Doubly whammy: meniscus tear and rotator cuff tear, same side. How to train?

Medical Q&A [Moderated]
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I’m 68 and have been lifting on and off for about 5 years. I had recently started back and was making good progress. Neither injury was related to weight lifting. I currently have an appt for PT for the meniscus tear in a little over a week, but not yet for the rotator cuff tear, as it was just diagnosed yesterday. PT appts generally take about 6 weeks in the medical system I use. I don’t want to be entirely inactive until then.

Q1 My understanding is that neither injury can technically heal, but PT has the potential to restore practical function. At what point is surgery the best option? I know in a lot of situations, surgery outcome long-term isn’t better than rehab.

Q2 What strength training can I do that is lower risk for making things worse?

Specifics: the meniscus tear is minor. I believe the doc said likely microscopic based on exam, no MRI but with x-rays of knee. Very minor arthritis was observed.

Rotator cuff: these are the findings that were different (left column) from the healthy side in first block.
Second block special tests Hawkins and Neer are for injured side.

External rotation: 5/5
Empty can testing: 4/5
Bear Hug: Normal
Pain with RC testing: Yes		 External rotation: 5/5
Empty can testing: 5/5
Bear Hug: Normal
Pain with RC testing: No
Special Tests Hawkins: Positive
Neer: Positive

Meniscus injury I’m still scratching my head about: it was after a 5 min warm up that included walking + 1 min jogging. I had just started more moderate jogging and felt some odd pain in the first few steps which then seemed to resolve, so I continued the rest of the HIIT workout which I had been doing 1x/wk. LISS: I had been doing Zone 2 on stationary bike 3x week for 2x45 min, 1x 60 min.

Rotator cuff was acute injury (playing tug with my 75 lb dog and lifting her up on her hind legs) on top of chronic issues in that shoulder downstream from a mastectomy 13 years ago and use of aromatase inhibitors for 2 years, which were hard on my joints. (switched to Tamoxifen after 2 years.)

Strength training that I’d been doing: 2x week with 2 working sets 1-3 RIR for each exercise.
Day 1 BP, DL, safety bar squat. Day 2: had started figuring out working sets on machines at a new gym: supported rows, assisted pull-ups and then experimenting with chest press/fly; leg extension, hamstring curl, ab/adduction, etc. to determine working sets.

Latest 1 Rm on deadlift 170 lbs (bw 145) and I was doing 8x 105lbs @8 for safety bar squat. Prior to a recent 2 week stay out of the country where I had no access to training, my hardest working set on DL was 8x135 @ 8. (this was post meniscus tear). However, that particular day, I was only able to do 8x65 then 3x 85 on the SBS. Based on past experience, I will likely have to build back up to the 135 on the DL after 2 weeks off.

Shoulder doc said no more bench press right now.

*Is it reasonable to continue the DLs and SBS and just stop when I feel any knee pain? (I’ve continued through mild knee pain on the ab//ad machine at the gym, which set me back.

  • Are farmer’s carries likely to hurt the rotator cuff? I was doing 5 min walks with 20 lb kettlebells as warm up, but it did start to hurt my shoulder at the end. I don’t know if it would be wise to do uneven weights with the knee issue, or just do less weight for longer.

Also, at a different local gym at a major university, the personal trainers all have masters degrees in a related field or are interning as part of their master’s degrees. I was planning on booking a session with one of their trainers to help me establish working sets on machines where I could use left side only. I believe I’ve read that training the uninjured side can help maintain strength on the injured side.
*Is that correct?

  • Any other thoughts? I am frustrated and discouraged because I know how easy it is to lose strength at my age and hard to build it back, but am trying to keep a positive attitude and come up with a good plan.
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Hi there,

First of all, amazing job picking up training and progressing to that point! I’m sorry to hear about these setbacks, but they do sound like things we can get through. I do have a few questions/concerns about the story here, mainly relating to how, exactly, these things were confidently diagnosed.

  1. It is not possible to diagnose a “microscopic” meniscus tear based on an X-ray or a physical exam. It sounds to me like the doctor may have been hypothesizing what “could” be going on, but it was delivered in a way that may have sounded more definitive. I would not be confident in diagnosing this as a significant meniscal tear, based on the information you’ve provided.

  2. Similarly, you do not appear to have deficits significant enough to where I’d be confident diagnosing a significant cuff tear by exam alone. I did not see anything regarding imaging of your shoulder (nor am I suggesting you necessarily need it, based on this information alone) – which leaves me questioning this diagnosis as well.

In addition, in both of these situations it can be common for people to have abnormalities like small meniscal tears or minor rotator cuff tears apparent on an imaging study that’s been there for years and not causing any symptoms/issues all along, but once someone experiences pain and gets a test done, we “find” that and associate the two as cause-and-effect, when it may be incidental.

Of course, I am not questioning/doubting whether you have painful injuries involving these areas that we ought to manage. But hopefully all of this helps to illustrate that these things can be pretty complicated! And importantly, diagnostic label we apply to the situation does have a lot of significance.

So, how to move forward from here?

Given the delays in your healthcare system, if you have the resources for it, I think a consultation with our rehab team would be the best strategy to get some clear, individualized guidance from someone who understands what you do in your training, and what you’re trying to get back to doing. They would also be able to help provide more individualized answers regarding surgical options (which, based on what you’ve provided here, I do not think is likely to be necessary).

Short of that, there will be a bit of trial and error involved in finding the activities that you can tolerate and progress. I think stationary biking is a great activity to keep in the rotation, assuming your knee feels well with a given duration & intensity of effort. If you can tolerate that well, moving on to single- and double-leg exercises with a controlled tempo would be my next step from there. This could involve things like single- and double-leg leg presses/extensions, box squats, box step-ups (with the height/range of motion on all of these modifiable based on your tolerance), and gradually progressing from there to larger range of motion and heavier-loaded movements like split squats/lunges, lateral lunges, and goblet/barbell squatting.

For the shoulders, starting with some low-load dumbbells at a variety of pressing angles (flat, incline, overhead), and pulling movements (seated cable/machine rows and lat pulldowns), again with controlled tempo would likely be the place I’d start.

As for progression, I have an article written that touches on this topic here: Pain in Training: What To Do? . Specifically see the section titled “Step 2: Progression and Expectation management”.

To your remaining questions:

*Is it reasonable to continue the DLs and SBS and just stop when I feel any knee pain? (I’ve continued through mild knee pain on the ab//ad machine at the gym, which set me back.

Yes, it is reasonable to continue these movements if you can tolerate them well. In the very early rehab phase I would aim to cap your loads just below the threshold where you experience pain. Given that this isn’t possible to predict in advance, for the first few days I’d just do a few working sets at the lowest loads to see whether you can get through the session (and the 24-48 hours afterwards) without flaring things up. If so, that’s great news and means you’ve found an entry point into the rehab process.

  • Are farmer’s carries likely to hurt the rotator cuff? I was doing 5 min walks with 20 lb kettlebells as warm up, but it did start to hurt my shoulder at the end. I don’t know if it would be wise to do uneven weights with the knee issue, or just do less weight for longer.

If you were able to tolerate 5 whole minutes of this before the discomfort set in, that’s also a good sign! I’d just cap your duration (and potentially the weight) at a much shorter time period to start, and see if you can similarly find a starting point where things aren’t flared up by the activity.

And lastly, even though I’m not 100% sure this is a significant meniscus issue at this time, we do have a resource on that topic that may be helpful.

I hope this helps! And again, if you are in need of further individualized guidance, our rehab team are the best at this kind of thing, and I’d recommend setting up a consultation with them.

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Thank you so much for reminding me of this!
“In addition, in both of these situations it can be common for people to have abnormalities like small meniscal tears or minor rotator cuff tears apparent on an imaging study that’s been there for years and not causing any symptoms/issues all along, but once someone experiences pain and gets a test done, we “find” that and associate the two as cause-and-effect, when it may be incidental.”

Funny, bc I share that with all my friends with back pain having watched several presentations of yours. (I was fortunate to have a surgeon when I slipped a couple discs 30 years ago tell me that based on data from one of the Nordic countries (can’t recall), I’d likely never have a problem with them again. And I haven’t! ) I hadn’t thought of it wrt my issues, though.

It’s also thanks to the BBM docs that my new instincts have been to keep moving, not “rest.” But after making the knee worse, I want to be wise about it.

Thanks, too, for the nudge about your rehab. I did manage an appointment later this month, but I am very eager to stay moving.

Meniscus: As I said, I completed the trail run which was a combo of jogging on flatish spots and walking up inclines along with dodging roots and rocks. I did it for HIIT because it’s not boring! But I thought it was fine, then developed mild swelling above my knee that didn’t go away for a few weeks, when I decided to go to the ortho urgent care. At that point, range of motion was only slightly constricted by the swelling & I had no pain. I left thinking NBD and complied with advise to ice, elevate, week of Alleve and wear a sleeve on the knee then made it worse figuring out a top working set on the ab/ad machine. Swelling is worse and sometimes even walking starts to aggravate it, but it’s not predictable for how long it will be fine. Hiking 10,000 steps can be okay one day and it can start hurting after 3,000 a few days later.

I had not thought of it as significant, but prior to the incident on the trail, I had occasional times when my knee would “catch”, there was literally a second or so of pain that made me yelp, but I thought of it as a “glitch” since it happened rarely and resolved so quickly. However, since the ab/ad machine, the “catching” has been frequent, sometimes more than once a day. I had a history of chondramalasia sp) from playing field hockey in college, which hasn’t bothered me since graduating college. The swelling has subsequently been worse, though generally have decent, but not full ROM. Go down steps injured leg first. I asked her for a referral to PT after about a month.

Rotator cuff: It was getting worse after the tug with the dog and I noticed lack of strength as well as increased pain with very minor tasks. I tested it myself and with arm extended could just manage 1.25 weight whereas in the other arm, I could do 10 lb weight in any direction. Any more weight and significant pain. I can still pick up things if I keep my elbow into my side. That shoulder is a flaming hot mess, so I’ll hold out some hope that maybe something else is wrong, but the PT who I’ve seen as needed for 13 years and was working with my shoulder was concerned about the rotator cuff. I did get an x-ray of the shoulder but don’t really recall much beyond one space in the joint was not as open as it should have been and some minor arthritis and a developing bone spur. Recommended 6 weeks of PT, if it hadn’t resolved, then MRI and consultation about next steps.

Thanks again for the input. I will read the articles linked and contact your rehab.