Pain Management Strategies in Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty (rTSA) is a commonly utilized procedure for rotator cuff arthropathy, irreparable rotator cuff tears, and complex proximal humerus fractures. Although rTSA significantly improves long-term pain and function, postoperative pain remains common and is closely associated with increased opioid consumption, prolonged hospitalization, delayed recovery, and reduced patient satisfaction. Within the modern context of the opioid epidemic, optimizing pain control while minimizing narcotic usage is essential. This review summarizes recent evidence on pain management strategies for rTSAs, with emphasis on regional anesthesia techniques, multimodal analgesia, periarticular injections, Enhanced Recovery After Surgery (ERAS) protocols, and patient-specific factors influencing pain outcomes.

Recent studies demonstrate that interscalene nerve blocks provide effective early postoperative analgesia and reduce opioid requirements, though complications such as phrenic nerve paralysis and rebound pain persist. Alternative regional techniques, including combined suprascapular and axillary nerve blocks, could offer comparable analgesia with reduced adverse risks in select patients. Multimodal analgesia protocols consistently decrease opioid consumption, improve early pain scores, and shorten hospital length of stay, although outcomes vary based on regimen composition. Periarticular injections further enhance analgesia when used alone or as adjuncts to regional anesthesia. ERAS protocols are associated with improved postoperative outcomes in hip and knee arthroplasty, but evidence of their application remains limited in rTSA. Patient-level factors, including preoperative opioid use, mental health conditions, and comorbidity burden, strongly predict postoperative pain and prolonged opioid dependence. Postoperative pain management after rTSA has evolved toward a multimodal, patient-centered approach integrating approaches such as regional anesthesia, non-opioid multimodal analgesia, and periarticular injections. Despite recent advances, optimal regional anesthetic techniques and the implementation of standardized ERAS protocols in rTSA remain areas of necessary future investigation.