Well, thank you very much for having me. I just got news that my flight got canceled, so I'm going to actually talk to you all about rotator cuff for the next four hours. I hope everybody's ready here. One thing we should get out of the way right up front, right? Your initial response when you see this is that healthy people don't tear their rotator cuff. So pay attention to number 31 on the bottom left corner of the screen there. That's our defensive back. And remember, healthy young people traumatically don't tear their rotator cuff. So he goes up, comes out on the arm, sort of tries to swat the ball away, misses the ball, and then hits the ground really hard with his arm. So a better view of it here, potentially. Same thing, misses, hits it, and to make matters worse, they got the first down. So this is what we're dealing with. And you initially see this man on the field, and your initial thoughts don't go to the fact that, oh, he's got a rotator cuff tear, right? We're all football doctors. We think it's going to be a dislocation, an AC joint, something of that nature. But in reality, they actually can get these tears. And so let's talk about it a little bit because it's not the tears necessarily that you need to worry about in football, but it's the whole spectrum of rotator cuff injury. So rotator cuff injury can start with something as simple as bruising the rotator cuff, moving to the more common things that we see in young healthy people like tendinopathy or partial thickness tears. And then there are actually incidents of full thickness rotator cuff tearing. So to jump in here, Jim Bradley actually gave a great description several years ago about a single team's experience with rotator cuff contusion alone. And it actually comprised almost 50% of the shoulder injuries for an entire season. So of all the shoulders you're going to see, dislocations, AC joint, everything else we're talking about, 50% of what you'll see still in football is a rotator cuff contusion. The vast majority of those are from direct blow. Whether somebody knocks into your shoulder with their helmet or you land on it, things like that. There can also be the indirect blows, which are when you fall onto a flexed elbow and people will complain that they jammed their shoulder. Defensive backs, like I showed you in that first video, are the most likely to get something like this, followed by linebackers and offensive linemen. The thing really that strikes you about rotator cuff contusion when you see it the first time is you think that this person has a massive rotator cuff tear. They have essentially, in some cases, a pseudo-paralytic arm. They can't raise their arm. They hike their shoulder. They lack external rotations. It's really, really kind of dramatic. The good news is, like I said, 50% of the time you see that, it's going to be a rotator cuff contusion. And from Bradley's study, again, only about four days get missed with that. And so it's striking, right? For us on Monday morning, we'll see a man that can't move his arm and you think, my gosh, we're going to have to do a tendon transfer or fuse his shoulder. And instead, by Thursday, he's practicing like nothing happened. There are some MRI features that can stand out that will lead you into thinking that things are more serious as a contusion. Things like bone bruises, chronic tendinopathy, those sorts of things can actually portend a slightly longer recovery than that average of three to four days. Moving on, though, the next element or the next more serious actor is that tendinopathy or partial thickness rotator cuff tearing. And these are more likely a chronic condition, right? This is something that you're going to see from your athlete in the weight room that they want to do overhead stuff. They're doing more of the dynamic kind of overhead lifting. So it's really something that you think about it more as a chronic problem that reared its head by virtue of an injury out there on the field. It's still unclear whether or not these things progress to becoming more significant or full thickness tears. There's a lot of conjecture going back and forth about that. But again, I would argue that it's not very clear one way or the other. So I've grouped together contusion, tendinopathy, partial thickness rotator cuff tear, because the honest answer is, is you treat them all fairly similar. How do we work these up? Well, I would say here, this is one where an early MRI is useful, but probably honestly essential. Because if you have somebody that has this cuff contusion versus some other problem, you're going to manage that very, very differently from what you would if it were a small full thickness tear or, heaven forbid, a large thickness tear. If there is a contusion, this is one where you really want to start motion and rehab early. We don't force these guys to go through a painful arc of motion, but we want them to really go right up to that edge of pain so that they can start to get some of that motion back. We don't force them past that, though. We are very, very liberal with our use of anti-inflammatories here. For us, this is a young, healthy 20-something-year-old population. They can handle indecine no problem. I would not recommend that on your sort of, speaking as a 50-year-old, unless you want your stomach to fall out your backside or something like that. There is a role for injections here. It's unclear, though, what the right role for that is. I would again submit, if you have something that is a contusion that is looking like it's going to be one of those three- to four-day injuries, probably not a big need to do an injection. You'd wind up slowing down their rehab to a point that doesn't really benefit them. If you are thinking that it's more on that partial thickness tear or tendinopathy picture, perhaps be a little bit more liberal about your use of injections. I purposely wrote injections here because, you know, we think about these mostly as steroids that we're going to put into the shoulder, cortisone and things like that. But there is likely going to, you know, and Scott Rodeo will tell us in a little bit why we should be putting PRP or things like that into it that may pretend a little bit quicker return. Again, some of that data is, a lot of that data is still evolving. And then I think the final take home about these, you know, this first grouping of tendon problems is that there's a low risk of surgery. Very rarely are you going to need to operate on a football player for a contusion or for a partial thickness tear or for a tendinopathy, things like that. These are ones that you really, if you manage them appropriately, non-operatively at the beginning, your player's likely going to get back with very little fanfare and very little to no consequences downstream. So when do we let these guys get back? You know, for us, it's really just a question of when their physical exam is basically back to normal. You don't want somebody going out there over-impaired where they can't get their arm into a certain position, things like that. We tend to follow a step rise progression in terms of their return to play. We start them off with the individual drills, just seeing if you can run around and get hit, team drills where they're doing stuff with some of the guys in their unit, and then finally return to full activity. And at each step along the way, you just want to make sure that the shoulder is responding appropriately and that they're not having a lot of pain or limitation. One thing that really is key here is your player is going to say, well, I'm cleared, therefore I'm good and I don't need to do anything anymore. And what I remind our guys of is that these things tend to fall off a cliff, is the line that I use, that if you stop rehabbing these when you're quote-unquote cleared, these guys will start impinging, they'll get a raging tendinitis, and you'll be chasing it for the next several weeks. So I do think it's worth your while spending some time with them saying, hey, I've cleared you, you can go back out and hit other large people at high rates of speed, just remember to do your band work. There's some role for specialized padding. Our athletic trainers are far smarter than the doctors in our organization, and they can zoo up all kinds of different kinds of padding and protective devices that do seem to offer some benefit for the players. So I would, again, say have a low threshold to do things like that. So we talked about sort of the fake, if you will, rotator cuff tears. What about these real tears, where you see somebody who does have an acute injury and they have a small tear like this? Do we worry about fixing the small tear? Do we think that this is a tear that's going to become a bigger problem? Just because I wanted to suck up to G a little bit for involving me in this talk, this was, G, it's amazing how good the internet is. I think this was like a poster at a local symposium that you gave, but it's actually very useful, and it says that it was looking at a hockey player and a football player and looking at these small tears diagnosed early in the season and then progressed to actually a full thickness, bigger tear by the end of the season that really did require operative repair. So one of the things that you can look at here is thinking about, okay, well, I've got this small tear that I know about. I have this data in the general population that says somewhere between 50 and 80 percent of these tears progress. It's not clear to us whether or not that's worse in a contact athlete. I think we'd all feel pretty comfortable saying it's certainly not better in a contact athlete. And what I would say with these is a lot of times you don't need to overthink it, that if the player is going through the season and they continue to have pain and they continue to have weakness, it's going to really let you know that this thing is not doing well without surgery. And I think the other recommendation out of this case series was to image it again, right? So if you've made the decision at the beginning of the season that the player is pretty good to go and can go out there and you can limit it, you can do some injections, things like that, image it at the end of the season. Because what you don't want to do is look at that two years later and find out that that small tear has now become a massive tear with a lot of atrophy, things like that. So I do think it's incumbent upon you to continue to follow those if you decide that you're going to leave them alone. There is definitely the evidence of the full thickness tears. Now these are the bigger ones that you can see. Gibbs looked at this in 2016 looking at the Combine data and saw that there was 49, this was over about a 10-year period, 49 pre-draft players that had a rotator cuff tear, 22 of those wound up having surgery. And if they did have a rotator cuff tear or a rotator cuff repair, they were less likely to be drafted, and if they were drafted, were drafted at a lower position to match controls. And these people actually played almost half the number of games as their matched controls. Similarly, how do they do? So we know that we should be a little bit nervous about these things when they're fixed or not fixed. This was a physician survey that came out in 2002 that looked at full thickness rotator cuff tears, 50 of them across 48 players, 90% of them went on to have surgery. But the good news here is 93% of them returned to play at or near the same level, so very high satisfaction. Dr. Warren, in 1996, gave us a study out of the New York Giants looking at 10 players that had surgery for a rotator cuff tear, and 7 out of 10 of those returned to play at or near their same level. And then finally, there's an adolescent study that was in AJSM a few years ago looking at contact athletes, but in that sort of late teens years, which again is pretty analogous to what we see in football, and found 100% returned to play, although two of them did re-tear. So I think the take home message you have there is if you do see a tear and you fix it, you can likely look at your athlete without a whole lot of fanfare and say you're going to get back and not really worry about this, at least in football. And remember, when you do fix these, just throw in a lot of anchors and keep throwing in anchors until it either obscures the MRI enough that you can't see the tear, or you have in fact fixed the problem. Both are perfectly acceptable. So thinking about these things, again, break these down into problems that you need to worry about and problems that you can watch. So rotator cuff problems, if you will, are contusions. These are the things that you're going to see an awful lot. Greater than 50% of all the shoulder injuries you're going to see are going to be a contusion. Early diagnosis is really key here. You want to make sure you're in that category of contusion, tendinopathy, partial thickness tear, and not in that category of full thickness tear. If you are in that category of full thickness tear, it's okay to let them back out there and treat it. Just remember you need to follow it. For the vast majority of these, rehab, injections, nonsteroidals tend to be the mainstay of treatment and do very, very well. If there is a full thickness tear, consider going ahead and fixing that, again, in a timely fashion. I don't know that there's any evidence that indicates you need to yank your player out or do anything like that. And also look at your athlete with a clear conscience and say, hey, we'll be able to get you back to doing good things. And then the final point I want to make here is that nothing that I said applies to quarterbacks. So obviously a very different animal. You know, we're not clear on whether or not quarterbacks look more like baseball players, where if you fix their shoulder you ruin them, or whether they look more like football players because it's a different throwing motion, et cetera. So I think you need to wade into that one a little bit more cautiously. And so I don't want you to rush out and do a bunch of rotator cuff repairs on your quarterbacks. And I know Dr. Bradley isn't here, but I wanted to remind him that there's also, we don't think about it in Boston in terms of championships. We think about it in terms of how we help our fellow man. And so this is how we measured social distancing during COVID. And we still had a few extra trophies, so we stay further away from each other. So thank you very much.

rotator cuff injuries

football players

traumatic events

non-operative treatment

quarterbacks