Moderate strength evidence supports the use of multimodal programs or non-opioid individual modalities to provide added benefit for postoperative pain management following rotator cuff repair.

Management of Rotator Cuff Injuries
A number of articles, of both high and moderate quality (Bain, G. I. 2001, Banerjee, S. S. 2008, Bang, S. R. 2010, Behr, A. 2012, Borgeat, A. 2010, Ciccone, Ii W. J. 2008, Clendenen, S. R. 2010, Coghlan, Ja 2009, Culebras, X 2001, Desmet, M. 2013, Desmet, M. 2015, Faria-Silva, R. 2016, Fredrickson, M. J. 2011, Hadzic, A. 2005, Hartrick, Ct 2012, Hoe-Hansen, C. 1999, Kim, Jy 2016, Klein, Sm 2000, Ko, S. H. 2017, Kraeutler, M. J. 2015, Lee, Ar 2012, Lee, Hj 2015, Lee, J. J. 2017, Lee, J-H 2011, Lee, Jj 2014, Lee, Jj 2015, Lin, Y. H. 2015, Liu, X. N. 2017, Mahure, S. A. 2017, Malik, T. 2016, Merivirta, R. 2012, Oh, J. H. 2009, Osti, L. 2015, Park, J. Y. 2016, Schwartzberg, Rs 2013, Shin, H. J. 2016, Sun, Z. 2018, Takada, M. 2009, Thackeray, E. M. 2013, Watanabe, K. 2016, Yamakado, K. 2014, Yun, M. J. 2012), addressed a variety of individual and multimodal pain management modalities. Based on this literature,  it is clear that any one of a variety of pain management non-opioid medications or modalities has a positive impact on patient pain control in the post-operative period. It should be noted that most of the literature validated a singular approach against a singular control group and did not perform a direct comparison against all other options, nor were indirect comparisons of the literature review findings using network meta-analysis statistically feasible. . This led to the inability to rank-order pain management modalities in a “most effective” to “least effective” manner. Because of this, the guideline development group framed the pain management recommendations as a more general list of pain management modalities, both singular and multimodal, which exhibited comparative efficacy, as compared to their within-study comparisons.

Defining multimodal therapy as using multiple but different modalities of pain management therapies simultaneously in the same post-operative period, the study group was able to arrive at the second multimodal pain management recommendation (recommendation B). The evidence assessing multimodal pain management supported the use of multimodal pain management treatment compared to a single modal approach. In particular, four high quality studies (Jo, 2014; Perdreau, 2015; Syed, 2018; Han, 2013) support the concept of multimodal therapy although the specifics of which mix of options is the most optimal requires further research.

Risks and Harms of Implementing this Recommendation
While the study group’s conclusion that there are various successful options of both singular and multimodal post-operative pain management has moderate strength of evidence, the analysis did not include a risk benefit comparison of options.  Each individual medication or modality carries its own inherent risks and benefits which should be taken into account by the health care provider prescribing the intervention.

Future Research
The analysis of this question has exposed the need for future research particular into the pros and cons of each medication, modality, and multimodal program as they are compared to each other.  The collective data and indirect comparisons from the high quality articles cited in this recommendation could be used to perform a network meta-analysis, providing valuable information to best guide future management.
  1. Bain, G. I., Rudkin, G., Comley, A. S., Heptinstall, R. J., Chittleborough, M. Digitally assisted acromioplasty: The effect of interscalene block on this new surgical technique. Arthroscopy 2001; 1: 44-49
  2. Banerjee, S. S., Pulido, P., Adelson, W. S., Fronek, J., Hoenecke, H. R. The efficacy of continuous bupivacaine infiltration following arthroscopic rotator cuff repair. Arthroscopy 2008; 4: 397-402
  3. Bang, S. R., Yu, S. K., Kim, T. H. Can gabapentin help reduce postoperative pain in arthroscopic rotator cuff repair? A prospective, randomized, double-blind study. Arthroscopy 2010; 9: S106-11
  4. Behr, A., Freo, U., Ori, C., Westermann, B., Alemanno, F. Buprenorphine added to levobupivacaine enhances postoperative analgesia of middle interscalene brachial plexus block. Journal of Anesthesia 2012; 5: 746-51
  5. Borgeat, A., Aguirre, J., Marquardt, M., Mrdjen, J., Blumenthal, S. Continuous interscalene analgesia with ropivacaine 0.2% versus ropivacaine 0.3% after open rotator cuff repair: the effects on postoperative analgesia and motor function. Anesthesia & Analgesia 2010; 6: 1543-7
  6. Ciccone, Ii W. J., Busey, T. D., Weinstein, D. M., Walden, D. L., Elias, J. J. Assessment of Pain Relief Provided by Interscalene Regional Block and Infusion Pump After Arthroscopic Shoulder Surgery. Arthroscopy - Journal of Arthroscopic and Related Surgery 2008; 1: 14-19
  7. Clendenen, S. R., Rajendran, S., Kopacz, D. J., Greengrass, R. A., Robards, C. B., Weinstein, D. M., Brodersen, M. P., Ortiguera, C. J., Crook, J., Logvinov, I. I. Pregabalin as an adjunct to a multimodal analgesic regimen to achieve opioid sparing in arthroscopic rotator cuff repair. Jurnalul Roman de Anestezie Terapie Intensiva/Romanian Journal of Anaesthesia and Intensive Care 2010; 1: 5-10
  8. Coghlan, Ja, Forbes, A, McKenzie, D, Bell, Sn, Buchbinder, R Efficacy of subacromial ropivacaine infusion for rotator cuff surgery. A randomized trial. Journal of bone and joint surgery. American volume 2009; 7: 1558-1567
  9. Culebras, X, Gessel, E, Hoffmeyer, P, Gamulin, Z Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes. Anesthesia and Analgesia 2001; 1: 199-204
  10. Desmet, M., Braems, H., Reynvoet, M., Plasschaert, S., Van Cauwelaert, J., Pottel, H., Carlier, S., Missant, C., Van De Velde, M. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: A prospective, randomized, placebo-controlled study. British Journal of Anaesthesia 2013; 3: 445-452
  11. Faria-Silva, R., de Rezende, D. C., Ribeiro, J. M., Gomes, T. H., Oliveira, B. A., Pereira, F. M., de Almeida Filho, I. A., de Carvalho Junior, A. E. Association of clonidine and ropivacaine in brachial plexus block for shoulder arthroscopy. Brazilian Journal of Anesthesiology 2016; 4: 335-40
  12. Fredrickson, M. J., Abeysekera, A., Price, D. J., Wong, A. C. Patient-initiated mandatory boluses for ambulatory continuous interscalene analgesia: an effective strategy for optimizing analgesia and minimizing side-effects. British Journal of Anaesthesia 2011; 2: 239-45
  13. Hadzic, A., Williams, B. A., Karaca, P. E., Hobeika, P., Unis, G., Dermksian, J., Yufa, M., Thys, D. M., Santos, A. C. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005; 5: 1001-7
  14. Han, Ss, Lee, Yh, Oh, Jh, Aminzai, S, Kim, Sh Randomized, controlled trial of multimodal shoulder injection or intravenous patient-controlled analgesia after arthroscopic rotator cuff repair. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2013; 12: 2877-83
  15. Hartrick, Ct, Tang, Y-S, Siwek, D, Murray, R, Hunstad, D, Smith, G The effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery: A double-blind, randomized controlled trial. BMC Anesthesiology 2012; 0:
  16. Hoe-Hansen, C., Norlin, R. The clinical effect of ketoprofen after arthroscopic subacromial decompression: A randomized double-blind prospective study. Arthroscopy 1999; 3: 249-252
  17. Jo, Ch, Shin, Js, Huh, J Multimodal analgesia for arthroscopic rotator cuff repair: a randomized, placebo-controlled, double-blind trial. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2014; 3: 315-22
  18. Kim, Jy, Song, Ks, Kim, Wj, Park, Yh, Kang, H, Woo, Yc, Shin, Hy Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy 2016; 3: 931-939
  19. Klein, Sm, Grant, Sa, Greengrass, Ra, Nielsen, Kc, Speer, Kp, White, W, Warner, Ds, Steele, Sm Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesthesia and Analgesia 2000; 6: 1473-1478
  20. Ko, S. H., Cho, S. D., Lee, C. C., Choi, J. K., Kim, H. W., Park, S. J., Bae, M. H., Cha, J. R. Comparison of Arthroscopically Guided Suprascapular Nerve Block and Blinded Axillary Nerve Block vs. Blinded Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Clinics in Orthopedic Surgery 2017; 3: 340-347
  21. Kraeutler, M. J., Reynolds, K. A., Long, C., McCarty, E. C. Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression. Journal of Shoulder & Elbow Surgery 2015; 6: 854-9
  22. Lee, Ar, Yi, Hw, Chung, Is, Ko, Js, Ahn, Hj, Gwak, Ms, Choi, Dh, Choi, Sj Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block. Canadian journal of anaesthesia = Journal canadien d'anesthésie 2012; 1: 21-7
  23. Lee, Hj, Kim, Ys, Park, I, Ha, Dh, Lee, Jh Administration of analgesics after rotator cuff repair: a prospective clinical trial comparing glenohumeral, subacromial, and a combination of glenohumeral and subacromial injections. Journal of Shoulder and Elbow Surgery 2015; 5: 663-8
  24. Lee, J-H, Cho, S-H, Kim, S-H, Chae, W-S, Jin, H-C, Lee, J-S, Kim, Y-I Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. Canadian Journal of Anesthesia 2011; 11: 1001-6
  25. Lee, J. J., Hwang, J. T., Kim, D. Y., Lee, S. S., Hwang, S. M., Lee, N. R., Kwak, B. C. Effects of arthroscopy-guided suprascapular nerve block combined with ultrasound-guided interscalene brachial plexus block for arthroscopic rotator cuff repair: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy 2017; 7: 2121-2128
  26. Lee, Jj, Kim, Dy, Hwang, Jt, Lee, Ss, Hwang, Sm, Kim, Gh, Jo, Yg Effect of ultrasonographically guided axillary nerve block combined with suprascapular nerve block in arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2014; 8: 906-14
  27. Lee, Jj, Yoo, Ys, Hwang, Jt, Kim, Dy, Jeon, Sj, Hwang, Sm, Jang, Js Efficacy of direct arthroscopy-guided suprascapular nerve block after arthroscopic rotator cuff repair: a prospective randomized study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2015; 2: 562-6
  28. Lin, Y. H., Chiou, H. J., Wang, H. K., Lai, Y. C., Chou, Y. H., Chang, C. Y. Comparison of the analgesic effect of xylocaine only with xylocaine and corticosteroid injection after ultrasonographically-guided percutaneous treatment for rotator cuff calcific tendonosis. Journal of the Chinese Medical Association: JCMA 2015; 2: 127-32
  29. Liu, X. N., Noh, Y. M., Yang, C. J., Kim, J. U., Chung, M. H., Noh, K. C. Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Arthroscopy 2017; 5: 918-926
  30. Mahure, S. A., Rokito, A. S., Kwon, Y. W. Transcutaneous electrical nerve stimulation for postoperative pain relief after arthroscopic rotator cuff repair: a prospective double-blinded randomized trial. Journal of Shoulder & Elbow Surgery 2017; 9: 1508-1513
  31. Malik, T., Mass, D., Cohn, S. Postoperative Analgesia in a Prolonged Continuous Interscalene Block Versus Single-Shot Block in Outpatient Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study. Arthroscopy 2016; 8: 1544-1550.e1
  32. Merivirta, R., Kuusniemi, K. S., Aantaa, R., Hurme, S. A., Aarimaa, V., Leino, K. A. The analgesic effect of continuous subacromial bupivacaine infusion after arthroscopic shoulder surgery: a randomized controlled trial. Acta Anaesthesiologica Scandinavica 2012; 2: 210-6
  33. Oh, J. H., Rhee, K. Y., Kim, S. H., Lee, P. B., Lee, J. W., Lee, S. J. Comparison of analgesic efficacy between single interscalene block combined with a continuous intra-bursal infusion of ropivacaine and continuous interscalene block after arthroscopic rotator cuff repair. Clinics in Orthopedic Surgery 2009; 1: 48-53
  34. Osti, L., Buono, A. D., Maffulli, N. Pulsed electromagnetic fields after rotator cuff repair: a randomized controlled study. Orthopedics 2015; 3: e223-8
  35. Park, J. Y., Bang, J. Y., Oh, K. S. Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery. Knee Surgery, Sports Traumatology, Arthroscopy 2016; 12: 3877-3883
  36. Perdreau, A., Joudet, T. Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair. Orthopaedics & traumatology, surgery & research 2015; 8: S337-45
  37. Schwartzberg, Rs, Reuss, Bl, Rust, R Efficacy of continuous subacromial bupivacaine infusion for pain control after arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery 2013; 10: 1320-4
  38. Shin, H. J., Na, H. S., Oh, A. Y., Hwang, J. W., Kim, B. G., Park, H. P., Jeon, Y. T., Min, S. W., Ryu, J. H. A prospective, randomized and controlled study of interscalene brachial plexus block for arthroscopic shoulder surgery:A comparison of C5 and conventional approach, a CONSORT-compliant article. Medicine (United States) 2016; 37:
  39. Sun, Z., Wang, B., Niu, Z., Shan, S. Dexmedetomidine improves continuous interscalene brachial plexus block in patients after arthroscopic rotator cuff repair. International journal of clinical and experimental medicine 2018; 4: 4168-4172
  40. Syed, U. A. M., Aleem, A. W., Wowkanech, C., Weekes, D., Freedman, M., Tjoumakaris, F., Abboud, J. A., Austin, L. S. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. Journal of Shoulder and Elbow Surgery 2018; 6: 962-967
  41. Takada, M., Fukusaki, M., Terao, Y., Yamashita, K., Takada, M., Ando, Y., Sumikawa, K. Postoperative analgesic effect of preoperative intravenous flurbiprofen in arthroscopic rotator cuff repair. Journal of Anesthesia 2009; 4: 500-3
  42. Thackeray, E. M., Swenson, J. D., Gertsch, M. C., Phillips, K. M., Steele, J. W., Burks, R. T., Tashjian, R. Z., Greis, P. E. Diaphragm function after interscalene brachial plexus block: a double-blind, randomized comparison of 0.25% and 0.125% bupivacaine. Journal of Shoulder & Elbow Surgery 2013; 3: 381-6
  43. Watanabe, K., Tokumine, J., Yorozu, T., Moriyama, K., Sakamoto, H., Inoue, T. Particulate-steroid betamethasone added to ropivacaine in interscalene brachial plexus block for arthroscopic rotator cuff repair improves postoperative analgesia. BMC Anesthesiology 2016; 1: 84
  44. Yamakado, K. Efficacy of arthroscopically placed pain catheter adjacent to the suprascapular nerve (continuous arthroscopically assisted suprascapular nerve block) following arthroscopic rotator-cuff repair. Open Access Journal of Sports Medicine 2014; 0: 129-36
  45. Yun, M. J., Oh, J. H., Yoon, J. P., Park, S. H., Hwang, J. W., Kil, H. Y. Subacromial patient-controlled analgesia with ropivacaine provides effective pain control after arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy 2012; 10: 1971-7