Arthroscopic Rotator Cuff Repair

Loel Z. Payne, M.D.

Diet:

􀀀 You may resume clear liquids and light foods after surgery (jello, soup, etc.)

􀀀 Progress to your normal diet as tolerated as long as you are not nauseated.

􀀀 Many surgeries are done without general anesthesia. This allows you to resume a diet quicker with less nausea.

 

Managing the pain:

There’s no two ways about it, shoulder surgery is painful. I am going to describe the best ways I have found to try to manage that pain. The first 1-2 days are the hardest. Don’t worry, it will improve.

Before surgery you will be offered a nerve block which helps greatly with pain control and decreases your need to take narcotic medications. I would strongly encourage you to have the block as it does significantly help with pain after the procedure. Additionally, during surgery I will often inject a numbing medicine like novocaine that will give some pain relief for several hours after surgery.

It is important to begin taking your pain medication before this medicine wears off. This is usually about 6 to 8 hours after the procedure. However, it may be as little as 2 hours or (if you’re lucky) it could be 12 to 16 hours. It is important to stay on top of the pain as it is more difficult to catch up.

I do not use a “pain pump” which drips the numbing medicine continually into the joint for several days after the surgery. Several recent studies have shown an increased risk of damage to the joint cartilage and subsequent arthritis as a result of prolonged exposure to this medication.

I believe in using multiple different ways to reduce pain. Our goal is to reduce the amount of narcotics required to control the pain. Narcotic medications (morphine, Percocet (oxycodone), Vicodin (hydrocodone), codeine and Dilaudid) have significant side effects. They can easily become addictive. They can be overdosed, especially in patients already taking other sedating medication such as sleeping pills. Narcotics decrease the body’s trigger to breathe and I may prescribe a medication to reverse this narcotic side effect (Narcan) if you are currently taking anti-anxiety or sleeping medication. It is best to avoid these drugs (and alcohol) while on pain medication. Narcotics cause constipation. They alter your ability to concentrate, cause drowsiness and should not be taken while driving. They can cause hallucinations. They frequently cause constipation and a stool softener, such as Metamucil of Sennokot DS, should be taken daily while on them. They often cause nausea and a medication for nausea, such as Phenergan or Zofran, is often prescribed with them. If you have a history of prolonged nausea you are likely going to be prescribed an anti-nausea medication.

Patients with significant reactions to all narcotics, may benefit from a newer drug called Nucynta (tapentadol) that does not typically have the same side effects. However, it may not be covered by many insurance formularies.

If you experience itching, take over the counter Benadryl one half hour before your narcotic.

            Surgery pain stems from multiple factors and you should address each of these to control the pain. Below is a chart to explain our multimodal pain control plan.

Preoperative pain management

Postoperative pain management

  1. Nerve block – anesthesia injections numbing medication around the nerves that go to the shoulder
  2. Local injection of numbing medication at the surgery site
  3. Anti-nausea medication such as Zofran or Scopolamine patch is given
  4. Tylenol or an anti-inflammatory such as Celebrex may be given
  1. Tylenol 650 mg every 6 hours around the clock. Limit to 3000 mg daily and avoid if history of liver disease. Use continuously for 3 days and then as needed.
  2. Naproxen 500 (2 Aleve) every 12 hours OR ibuprofen 800 (4 Advil) every 8 hours. Take with food and avoid if history of ulcers, severe reflux or kidney disease. Continue for 5 days and then as needed.
  3. Oxycodone 5 mg 1-2 every 4 hours as needed. This is the narcotic and should be used sparingly. However, if pain is severe and uncontrolled with other methods, you may take 3 pills at a time for the first 24 hours. Percocet and Vicodin (Norco) already have Tylenol in them so do not take Tylenol if you are on these medications. Straight Oxycodone does not.

Ice (see below) is very helpful

Physical therapy – stiffness is a common source of pain and therapy is often started several days postop

 

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Bandages:

􀀀 Your post-operative dressing is a large, white fluffy dressing and absorbent pads that are held in place with tape.

􀀀 Unless directed otherwise, remove this dressing 2 days after surgery and place large band-aids over the incisions.

􀀀 Because the surgery is performed arthroscopically, occasionally there will be water with a small amount of blood on this dressing. This is nothing to worry about. However, if you see a lot of bleeding, please call Dr. Payne.

 

Washing & Sling:

􀀀 You should be careful to keep the wound clean and dry for the first 48 hours after surgery.

􀀀 Beginning on the third day after surgery, it is OK to shower as long as the incisions are kept dry with plastic wrap. Remove the wrap after showering.

􀀀 It is OK to go into a swimming pool after the sutures are removed, but do not go in lakes or the ocean until three weeks after surgery.

􀀀 You will have a sling with a supporting pillow placed after surgery. The only time you are allowed to remove it is during showering or when doing your exercises. It is best to wear it at night to avoid unintentional movement of the arm.

 

Ice & Activity:

􀀀 One important goal following surgery is to minimize swelling around your surgery site. The best way to achieve this is with the frequent application of ice. This is most important the first 48 hours following surgery. The ice pack should be large (like a big zip-lock bag or bag of peas) and held firmly on the area of your surgery. Apply for 20 minutes every hour while awake if possible. Look for signs of frost-bite especially during the first twelve hours when the skin around your shoulder may be numb. Shoulder ice water devices such as a Cryocuff are also very helpful. Unfortunately, they are not covered by most insurances.

􀀀 Keep your elbow against the pillow and in front of the plane of the body to avoid stress on the repair

􀀀 Keep a pillow behind the elbow while lying down to prevent the elbow from sliding

backwards.

􀀀 While sitting in a chair you may remove the sling three times a day to perform elbow and wrist range of motion exercises. Gently undo the strap around your neck and waist. Allow the elbow to extend straight.  You may then stand up and support yourself with your good arm on the chair. Lean forward from your waist and let the arm hang straight down. Do not try to lift the arm. Let it hang like a dead weight. Once you are comfortable with this, you may gently swing the arm side-to-side like a pendulum. Use your upper body to generate the pendulum motion. Again, don’t try to move the arm using your shoulder muscles.

􀀀 You may return to sedentary work or school in 3-4 days after surgery if your pain is tolerable.

􀀀 Avoid driving unless otherwise instructed by Dr. Payne.

􀀀 Avoid long distance travel during the first week after surgery to reduce your risk of developing blood clots.

 

Sleeping:

􀀀 Many patients have difficulty sleeping after shoulder surgery. You may find that sleeping in a slightly upright position (i.e. reclining chair) will be your most comfortable position. Make sure to have your pain under control before you sleep.

 

Physical Therapy

􀀀 I usually order physical therapy to start 4 to 5 days after the surgery. If there is a very large tear or the shoulder required stabilization, I may wait several weeks before therapy begins. One of the most common complications of this surgery is stiffness. I attempt to provide as stable a repair as possible. However, even the best repairs can be pulled loose with inappropriate movements. It is important to listen to the therapist instructions so you will learn how the shoulder can be moved (passive movement) to avoid stiffness but protected by avoiding active movement. Your therapist will start gentle range of motion exercises on

your first visit. It is helpful to take pain medication before your therapy visits and have someone drive you to the appointments.

 

Follow up appointment:

􀀀 We try to give all of our patients a follow-up office visit at the same time we schedule your surgery.

􀀀 I usually want to see my patients in the office 10-12 days after surgery.

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What to watch out for:

􀀀 Pain that is not relieved by medication several days after the procedure.

􀀀 Drainage from the wound more than 2 days after surgery

􀀀 Increasing redness around the surgical site

􀀀 Fever greater than 101.5 degrees.

􀀀 Call our office for any concern (757-827-2480). If you feel it is a medical emergency, call 911 or go      to an emergency room.