There is great current interest by industry and by some surgeons in the use of "biologics" to enhance outcomes of rotator cuff surgery.
In our last post, Reza Jazayeri and Hafiz Kassam highlighted the growing recognition that perioperative nutritional optimization is a critical and modifiable factor in shoulder arthroplasty. Poorly nourished patients face double the risk of infection and revision, while even “healthy” patients often fail to meet the metabolic demands triggered by surgery. With elective arthroplasty, we have the opportunity to “prehabilitate” patients nutritionally, improving their resilience to the hypermetabolic-catabolic stress of surgery (Preoperative malnutrition is associated with increased risk of 90-day major medical complications and increased 2-year revision rates following total shoulder arthroplasty).
Reza and Hafiz prepared this post on the application of this approach to patients having cuff repair surgery.
Why rotator cuff repair is an even greater challenge
Unlike arthroplasty, rotator cuff repair (RCR) requires direct tendon-to-bone healing — a biologically demanding process with higher metabolic thresholds. Recent data underscore this reality.
Patients ≥65 undergoing RCR with a Geriatric Nutritional Risk Index <103 had a ~5.6× higher risk of retear compared to those ≥103, even after adjustment for confounders (Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair)
Notably, this >103 cutoff is higher than arthroplasty thresholds (>98), reflecting the greater biologic demand of tendon-to-bone healing.
Alarmingly, 66% of patients were not optimized, highlighting a major opportunity for intervention .
Nutrition education & dietary intervention
Meeting these elevated demands requires deliberate action. High-protein diets and patient education programs have been shown to be effective.
The winner of the 2019 Ranawat Award (Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor) showed that a high-protein/ anti-inflammatory diet can significantly reduce complication in joint arthroplasty and the 2023 Lui study demonstrated that structured nutrition education significantly improved recovery rates after rotator cuff repair (The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair).
Targeted supplementation: beyond diet
Diet alone is often insufficient to meet perioperative anabolic demands. Evidence supports the use of targeted supplementation, particularly in the immediate perioperative window spanning 1 week pre-op (priming phase) to 2 weeks post-op (hypermetabolic phase).(Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery)
Essential amino acids (EAAs/BCAAs) — accelerate collagen synthesis and blunt muscle breakdown. ,
Have been demonstrated in multiple RCTs in arthroplasty, trauma and spine to decrease complications, preserve muscle mass and improve functional recovery. (Amino Acid Supplementation May Help Prevent Muscle Wasting After Orthopedic Surgery) (The Role of Amino Acid Supplementation in Orthopaedic Surgery)Leucine = key EAA → activates mTOR, driving protein synthesis.
RCR (rat model): preserved supraspinatus mass, reduced atrophy
Sarcopenia (older adults, 5 g/meal): overcame anabolic resistance, boosted muscle protein synthesis
Impact: protects muscle in cuff healing + counters sarcopenia → stronger recovery potential. (Leucine attenuates muscle atrophy)
Creatine & HMB (Hydroxymethylbutyrate-a leucine metabolite) — both have been well studied in both sarcopenia and sports performance, shown to reduce muscle loss (anti-catabolic), enhance muscle protein synthesis, and improve strength are now being implemented in surgical recovery.
Conditionally essential amino acids (arginine, glutamine) — key substrates for collagen and bone synthesis, nitric oxide–mediated blood flow, and immune function. In a JBJS 2022 RCT of trauma patients, 2 weeks of postop supplementation led to significant reduction in complications, preservation of muscle mass and improved fracture union rates. (Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting )
Advances in nutritional science and basic research are increasingly translating into clinical practice. Emerging data now support targeted supplementation strategies that can be implemented in orthopedic surgery to improve outcomes by providing the key substrates needed to meet the hypermetabolic demands of the surgical stress response.
It is exciting that we now have clinically formulated supplementation protocols—combining these select nutrients supported by clinical studies that can be used to provide meaningful support for our patients. (Selected Nutrients to Oppose Muscle Disuse Following Arthroscopic Orthopedic Surgery)
Nutrition should no longer be neglected as a variable in surgical recovery. We now have the practical resources and evidence-based strategies to address this critical determinant of patient outcomes.
1. Protein: Foundation for Healing
Target intake: ~1.6–2.0 g/kg/day (≈0.7–0.9 g/lb/day), spread across meals.
For a 180 lb patient, that’s about 125–160 g/day.Why: Adequate protein supplies amino acids for collagen synthesis and muscle preservation.
Sources: Lean poultry, fish, eggs, Greek yogurt, whey or collagen peptides, tofu, beans.
2. Collagen & Vitamin C
Collagen peptides (10–15 g/day) may support tendon healing when paired with vitamin C.
Vitamin C (at least 75–100 mg) helps activate collagen cross-linking.
Practical tip: Take collagen powder with a glass of orange juice about an hour before rehab exercises.
3. Anti-Inflammatory Support
Omega-3 fatty acids (EPA + DHA, 1–3 g/day): May reduce inflammation and pain. Found in fatty fish (salmon, sardines) or fish oil.
Fruits and vegetables: Rich in antioxidants and polyphenols (berries, leafy greens, peppers).
Spices: Turmeric and ginger have modest anti-inflammatory effects.
4. Micronutrients Critical for Recovery
Vitamin D: Supports bone, muscle, and immune health. Ensure serum levels are adequate; supplement if low (often 1000–2000 IU/day).
Calcium: 1000–1200 mg/day from diet (dairy, fortified alternatives, greens).
Zinc: Important for wound healing (found in meat, shellfish, nuts).
Magnesium: Aids in muscle and nerve function (nuts, seeds, whole grains).
5. Energy Balance
Adequate calories are essential.
Too few: impaired wound and tendon healing.
Too many: risk of fat gain during limited activity.
Emphasize nutrient-dense foods rather than empty calories.
6. Timing Around Surgery
Pre-op (2–4 weeks before): Focus on optimizing protein intake, correcting vitamin D deficiency, and ensuring good hydration and fiber for bowel health.
Immediate post-op: Small, protein-rich meals; hydration; avoid constipation from pain medications.
Rehab phase: Time protein (and collagen + vitamin C) before therapy sessions to support muscle protein synthesis and tendon adaptation.
Bottom line:
Patients undergoing rotator cuff repair can optimize nutrition by ensuring high-quality protein, collagen + vitamin C, omega-3s, vitamin D, and overall nutrient adequacy, while avoiding undernutrition. The goal is to fuel healing, preserve muscle, and support tendon/bone recovery.
What goes in your mouth has a lot to do with how you heal
Oak Creek Wildlife Feeding Center
2022
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).
