Terry Buisman PT, Pres. ORSI and Zach Zenner MS, AFDNP
The shoulder complex is the most complicated musculo-skeletal structure in the body. We of course take this for granted for much of our lives relying heavily on the incredible amount of inherent flexibility and functional strength of which the shoulder girdle is endowed. With feats of throwing baseballs at over 100 MPH or painting houses over a 30 year career, the joint takes its share of use and abuse, at times leading to surgical intervention.
The majority of shoulder issues can be resolved without surgery; however 10-20% of the population with shoulder pain and dysfunction will require surgical intervention. Many of the structures addressed during surgery have been subject to trauma for multiple decades and the quality of this tissue is fair to poor at time of surgery. As well, many of the structures that need to be repaired have a relatively poor vascular (blood) supply which further challenges the healing process, appreciating that surgery is additional trauma as well. A rotator cuff repair is generally a 9-16 month rehabilitative project to regain normative function.
Preparing the joint thru a pre-surgical round of physical therapy care is often advantageous to best prepare the shoulder for the recovery process. Nutritional science is also of benefit in maximizing tissue quality and from a pre and post-surgical perspective.
Zach Zenner MS (Nutrition, George Washington Univ.), Certified Functional Diagnostic Nutritional Health Coach has joined the ORSI team, providing nutritional counseling for our clients. His article on this subject matter follows.
DISCLAIMER: If you are pre-diabetic or have type I or type II diabetes not all of these recommendations will be suitable for you. Every patient requires different recommendations, even in nutrition. If you have any questions about your individual situation reach out to me at zzenner@zion-performance.com or book a free consult at www.zion-performance.com . What is discussed in this article are broad general guidelines, not specific to certain situations, thus it should not be considered medical advice or official recommendations from ZION Performance. As always consult your doctor before making any significant change to your diet.
Pre-Surgical Nutrition by Zach Zenner
A preconceived notion prior to undergoing surgical intervention for a musculo-skeletal injury is that the burden of success falls on the surgeon and surgical team. The normative tendency will be that the patient will wait until after surgery before putting forth their own effort to achieve a full recovery. Commonly, these personal efforts arise with the onset of their physical therapy care.
Obviously, the role of the medical and physical therapy staff plays a significant factor in one’s surgical outcome but there are many opportunities that the patient has to improve upon their long term success as well. One such area is that of nutrition. This article will explore what a surgical patient can do from a nutritional perspective prior to surgery to improve the success of their procedure.
Surgery is a significant stressor to the body, not only because of the wound and subsequent tissue healing but also because of the mental stress that accompanies this distinctive event in a person’s life. Whenever we encounter any stress, our body jumps into action by increasing the secretion of cortisol and glucagon to meet the demands of that stress. These hormones do a lot to our body, but for this conversation we’ll discuss one of their biggest impacts: increase blood glucose (sugar). This can put patients into a state of insulin resistance with hyperglycemia that can last anywhere from a few hours to a few weeks following surgery (Hirsch et al., 2021). The glucose that causes the rise in blood levels has to come from somewhere. It varies depending on a patient’s nutritional state, but in surgical situations it often comes from muscle which leads to muscle breakdown. With these factors in conjunction with a decrease in activity, patients can experience significant skeletal muscle loss (Hirsch et al., 2021; KILROE et al., 2020). In fact, some studies have shown adults over 65 can experience muscle loss at 1% per day for the first two weeks following surgery (Hirsch et al., 2021). This is where nutritional support can come in handy. Proper diet and supplementation can mitigate some of these negative effects, which allows for the preservation of more muscle. More muscle preservation can lead to a faster recovery and return to function.
What can be done prior to surgery to combat these effects? First up are carbohydrates. Studies have shown that consuming 175 grams to 200 grams of oral carbohydrates the night before or 4 hours before surgery helps spare muscle from being broken down (Hirsch et al., 2021). Consequently, this strategy has shown to prevent the loss of muscle and muscle strength post-surgery (Hirsch et al., 2021). The magnitude of post-operative insulin resistance and cortisol levels have also been shown to be reduced by this technique of carbohydrate loading prior to surgery (Svanfeldt et al., 2007).
Consuming high amounts of high-quality protein is another way to prevent muscle loss following surgery (Dreyer et al., 2018). High quality can be defined as providing a high percentage of essential amino acids that are well-digested. The recommended amount of protein per day is 0.54-0.9 grams per pound of body weight for one week leading up to surgery (Gillis & Wischmeyer, 2019). For example, if a patient weighed 200 lbs. their recommended range of protein intake per day would be 108-180 grams of protein per day (that’s grams, not ounces). One study by Dreyer et al. showed that supplementing with protein for 6 days leading up to surgery and then for 6 weeks following surgery decreased muscle atrophy by an average of 5% (Dreyer et al., 2018)!
The final nutritional “lever” to pull leading up to surgery is something called immunonutrition. Immunonutrition is a combination of arginine, omega-3 fatty acids, and antioxidants delivered at high levels. In one study this combination reduced the number of patients that had a prolonged hospital stay following surgery by 23% (Wischmeyer et al., 2018). Another study demonstrated an 11.5% reduction in surgical site infections with this same combination (Moya et al., 2016). Breaking down the components of immunonutrition, arginine is a conditionally essential amino acid that is rapidly depleted after surgical stress. Arginine is important for the activation of powerful immune cells including T lymphocytes, T helper cells and phagocytosis (eating the bad guys). Arginine is also a precursor to nitric oxide and proline both of which are important for wound healing (Wischmeyer et al., 2018). Fish oil contains omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) which play a well-known and significant role in anti-inflammatory processes, reducing oxidative injury, and generating resolvins (Wischmeyer et al., 2018). Fish oil has also been shown to be protective against muscle loss in disuse situations like surgery (McGlory et al., 2019).
The impact a patient can have on their surgical outcome cannot be overstated. Start pre-surgically with solid nutrition and supplementation to put oneself in the best position possible for a full recovery.
Pre-surgery Macronutrient & Food Recommendations:
- 175-200 g of oral carbohydrate the night before or 4 hours before surgery
- 0.54-0.9 grams of protein per pound of body weight per day for the week leading up to surgery
- 1 serving fruits and vegetables every day for antioxidants
Supplemental Product Recommendations:
- Klean Recovery by Klean Athlete – oral carbohydrate
- Whey Protein Isolate of any kind – oral protein supplement to reach protein goal
- Nitro Benefts by Davinci Labs or L-Arginine from Designs for Health – arginine for blood flow
- OmegAvail Hi-Po from Designs for Health – fish oil for anti-inflammatory effects
*You can get 20% off all of these supplements when you work with ZION Performance*
Sources:
Dreyer, H. C., Owen, E. C., Strycker, L. A., Smolkowski, K., Muyskens, J. B., Kirkpatrick, T. K., Christie, A. D., Kuehl, K. S., Lantz, B. A., Shah, S. N., Mohler, C. G., & Jewett, B. A. (2018). Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. JB & JS Open Access, 3(2), e0006. https://doi.org/10.2106/JBJS.OA.18.00006
Gillis, C., & Wischmeyer, P. E. (2019). Pre-operative nutrition and the elective surgical patient: why, how and what? Anaesthesia, 74 Suppl 1, 27–35. https://doi.org/10.1111/anae.14506
Hirsch, K. R., Wolfe, R. R., & Ferrando, A. A. (2021). Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. Nutrients, 13(5). https://doi.org/10.3390/nu13051675
KILROE, S. P., FULFORD, J., JACKMAN, S. R., VAN LOON, L. J. C., & WALL, B. T. (2020). Temporal Muscle-specific Disuse Atrophy during One Week of Leg Immobilization. Medicine & Science in Sports & Exercise, 52(4), 944–954. https://doi.org/10.1249/MSS.0000000000002200
McGlory, C., Calder, P. C., & Nunes, E. A. (2019). The Influence of Omega-3 Fatty Acids on Skeletal Muscle Protein Turnover in Health, Disuse, and Disease. Frontiers in Nutrition, 6, 144. https://doi.org/10.3389/fnut.2019.00144
Moya, P., Soriano-Irigaray, L., Ramirez, J. M., Garcea, A., Blasco, O., Blanco, F. J., Brugiotti, C., Miranda, E., & Arroyo, A. (2016). Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study). Medicine, 95(21), e3704. https://doi.org/10.1097/MD.0000000000003704
Svanfeldt, M., Thorell, A., Hausel, J., Soop, M., Rooyackers, O., Nygren, J., & Ljungqvist, O. (2007). Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. The British Journal of Surgery, 94(11), 1342–1350. https://doi.org/10.1002/bjs.5919
Wischmeyer, P. E., Carli, F., Evans, D. C., Guilbert, S., Kozar, R., Pryor, A., Thiele, R. H., Everett, S., Grocott, M., Gan, T. J., Shaw, A. D., Thacker, J. K. M., & Miller, T. E. (2018). American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesthesia & Analgesia, 126(6), 1883–1895. https://doi.org/10.1213/ANE.0000000000002743
Post-Shoulder Surgical care by Zach Zenner
After being discharged from the hospital following any major orthopedic operation the next step on the patient’s checklist to a full recovery is to start their physical therapy. While at physical therapy they might receive anti-inflammatory modalities, specialized exercises, manual therapy, and more. To make the most out of these rehabilitation programs and to maximize recovery patients should also prioritize their nutrition. Nutritional choices can have a drastic impact on both recovery and the risk of a retear. This article will explore what surgical patients can do nutritionally following major shoulder surgery to help ensure a full recovery and return to function.
To summarize a previous article on pre-surgery nutrition: Surgery is a major stress to the body which leads to muscle loss independent from the muscle loss that occurs from the disuse of the surgical joint. The less muscle loss you have, the faster the recovery and return to function. Nutritionally we can combat this stress and help preserve muscle a few different ways. Just like with pre-surgery nutrition first up is carbohydrate intake. Following an operation carbohydrate should be consumed at 3.63 grams per pound of body weight per day for at least 3 days following surgery. This is to maximize glycogen (energy) stores following the big stressful event, which depletes glycogen (Hirsch et al., 2021). When consuming these carbs, the emphasis should be on complex carbohydrates like vegetables and whole grains to increase the intake of valuable micronutrients and fiber which have implications for reducing inflammation and muscle recovery (Hirsch et al., 2021).
Next up is protein. Protein is king post-surgery. The recommended range for daily protein intake following surgery is 0.73 – 0.91 grams of protein per pound of body weight per day for the entire time the body repairing and strengthening (Wischmeyer et al., 2018). For a 200 lb. patient that’s 146-182 grams each day. So, until the joint is back to full function, protein intake should be close to 1 gram per pound of body weight per day. Good thing that isn’t ounces! Reaching this protein goal day after day can get difficult, and expensive. Protein powders can make this goal easier to accomplish, and look at cheaper meat options like turkey and chuck roast to save money. The benefits of protein have been shown in the literature. One study by Dreyer et al. showed that supplementing with protein for 6 days leading up to surgery and then for 6 weeks following surgery decreased muscle atrophy by an average of 5% (Dreyer et al., 2018)! When protein, essential amino acids, and leucine are increased in the diet muscle disuse atrophy can decrease, and muscle function preserved (Howard et al., 2020). Eat your protein!
There are some other general dietary guidelines worth mentioning. First, regularly consuming fruit has been associated with faster rotator cuff recovery compared to those that did not regularly consume fruit (Liu et al., 2023). This could potentially be due to the antioxidant and vitamin C content in many fruits. Vitamin C plays a role in the formation of collagen, can improve the gliding resistance of tendons, and reduce fibrotic scar tissue at the site of injury (Fusini et al., 2016). Next, a lack of blood sugar control (diabetes), higher body fat percentage, and elevated body mass index (BMI) are risk factors for the occurrence and severity of rotator cuff tears (Gumina et al., 2014; Hong et al., 2020). Diabetes is also a significant risk factor for a rotator cuff retear (Hong et al., 2020). A reasonable conclusion from these studies is maintaining a “normal” BMI and improving both body fat percentage and blood sugar levels are good useful for improving surgical outcomes and recovery.
The final aspect of nutrition post-shoulder surgery worthy of discussion is supplements. The supplements studied in shoulder surgery cases look to assist the healing process by decreasing harmful inflammation, decreasing oxidative stress, increasing blood flow, and increasing collagen synthesis and quality (Oryan et al., 2011; Vitali et al., 2019; Yazar et al., 2022). The beneficial results (when seen) typically include improved joint pain, stiffness, range of motion, function, and repair (Fusini et al., 2016; Lugo et al., 2016; McGlory et al., 2019; Schön et al., 2022; Yu et al., 2020). Many studies even demonstrate that supplements can have an equal or greater benefit than non-steroidal anti-inflammatories (NSAIDs), but without the harmful side effects (Fusini et al., 2016; Henrotin et al., 2022; Vitali et al., 2019). Well-studied compounds in supplements that would likely benefit a shoulder surgery patient include: Glucosamine and chondroitin sulphate, methylsulfonlymethane (MSM), curcumin, Boswellia, vitamin C, and omega-3’s. Supplements that have less evidence, but may have benefit include: Bromelain, trypsin, undenatured collagen type II (UC II), and rutin. Supplements should always be, for lack of a better word, supplemental. Proper healing and recovery begin with the proper fuel; Consistent protein intake. Further, supplements are never miracle pills and can take weeks to have an effect. Those claiming otherwise are likely embellishing the benefits.
In conclusion, the opportunities patients have from a nutritional perspective are wide-reaching and impactful. From protein to supplements what is consumed during recovery from shoulder surgery has a direct impact on how the shoulder will recover, and how soon the patient can return to full function. If these recommendations seem complex or confusing don’t hesitate to find a nutrition expert to help you on your journey!
Post-Surgical Nutrition Recommendations:
- 3.63 grams of carbohydrate per pound per day for 3 days following surgery – focusing on complex carbohydrates (not super sugary stuff)
- 0.73 – 0.91 grams of protein per pound of body weight per day for the entire time the body repairing and strengthening
- Have 1 serving of fruit and vegetable each day for antioxidants
Post-Shoulder Surgery Supplemental Product Recommendations:
- Whey Protein Isolate of any kind – oral protein supplement to reach protein goal
- OmegAvail Hi-Po from Designs for Health – fish oil for anti-inflammatory effects
- Joint Support Nutrients from Thorne
- Arthrosoothe from Designs for Health
*You can get 20% off all of these supplements when you work with ZION Performance*
Sources:
Dreyer, H. C., Owen, E. C., Strycker, L. A., Smolkowski, K., Muyskens, J. B., Kirkpatrick, T. K., Christie, A. D., Kuehl, K. S., Lantz, B. A., Shah, S. N., Mohler, C. G., & Jewett, B. A. (2018). Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. JB & JS Open Access, 3(2), e0006. https://doi.org/10.2106/JBJS.OA.18.00006
Fusini, F., Bisicchia, S., Bottegoni, C., Gigante, A., Zanchini, F., & Busilacchi, A. (2016). Nutraceutical supplement in the management of tendinopathies: a systematic review. Muscles, Ligaments and Tendons Journal, 6(1), 48–57. https://doi.org/10.11138/mltj/2016.6.1.048
Gumina, S., Candela, V., Passaretti, D., Latino, G., Venditto, T., Mariani, L., & Santilli, V. (2014). The association between body fat and rotator cuff tear: the influence on rotator cuff tear sizes. Journal of Shoulder and Elbow Surgery, 23(11), 1669–1674. https://doi.org/10.1016/j.jse.2014.03.016
Henrotin, Y. E., Michlmayr, C., Rau, S. M., Quirke, A.-M., Bigoni, M., & Ueberall, M. A. (2022). Combination of Enzymes and Rutin to Manage Osteoarthritis Symptoms: Lessons from a Narrative Review of the Literature. Rheumatology and Therapy, 9(5), 1305–1327. https://doi.org/10.1007/s40744-022-00472-7
Hirsch, K. R., Wolfe, R. R., & Ferrando, A. A. (2021). Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. Nutrients, 13(5). https://doi.org/10.3390/nu13051675
Hong, C.-K., Chang, C.-J., Kuan, F.-C., Hsu, K.-L., Chen, Y., Chiang, C.-H., & Su, W.-R. (2020). Patients With Diabetes Mellitus Have a Higher Risk of Tendon Retear After Arthroscopic Rotator Cuff Repair: A Meta-analysis. Orthopaedic Journal of Sports Medicine, 8(11), 2325967120961406. https://doi.org/10.1177/2325967120961406
Howard, E. E., Pasiakos, S. M., Fussell, M. A., & Rodriguez, N. R. (2020). Skeletal Muscle Disuse Atrophy and the Rehabilitative Role of Protein in Recovery from Musculoskeletal Injury. Advances in Nutrition (Bethesda, Md.), 11(4), 989–1001. https://doi.org/10.1093/advances/nmaa015
Liu, J., Wang, W., Wang, Z., Wu, Q., Zhu, Y., Wu, W., & Zhou, Q. (2023). The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair. Nutrients, 15(21). https://doi.org/10.3390/nu15214587
Lugo, J. P., Saiyed, Z. M., & Lane, N. E. (2016). Efficacy and tolerability of an undenatured type II collagen supplement in modulating knee osteoarthritis symptoms: a multicenter randomized, double-blind, placebo-controlled study. Nutrition Journal, 15, 14. https://doi.org/10.1186/s12937-016-0130-8
McGlory, C., Calder, P. C., & Nunes, E. A. (2019). The Influence of Omega-3 Fatty Acids on Skeletal Muscle Protein Turnover in Health, Disuse, and Disease. Frontiers in Nutrition, 6, 144. https://doi.org/10.3389/fnut.2019.00144
Oryan, A., Moshiri, A., & Meimandiparizi, A.-H. (2011). Effects of sodium-hyaluronate and glucosamine-chondroitin sulfate on remodeling stage of tenotomized superficial digital flexor tendon in rabbits: a clinical, histopathological, ultrastructural, and biomechanical study. Connective Tissue Research, 52(4), 329–339. https://doi.org/10.3109/03008207.2010.531332
Schön, C., Knaub, K., Alt, W., Durkee, S., Saiyed, Z., & Juturu, V. (2022). UC-II Undenatured Type II Collagen for Knee Joint Flexibility: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Study. Journal of Integrative and Complementary Medicine, 28(6), 540–548. https://doi.org/10.1089/jicm.2021.0365
Vitali, M., Naim Rodriguez, N., Pironti, P., Drossinos, A., Di Carlo, G., Chawla, A., & Gianfranco, F. (2019). ESWT and nutraceutical supplementation (Tendisulfur Forte) vs ESWT-only in the treatment of lateral epicondylitis, Achilles tendinopathy, and rotator cuff tendinopathy: a comparative study. Journal of Drug Assessment, 8(1), 77–86. https://doi.org/10.1080/21556660.2019.1605370
Wischmeyer, P. E., Carli, F., Evans, D. C., Guilbert, S., Kozar, R., Pryor, A., Thiele, R. H., Everett, S., Grocott, M., Gan, T. J., Shaw, A. D., Thacker, J. K. M., & Miller, T. E. (2018). American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesthesia & Analgesia, 126(6), 1883–1895. https://doi.org/10.1213/ANE.0000000000002743
Yazar, İ., Sarıkaya, B., Koyuncu, İ., Gönel, A., Bozkurt, C., Sipahioğlu, S., Çetin, B. V., & Altay, M. A. (2022). Evaluation of oxidative stress in degenerative rotator cuff tears. Journal of Shoulder and Elbow Surgery, 31(10), e490–e497. https://doi.org/10.1016/j.jse.2022.03.011
Yu, G., Xiang, W., Zhang, T., Zeng, L., Yang, K., & Li, J. (2020). Effectiveness of Boswellia and Boswellia extract for osteoarthritis patients: a systematic review and meta-analysis. BMC Complementary Medicine and Therapies, 20(1), 225. https://doi.org/10.1186/s12906-020-02985-6
Zach Zenner is a former NFL running back who developed a passion for nutrition and optimization during his football career. Zach is now a certified health coach, nutrition expert, and partner of OrthoRehab through his company ZION Performance.