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– Preoperative education: Patients should be educated prior to surgery about the expected postoperative pain and the pain management plan. Setting appropriate expectations can reduce anxiety and improve coping.
– Preemptive analgesia: Administration of analgesic medications prior to surgical incision can reduce intraoperative nociception and postoperative pain. Options include:
1) NSAIDs: Oral NSAIDs like ibuprofen, naproxen, or celecoxib given 1-2 hours preoperatively can provide preemptive analgesia. Contraindicated in patients with renal insufficiency, history of GI ulcers/bleeding, or NSAID allergy.
2) Acetaminophen: Oral acetaminophen 1000mg given 1 hour prior to surgery can reduce postoperative opioid requirements without significant adverse effects.
3) Gabapentinoids: A single preoperative dose of gabapentin 600-1200mg or pregabalin 150-300mg can reduce postoperative pain scores and opioid consumption. May cause sedation.
– Local anesthetic infiltration: Injection of long-acting local anesthetic like bupivacaine or ropivacaine into the surgical site provides analgesia for 8-12 hours postop. Typically injected into the glenohumeral joint, subacromial space, and/or incision sites at end of procedure.
– Interscalene nerve block: Preoperative or postoperative interscalene brachial plexus block with long-acting local anesthetic provides excellent analgesia for 12-24 hours. Reduces postoperative pain scores and opioid requirements. Risks include phrenic nerve palsy, Horner’s syndrome, hoarseness, and rare neurologic injury. Contraindicated with contralateral phrenic nerve palsy or pneumothorax.
– Intra-articular analgesia: Injection of morphine, clonidine, ketorolac, or magnesium sulfate into the glenohumeral joint at end of procedure can improve early postoperative analgesia as an adjunct to local anesthetics. Benefits are modest.
– Oral analgesics: Scheduled acetaminophen and NSAIDs should be given postoperatively if no contraindications. Regular dosing provides better pain control than PRN.
1) Acetaminophen 1000mg PO/IV q8h
2) Ibuprofen 600mg PO q6h, naproxen 500mg PO BID, or celecoxib 200mg PO BID
3) Combine acetaminophen with an NSAID for synergistic effect
– Opioids: Short-acting opioids like oxycodone or hydrocodone should be available for moderate to severe breakthrough pain not controlled with scheduled non-opioids. Long-acting or extended-release opioids are not recommended. Prescribe lowest effective dose for shortest duration to minimize risks of dependence, tolerance, and adverse effects.
– Ice therapy: Application of ice packs or compressive cryotherapy devices to the shoulder can reduce pain and inflammation postoperatively. Apply for 20-30 minutes every 2 hours while awake for the first 48-72 hours.
– Early mobilization: Gentle passive range of motion exercises started on postoperative day 1 can reduce stiffness and muscular spasms that contribute to pain. Progression of rehab and active motion should follow surgeon’s protocol.
– Patient-controlled analgesia (PCA): For inpatients, IV PCA with opioids like morphine, hydromorphone, or fentanyl allows self-titration of analgesic dose. Provides better pain control and higher patient satisfaction compared to PRN nurse-administered opioids. Transition to oral analgesics when taking PO.
Combining multiple analgesic agents and techniques that target different pain pathways allows effective pain control while minimizing side effects and opioid use. Recommended multimodal regimens include:
1. Preoperative celecoxib
+ acetaminophen, interscalene block with ropivacaine, intraoperative local infiltration with bupivacaine, postoperative scheduled acetaminophen
+ ibuprofen
+ PRN oxycodone
2. Preoperative gabapentin
+ celecoxib, intraoperative local infiltration with liposomal bupivacaine, postoperative scheduled acetaminophen
+ naproxen
+ PRN hydrocodone
3. Preoperative acetaminophen, postoperative interscalene catheter with ropivacaine infusion, scheduled acetaminophen
+ ketorolac (parenteral) or ibuprofen (PO)
+ PRN IV PCA hydromorphone
The optimal multimodal protocol will depend on patient factors (e.g. comorbidities, preferences), surgical factors (e.g. open vs arthroscopic, tear size) and institutional factors (e.g. formulary restrictions, provider preferences). The regimen should be individualized and adjusted based on the patient’s response.
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.