a good idea and if we’re concerned about arthritic changes down the road. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 190: Getting Back to High Level Activities with an Irreparable Rotator Cuff
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- Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?
- Can You Have a Rotator Cuff Tear and No Symptoms?
Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about getting back to high-level activities when you have an irreparable rotator cuff.
Mike Reinold: All right, what do we got for a question today?
Student: All right, we got Dillon from Montana…
Mike Reinold: Dillon!
Student: Big fan of the podcast. We have a 48 year old male with an irreparable infraspinatus, who is very active. What kind of outcomes should we expect as he rehabs? His goals is to eventually get back to Spartan Races. Is this feasible or will arthritis develop so bad he will need a shoulder replacement?
Lenny Macrina: Yes.
Mike Reinold: Two different questions but I like that. Is it feasible? Yes. All right, so a 48 year old patient with an irreparable rotator cuff, which is a conundrum. I just wanted to use that word in an episode today. So we’re in a conundrum, right? You have an irreparable cuff, which usually means it’s a pretty big cuff tear and it’s probably retracted, right Len? I mean, why else would it be a irreparable?
Lenny Macrina: Probably yeah.
Mike Reinold: 48 year olds, it’s probably not like ridiculously chronic. So it’s probably a large tear that’s retracted, meaning they don’t have a chance to put it back. And he wants to get back to high level activity, specifically a Spartan race. But if you’re a Spartan racer, you’re probably a fit person, right? You do a bunch of other things. So why don’t we start with that question and let’s do the two together because I think we will need to address the potential for arthritis down the road. But is it feasible for this person to get back to Spartan races? What do you guys think?
Lenny Macrina: Yes.
Mike Reinold: All right, great episode. How many times did we do that, Joe?
Lenny Macrina: Wrap it up! I would say yes, right? I mean, yeah, yeah Dan.
Dan Pope: There’s a lot of layers to this, I think. So one, I think it depends on where the person’s at. So I’ve seen some CrossFit athletes that have fully retracted rotator cuff tendons and they can still do CrossFit. They might have some pain, sometimes they might not have much pain. So I think it depends on the person that’s in front of you. My big concern is that, if they have too much rotator cuff damage over the course of time, do they get to the point where they have to get a reverse total shoulder eventually as opposed to a total shoulder replacement?
Mike Reinold: Right.
Dan Pope: And I guess it depends on which tendons are retracted, how many, that type of deal, which I don’t fully know, but I guess long story short, probably yes. But the other part is you probably do need to be careful and have that first checked out by the doctor frequently over the course of time to make sure they’re not progressing to the point where they can’t get regular shoulder replacement. Best case scenario.
Mike Reinold: Heck of a disclaimer right there. I like how you did that there. Just make sure your frequent check ins with the physician to make sure you’re on path. So Len, it sounded like you agreed, right? I mean, you agree it’s feasible, right? Why do we think it’s feasible?
Lenny Macrina: When you tear a tendon, other muscles can take over. So you have your posterior, you have your Teres Minor, you have other muscles that can definitely compensate and help. But I also think, not knowing the whole situation, is age, to have a 40 year old with an irreparable infraspinatus.
Mike Reinold: Oh wait, they said infra?
Lenny Macrina: Yeah.
Mike Reinold: Oh rats, I was going to base this all on supraspinatus.
Lenny Macrina: Very, very unusual. So, sounds like it may have been a freak injury but I would also try to get, not knowing the situation, a second opinion. Because nowadays, with internal bracing and tendon transfer, they can do it like, a lat transfer or something like that. I think there’s ways to get around this but maybe, maybe, maybe. But I would want to consult with like surgeons that specialize in these types of surgeries and really try to push them in that direction to give them the best opportunity to continue to train because they’re only 48 and if this was a 68 or 78 year old, I’d say, different story, work on strengthening, it is what it is and activity levels down. But this is a 48 year old. So I think there’s still a good opportunity to do more for this person than if they just got one opinion who said irreparable. But then again, not knowing the whole situation. But I think the body is amazing that it can overtake these issues and figure out a way to still perform.
Mike Reinold: The body’s a wonderland.
Lenny Macrina: My body’s a wonderland.
Mike Reinold: So, it’s kind of funny. So irreparable, we got that. Is it feasible to do these things? Of course everything’s feasible. I don’t think we should ever tell anybody like, you can’t or you shouldn’t or whatever. I mean, everything’s feasible. It just depends on where they’re at. Now I would just add, before we maybe get Mike and Lisa to chime in a little bit here, but like I would just add that the fact that it is an infraspinatus worries me a little bit, that not the feasibility is there, but maybe my optimism is less. I’m a little bit more pessimistic that this will go up. But again, anybody can do anything. It’s just whether or not it’s a good idea. So I don’t know. I think we covered the feasibility thing. Why don’t we switch gears and say, what are the chances of this person developing arthritis and how do we manage that, I guess? And does that matter? And those types of things. I mean, who wants to? Mike?
Mike Scaduto: Do you think, considering the mechanism of injury for the original cuff tears is important there? Because if it was a traumatic injury versus a chronic overused training type injury, it probably speaks to how you have to modify their training going forward. So if it’s somebody who was maybe training suboptimally and ended up tearing their rotator cuff to this point, you probably spend a lot of time educating them on how to modify their training going forward and that’ll be a big piece of their rehab. I don’t know. What are your thoughts on that?
Mike Reinold: I think that makes sense. If it was a snowboarding accident and it’s this freak accident and everything else is great, then yeah, absolutely. But yeah, if part of this attrition of the rotator cuff is from poor activities and things they’ve done in the past… but by all means, I think the feasibility question goes downhill and you could argue then also the chronic arthritis concept goes up, right? So that’s a good thing is understanding why this happened. Was it an acute traumatic like goofball kind of thing, or was it a chronic attrition that I think changes that? So a good point.
Mike Scaduto: If it was acute trauma, a traumatic injury, like what else happened? Did they dislocate their shoulder? It was an instability event, something like that could also play into the prognosis.
Mike Reinold: Right, that’s a good point. So put it all together. And I think that is going to be something that we consider with, is this person at risk for arthritis? Lisa, anything? I know we kind of covered a bunch, but.
Lisa Russell: Yeah, I mean, even just on the arthritis side of things, in terms of how it happened and what the trauma was and thinking short term traumatic arthritis versus longer term overuse, depending on what the mechanics of the shoulder end up being and I mean, you’re just educating the person of what they’re working with and how they need to deal with it and what to avoid or what you know. I guess that goes back to even the strengthening side of if we’re just working without surgery or like Lenny said you’d go back and find somebody else who can be more creative, but just telling the person what they’re working with and how to keep their shoulders safe.
Mike Reinold: Right. I think I liked what you said there was that, it’s almost like taking their symptoms into account to an extent to here and that’s probably the biggest thing that I would recommend kind of moving forward is that you take their symptoms into account. If they’re not having any symptoms and they’re super strong with the surrounding musculature, then I don’t see a reason why we should limit them, right? Because if you’re getting arthritis and it’s building up over time, you’re probably getting symptoms as well. It’s not like you’re developing raging arthritis behind the scenes, have no idea and then all of a sudden, one day, it’s too late, right?
Dan Pope: I don’t know, I looked into this research at one point because I felt like I didn’t have good answers for my patients, because you can’t have cuff pathology, right? And maybe not have pain, we know that. The other thing is that, most people after they have a rotator cuff tear, it continues to worsen over the course of time, right? It just gets worse and that’s kind of natural. What’s challenging is that, if you do get a retracted tear and you can’t do surgery on anymore, that may end up being a problem. The other problem is that we can’t really guess if people are worsening over the course of time and there’s a few variables that do. I think one of the things I was finding, smoking is bad, that’s going to make that tendon get worse faster and the other one was pain. So I do think there is some, I don’t know, some viability to the whole idea of let’s train but let’s be careful about pain, if things are worsening, go talk to the doctor and let’s make sure it’s not a worsening problem.
Mike Reinold: And like you said previously, it’s like, get a good relationship with a doc, maybe you’re checking in with them every now and then. If you want to use your body to the max and you have this scenario, then maybe you need to have more check-ins, just to make sure you’re not going in the wrong direction. But I think the problem, just to kind of summarize here, is yes, is it feasible? Of course it’s feasible. Is it a good idea? Maybe, maybe not. I mean, it really depends on the scenarios there. But what happens when you have a cuff tear, is that you’ve lost the complete dynamics of the glenohumeral joint. And it’s not going to work perfectly. Like Lenny said, could they compensate? Can others help? Absolutely. Could they do a good job of that? Absolutely.
Mike Reinold: But your room for error goes down, right? And then you just have a smaller cliff that you could fall off, that you just got to be careful with that. Because what’s going to happen with the cuff, is you’re going to lose that ability to center the humeral head and over time, you’re going to probably superior migrate. And that is where you’re going to develop your arthritis. But again, I think you’re going to know it’s coming, but don’t be the knucklehead that keeps working through it until you get a raging arthritic situation because then you’re going to really be in trouble. So, very feasible that they get arthritis. It’s probably actually likely, anybody thinking he has a chance of not getting arthritis, you know? And arthritis in the shoulder kind of stinks, so you know, something that kind of keep in mind.
Mike Reinold: So hopefully those tips help. Hopefully those were at least some things that you can have some conversations with, if you have somebody that’s very similar to that. So I think that’s actually pretty common as our activities, as we age, increase and as the activities we’re doing in our twenties and 30s increase. I think we’re going to see a lot more of this in 10 years or so. So thank you everyone!
Mike Reinold: But anyway, another great question. Thank you so much. If you have a similar question, head to MikeReinold.com and click on that podcast link and you can fill up the form to ask us a question. Hopefully we’ll feature it on a future episode. We’ll see you in the future.