Palm Beach Shoulder Service

Conditions

Rotator cuff tears Frozen shoulder Shoulder replacement Reverse shoulder replacement Revision shoulder surgery Broken shoulders Dislocation and instability All conditions

The practice

What I do differently About Dr. Routman Your visit Second opinion Research and publications Supporting research For referring physicians

After surgery

Instructions After arthroscopy After a replacement

Elsewhere

Howard D. Routman, DO

The practice

What I do differently

Most shoulder websites say the same things. This page is about the parts of my practice that are not standard, and why.

Call (561) 627-8500 Common questions

Rotator cuff repair without the pain it is known for

Rotator cuff repair has a reputation for being very painful. In my experience, with the right protocol, that is not what patients go through. The protocol gets ahead of the pain instead of chasing it:

  • Before surgery: gabapentin, Celebrex and Tylenol, so the medicines are already working when the operation starts.
  • During surgery: a nerve block at the base of the neck, using a long-acting form of numbing medicine, if the anesthesiologist agrees you are a candidate.
  • After surgery: ibuprofen, gabapentin and Tylenol on a schedule, so the pain does not get a chance to build.
  • For breakthrough pain: a small prescription of tramadol. In my experience, most patients take one or two tablets in total.

Because the pain is controlled before it builds, most patients never need strong opioids like oxycodone or hydrocodone. If you do need more, call the office and the plan is adjusted to you.

This did not start with rotator cuff repair. In 2017 I published results from my own shoulder replacement patients: adding a long-acting numbing medicine and a single dose of steroid during surgery shortened the hospital stay and cut both narcotic use and pain.1 A later 100-patient randomized trial of rotator cuff repair, at three centers including mine, found that with a multimodal plan most patients needed 15 or fewer oxycodone tablets over two weeks, and that patients who got the long-acting block had less pain in the first two days.2

Tell us before surgery if you take medicine for depression or anxiety, or have had seizures. Tramadol can interact with these, and the plan can be changed.

Before surgery, I plan your new shoulder on a 3D model built from a CT scan of your own shoulder. During surgery, a navigation system tracks my instruments in real time and shows me where the implant is going compared with that plan.

In January 2026 I performed the first cases with the newest version of this system.

I am a design surgeon and paid consultant for Advita, previously Exactech, which makes the Equinoxe shoulder and the GPS navigation system. My industry relationships are listed in full on my CV.

Recovery after a reverse replacement, usually at home

Most of my reverse shoulder replacement patients do not need formal outpatient physical therapy. You get a home program to do on your own. If you want therapy, or need it, I write the prescription.

All-arthroscopic rotator cuff repair since 2001

I have repaired rotator cuffs through small incisions with a camera inside the joint, without opening the shoulder, since 2001.

The first reverse shoulder replacement in South Florida

In July 2003, as part of an FDA investigational device study, I performed the first reverse shoulder replacement done in South Florida.

References

  1. Routman HD, Israel LR, Moor MA, Boltuch AD. Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26:641–647. doi:10.1016/j.jse.2016.09.033
  2. Mandava NK, Sethi PM, Routman HD, Liddy N, Haidamous G, Denard PJ. Opioid requirement after rotator cuff repair is low with a multimodal approach to pain. J Shoulder Elbow Surg. 2021;30:e399–e408. doi:10.1016/j.jse.2020.09.032

Common questions

Is rotator cuff repair as painful as people say?

In my experience, no. The pain this operation is known for is handled before it builds: a long-acting nerve block, and medicines started before surgery and taken on a schedule after. Most patients never need strong opioids like oxycodone.

Why don't most patients need oxycodone?

Because the pain is controlled before it builds, not chased after it starts. A small prescription of tramadol is there for breakthrough pain. In my experience, most patients take one or two tablets in total.

What if I need more pain medicine?

Call the office. The plan is adjusted to you. The aim is that you are comfortable, not that you take as little as possible.

Is tramadol an opioid?

Yes, a milder one. Because the rest of the protocol controls most of the pain, tramadol is there for breakthrough pain only, and most patients need very little of it.

What medicines are in the pain plan?

Before surgery: gabapentin, Celebrex and Tylenol. After surgery: ibuprofen, gabapentin and Tylenol on a schedule, with tramadol only if needed. The exact doses are on the sheet you get before surgery.

What is the nerve block?

Before surgery, the anesthesiologist numbs the nerves that run from the neck to the shoulder and arm. I use a long-acting form of numbing medicine. The anesthesiologist decides whether you are a candidate. Expect the arm to feel dead and numb for the first few days. That is normal.

What if I take medicine for depression or anxiety, or have had seizures?

Tell us before surgery. Tramadol can interact with some medicines for depression and anxiety, and it is not right for everyone with a history of seizures. The plan can be changed.

What is GPS navigation in shoulder replacement?

Before surgery I plan your new shoulder on a 3D model built from a CT scan of your own shoulder. During surgery, a navigation system tracks my instruments in real time and shows where the implant is going compared with that plan.

Will I need a CT scan before shoulder replacement?

Usually, yes. The plan the navigation system follows is built from it.

Is Dr. Routman paid by the company that makes the navigation system?

Yes. I am a design surgeon and paid consultant for Advita, previously Exactech, which makes the Equinoxe shoulder and the GPS navigation system. My industry relationships are listed in full on my CV.

Will I need physical therapy after a reverse shoulder replacement?

Most of my reverse patients do not need formal outpatient therapy. You get a home program to do on your own. If you want therapy, or need it, I write the prescription.

How long has Dr. Routman done all-arthroscopic rotator cuff repair?

Since 2001. The tendon is repaired through small incisions with a camera inside the joint, without opening the shoulder.

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