Using Nutrition To Maximize your Surgical Recovery

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Why is Nutrition Important Around Surgery?

Think of surgery like your race or event. Just like an athlete, preparation will improve your chances of a good result. Surgery places stress on your body leading to unique needs. Supplementing your regular diet before and after surgery will increase the chances of a good outcome, lower the risk of complications such as infection, and speed up your recovery.

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Who Needs to Think About Their Nutrition After Surgery?

Many people think they do not need to worry about their nutrition after surgery because the “eat well” or are “healthy.” First, studies show people underestimate their risk for nutritional deficiency. Secondly, data shows that all comers, even young and middle- aged adults, benefit from nutritional optimization and have a faster recovery with supplementation.

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How Can I Improve My Nutrition for Surgery?

Here are several tips:

As a general recommendation you should aim to eat a well-balanced diet
- Avoid alcohol. Alcohol is not only toxic, but also impairs sleep which is critical to recovery
- Avoid highly processed foods
Drink plenty of water. This helps limit constipation‍
Aim for 1 gram of protein per pound of body weight for 2 weeks prior to surgery and for at least 2 weeks after surgery. My recommendation is for 3 months after surgery
Take Vitamin C 500 mg twice daily for 6 weeks after surgery
Take Vitamin D 2000 IU 1 month prior to and for 3 months after surgery unless your levels are abnormally high
Consider these additions:
- Magnesium. Lowers pain and improves sleep
- Collagen. Supports tendon healing
- Curcumin. An anti-inflammatory shown to reduce pain and decrease adhesions
- Creatine. Shown to improve strength and improve mental function
- Omegas. Anti-inflammatory and muscle support

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How Much Protein Do I Need After Surgery?

Your body’s need for protein doubles after surgery. Just like an athlete prepares for an event by eating well, you should prepare for surgery by doing the same. Studies have shown that protein loading 1-2 weeks prior to surgery and protein supplementation after surgery (up to 3 months) improves recovery and decreases muscle atrophy. A major key is Leucine which is the most important amino acid in muscle synthesis. Leucine is an essential amino acid, meaning that it must be obtained from the diet. Most off-the-shelf protein powders contain 1 to 1.5 grams of Leucine. However, the medical studies on Leucine recommend 3 grams per serving. Glutamine is also important in muscle synthesis and immune function and should be considered.

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What Vitamins and Minerals are Important for Healing After Surgery?

Several vitamins and minerals have been shown to impact outcomes, most notably Vitamin D, Vitamin C, and Magnesium.
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Vitamin D

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Vitamin D is important in tendon and bone function. About 1/3 of people in the US are Vitamin D deficient. Vitamin D levels have been associated with rotator cuff healing. Consider supplementing with a minimum of 800 IU daily for 1 month prior to surgery and 3 months after surgery. My recommendation is 2000 IU daily.

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Vitamin C

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Vitamin C is important for collagen formation. Supplementation with 500 mg twice daily has been shown to lower pain after surgery and may also improve rotator cuff healing.

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Magnesium

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Clinical studies have shown that Magnesium reduces pain after surgery. Additionally, lab studies suggest that Magnesium can improve tendon healing. Magnesium is also important for Calcium and Vitamin D absorption. Interestingly, about 50% of the US population does not get enough Magnesium in their diet. Therefore, I believe it is reasonable for most people to start taking
Magnesium the month prior to surgery and for 12 weeks following surgery. Magnesium oxide or citrate can cause stomach discomfort or diarrhea. Magnesium glycinate is better tolerated. I recommend 200 mg daily.

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How Do I Put These Recommendations Together Into A Complete Nutrition Plan After Surgery?

This is a lot to keep track of! To make this process easier we recommend a comprehensive option which is specially formulated nutrition kit designed for surgical patients:

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www.mythriveprotocol.com

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This kit provides a 4 week supply of single-serve shakes. Ideally you take starting 1 to 2 weeks prior to surgery to load, but studies have shown that even starting immediately after surgery is beneficial. There is also an option to purchase a 3 month supply. Finally, there is a carbohydrate drink for the night prior to surgery. Carbohydrate loading the night prior to surgery with this low sugar formulation has been shown to reduce length of stay after surgery.Another option is to use an off-the-shelf protein powder and supplement between meals. The cost of the kit is higher than a standard protein powder because the Leucine and Glutamine content are higher than what you will find in the store. Additionally, if you include the cost of the additional vitamins (D, Ca, C, and Magnesium), collagen, curcumin, and omegas included in the kit you will see that the cost difference is lower and likely worth the potential benefit and convenience.

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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.