The Shoulder Surgery Recovery Plan Surgeons Don't Tell You

My name is Dr. Patrick Denard. I'm an orthopedic surgeon who practices in Medford, Oregon, and I want to share with you what I've learned about how you can maximize your recovery after shoulder surgery, and honestly, any surgery for that matter. It just happens to be that I'm a shoulder surgeon, so I think about this in terms of the shoulder, but this applies to any surgery, whether it's orthopedic or surgery in general. So my background from a research and practice standpoint is that I do exclusively shoulder, and I've done over 10,000 surgeries over time, several publications, and many book chapters. But in addition to that, I've been an athlete for much of my life. I had an interest early on in supplementation, how to improve performance, and I've been an orthopedic patient. And so I've gone through recovery and know what that's like and know how you can get very little information to actually help you get through the recovery in a timely manner. So my big piece of advice to start is to say, don't be passive. Passive in this process. You can take control of your recovery. It's not something that happens to you, it's something you can actively shape, and surgery is a choice, and you have— in many cases at least— and you have the choice of how you're going to get through this. I would really encourage you to think about this like an athletic event, okay? This is your Super Bowl, this is your Olympics, and you want to prepare as much as you can for this event. Now, athletes know that small edges make a large difference in performance, and they do everything they can to maximize that. And I think about these variables in athletics and in surgery. So in athletics, you have the physical capabilities of the individual, you have their mental toughness, the event— and the event has a lot of variability, of course. There may be rain or, or, uh, away event or a home event. And then there, of course, is nutrition. Now, when you think about this in surgery, there's a lot of parallels. You have your condition You have your grit or your mental toughness. You have the surgeon, and then you have your nutrition. Now, if we think about these, your condition is not modifiable at this point. Your mental toughness, you can alter a bit, but right before surgery, that's probably something that's hard to change a lot because it's something that's been shaped over time. Hopefully you, you, you make a good decision with your surgeon, but ultimately, once you're in their hands, you're in their hands. But nutrition is, simply put, the biggest thing or simplest thing that you can modify that's within your control. So I really think it's the easiest lever to pull on, and it matters because I'm gonna show you the evidence really shows that it makes a large difference in improving your speed of recovery and reducing your risk of complication, preserving muscle, et cetera. Now the reality nutritional support, the good news is this, it's very easy to implement once you kind of get a handle of all these factors that go into this. The bad news is you have to do this on your own. Insurance doesn't pay for it, the government doesn't cover it. In fact, the government just recently recognized the fact that nutritional education was important in medical school. However, the other piece of good news is that the cost of doing something like this is very low. So what do most physicians tell their patients about nutrition? They really say, they don't give them any guidance, they say, Hey, you can do anything, you know, you just want to eat well. I think that's a big mistake. When you really think about, again, the athlete parallel, they have all this preparation guidance, and we take somebody who's even of a less physical status, whether they're a middle-aged person or an older adult, they're in a much more compromised position, but we don't give them guidance. Personally, for me, As somebody who's done a lot of surgeries, I actually don't wanna do the surgery if somebody's not gonna invest in their nutrition because I believe it's that impactful. Now, patients at the same time have increasing demands. They wanna stay active, they wanna get back sooner if they're middle-aged or older adult, and even young athletes have the same desires to get back as quick as they can. So let's talk about some of the evidence around nutrition and why this is so important. So nutritional deficiency is actually a very common problem. A lot of people think that they eat well and they're gonna be fine. Uh, people overestimate their nutritional status. In fact, studies on surgical patients show that roughly 50% of patients have some sort of nutritional deficiency. Now, even if you don't, you can still benefit, and I will show you evidence to speak to that. That said, malnutrition, that is any sort of risk factor, leads to a much higher rate of complications. Again, this study at Germany, 50% of people were at risk, 40% increased risk of complications, twice the length of stay. If you look at data from total hip arthroplasty, you see very large rates in discharge to non-home locations, 25% increased risk of transfusion, 28% increased risk of reoperation, and 100% increase in mortality. So double the mortality rate that is death. Fortunately, that's low overall, but nonetheless, the rate goes up substantially. Infection risk also goes up substantially in people who have nutritional risk factors. It's about 3 times higher. If you look at rotator cuff specifically, which is close to my heart, you see that 50% of people have some sort of nutritional risk factor when you look at people undergoing rotator cuff repair. This is based on GNRI, which is a function of albumin. And this study out of Japan looked at factors associated with retail re-tear, that is failure of the tendon to heal. And surgeons always talk about age and tear size, and these had small, uh, consequences that were statistically significant, meaning that they were meaningful, but the magnitude of difference was much less. The largest difference was with nutritional status, and that was about a 400 to 600% increased risk of re-tear with people with poor nutritional status. This is unpublished data of mine. We've looked at my patients who have undergone total shoulder replacement. We've just submitted this, and we essentially found very similar findings. In people who have lower nutritional status going in, they have a 13 times higher risk of any complication. They have a 6 times higher rate of reoperation. We've also looked at stress fractures. Stress fractures occur after somebody has a reverse shoulder replacement. This occurs in about 4% of people, and it's a problem that people really have a hard time getting a handle on. They've really talked about, patient factors, but not really honed in, and also talked about implant factors. But in our data shows that nutritional status makes a big difference. It was a threefold increase in this risk with people who had a low GNRI. Again, that's low albumin, which is essentially, um, a marker of protein. Now here is one of the key factors. If you give people guidance, which I try to do for my patients, you can reduce their risk of complication. You can reduce that rate by 40% and lead to a lower length of stay. So now let's talk about the details about, about how this occurs. So I wanna go over protein optimization, carbohydrate loading, micronutrient support, and then how you put this all together. So protein optimization first. Now, after surgery, the reality is that patients only consume about 30% of their protein requirements. And this is really significant because you get muscle loss. Whether you are immobilized from a sling or a cast or brace, or you're just not moving as much because of any surgery, you get muscle wasting. 5 days of bed rest, for instance, has been shown to be equivalent to 5 years of aging. So the goal here is to minimize muscle loss and maximize healing. You want to reduce that recovery curve, make that shorter. And this applies to healthy individuals. It also applies to young adults where studies have also shown that this is effective. The real key is amino acids. So leucine is the most important amino acid for muscle protein synthesis. This activates the mTOR pathway. Glutamine also plays a role in immune function, is the most abundant amino acid in the body. This is an interesting study where they took healthy individuals, mid-age, uh, placed them in bed rest for 2 weeks and either gave them a regular diet or added leucine. And when they added leucine, these people had 3 times less muscle loss. So simply having that amino acid, 3 grams in this case, which is the, what we would call the clinical dose, led to much less muscle loss. Data in surgical recovery also shows this is a benefit. So this study out of Japan, patients were given one week prior to surgery, they had protein supplementation, and then 2 weeks afterwards, 30 patients in each group And you can see over time, the blue is the amino acid group. They had less decrease in muscle mass. This is in the quadriceps or rectus femoris. But what's really interesting too is these strength differences were maintained at 2 years. And what this shows is that there's probably a critical period. So it's not simply that you're going to get it back if you don't intervene and get the strength back at a critical window. You may not get it back, period, after surgery. And this is why maybe perhaps some people say, "I never really got to where I wanted to be," or at least one of those reasons. This has also been shown in spine literature to be effective. So people undergoing spine fusion— it's a big operation— those who receive protein supplementation have less pain after surgery, and they have a higher fusion rate, so clearly indicating a higher chance of healing. Final piece of evidence, this is from trauma literature, people who have broken bones, a randomized controlled trial, meaning people were put in two groups, they had almost 200 people in each group. They gave the one group that had supplementation of amino acids after surgery, because that's when they could start, obviously you can't prep for fracture. You see lower risk of complications, nonunion, which means the bone didn't heal, lower rate there, and lower mortality, again, a much lower rate of mortality, 4% versus 0.1%. 5%. So massive differences. If you're looking at that, that's an 8-fold reduction in mortality. The next thing I want to talk about is carbohydrate loading. We know from athletes this is really important. If you look at an athlete before an event, they carb load the night before, and the reason is they want to have the immediate energy to get through that stressful event. And yet what we do in surgery is we tell people not to eat or drink or NPO after midnight. The reality is most people don't eat for 12 to 16 hours. When this occurs, your glycogen stores go down, you get catabolism, meaning your body has to break down other parts to provide energy for that recovery. At the same time, you have the stress of surgery, and then you have increased insulin resistance, which leads to free radical production. Now, I've experienced this as an athlete who has underprepared from a nutritional standpoint and tanked after that, or in the middle of that event. And so what we try to do here by giving carbohydrate loading in a similar vein is prep the patient to undergo surgery so when they have this stress to their body, which surgery is, they have that energy to appropriately recover. You need that immediate energy, which is why carbohydrates are important in the form of glycogen. So if you give 100 grams of carbohydrates the night before surgery, in some cases you can also give 50 grams and, uh, as well 2 hours prior. Studies show less length of stay, less reduction in muscle loss, decreased insulin resistance, improved patient comfort, which is really important, and also faster return of bowel function. The evidence in total hip replacement is also similar. You see here with carbohydrate loading prior, decreased length of stay, lower pain, lower narcotic usage even, and people just feel better. They have less hunger and anxiety. Are out of the hospital sooner. So very simple thing to improve recovery after surgery. There's also several micronutrients that have been shown to impact surgical outcomes. So vitamin D is one of those. For instance, vitamin D has been shown that people who have low vitamin D levels, that are vitamin D deficient, have 3 times a higher rate of retear after they have a rotator cuff repair. So personally for me, I order vitamin D level on all my patients who are undergoing a rotator cuff repair. And vitamin D deficiency is actually quite widespread. If you look across all comers, it's about 1/3, but actually in people undergoing shoulder— or sorry, joint replacement— it's closer to 3/4 actually have vitamin D deficiency. And there's seasonal variation. I mean, it can be worse in the winter. People who have vitamin D deficiency again have a higher length of stay after surgery. Vitamin C is another one. Vitamin C plays critical roles in recovering collagen synthesis, antioxidant production, immune support, and wound healing. Data shows less pain, less inflammation, and even blood— less blood loss with vitamin C supplementation. I advocate that all my patients have 500 milligrams of vitamin C twice a day. Specifically with regard to the rotator cuff, data shows that their chance of healing, that is, better with vitamin C supplementation— this study, people were given 500 milligrams twice a day and they had half the rate of retear. So a very simple thing to improve your chance of healing. Magnesium is another one that has a high rate of deficiency in the general population. Studies show if you supplement magnesium, you have less post-operative pain. You also have improved sleep duration and decreased sleep latency. Now this is really important because sleep is another critical part of recovery. You have to have your body ability to recover, and that involves rest. I advocate magnesium glycinate, 200 milligrams daily, to help with sleep. Personally, I take this on a daily basis as well. Creatine has not been shown to directly improve surgical recovery, but I think it makes sense to consider. There is data in young individuals who have been immobilized showing that if they supplement with creatine, they have 81% less strength loss. And we know in individuals who are both young but also older, if they add creatine to a weight training program, they have improved muscle gains— about twice the muscle gain improvement with creatine supplementation. We know creatine is safe. There's even data suggesting it has cognitive benefits. So I am a big advocate of this approach. Additional nutrients that can be considered include collagen, curcumin, and omega-3 fatty acids. Collagen— basic science data supports that it actually does improve tendon thickness. Curcumin has been shown to decrease inflammation and also lead to less pain and adhesions after surgery and laparoscopic surgery. And omega-3 fatty acids help decrease inflammation and improved muscle preservation. Also, in a casting scenario, which is a good marker of recovery because you're immobilized, there was 43% less muscle loss in a casting scenario. So I advocate taking omegas twice a day in the surgical recovery period. Now, when it comes to delivery, I'm now telling people to do a lot of things, and you have to remember this goes on top of a multimodal pain approach where you have to take medications to help keep your pain levels low. And so this becomes a lot of things to consider. So this can become a little bit complex. Some people are very good about tracking all these things, but other people get a bit confused about this and try— when you try to piece it all together and have the right doses, it can be a lot to manage. And this is why I helped to put together this protocol called Thrive Protocol. This is where we basically package all these things into one protein kit that you take a day, as well as a carbohydrate drink that has all the contents that are shown to improve recovery. Now you can certainly do this on your own. You can go get protein, you just have to make sure you're getting a high amount of leucine. Typical over-the-protein— over-the-counter proteins are going to give you 1 to 2 grams. You want to make sure you get a high dose. You want to supplement on top, but you could add collagen as well. You could add omegas, you could take curcumin, you could take vitamin C 500 a day, vitamin D magnesium also in there, and you could do a carbohydrate drink. It's just, this just makes it simple. So I'm happy if my patients do either. This is just one approach. What I advocate for people is that they begin 7 to 14 days prior to the procedure. The night before, they do a single carbohydrate drink that's 100 grams complex carbohydrate. The advantage here is no sugar. I actually also use this for preparation of athletic events. When I did my Spartan Run recently, or when I did my half Ironman, uh, last year, I took, um, this carbohydrate drink the night before to carbohydrate load, and then also, uh, in the morning prior. And then you want to continue afterwards because you got to get through the surgery, but then you got to go through the healing period at a minimum of 14 days. Some data actually suggests out to 3 months. In an ideal world, I would recommend people do it to 3 months. The summary here is that think of shoulder surgery or any surgery for that matter as your game day. You want to prepare, have the right mindset, but really think about nutrition as the most controllable variable within your hands. And implementation really can be simple, uh, if you want to streamline it with a kit. So thank you and good luck in your recovery.