Questions surrounding rotator cuff tear in Manny Pacquiao’s shoulder

Boxer Manny Pacquiao poses for fans at a rally in Las Vegas several days before his fight against Floyd Mayweather Jr. on May 2. AP Photo/Chris Carlson

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.

In the hours after the fight, Pacquiao’s team, as well as his promoter, Top Rank, released a statement that said the Filipino fighter had suffered an injury while throwing a punch in training about three weeks earlier.

Top Rank claims that Pacquiao’s team had discussed the shoulder injury and proposed Toradol treatments with the U.S. 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. In a pre-fight questionnaire, 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?”

Top Rank disclosed more details via Twitter 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 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.

Manny Pacquiao now faces 14 separate lawsuits filed in eight different federal courts by fans alleging that they paid a lot of money to watch a fight without knowledge that the fighter was injured.

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.

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.

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 percent lower than his average and his lowest total ever in a fight.

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

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.

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 injuries try to play through them and have surgery after the season.

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.

Dr. David Geier is an orthopaedic surgeon in Charleston. For more information about shoulder injuries and other sports medicine topics, go to his website at