Tennis and Therapy: a Dialogue

By Bill Cosgrove, Tennis Player, and
Terry Buisman, Physical Therapist

Note: Physical Therapist Terry Buisman and patient Bill Cosgrove give their respective takes on the process of rehabbing a rotator cuff.

Terry’s comments are in bold.

So you’ve had an MRI scan of, say, your rotator cuff (or back or hip or knee). Along with a little shot of Valium for relaxation, maybe, and some Beethoven for sound abatement, and you are awaiting the results. After all the symptoms, tests, exams, and finally the MRI itself, you almost expect there to be something big, dramatic, time-consuming, and of course money consuming at the end of it all. Justice almost requires it, we suspect. And justice will out, regrettably.

It is a common complaint with the “medical process” these days that it takes multiple trips to different providers to get to the bottom of things with respect to a definitive diagnosis. At a time when deductibles and co-pays take a considerable bite out of one’s non-discretionary budget, the efficiency of the process has become paramount. The point of all of this is finding the specialist first.

With respect to musculo-skeletal injury and contrary to the way medicine was practiced decades ago, it is no longer the duty of the primary care physician to get to the bottom of things. This task is now falling in large part onto the physical therapist (now a doctor in their own right with the DPT being the educational norm).

Turns out you’ve got gaps where muscle should be, disconnected tendons where connections should be, and maybe tears (of both kinds) where they shouldn’t be. And nice, white, slick fat has moved in for what looks like permanent residency where robust rotator cuff tissue should be. And now what should it be—surgery or therapy?

In the context of a shoulder injury, if you 1) can raise your arm overhead without too much pain, and 2) were not subject to significant direct trauma that is not feeling better, you can generally be successfully managed at a physical therapy level. Start the process by finding the orthopedic shoulder specialist (MD) in your area and inquire about their PT provider preference.

If symptoms are not improving in a few weeks, you will be sent to the orthopedic doctor for further evaluation including the possibility of an x-ray or MRI (with significant weakness). Although improving, the primary care physician is often too aggressive at ordering imaging testing, and going about the process as noted above will save you time and money.

So how do you decide? One decision you may be tempted to make is to not ask too much about the official medical terminology of your Tommy John-type injury so you can look it up on the Internet. Why not, you ask? Overkill and masochism. Overkill because you don’t need cryptic language on top of mangled muscle. And masochism because you don’t need to be cruel to yourself these days when Nature seems to be doing that job pretty well unassisted, thank you very much.

I’ll soften the vernacular blow by using terminology commonplace to car repairs; i.e., the rotator cuff muscles function in similar fashion to lug nuts. Having arthritis is similar to driving down a bumpy gravel road all day instead of using the interstate. This is well appreciated by the patient since the educational component is crucial; this is a lifelong challenge.

You have to see a specialist, more than likely, other than Mother Nature, who may use language to describe your rotator cuff that your other mother might blanch at: subacromial and glenohumeral crepitus, diffuse shoulder girdle atrophy, scapulothoracic trap hiking, winging, and dyskinesis…. Well, you get the idea. While these descriptions may not sound exactly like chopped liver, your shoulder may well feel like it, especially if you start a tally sheet for everything that’s haywire up there, or even soft, squishy, weak, delinquent, or negligent.

The answer is function. 50% of 60-year-olds have a rotator cuff tear and are functioning well. Even if there is a rotator cuff tear, there is often enough functional strength available via the balance of the rotator cuff musculature (4 total) to allow most adults to accomplish all of their daily tasks and recreational activities without significant problems. The crucial component is the restoration of functional mobility (making the joint less stiff, especially with overhead motions), which will in turn diminish the compressive loading on the site of the tear.

You may have to simply resign yourself to putting up with language and afflictions that are unpalatable, if not unpronounceable. “Glenohumeral joint osteoarthritis,” “acromioclavicular joint degenerative joint disease,” “long head bicep tendon rupture,” and “articular cartilage defect of the medial head” may sound slightly illicit if not illegal, indecent, or seductive, but they might actually be kind of pleasantly provocative under other circumstances.

My rule of thumb regarding the successful initiation and subsequent continuing with a conservative (non-surgical) rehab program is as follows: 1) The resolution of night pain; 2) Pain during the day that is at most still below the level of annoyance; 3) Rotator cuff strength that is graded at a 3 or better on a scale of 1-5 (where 1=trace strength, 2=poor, 3=fair, 4=good, 5=excellent strength) that improves to a 3+ or better in one month of rehabilitation. This can usually be done with 1-2 visits per week to the qualified PT in conjunction with daily home exercises.

Something less than surgery might be the thing for you if only because, even with the relatively recent development of arthroscopic surgery for rotator cuff repair, there could be 6-8 weeks of immobility, 3-4 months of therapy, and 6 more months until full recovery. If you so choose, you may get a similar but lesser sense of unpronounceable excitement from the recommended treatment short of surgery. Professional therapy and home exercise programs on rotator cuff tears include “scapular and periscapular stabilization protocols, as well as proprioception.” How could you reasonably ask for any more than that?

With the above noted patient population, 80% will recover and not need surgical intervention. The crucial component with regard to successful nonsurgical therapy: do your exercises, and not too aggressively.

Few of us are as aggressive on the tennis court as we may have been in our 40s or 50s. But I know some of us are inclined to be a little too aggressive in doing the therapy necessary to get us back on the court where our aggressiveness can be less aggressive again, if you follow my meaning.

Following surgical intervention for a rotator cuff tear, however, you can expect a 6-12 month window to fully rehabilitate your shoulder. Easy ground strokes will be viable around the 5th or 6th month, but closer to 12 months is necessary to efficiently restore functional mobility and strength for the serve. The patient does not generally receive formal PT care during this time period, but
has classically transitioned to his or her home program. Lack of diligence with one’s home exercise program is the primary reason for perceived failure of the surgical procedure, primarily due to the lingering mobility and strength loss that limits a mechanically sound overhead motion.

This post surgery healing is a difficult challenge, even with the advent and progression of arthroscopic surgery, in which the patient experiences less overall pain following the procedure. But this reduced pain may create the inaccurate perception that the patient is further along in the healing process leading to excessively aggressive use of the shoulder, which may in turn jeopardize the repair. Any repaired rotator cuff tendon usually requires 9-12 weeks to fully heal.

Say you opt for the conservative approach of therapy and home exercise, along with a good dose of hope and prayer. Suddenly you are in the hands of a Physical Therapist instead of an MD, and he’s not even wearing a lab coat, scrubs, or stethoscope. And he hasn’t asked even once if you smoke, drink, or do drugs, not to mention whether you feel safe at home. How can you know if you’re getting the real McCoy?

Again, doing your homework to find a competent PT via the guidance of your local shoulder orthopedic specialist (MD) is the route to take. As well, you would be surprised with the conversations that entail at the holiday party if you arrive in a sling. Chances are that one of your party cohorts has had a similar experience and can guide you as well. By the way, smoking greatly decreases
one’s chances of success with respect to rotator cuff injuries by impairing the available blood supply to healing tissues.

One standard to go by is how much examination and manipulation you get each time you have a therapy session. Up to your first meetings with a PT you will have had plenty of interesting and attention-getting twistings and turnings of your shoulder (hip, knee, back) by doctors and others for diagnosis purposes. And then the PT will continue to torture your rotator cuff to measure where you are as well as to improve range-of-motion and strength. But it seems important that this happens at each therapy session thereafter. The alternative of simply having a therapist or assistant run you through your regimen of therapy activities, check your form, and maybe add some new ones does not seem as productive, though it may be less painful. But then lots of things are less painful than that.

A thorough examination is crucial. PT’s are the problem solvers and need to know exactly how the shoulder girdle (collar bone, arm, shoulder blade, as well as neck and torso) is functioning. Manipulation by definition is moving the bones of the joint beyond their current limitations with a fairly forceful one-time movement. This classically does not occur during a PT session, though movement of a lesser intensity is utilized but should not result in lingering pain or stiffness.

So by now you are getting well acquainted with your shoulder girdle. Your chopped liver rotator cuff is evaluated, range-of-motion and strength determined, and you’re sent home with maybe a handful of exercises to do daily until your next formal session with your PT a week or so later. What you want is a PT who runs you through the mill each time, and for that you may be grudgingly grateful, kind of like that peculiarly positive feeling you get after playing tennis badly but winning the set.

Our goal is to safely challenge each patient with an individualized home program that maximizes their progress taking into consideration bony and soft tissue healing constraints as well as other information that was gleaned in the examination process. The evaluation process is a dynamic one and the ability to see the same PT week after week is crucial in this process; a one-size-fits-all protocol is not acceptable.

As for the therapy exercises themselves, they will have exotic, engaging names like Grasp, Wand Extension, Airplane, Wall Slide, Physio Ball T, Prone External Rotation, and Bow and Arrow. They aren’t always as much fun as their names imply. In fact, some might more accurately be called The Whipping Post, Handcuffs, Prone Crucifixion, Sky Diving, and The Rack. Ultimately, though, doing your therapy exercises daily will be good for you, and will test your ingenuity for finding furniture at home upon which to do them, as well as your ability to repair that furniture.

Yes, we try to keep it interesting. Motivating the patient to work in diligent fashion is crucial to one’s success. It is very much a team effort and the successful attainment of each person’s goals and return to a desired lifestyle are highly rewarding for me. Once our work together is completed, the PT will often contact the patient’s tennis instructor to help guide in the next phase of the process with regard to return to play.

Your instructor will undoubtedly be glad to hear the good news; mine I’m not so sure.