What is the best management approach for a patient with persistent hand swelling, pain, and new lumps after rotator cuff repair surgery, currently taking Paracetamol (acetaminophen) for pain management?

Management of Persistent Hand Swelling and Pain After Rotator Cuff Repair

The patient's symptoms strongly suggest complex regional pain syndrome (CRPS) following rotator cuff repair, which requires a multimodal approach including NSAIDs, physical therapy, and potential referral for specialized pain management beyond paracetamol alone.

Clinical Assessment and Diagnosis

• The patient's presentation of persistent hand swelling, new lumps, shooting pains, numbness, and tingling 8 months after rotator cuff repair is consistent with complex regional pain syndrome (CRPS), which occurs in approximately 19.4% of patients following arthroscopic rotator cuff repair 1
• Positive carpal tunnel tests and pain on thumb abduction resistance suggest peripheral nerve involvement, which is common in post-surgical CRPS 1
• The normal MRI findings of the repaired rotator cuff with features of adhesive capsulitis support a diagnosis of secondary complications rather than repair failure 1

Pain Management Recommendations

First-line Pharmacological Treatment

• Oral NSAIDs should be added to the current paracetamol regimen as they have demonstrated superior efficacy compared to paracetamol alone for rotator cuff-related pain 2, 3
• NSAIDs have been shown to reduce opioid requirements and decrease pain levels in the post-rotator cuff repair period without increasing risk of tendon re-tear 3
• NSAIDs should be used at the lowest effective dose and for the shortest duration, with periodic re-evaluation of the patient's response 4

Topical Treatments

• Topical NSAIDs should be considered as they are effective and safe treatments for hand pain, especially when only a few joints are affected 4
• Topical capsaicin may be considered as an alternative topical treatment, though it is associated with frequent local adverse effects (burning and stinging sensation) 4

Non-pharmacological Interventions

• Local application of heat (paraffin wax, hot packs) before exercise can provide symptomatic relief 4
• A structured exercise regimen involving both range of motion and strengthening exercises should be implemented, focusing on gentle progression to avoid exacerbating pain 4
• Splints for the thumb and hand may be beneficial to prevent further deformity and provide pain relief 4
• Transcutaneous electrical nerve stimulation (TENS) has shown benefit for post-rotator cuff repair pain and should be considered as it reduces pain scores and opioid consumption 4

Comprehensive Management Plan

1. Immediate interventions:

   • Add an NSAID to the current paracetamol regimen 4
   • Consider topical NSAID application to the affected hand 4
   • Implement local heat application before gentle exercises 4

2. Rehabilitation approach:

   • Restart physiotherapy with modified protocols that accommodate pain levels 4
   • Consider a splint for the thumb and wrist to reduce pain during activities 4
   • Implement TENS therapy as an adjunct to medication 4

3. Advanced interventions if no improvement:

   • Consider referral for specialized pain management for potential CRPS 1
   • Evaluate for intra-articular corticosteroid injection for thumb base pain 4
   • Consider comprehensive enhanced recovery protocols that include multimodal analgesia 5

Important Considerations and Pitfalls

• Paracetamol alone may be insufficient for managing complex post-surgical pain; evidence suggests ibuprofen provides better improvement in pain severity and functional activity compared to acetaminophen for rotator cuff-related pain 2
• Avoid prolonged immobilization as it may worsen stiffness and adhesive capsulitis noted on the MRI 4
• The presence of hand symptoms 8 months post-surgery is concerning for CRPS, which requires early recognition and aggressive management to prevent long-term disability 1
• An opioid-free or opioid-minimizing approach should be prioritized, as studies show that with appropriate multimodal pain management, the majority of patients can manage rotator cuff repair pain without opioids 6

Follow-up Plan

• Re-evaluate in 2-4 weeks after implementing the above recommendations
• If symptoms persist or worsen, consider referral to a pain specialist for evaluation of CRPS and potential interventional procedures 1
• Monitor for adverse effects of NSAIDs, particularly in this 64-year-old patient 4