Those of you who listen to Tod Burros’ Run to Daylight Podcast have heard me talk about Andrew Luck’s shoulder ad nauseum.
Luck has had pain in his right throwing shoulder since Week 3 of the 2015 season. He missed two games that year due to this injury. Upon further review, it seems that Luck played the rest of that year plus the entire 2016 season with an unstable shoulder. That is not good, as it can lead to cartilage damage, stretch out other portions of his shoulder’s joint capsule (the balloon around the shoulder that contains its stabilizing ligaments), overstress the rotator cuff, and/or lead to chronic inflammation of the joint lining (synovitis) that can increase the time needed for the shoulder to fully recover.
Andrew Luck underwent a labral repair in January 2017. Now that the 2017 fantasy season is over, I think it might be a good time to look ahead to what we may expect from him going forward.
Arthroscopic Labral Repair
To see a video of a labral repair please go to:
Luck’s Injury History
Luck was expected to return to play within six months, although it sometimes takes nine months for a quarterback’s throwing shoulder to be 100 percent. As you know, Luck never returned to play. As he ramped up his graduated throwing program in practice, he developed pain refractory to steroid injections and further rehabilitation. It was even reported that the ‘zip’ on his throws was worse than balls thrown by Scott Tolzein, Phillip Walker, and Jacoby Brissett. In case you’re not intimately familiar with the other Indianapolis QBS, that’s not good.
Then it came out that Luck’s labral repair was in the back (posterior) of his shoulder, not the front, which is the far more common location for throwers. Posterior labral injuries are more common in offensive and defensive linemen, who experience significant forces against their arms when they’re punched out in front of them. It was reported that this was why it was taking Luck longer to return. But that doesn’t make sense for a QB: Throwing stresses the front of the shoulder (anterior) more than the back or posterior, so this should have allowed him to return to throwing quicker.
Clearly, there’s a lot we haven’t been told. And a lot of what we were told is misinformation. Something did not go as planned. So what could be happening?
There are five possibilities:
1) Cartilage injury (‘Pre-Arthritis’) from shear forces on his shoulder’s cartilage caused by throwing on an unstable shoulder for nearly two seasons: This would have been recognized during shoulder arthroscopy and known by Luck and his surgeon. However, that doesn’t mean that they’re telling us. Because it would probably decrease the longevity of his career and potentially decrease his throwing ability while he played, it would decrease Luck’s value as a football player. If there is cartilage loss, his ability to throw might never be the same again. This would be an analogous injury to what Sam Bradford has in his knee.
2) Rotator Cuff tendinopathy (damage): This is possible, as it was reported that Luck’s problems were from compensatory damage to the other structures of his shoulder. This is usually the rotator cuff, as it’s the weak link in the shoulder, especially when stressed by activities such as throwing. The rotator cuff is also the structure that is overworked trying to stabilize a shoulder that’s been destabilized due to ligament damage. It’s possible that this was not fully appreciated by his surgeon, as many are still not aware that rotator cuff tendinopathy can be a ‘hidden lesion.’
When the arthroscope is inserted into the shoulder and turned to view the top of the shoulder, many assume they’re visualizing the rotator cuff. But, in many cases, that’s not true. What’s viewed in many cases is the shoulder capsule.
Arthroscopic view of the top of the shoulder. The humeral head (ball of the shoulder) is to the left. Next to it is the shoulder capsule, which needs to be debrided (removed) to visualize the rotator cuff.
The joint capsule and rotator cuff are debrided with a motorized shaver.
A motorized shaver is used to debride the joint capsule and rotator cuff. Damaged rotator cuff tissue is friable and removed by this process. Normal rotator cuff tissue is robust and remains. This is the surgery that Cam Newton had last offseason.
Following debridement, the damaged rotator cuff tissue has been removed, leaving only healthy, non-painful tissue. The crescentic hollow the shaver lies in is the area the damaged rotator cuff tendinosis was removed from.
If the top of the shoulder capsule was not challenged, it’s possible that Luck’s rotator cuff damage was missed. This could cause pain and loss of velocity while throwing.
To view a video of Arthroscopic Rotator Cuff Debridement please go to:
3) Excessive tightness of the repaired posterior capsule. The posterior joint capsule in the back of the shoulder is thin. When damaged or stretched it becomes even thinner. Repairing it can be like operating on wet tissue paper. Consequently, rehabilitation following posterior labral repair is slow compared to the more aggressive rehab used following the more commonly performed anterior labral repair. This slower rehab is chosen to allow the posterior capsule time to thicken with scar and become stronger so that the sutures don’t cut through it, like wires through cheese. But it can be difficult to know how much a particular individual will scar after surgery. It’s tricky, and this posterior capsule can sometimes become too tight. Often it can be stretched out, but it can become too tight to stretch. This inhibits the follow-through phase of throwing, decreasing the power and velocity of Luck’s throws, as well as leading to pain during repetitive throwing.
4) Previously subtle anterior instability has now become symptomatic: Luck’s shoulder may have been unstable posteriorly (the ball subluxed out the back of the socket) and also had subtle anterior instability in the front of the shoulder, which is more typical in throwers. It’s difficult to stabilize two directions of instability at once in a thrower. As above, posterior shoulder repairs need to be rehabilitated slower, to allow more scar formation to occur. However, if the shoulder is stabilized in both the front and the back during the same surgery, that’s twice as much surgery, with twice as much scar formation. The resulting stiffness can be significantly problematic. Many surgeons will surgically address the major direction of instability and leave any subtle instability to be treated via rehabilitation. This is often the best way to proceed.
The downside of not addressing the anterior instability is that the newly increased tightness in the back of the shoulder can push the ball (humeral head) forward on the socket, causing the previously asymptomatic anterior instability to now become painful during throwing. Anterior instability causes pain, weakness, and the ‘dead arm’ syndrome in the late cocking phase of the throwing motion, decreasing the shoulder’s ability to ‘wind up’ and provide power to throws.
5) It was recently reported that the problem is Luck’s biceps tendon. The biceps tendon is a ‘helper’ or ‘backup system’ for the rotator cuff. The biceps tendon is not a common location for compensatory injuries. It’s certainly possible, but 95 percent or more of biceps problems are due to an underlying rotator cuff issue (which may have already been treated by arthroscopic debridement). It’s also possible that the diagnosis of a biceps problem was missed. This can happen because, while the diagnosis of biceps tendinopathy can be straightforward when it’s an isolated issue, it’s a much more difficult diagnosis to make when combined with other problems. The symptoms and physical examination of biceps disorders about the shoulder overlap those of rotator cuff tendinopathy and instability. Despite what you might read in the sports section, the accuracy of MRI leaves much to be desired. And much of the biceps tendon cannot be viewed during arthroscopy. So Luck’s preoperative symptoms may have been ascribed to his instability. It’s tough to know.
Fortunately, if Luck’s problem is due to the biceps tendon, this can be easily and predictably treated with a biceps tenodesis. Biceps tenodesis can be performed arthroscopically or by open surgery. During a tenodesis, the biceps tendon is cut out of the shoulder and reattached just below that joint, so it still powers the arm but doesn’t cause shoulder pain.
To see videos of arthroscopic and open biceps tenodesis please go to: http://www.rearmyourselftexas.com/shoulder/biceps-tendon-disorders-at-the-shoulder/
I believe that Luck has proven that nonoperative treatments aren’t currently effective for him. In my opinion, what Luck needs is to return to the operating room for an examination of his shoulder while he’s under anesthesia to detect any residual instability. This would be followed by an arthroscopic re-evaluation of his shoulder and debridement of any remaining rotator cuff tendinopathy. If the biceps is thought to be problematic, an open tenodesis, which is stronger and allows for quicker rehabilitation than an arthroscopic tenodesis, could be performed. But then again, nobody’s asked me.
Instead Luck, who is said to be fairly headstrong, went to Europe to seek treatment. Probably for a stem cell injection. This is not a positive development. Stem cells have no proven efficacy for anything yet, let alone problems in the throwing shoulder of an elite athlete. This is the injured players equivalent of a Hail Mary. But, as you know, most Hail Marys fail. You can ask Ryan Tannehill how great stem cells worked on his partially torn ACL that subsequently fully ruptured, causing him to miss the entire season.
So where are we? Basically we’re unsure – again – if Luck will be ready for next season; the clock is already ticking. And we’re unsure if he’ll ever be 100 percent again. Any of the aforementioned issues could affect his throwing accuracy, strength (ability to throw deep balls), stamina (production late in games), confidence to throw into tight windows, willingness to risk further contact by running, etc.
Ian Rapoport reported that Luck’s current problems are due to changes in his throwing mechanics and ‘overcompensation’ from playing for nearly two seasons on an unstable shoulder. This strongly suggests a rotator cuff problem, which can then lead to biceps problems. Stem cell injections suggest a cartilage injury, although they could have been injected into his biceps tendon, or his rotator cuff, under ultrasound guidance. I’ve never examined Luck, scoped his shoulder, or seen his operative report so I can’t be sure. But I can be sure that, unless I see Luck throwing at 100 percent before next season, I’ll be downgrading all Colts players on my draft board.