Shoulder pain is common in water athletes such as SUP, prone paddling, and surfing. If left unchecked that niggling shoulder pain can progress and may even turn into a lesion that requires surgical intervention. If you have a surgical lesion you have two options. Option one is to stop doing what you love. Option two is to take a few months off to get surgery and get things fixed. Don’t dilly dally. If you have a surgical condition in your shoulder and you continue to paddle on it you might make things worse.

Step 1 if you have shoulder pain – stop asking your buddies for advice

If you have shoulder pain that lasts longer than a few weeks, step 1 is to get a proper diagnosis. Although many shoulder injuries will not require surgical intervention,  if you have a surgical lesion of the shoulder you need to deal with the the problem before it gets worse.

Too many surfers, prone paddlers, and stand up paddlers wait and hope things will get better on their own. Many athletes visit ART and massage therapists, acupuncture therapists, physical therapists, and consult with their buddies at the beach for advice(1). Knowing how big of a headache shoulder surgery can be, these otherwise well meaning individuals often advise against getting surgery or recommend finishing out the season.

They might even prescribe  therapies to “open up the tissues” or “get things moving.” Although these alternative therapies have their place, unless you are 100% certain  that you do not have a surgical lesion, it is recommended to get a diagnosis before implementing any therapy.  The problem is that allowing a surgical lesion to progress without intervention may lead to a worsening of symptoms, a more invasive surgery to correct the issue, and a dramatically longer rehabilitation time.

For example, many paddlers and surfers have “bone spurs” from previous injuries (such as a broken collar bone). Removing a bone spur and alleviating the pain associated with the bone spur is a relatively simple procedure with a minimal recovery time of about 4-6 weeks.   Conversely, paddling or surfing with a bone spur rubbing on an adjacent tendon can result in a complete or partial tear of one of the rotator cuff tendons. Repair of a torn rotator cuff  carries a much longer recovery time of about 4-8 months.

The first take home message is that if you have a surgical lesion of the shoulder,  you should think of  it something along the lines of having a rock in your shoe. You cannot push on it, you cannot pull on it, and you cannot will it away. The rock needs come out and the sooner you get it out the better. Waiting may only make things worse.

Get an accurate diagnosis

Ruling out a surgical shoulder lesion will require a visit to the orthopedic surgeon. Your surgeon will likely order an MRI.  Although an MRI is diagnostic in most cases,  in some cases,  MRI will not 100% rule out the possibility of a surgical lesion. To discuss the reasons why an MRI may not be 100% diagnostic is outside the scope of this article. Nonetheless, what you need to know is 1) if the MRI identifies a surgical lesion it is surgical. 2) if there is no surgical lesion on an MRI that may not 100% rule out a surgical lesion. In a small percentage of cases a partial  rotator cuff may not be identified on MRI but will be identified by surgical exploration of the joint.

Paddlers and surfers should also keep in mind that if there is a long delay between the MRI and surgical exploration it is possible that the joint pathology progressed in the interval between imaging and surgery. This is another cause for the so-called “MRI misdiagnosis.”

Don’t dilly dally with your surgery

It is extremely common for paddlers and surfers with partial rotator cuff tears or other surgical joint pathology, such as bone spurs,  to be diagnosed with a surgical lesion and hold off on surgery. There are loads of reasons why surgery is delayed including

• I want to get through this big race/end of season/whatever
• Right now is not a good time with work/family/whatever
• I want to see if it heals on its own

Rotator cuff tears are not life threatening. Unless you are a professional athlete, surgery is not an absolute requirement. If you want to live in pain that is your decision. Therefore, your surgeon will likely leave the decision up to you but do not take his or her seeming lack of conviction the wrong way.  Many good surgeons will not pressure you into doing surgery.

The problem is that if you hold off on surgery your lesion may progress and become worse. Partial tears may wind up complete tears. Bone spurs can cause partial tears. The main problem is that more significant lesions have significantly longer recovery time.

For example, one of our editors had and old collar bone injury that caused impingement on their rotator cuff. At the onset of symptoms, the original injury  could have been corrected with a simple revision procedure and a 4 week rehabilitation. Unfortunately, he delayed surgery and the bone spur caused a partial supraspinatus tear which  turned into surgical ordeal with a 6 month rehabilitation.

There is no good time for surgery. Your real choice is not whether you can finish this season but whether you want to put next season in jeopardy.

“Any way you look at it – shoulder reconstruction surgery is misery”

There is no doubt about it, if you need rotator cuff reconstruction surgery, it is a painful and miserable experience.  We are by no means advocating jumping into surgery unless you absolutely need it. The good news is that many athletes tolerate the pain of the surgery and the immediate postoperative window pretty well. That is not the issue.

The issue is that tendons, because they have an inherently poor vascular supply and there is unavoidable postoperative motion at the surgical site, do not heal rapidly. Getting them to heal at all will required prolonged immobilization of your arm. You can expect to be in a sling for 3-6 weeks and you won’t be doing anything more than lifting the television remote with your arm for at least 4-8  weeks. You also won’t be in the water for 4-6 months. These ranges vary widely depending on your injury, your age, and how well you listen to your doctor and physical therapist during the recovery period.

During your recovery, you are going to scour the internet looking for some doctor with some secret  accelerated rehabilitation program or other voodoo that will somehow speed up your recovery. Everyone does. You are not special.  Our recommendation is to stop the nonsense. Tendons take time to heal and, unless you are Wolverine, there is nothing you can do to speed up the process. Conversely, you can make things ALOT worse for yourself by doing too much too soon.

During the first 2 weeks after surgery the only thing holding your reconstruction in place is a thin piece of suture. After that, your tendon will heal at a rate of approximately 15% each month. Simple math will tell you that it will take a year before the tendon is at full strength. Most doctors do not recommend testing the repair and strengthening the muscles of your shoulder until about 12 weeks after surgery.

Stated another way, for at least 3-6 months you are going  to be stripped of everything and anything you enjoy doing. The most painful part of any shoulder reconstruction is going to be dealing with your head as you try to keep yourself calm for months on end when you cannot go in the water. The following chart demonstrates what you will be going through during your recovery.

As you can see, your level of insanity grows exponentially over time. You are going to do OK for about a month then things are going to go haywire.  Again, this is why we strongly recommend getting an early diagnosis and early intervention. It is much more difficult (mentally) to deal with the effects of surgery as time goes on and anything you can do to limit your recovery time will help.

We recommend that all paddle athletes have a plan of action or you will literally go nuts. You need to plan something to do with your time or your head will get the best of you. Write a book. Plan on daily hikes. Get a bike trainer. Learn to master those godforsaken stairs at the gym. Go on long walks with your dog. Feed the pigeons.  Do whatever it is you need to do but keep yourself occupied.

Recovery plan for the paddle athlete

First and foremost, you need to listen to your surgeon and your physical therapist. Do not follow anything you find on the internet  (including this article) because 1) it may not apply to your situation and 2)it may not apply to your situation. Every surgical repair is different. Everyone responds to surgery differently.

Additionally, in a discussion with Dr. Brad Thomas (a competitive paddler and orthpedic surgeon) he said that, as a paddle athlete, your success and early return to activity,  has as much to do with your physical therapist as it does your surgeon. In fact, he only has a limited number of physical therapists he works with.

In our experience, there are physical therapists will treat you like that 90 year old lady. It is very easy to err on the side of caution with therapy but athletes might (again might) need to be treated differently. According to Mike VanGildner of Longevity Physical therapy (who got Matt Wright starting to paddle again at 3.5 months after a partial rotator cuff tear)

“Early stage post-rotator cuff repair physical therapy is all about caution to not disrupt the surgery, restoration of range of motion (usually first passively then actively), and prepping the rest of the core (ankles, hips, spine, shoulder blades) to be able to zoom ahead when its time to get the shoulder strengthened. After that, its all about restoring local (gleno-humeral and scapula-thoracic joints) and global (the entire synergistically-working body) mobility, strength, stability, and proprioception, in ways that ultimately replicate the activity or sport that the patient is returning to.

General guidelines regarding a return to activity for paddle athletes and surfers.

1. Bone work without rotator cuff repair: Mumford procedure, bone spur, AC joint arthroplasty etc. You can expect to be back in the water at 100% by 2 months. You will be doing activity including running very soon after surgery.

2. Partial rotator cuff tear: return to function in 4-5 months

• Complete immobilization for one week
• Start to go without sling in the house but keep sling on in public for 3 weeks. Out of sling at 3 weeks.
• Depending on your surgeon you might not be doing any phycial therapy until 2 weeks. Some start passive motion earlier than three weeks. Either way, you won’t be doing much active motion until about 2 months. Strengthening will start at about 3 months with a progressive return to the water at about 4 months.

• Activities to keep your sanity
  • Stationary bike at 1 week
  • One arm elliptical trainer at 1 week
  • Jogging at 6 weeks
  • Bike outside at 8 weeks
  • Gradual introduction to paddling at 3.5-4 months. SUP before prone paddling or surfing.

Full thickness tear: recovery depends on the thickness of the tear but will generally require at least 6 months with aggressive and accurate physical therapy.

• Complete immobilization for one week
• In sling for at least 6 weeks
• Depending on your surgeon you might not be doing any physical therapy until 4 weeks. Some start passive motion earlier. Either way, you wont be doing much active motion until about 2 months. Strengthening will start at about 3 months with a progressive return to the water at about 6 months.

• Activities to keep your sanity
  • Stationary bike at 2-3  weeks
  • one arm elliptical trainer at 3-4 weeks
  • Jogging at 8-10 weeks
  • Bike outside at 12-14 weeks
  • Gradual introduction to paddling at 6  months. SUP before prone paddling or surfing.

The things they do not tell you until it is too late.

There is a lot written about shoulder surgery online. What these articles leave out are the  industry secrets that nobody tells you until you get home. Here they are:

1. You are going to be on pain meds for at least a few days. You will also get constipated. Become one with Miralax. You will be glad you did. Dose early and often.

2. Get a Lay-Z-Boy: you won’t be sleeping on your side any time soon. You won’t actually be sleeping at all. In fact, you are going to be sleeping on your back for a long time and your shoulder will remain achingly painful at night. Get used to it. Plan on sleeping in the living room. A La-Z-Boy helps. This is not a joke.

4. If you do not have a lazyboy get a Tempurpedic pillow. These things will keep you upright in the couch and support your arm.  We have no idea how anyone actually sleeps on them like a normal human being. They are heavy as heck. We call them “dead man pillows.”

5. Get some button down shirts: you wont be pulling off a t-shirt any time soon. You should also consider getting an xxl or xxxl tech-t so you can get in and out of it when it comes time to break a sweat.

6. Rotator cuff surgery is like having a baby (we think anyway as we have not had any babies). It is really bad going through it but you seem to forget how bad it is just a few weeks later. When asked, you will say you would do it again. The benefits outweigh the short term inconveniences.

7. You are going to do something along the way that convinces you that you ruined the surgery. Your spouse will fall on you, you will trip, you will reach out for something as a reflex, you will do too much too soon. Everyone does it. Dont panic. Chances are you didn’t hurt anything but check with your doctor just in case.

Recommended surgeons and physical therapists in Southern California

Several of us were in the unfortunate position of having to have shoudler surgery but we were fortunate to have worked with the following surgeons and physical therapists who we can recommend without reservation.

1. Dr. Brad Thomas: Beach Cities Orthopedics 310-546-3461. Manhattan Beach and Torrance, CA
2. Drs. Loren and Skyhar. Core Orthopedic Medical Center . 760-943-6700. Encinitas, CA
3. Longevity Physical Therapy – http://longevityphysicaltherapy.com 760-230-2316, Encinitas, CA
4. Peak Physical Therapy: http://www.peakptc.com 760-230-5432, Cardiff, CA.

Footnotes:

(1): we are not saying that ART, acupuncture, etc. has no value. Please re-read this paragraph if you think that is what we said. What we are saying is that you need to get a diagnosis before you can responsibly approach your injury. That is all we are saying.