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Returning to CrossFit After Rotator Cuff Repair

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Returning to CrossFit after a major surgery like rotator cuff repair is a long process that shouldn’t be rushed. But that doesn’t mean it’s not possible.

Here are some steps you can take to progress someone from post-operative to advanced exercises like snatches, kipping pull ups, and muscle ups.

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#AskMikeReinold Episode 271: Returning to CrossFit After Rotator Cuff Repair

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Show Notes


Transcript

Kim Le :
Question is Julia from Alabama, wants to know following a full thickness supraspinatus rotator cuff repair, when would it be okay for a patient who’s a CrossFitter to return to Olympic lifting, strict pull ups, as well as tipping in other gymnastics movements, such as toes to bar and insane pushups and muscle ups?

Mike Reinold:
Wow. It is interesting. Good question, Julia. Roll tide. Good question. I like that. Len, did she have too many words for one sentence? Is that a run?

Lenny Macrina:
I was offended by the question because of all the run on sentences.

Mike Reinold:
I thought that was a great question. I just want to run the grammar by you if you’re a long time listener. Awesome. This is the Dan Pope show here for this, but I like at least how Julia is specific. She probably has somebody in mind, which is kind of cool. But a full thickness cuff tear, which I think is important to say and Supraspinatus is, by the way, that’s usually what a full thickness cuff tear is. That’s not the crazy part for me. But full thickness, meaning this was like a real tear. It’s not a partial, it’s not a transtendinous. When can you get back? And then she lists everything, right? So there’s a ton of things, but it’s a really good question, and I’m sure there’s a lot to it. But I would say the majority of PTs out there are probably scared of getting their cuff patients back to these types of activities, right? How do you approach this, Dan?

Dan Pope:
That’s a big question. And we could probably spend long, long time on this. I’ll try not to. What I will say is that these are my best guesses, right? And there’s actually one research article that came out recently and talked about how long it took to get it back to some of these movements. So like the snatch and the muscle up were around 9 to 11 months, but most of those folks were acute tears and partial thickness actually. It’s probably a little bit different for those folks compared to someone who has a larger cuff tear. Generally speaking, I think that around the 12 week mark is when you can start what we consider traditional weight lifting type stuff, right?

Dan Pope:
I think that’s going to really depend on the individual. It’s going to depend on the tear too. If someone’s doing extremely well with a smaller tear, then maybe that 12 week mark is appropriate. If not, you might have to extend that a little bit. Generally speaking, we start with dumbbell exercises first, and I like to try to work below the shoulder. So the first goals from a strength perspective are trying to get around 90% symmetry with some sort of dumbbell press, usually start with a partial range and progress through a full range of motion and the same thing with a dumbbell row. So we’re trying to see 90% symmetry.

Dan Pope:
Once we’re getting closer to 90% symmetry, we start going more overhead, right? And that’s going to be a little bit challenging for most folks because we need to have a good overhead pull down. Most CrossFit gyms don’t even have that. I think often we don’t think about building symmetry with overhead pulling, but that’s going to be super important because you’re going to want to be doing pull ups. Right? So once we get about 90% symmetry with pull downs and some sort of overhead dumbbell press. Go ahead, Mike.

Mike Reinold:
I was going to ask, how long do you think that usually takes to get 90% symmetry? So you start at week 12. How long does that take?

Dan Pope:
Lot of variability there. So, somewhere between four and five months maybe for those folks.

Mike Reinold:
I’m glad you said that because when you first said that, I imagine people grabbing dumbbells and all of a sudden just start bench pressing at week 12. I got a little anxiety from that.

Dan Pope:
That’s tough. It’s so hard because there’s no guidance, right? There’s no product cause I kind of tell you what’s okay and what’s not. I usually tell folks in terms of weight and what weight to start with, we’re starting with a pretty low. I use RPE or Rate of Perceived Exertion for most folks. When they go in the gym, they do a set that would be maybe an 8 or a 9 RPE. So a 10 out of 10 would be the hardest you can possibly push, a 0 is you’re not pushing whatsoever. Right? So starting with pretty light loads. And then basically, as their strength improves, we start to slowly increase over the course of time. I’m not expecting them to have symmetry until closer to that five month mark anyway, so you can already see this is a long, long drawn out process.

Dan Pope:
Once folks have some of that symmetry, then we actually start going towards barbell movements, and we start with the strict barbell movements first. So you’ll see a strict barbell overhead press and you’ll see a strict pull up, right? Once we show that we can do that well, and I usually see people for two to four weeks of doing barbell movements before we progress again, at that point, I’m thinking about standard programming. I usually program and exercise and see it through for about four weeks before we change it again. Then we move on to a push press. And then once a push press is tolerated, then a push jerk or a split jerk. So really from a jerk perspective, you’re probably not seeing people get back to heavier loading until maybe about 8 or 9 months, maybe later than that, right? The muscle up is interesting, just because you can’t scale as well as you can for a barbell. It’s really easy to put more weight on a barbell or take weight off or use like a lighter Barb bell.

Dan Pope:
You can’t really do that for a muscle up. There are some ways to do it. There’s a ring thing the Power Monkey fitness guys sell. That’s awesome. You can use partial body weight, but generally speaking, it’s a little harder to progress because you can’t scale it as well. And you have a lot of athletes that are coming at different levels of fitness, right? You have someone that tears a rotator cuff that is nowhere near close to doing a muscle up prior to having injury. And some folks can do a lot of muscle ups and they get hurt and their progress is going to be faster. Right? So keep that in mind. But generally, the way I go about this is the same way. We want to see someone progress their way up to being able to strict pull up and also a strict dip.

Dan Pope:
And the way we do dips is pretty similar as well. The only difference is that a dip needs a lot of extension of the shoulder, which is a decent amount of stress on the rotator cuff. And it’s one of those movements that typically is sore and painful, even moving out months and months from the surgery, right? So get your symmetry with a dumbbell bench press and then start on a stable implement. So basically like power low bars or a dip station to get to the point where you can tolerate dips well, and then we move over to the unstable elements, right? So we start progressing over towards ring dips, ring pullups. As we’re tolerating those well, we start to incorporate a transition phase.

Dan Pope:
So working on drills that allow you to transition from the pull up to the bottom of the dip and then round the 9 to 12 month mark is probably when you can start doing repetitions of a muscle up. And one thing I will say with CrossFit is that there’s a big difference between being able to do strict and kipping pullups in a skill kind of place and doing them in a Metcon environment. Right? So if possible, I’d love athletes to be able to get a strict muscle up before we start doing more dynamic motions like kipping, right? That’s not always the case because some athletes just don’t have the strength to do strict, but I want to see them doing strict muscle ups in more of a controlled strength environment, like three sets of five for a few weeks before we actually progress towards doing them inside of a conditioning environment.

Mike Reinold:
I like that. I like what you kind of said there, because you kind of led us through a progression where you talked about like loading somebody in mid range of motion before you get to end range of motion, then loading it controlled towards end range of motion before you start doing that with speed and load. Then obviously adding all those things together would be the end. So, probably the things that have load with speed at end range, like a snatch or a Kip or definitely a muscle up, those types of things. You see how Dan broke down those into pieces to do them in components. So that way, at least you have the skill and the stress involved, but maybe not actually putting it all together with speed and loqe at end range. Right? You put that together.

Dan Pope:
Yeah, for sure. There’s a lot to it obviously. Like I said, I’m guessing. I sat down for a long time and thought about this. I worked a lot with Dave Tilley back in the day. I reached out to Dr. Rocket, who’s the Head Surgeon for CrossFit HQ. And we just kind of figured out what we think is appropriate at given timelines. But, we don’t really know. We’re guessing.

Mike Reinold:
You got to think that these people that are having this surgery isn’t like an 85 year old degenerative rotator cuff tear. Hopefully this is a younger type person with better tissue quality, a smaller tear that they’ll be able to respond to this a little bit better. But also you do have to wonder, well you still got here, right? You’re 30 with a full thing, this rotator cuff tear. That’s the elephant in the room, I guess. But when you look at some science behind rotator cuff repairs and when they fail and don’t fail, I think the majority fail early. Right? And it’s during the phases where we’re doing nothing related to CrossFit too. So keep that in mind. So, things like a dip muscle up type thing probably scares me the most. Dan, do you agree with that? I was just trying to think of that. That excessive extension position tends to scare me. Like, am I off on that?

Dan Pope:
I don’t think so. I think this is a common position that hurts people that don’t have a rotator cuff tear after surgery. It’s just a tough position for the shoulder in general, right? You’re in full extension and range of motion. You have your full body weight on there. If you’re thinking about it from a muscle up perspective, you’re throwing yourself into position onto an unstable implement, right? So that’s a ton of stress in that area. And on top of that, a lot of folks don’t have the strict strength to do a regular muscle up, let alone once you start kipping. So what happens is that athletes don’t really have the strength to do a strict muscle up. They can’t pull themselves into the position and they’re not very good at dipping out of it. So they use their legs, right? You kip, you have an aggressive kip, you get onto the rings, right?

Dan Pope:
You’re in this unstable position, you can’t really kip out of it. So you use your legs to kip out of it too. Right? So I think the nature of the movement by itself, it’s very challenging. You’re throwing yourself into positions and you have to have a ton of stability there, right? So it’s a weird dynamic element, and you have to be able to handle those positions well, so at least for me, I think you have to be able to handle the bottom position of a pull up extremely well, right?

Dan Pope:
Just because that’s where all your kipping goes and it’s where you land from a kip. The other part is you have to establish a ton of strength and stability and the catch position of a muscle up because that’s also where things tend to go wrong and where you throw yourself into. Right. So you’re just preparing these positions very thoroughly before you do it in a more dynamic fashion. And for me, that means I’m doing dips, but I’m also doing like Pauls dips where I go in the bottom position of a dip and I hold there and then I press back out, and maybe I pause the top too, go back down, pause at the bottom. Because really you want to display a lot of strength and control in the areas that are probably hardest on the body and most likely to cause more injury.

Mike Reinold:
And I think a lot of people that I get fearful of, especially that study you alluded to that just recently came out. I think if you break down those subjects, I don’t know if those subjects apply to the whole spectrum of people with rotator cuff repairs. So you see that, and you want to go fast. This is the type of thing where, if this doesn’t go well, it’s going to stink, right? Like you’re going to be in a bit of a jam with now a retear. Your tissue quality is worse. It’s probably retracted. You’re going to be in a jam here. So just, be smart. I know we all want to get back into there, but I think the big thing I got out of Dan is there’s a ton we can do during these early phases in the mid range of motion.

Mike Reinold:
Right. And then even in the latter stages, with end range of motion before we get to speed and load at end range, right. There’s a ton we can do. You’re going to be very happy in the gym. Right. You may not be competing for time. Right. But you’re going to be very happy in the gym, towards that give or take nine by month mark down there. So see some of that light at the end of the tunnel, but be smart I guess, is what I said. I’m not like conservative with my athletes in any way, but I just want to make sure that this goes well for these people.

Dan Pope:
One thing I will say too, is that getting back to CrossFit after rotator cuff tear is hard, right? You’re trying to get back to really, really challenging movements. If someone is, let’s say a bodybuilder, they’re probably going to be pretty happy with their training around like the five to six month mark. They’re starting to load a little bit more, they’re back to most of the movements they enjoy.

Dan Pope:
For someone who’s going to CrossFit, I think it’s going to be quite a bit longer, just because there’s more stages, and CrossFit’s very dynamic and it’s challenging on the body. So if you are a person considering a rotator cuff repair, at least in that study the outcomes are quite good. People did really well with this. So I think that people can do well with a rotator cuff repair. And if you’re a young person with a full thickness, I think you probably should, but it’s going to take a long time. So you have to set that expectations. That’s like 9 to 12 months until you’re back to doing everything that you want to be able to do. And even then I think for a year, year and a half following that you probably need to be very cautious. Right.

Mike Reinold:
I like that. And just realize you can have fun at CrossFit, but maybe you’re not as super competitive initially when you get back, I think is what you’re saying. That’s good. And then I would just say, now is a good time to reflect. If you’re doing CrossFit and you’re having some shoulder pain, you get checked by a quality professional, like Dan Pope from fitnesspainfree.com, because you don’t want this to become a rotator cuff tear. Because that’s going to be a big problem for you. So, don’t neglect shoulder pain during your lifts and stuff. Because there’s a lot of things we can do that can keep you in the gym training and not do some damage to the tendon for the long term.

Mike Reinold:
So kind of keep that in mind too, is to be proactive with this if you’re having some pain. So, that’s awesome. Sincerely, Dan’s the man. We kid around with Dan with this sort or stuff, but he’s got tons of articles on this, on fitnesspainfree.com. You’ve got even courses and programs that teach you this. So this is hard to cover in 15 minutes, obviously, Julia, but go check out Dan’s website. He’s got a huge database of content on there and even some in depth courses. Right, Dan?

Dan Pope:
Thank you. Thank you very much, Mike. Yeah, definitely check it out. If you want to send some specific questions, I think you know where to find me on Instagram or whatever. Hopefully I can help you out.

Mike Reinold:
All right. Great episode. Thanks Julia. Roll tide. We appreciate it. If you have a question like that, please head to mikereinold.com, click on that podcast link. Be sure to go to Apple podcast, Spotify and subscribe to this podcast, so you get notifications when you have new episodes and we’ll see you on the next episode. Thanks so much. Take care.

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