Paul George returns: On the anatomy and impact of his shoulder surgeries

Paul George is back! But what exactly did he return from? On the LA Clippers’ star’s return from shoulder surgery.

LA Clippers star Paul George made his triumphant return Thursday night, putting up 33 points, nine rebounds, four assists, and a plus/minus of plus-7 in a mere 24 minutes of action. The Clippers ultimately lost to the New Orleans Pelicans 132-127, but seeing the 6-foot-8 sharpshooting defensive wizard not afraid to engage in contact with his shoulders or pull up for an open jumper was a sight for sore eyes for Clippers supporters and general NBA fans alike.

George had two surgical procedures late last spring to repair significant pathology in each of his shoulders: A repair of a partial supraspinatus tear in his right shoulder was completed in May, and a repair of a small labrum tear in his left followed a month later. Each of these procedures would be considered “major surgery” on their own, but completing both at the same time is almost unprecedented in the NBA.

It’s worth taking a moment to discuss the anatomy involved in each of George’s procedures as well as the general rehabilitation process.

The Supraspinatus

The supraspinatus is one of the four muscles that comprise the rotator cuff and is the most frequently injured of the group. Its two main jobs are to assist with elevating the arm as well as keeping the head of the upper arm bone, known as the humerus, centered within the socket of the shoulder. Any tear to the tendon of the supraspinatus results in an impaired ability to complete its jobs.

Tears of the supraspinatus tendon are referred to as “full-thickness,” meaning that greater than 50 percent of the fibers that comprise the tendon are ruptured, or “partial-thickness,” meaning that less than 50 percent of the fibers were damaged. Partial-thickness tears are the less severe of the two, as full-thickness tears usually result in profound dysfunction and inability to properly use the shoulder, whereas the end result of partial-thickness tears is often pain with overhead activities, such as shooting a basketball, as well as generalized, but not complete, weakness of the shoulder.

Tears are characterized as being acute or chronic in nature; acute tears of the supraspinatus tendon frequently happen when the structure is exposed to brief, intense forces, such as during falls or when throwing a heavy object, while chronic tears occur due to the accumulative stress of repeated use over time.

The Glenoid Labrum

The labrum, more accurately referred to as the glenoid labrum, is a ring of cartilage located within the socket of the shoulder and acts as a stabilizing and cushioning device. Much like with supraspinatus tears, the glenoid labrum can be injured acutely when subjected to brief, intense forces or chronically over time.

The labrum usually tears in one of two locations: the superior rim or the anterior/inferior rim. Tears of the labrum that occur at the superior rim are called SLAP (superior labrum, anterior to posterior) lesions and are most associated with repetitive overhead activities. These injuries are frequently diagnosed in baseball pitchers and swimmers, and it’s common to have accompanying biceps pathology, as one of the biceps tendons attaches to the superior rim of the labrum. Tears that occur at the anterior/inferior labrum are known as Bankart lesions and frequently occur after shoulder dislocations.

The Rehabilitation Process

Regardless of whether either injury was acute or chronic in nature or where the glenoid labrum tear was located (we don’t know exactly in either case in regards to George’s injuries), the recovery timeline is approximately the same for both injuries: 4-6 months.

The surgeries required to remediate the partially torn supraspinatus tendon as well as the labrum tear involves sewing the ruptures back together and immobilizing the shoulder for a period of 4-6 weeks (this explains, in part, why the surgeries were separated by a month). Neither the supraspinatus tendon nor the glenoid labrum has a great blood supply, so it can take some time for the surgery to take hold.

After the first 4-6 weeks have passed, the player is then guided through a return to play protocol that involves regaining full range of motion as well as an appropriate amount of baseline strength and coordination of the rotator cuff musculature. Basketball specific exercises usually begin around the three-month mark, with clearance for return to game action occurring anywhere between month four to six.

The Future Impact

If Thursday night was any indication, the long-term negative impact of George’s shoulder surgeries should be minimal, both for PG-13 as well as for the Clippers. The prognosis for both injuries is theoretically good for NBA players; however, to my knowledge, no long-term studies have been conducted.

George looked comfortable during his debut, if not a little out of shape. It will take time to redevelop the definition of his shoulder musculature as well as get his game legs back, but there is likely little need for concern moving forward. Both injuries are completely healed and all that is needed is some time in order for George to return to his All-NBA ways.

In the meantime, it would make sense for the Clippers to handle George much like how they have handled teammate Kawhi Leonard: limit the number of appearances during back-to-backs and gradually increase his number of minutes per game, but otherwise let him be Paul George when he’s on the court.

The Clippers have an embarrassment of riches, particularly on the wing, so there should be little pressure to push George to his limits at this point. As they have indicated with their handling of Leonard, the Clippers’ focus is on peaking during the playoffs, so right now their goal should be, and likely is, returning George at a comfortable pace. Doing so would help ensure that George not only returns to his previous form and abilities but also that the Clippers are at their most dangerous when it matters most.