Prehab & Holistic Care
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Outcomes in surgery are combination of 3 major factors: the surgeon, the patient, and rehabilitation. While many surgeons just focus on the surgery and rehab, we utilize a holistic approach to attempt to achieve the best possible outcome. Specifically, we believe in identifying and treating modifiable patient factors. These are best addressed beginning prior to surgery. Multiple studies have shown that “prehab” improves surgical outcomes. The core components of prehab include exercise, nutrition, and psychology. Additionally, biologic enhancements can help improve outcomes after shoulder surgery.

Exercise

We highly encourage exercise prior to and after surgery. The World Health Organization recommends 150 mins of exercise a week and two days of the strength training per week. We recommend 20-30 mins a day of aerobic exercise prior to shoulder surgery. At a minimum this should consist of walking. In addition to general exercise, we recommend prehab for the shoulder. This is important for helping maintain muscle strength as well as bone density in the shoulder. See chapter 7 on the rehab page for exercises that are recommend the month prior to surgery. After surgery, early walking and/or stationary bike exercises are encouraged on a daily basis.

Nutrition
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As outline on our nutrition page, your body’s need for protein doubles after surgery. We recommend increasing your protein intake prior to surgery and consuming a carbohydrate drink the night prior to surgery. Both methods have been proven to improve speed of recovery. In addition, we encourage and perform lab testing prior to surgery to assess your specific needs. These include a Vitamin D level, Albumin level, and Lipid panel.

Vitamin D
Vitamin D is important for tendon and bones. Vitamin D deficiency occurs in 1/3 of people in the United States. Low levels have been correlated with increased risk of infection and failure of rotator cuff healing. If you test positive for Vitamin D deficiency, we will recommend treatment with high dose Vitamin D prior to surgery to help improve your levels.
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Albumin
Albumin is a protein found in your blood. Low levels are associated with increased risk of complication. At least one study has found that this risk can be reduced by identification of low albumin prior to surgery with education on increased protein intake.

Lipid Panel
Elevated cholesterol levels have been associated with failure of rotator cuff healing. If you have not had a recent test, we will recommend performing a lipid panel. Lowering cholesterol levels prior to surgery may be beneficial and improve overall health.

Glucose Monitoring
Elevated glucose levels (hyperglycemia) are common after surgery. Even among diabetics this is estimated to occur in over 50% of cases due to stress of surgery. These events increase the risk of complication including infection. The goal is to minimize these events. Common approaches include exercise, a high protein diet, and the use of a pre-surgery carbohydrate drink. Additionally, Dr. Denard offers his patients to use a continuous glucose monitor for those patients who want the tightest control possible.

Psychology
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Surgery or recovery from injury is not just a physical journey, but also a mental journey. Studies have shown that low resilience, anxiety, and depression negatively impact shoulder surgery outcomes. On the flip side, pain after surgery can be modified with deep breathing, music, hypnosis, and meditation.

While we do not directly treat psychologic conditions, Dr. Denard has his patients complete general health questionnaires prior to surgery and recommends that these factors are considered prior to surgery. Prior to and after surgery, he also recommends music and provides guided meditation resources to his patients. Such relaxation or deep breathing techniques have been shown to reduce pain and anxiety after surgery.

Biology

‍There is no doubt that improving and modifying biology is the next major frontier in shoulder surgery. The biomechanics (anchors and sutures) of rotator cuff repair have been relatively optimized. But many tears have poor biology (atrophy, short tendon, etc.) and a limited ability to heal. The two most biologic options that may be considered to augment healing after shoulder surgery are: Platelet Rich Plasma (PRP), and Bone Marrow Aspirate.

Platelet Rich Plasma
PRP is obtained from your blood. This blood is then spun in a special centrifuge which separates the blood into different layers to get a high concentrate of growth factors that may aid in rotator cuff healing. Overall, studies show that the use of PRP improves rotator cuff tendon healing. The difference is greater for larger tears since healing decreases as tears enlarge in size. For instance, in one meta-analysis of 11 studies the healing rate for medium to large tears was nearly doubled with the use of PRP.
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Bone Marrow Aspirate
The concept of BMAC is to deliver a higher concentration of growth factors to the repair site compared to PRP. Bone marrow has a higher concentration of growth factors and is where most stem cells are located. This is NOT considered “stem cell therapy.” In this procedure 60 ml of blood is obtained from the bone of the shoulder. In a 2014 study performed in Europe the healing rate of rotator cuff repairs augmented with BMAC had a healing rate of 100%, compared to 66% in the standard repair group. A recent large study also showed a 3x lower risk of revision surgery for rotator cuff repairs that had BMAC.
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Rotator Cuff Tear Symptoms

The rotator cuff is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor). The rotator cuff surrounds the ball and socket joint (glenohumeral joint) and provides stability to the joint as well as movement. Because the shoulder is a shallow joint and the most mobile joint in the body, it requires the rotator cuff for stability. If let untreated tears can lead to arthritis of the shoulder (rotator cuff arthropathy). This doesn’t mean that good function can’t be maintained with a tear. In fact, many people are able to maintain function despite a tear because the shoulder remains balanced with the remaining rotator cuff and other muscles that control shoulder movement.

Muscle inserts into bone via tendon. In the vast majority of cases, when a tear occurs the tendon pulls away from the bone. Broadly speaking, tears are classified as partial or full-thickness. Partial tears go part way through the tendon while full-thickness tears represent complete detachment. Frequently, an MRI will report “partial-tearing.” Since most people over the age of 40 to 50 have some changes within the rotator cuff, partial tears usually not a problem. The distinction with partial tears is when the tears are considered “high-grade,” meaning that they go almost all the way through the tendon.

Causes

Rotator cuff tears may occur after an injury or repetitive activity over time, but most cases occur without an injury. As we age the rotator cuff tendon degenerates and age and genetics are the greatest risk factors for a tear. Studies show that about 50% of people over the age of 65 have a full-thickness rotator cuff tears. Most of these people don’t even know they have a tear!

Treatment

Treatment for rotator cuff tears is based on age, health, and response to conservative treatment. The rotator cuff tendon is not capable of repairing itself. Rather then tear will stay the same size or enlarge over time. In people under the age of 60, the risk of progression is about 50% in a two-year period. The ability to get healing with a surgical repair depends upon age, the tear size, muscle atrophy, associated arthritis, and health (smoking and diabetes for instance). One must also consider timing of repair. Traumatic tears have a better outcome if fixed within 6 months of injury. Additionally, after about six months of symptoms atrophy may occur. Unfortunately, atrophy of the rotator cuff is not considered reversible. Based on this, if someone desires repair, I typically recommend performing this within six months of beginning treatment.

Guidelines for surgery are general and must be individualized as noted above. But, as a general guideline, I recommend repair for all full-thickness tears in people under the age of 60 given the risk of increase in tear size. For people between the ages of 60 and 70, treatment is based on the above factors with health and activity expectations being the most important factors. For people over the age of 70, I nearly always recommend an attempt at conservative treatment. Surgery is then considered if one does not respond to conservative treatment.

For partial tears, conservative treatment should almost always be attempted first since these tears progress slowly or may not progress at all. Then surgery is considered if one does not respond to 4 to 6 months of conservative treatment.

Treatment options include:

Medications:

Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.

Injection:

Injection of a steroid (cortisone) may be used to provide pain relief and facilitate physical therapy. I perform these injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections over a 2 year period are allowed. Beyond this there are typically diminishing returns and excessive injections may be detrimental to the rotator cuff.

Alternative injections include Toradol (an anti-inflammatory agent similar to ibuprofen), prolotherapy, or platlet-rich plasma (PRP). ). I use Toradol in people who do not tolerate steroids. Prolotherapy involves injecting a substance such as sugar into tissue to “stimulate a healing response.” I do not perform prolotherapy as it has not been shown to improve symptoms in rotator cuff tears. PRP involves taking a small amount of blood from a patient, spinning in a centrifuge to separate the growth factors from the red blood cells, and then injecting the growth factors back into the shoulder to potentially decrease pain. While PRP has anti-inflammatory properties, it has not been shown to heal the rotator cuff. Therefore, it is not covered by insurance and is an out-of-pocket expense. Typically a series of 3 injections are performed at weekly intervals for 3 weeks.

Therapy:

‍Physical therapy with strengthening is one of the mainstays of treatment of rotator cuff tears. Long-term studies show that despite not healing the rotator cuff, therapy can lead to substantial improvements in function with good patient satisfaction. The core exercises in strengthening the rotator cuff are provided at the end of this handout. These exercises can be performed twice per day, 5 days a week.

Surgery:

Most tears, regardless of size can be repaired. I perform all my rotator cuff repairs arthroscopically. This is less invasive and therefore less painful than an open incision. It also allows a better view of the rotator cuff. This procedure requires general anesthesia, takes about 60 to 90 minutes to perform, and patients go home the same day. Small incisions are made in the shoulder, a scope is inserted, and the rotator cuff is repaired with anchors. Anchors are essentially headless screws which are placed flush with the bone. These anchors have sutures that are used to bring the tendon done to the bone so that the tendon can heal to the bone. The long-term outcome of this procedure is very good (>90% success in most cases) and the risk of complication is very low (1/5000 chance of infection). However, repair requires a long recovery period and the tendon takes about 12 weeks to heal into the bone. Therefore, a sling is worn for 6 weeks after surgery. Specific motion exercises afterwards are tailored to the tear pattern (patient-specific). The sling is removed at 6 weeks and motion is progressed. Strengthening is allowed at 12 weeks, followed by gym activities at 4 months. Full recovery takes 6 months for small tears and 12 months for large or massive tears.