Nutritional Considerations in Recovery from Orthopedic Injury or Surgery

By Dr. John R. Mishock, PT, DPT, DC

Nutritional interventions are not commonly used as the standard of care in recovery from injury or orthopedic surgery. However, it is well known that good nutrition is critical to optimizing health and wellness. The nutritional needs become amplified when individuals are healing and recovering from physical injury or orthopedic surgery. For those recovering from surgery, studies have shown that nutrition strategies can reduce hospital stay, increase wound healing time, reduce the risk of postsurgical infections, and enhance earlier functional return to activity. (Evans et al. Nutr Clin Pract., 2014)

How does our body heal following injury or surgery?
There are 4 phases of tissue healing (Hemostasis, inflammatory, proliferative, and maturation phases) independent of tissue damage. Immediately following musculoskeletal injury, the body starts the healing process through hemostasis (blood clotting) and inflammation (swelling). The inflammatory phase is essential for tissue repair, which lasts from a few hours to several days, depending on the injury’s nature. Following this initial period, inflammation can be counterproductive, delaying or inhibiting recovery. Healing progresses with the proliferative phase (rebuilding new tissue with collagen) and maturation phase (remodeling and strengthening tissue) of healing. Ingesting high-quality food and choice dietary supplements can accelerate the 4 phases of healing, enhancing the physical therapy and rehabilitation process.

What happens to muscle during inflammation and immobilization?
Beyond the inflammation, there is often immobilization or disuse following injury or post-surgical recovery. Inflammation reduces nerve input to muscle lending to muscle atrophy. Following injury or surgery, muscle begins to atrophy within 36 hours, and a significant loss of muscle mass occurs within 5 days. (Reich et al. J Appl Physiol, 2010) Muscle disuse atrophy (breakdown of muscle) and weakness occur at a rate of 0.5% per day, accompanied by 50% decline in muscle protein synthesis (muscle building). The muscle loss can be equal to 150–400 g of muscle tissue in just 1–2 weeks. (Wall B Clin. Endocrinol. Metab. 2013) One study demonstrated that 8% muscle loss can induce a 23% decline in muscle strength. (Wall et al. Acta Physiol. 2013) Early physical therapy and pain-free muscle contraction are critical to mitigating muscle atrophy and weakness.

Due to the significant catabolic (tissue breakdown) response, there is a considerable need for the right type of calories and protein to prevent the loss of lean body mass while complementing physical therapy and the rehabilitation process. Preventing muscle atrophy can significantly impact short and long-term recovery.

Is what you eat important during recovery from orthopedic injury?
During injury or post-surgical recovery, the basal metabolic rate (energy expended during rest) increases from 20% for minor injuries and surgeries to 100% for more severe bodily insults. (Demling et al., Eplasty. 2009) The bottom line is there is a need for more high-quality calories, avoiding ultra-processed foods with high amounts of chemicals, sugar, salt, and unhealthy fats. The athlete should eat 5-10 servings of colorful fruits and vegetables that provide phytochemicals and antioxidants that optimize cellular healing and recovery.

Why is protein important in recovery?
Due to the catabolic (breakdown) of muscle tissue, there is an elevated protein need of up to 80%. (Kerksick et al. Sports Nutr, 2017) Protein is needed to reduce muscle atrophy and build and repair healing tissue. Diets should emphasize fewer carbohydrates (approximately 40%) or a 2:1 carbohydrate to protein ratio (e.g., 260 g carbs and 130 g protein), which promotes positive changes in body composition. (Weigle et al. Am J Clin Nutr. 2005, Layman et al. Nutr Metab, 2009) Recommended protein (lean meats, poultry, and fish) is 1g/lb of body weight per day or minimally 20 to 40 g of total dietary protein per meal.

Should I take a protein supplement?
Supplementing protein is a simple and effective way to ensure adequate protein intake. Whey protein is considered the highest quality protein source, with more than 50% of the amino acid (building blocks of protein) coming from essential amino acids (amino acids the body cannot make). Whey protein is a fast-digesting protein source that rapidly increases essential amino acid availability in the blood. This makes it an ideal source of protein before and after exercise and rehabilitation. In contrast, casein protein (a milk-based protein) is slower to digest and should be ingested (30-40 g) 30 min before sleep to benefit overnight muscle protein synthesis. Plant-based protein could also be used, such as pea, soy, hemp, or rice.

Why do I need carbohydrates?
Carbohydrates are a key source of energy during rehabilitation. Their contribution to recovery is expansive, including roles in immunology, hormonal factors, and enzymatic processes. They also have a protein-sparing effect, reducing muscle protein breakdown. During recovery from an injury, approximately 4 to 6 g/lb or 55% of total calories. Avoid simple, ultra-processed carbohydrates such as cookies, cakes, doughnuts… Ingest complex carbohydrates, including whole grains, fruits, vegetables, and dairy. Carbohydrate needs increase as exercise activity increases.

How does fat in my diet impact my recovery?
Fat is a critical energy source for healing wounds and increasing cell growth and proliferation. Polyunsaturated and monounsaturated are essential for healing, especially omega-3 fatty acids, found in avocado, olive oil, fish, flax, nuts, and seeds. Omega-6 fatty acids (processed meats, fried and greasy foods, cakes and pastries, and ultra-processed foods) are pro-inflammatory and should be limited. Approximately 20-25% (0.8 to 2 g/lb per body weight per day) of calories should come from fat.

What dietary supplements should I take to enhance recovery?

Creatine monohydrate (Creatine):
Based on decades of research, creatine is the most effective supplement for improving intense exercise performance and enhancing muscle healing, repair, and hypertrophy. It also improves bone health, neuromuscular function, and brain health. A recommended dose of 20g (4 x 5 g daily) for five days, then 5g per day after.

Omega 3 fatty acids/Fish oil:
Omega 3 fatty acids have anti-inflammatory properties and may help control an exaggerated inflammatory response and reduce muscle loss. Omega-3 fatty acids regulate muscle protein synthesis enhancing the body’s utilization of amino acids for muscle building. (Calder et al. Br j Nutr., 2009). A recommended dose of 2000-4000 mg daily may reduce chronic inflammation and maximize protein synthesis. (Smith et al. Clin Sci, 2011)

Vitamin D:
Vitamin D is essential for calcium and bone regulation, but it also plays a role in innate and acquired immune regulation and skeletal muscle function (repair, regeneration, and hypertrophy). Vitamin D levels may experience impaired muscle repair, regeneration, and hypertrophy. Vitamin D is produced in the skin from approximately 20 minutes of sunlight daily. It is also found in fortified foods such as; cheese, yogurt, orange juice, and some cereals. A recommended dose of 2000-4000 IU per day. (Correia et al. Am J Clin Nutr, 2008)

Probiotics are the “good” bacteria that live in our gastrointestinal system (digestive system) that account for approximately 70% of the immune system. Because antibiotics are used following surgery, there can be a negative shift in the gastrointestinal flora, leading to changes in nutrient metabolism and immunity. The strands of lactobacillus acidophilus and Bifidobacterium longum have exhibited positive immune effects. (Maughan et al. Br J Sports Med, 2018) Probiotics can be found in yogurt or as dietary supplements. A recommended dose of >1010 colony-forming units. (Smith-Ryan et al. Jour of Athl Train. 2020)

Other vitamins and micronutrients:
Vitamin A, C, E, selenium, and zinc have a positive effect on wound healing and inflammatory control. Foods such as; kiwi, orange, strawberries, avocado, broccoli, carrots, spinach, seeds, almonds are excellent sources of these micronutrients. A multivitamin with an antioxidant formula could be used if these foods are not available. Turmeric (curcumin) is known for its anti‐inflammatory, antioxidant, and pain effects.

Is the timing of when I eat important to my physical therapy and recovery process?
Nutrient timing around physical therapy can help reduce muscle damage, enhance recovery, and improve body composition. Three to four hours before physical therapy, have 50-100 g of complex carbohydrate, 30-50g of protein, 15-20 g of fat. Fifteen to forty-five minutes before physical therapy have 25 g of protein (whey, pea, soy), 5 g of creatine monohydrate, and 2g of fish oil. Thirty minutes following physical therapy, have 25 g of protein (whey, pea, soy), 5 g of creatine monohydrate.


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