One of the most frequent concerns that comes up during surgical planning—particularly when we discuss the post-operative period—is pain management. Patients are understandably worried about pain medications, especially narcotics. This is a very valid concern.
Over the years, I have adjusted my post-operative recommendations with one primary goal in mind: minimizing the use of narcotics while still keeping patients comfortable and allowing them to recover effectively. To accomplish this, I use what is called a multimodal pain management regimen. This means we rely on multiple strategies—both physical measures and medications—rather than depending heavily on a single drug.
Swelling Control: The Foundation of Pain Control
Pain control actually begins before we even talk about medications.
One of the most important post-operative strategies—especially for lower extremity procedures—is elevation. Swelling creates pain. It also slows down rehabilitation because it interferes with joint motion and can even temporarily shut down muscle activation. Anything we can do to minimize swelling helps reduce pain and accelerates recovery.
Another critical component is icing.
In the past, patients commonly used ice packs directly from the freezer. However, these can be quite dangerous. They are extremely cold and should never be placed directly on the skin. They must be removed after about 20 minutes to allow the skin to recover. It is especially important never to fall asleep with a traditional ice pack on the skin, as frostbite can occur.
For these reasons, I now frequently recommend specialized cold-therapy devices. The two machines I most commonly use are Game Ready and NICE.
The latest versions of these machines do not require traditional ice. They function almost like a small refrigerator, cooling water internally and circulating it through a wrap. Because the temperature is controlled and not as extreme as freezer ice, the risk of skin injury or frostbite is significantly reduced.
In addition to cold therapy, these machines can also provide compression. I typically recommend starting compression a few days after surgery, once the incisional pain has begun to settle. When introduced at the right time, compression can be extremely helpful in controlling swelling. Reduced swelling not only improves comfort but also supports better motion and muscle activation during rehabilitation.
Many of these devices also have built-in programs that automatically cycle on and off every 20–30 minutes. As long as they are used appropriately, patients can safely run them for extended periods—even hours at a time—which I have found to be extremely helpful for managing both pain and swelling.
Multimodal Medication Strategy
In addition to physical measures such as elevation and icing, I use a multimodal medication approach.
One helpful strategy is to use several different medications at appropriate doses rather than relying on a high dose of a single medication. At first, this can feel overwhelming because it may involve taking multiple pills. However, this approach allows us to target pain through different mechanisms while minimizing side effects.
For example:
Acetaminophen (Tylenol) is tried and true. On its own, it is not particularly strong, but it has very few side effects—provided patients are careful not to exceed the maximum daily dose.
I often prescribe an anti-inflammatory medication. Frequently, I use Celecoxib, which is a selective anti-inflammatory that does not significantly interfere with bleeding—an important consideration in the post-operative setting.
I may also prescribe Gabapentin. Originally developed for neurological conditions, it has been found to help with nerve-related pain and can reduce the overall need for narcotics.
There is also a newer, non-narcotic pain medication that was recently FDA-approved called Journavx. We have started incorporating this into our pain protocols as well, although some insurance companies do not yet cover it.
Narcotics: Reserved as a Last Resort
For more painful procedures, I still prescribe Oxycodone, but in small quantities. I view narcotics as a medication of last resort, intended primarily for the first few days after surgery if pain is not adequately controlled by the other components of the regimen.
The goal is not to eliminate pain entirely—that is often unrealistic—but to make it manageable while minimizing risks and side effects.