I decided to write my latest newspaper column about Manny Pacquiao’s shoulder injury after getting so many questions about it in media interviews and from friends. I want to point out three things: One, obviously I am not involved in his care, so I don’t know the accuracy of the events leading to his injury and treatment. I have listed the media sources at the end of the article. Also I did not see the fight, so I base the analysis of the impact of his shoulder injury on those of boxing experts. Last, I don’t have a rooting interest or anger at the nature or outcome of the fight. I used to train in boxing (I loved it and am thinking out getting back into it for the training only). I wrote this post, though, to discuss rotator cuff injuries in elite athletes.

Instead of living up to its “fight of the century” hype, Manny Pacquiao’s loss by unanimous decision to Floyd Mayweather has been marred by controversy. On one hand, fans and most experts felt the fight was boring. Perhaps more importantly, an injury to Pacquiao’s right shoulder now casts doubt on whether the fight should have taken place at all.

Pacquiao injures his shoulder in training

In the hours after the fight, Pacquiao’s team, as well as his promoter, Top Rank, released a statement that the Filipino fighter had suffered an injury while throwing a punch in training about three weeks earlier. Doctors at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles reportedly evaluated Pacquiao and performed tests on his shoulder. Top Rank claimed that he could fight as scheduled with rest and other treatments, including Toradol injections.

Rotator cuff illustration

Use of Toradol before the fight denied

Top Rank claims that Pacquiao’s team had discussed the shoulder injury and proposed Toradol treatments with the United States Anti-Doping Agency. Pacquiao received Toradol injections during training and hoped to receive one just before the Mayweather fight. That night, the Nevada Athletic Commission reportedly denied a request by the Pacquiao camp for a Toradol injection, as it was unaware of the shoulder injury. The controversy largely stemmed from a pre-fight questionnaire in which Pacquiao or one of his advisors checked “no” to the question, “Have you had any injury to your shoulders, elbows or hands that needed evaluation or examination?”

Did Pacquiao reinjury his shoulder in the fourth round?

Francisco Aguilar, the Commission Chairman, could have prevented the fight if Pacquiao’s right-hand punches appeared to be weak in warm-ups, according to Lance Pugmire of The Los Angeles Times. The fighter entered the ring without a Toradol injection and lost the 12-round bout on all three judges’ cards. In the fourth round, Pacquiao threw aggressive combinations but later claimed that he felt pain like “a needle being stuck in his shoulder.”

Pacquiao found to have a rotator cuff tear

Top Rank did not specifically mention what tests were ordered in April, but it disclosed more details via Twitter at 11:36 PM, hours after the fight. “An MRI revealed a tear in @MannyPacquiao’s right shoulder. #MayPac” Two days after the fight, Dr. Neal ElAttrache, an orthopaedic surgeon at the Kerlan-Jobe Orthopaedic Clinic told ESPN.com that he diagnosed the fighter with a “significant tear” in his rotator cuff. “But this is a severe enough tear that it won’t heal without being repaired.”

ElAttrache performed an arthroscopic rotator cuff repair on Pacquiao’s right shoulder, later saying that he could not be “more pleased with the results.” He expects that Pacquiao could return to training in six months and possibly fight in 9 to 12 months.

In this arthroscopic image, the rotator cuff tendon (red arrow) has pulled off its attachment site on the humerus (yellow arrow).
In this arthroscopic image, the rotator cuff tendon (red arrow) has pulled off its attachment site on the humerus (yellow arrow).

Manny Pacquiao now faces 14 separate lawsuits filed in 8 different federal courts by fans alleging that they paid a lot of money to watch a fight without knowledge that the fighter was injured, according to Wendy Thurm, an attorney and sports business writer for The Guardian.

I cannot comment on the legal aspects of Pacquiao’s injury, but I think the physical aspects of his injury and treatment and how they could have affected the fight are worth discussing.

Challenges with competing with a rotator cuff injury

The rotator cuff is a group of muscles from the shoulder blade that attaches to the humeral head, or the ball of the ball-and-socket joint. They stabilize the shoulder while the larger muscles move the arm overhead, behind the back, or away from the body.

One of the classic problems an active person has if he has a tear in one of his rotator cuff tendons is pain and weakness reaching out away from his body. For most people, that issue could manifest with simple activities like trying to hold up a gallon of milk as you get it out of the refrigerator. For a boxer, it could be difficulty throwing punches with that hand.

Did a rotator cuff tear affect Pacquiao’s performance?

An analysis of Pacquiao’s fight by Gordon Marino of The Wall Street Journal suggests that Pacquiao’s injury could have affected his performance. He only threw 16 right-handed jabs per round compared to his normal average of 26. Only 18 of those jabs connected with Mayweather all night. Pacquiao barely used the right hook that he usually delivers after a straight left. And he only threw 429 punches in the entire fight, 50% lower than his average and his lowest total ever in a fight.

In this arthroscopic image looking from the side of the shoulder, the rotator cuff tendon has now been brought out to its insertion site and reattached with sutures and anchors.
In this arthroscopic image looking from the side of the shoulder, the rotator cuff tendon has now been brought out to its insertion site and reattached with sutures and anchors.

We can only speculate whether Floyd Mayweather’s strategy caused those changes or if Pacquiao’s bum shoulder did.

Would Toradol have helped Pacquiao?

Now knowing what his injury was, we can assume that a pre-fight Toradol injection might not have helped much. The controversial injection is an anti-inflammatory given to decrease pain during competition. Pacquiao might not have felt as much shoulder pain during the bout, but Toradol would not have helped any weakness from a tear.

Also listen:
Episode 68: Is the use of Toradol in professional sports dangerous?

Could Pacquiao have made his shoulder injury worse?

Finally many boxing analysts have debated whether Pacquiao could have done further damage to his shoulder by fighting through the injury. The answer depends largely on when the tear occurred. If he and his promoters knew about the rotator cuff tear before the fight, he might have aggravated it and caused more pain, but he could wait and do surgery later. We see athletes in many sports with shoulder dislocations, meniscus tears and other injures try to play through them and have surgery after the season.

Also read:
Rotator cuff injuries
5 signs your shoulder injury could be serious

On the other hand, if he only had an inflamed rotator cuff before the fight and completely tore it in the fourth round or another part of the fight, Pacquiao could have caused an injury needing surgery that he might have avoided with a period of rest and rehab. As we have seen with baseball pitchers, return to elite sports after rotator cuff repair surgery is challenging, to say the least.

Pacquiao earned a reported $100 million for the fight, which might explain fans’ frustrations. Now one of the great fighters of this generation faces months of legal and medical challenges.

Note: A modified version of this post appears as my sports medicine column in the May 15, 2015 issue of The Post and Courier.

Shoulder Statement From Pacquiao and Top Rank: JOINT STATEMENT FROM TEAM PACQUIAO AND TOP RANK. The Sweet Science. May 4, 2015.

Manny Pacquiao has successful shoulder surgery. By Lance Pugmire. Los Angeles Times. May 6, 2015.

Manny Pacquiao has shoulder surgery. By Dan Rafael. ESPN.com. May 7, 2015.

How Big of a Factor Was Pacquiao’s Injured Shoulder? By Gordon Marino. The Wall Street Journal. May 7, 2015.

Does Manny Pacquiao have a legal case to answer over his shoulder injury? By Wendy Thurm. The Guardian. May 11, 2015.