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| HOT TOPICS |
Non-steroidal anti-inflammatory drugs in sports: Take them or leave them?
Non-steroidal anti-inflammatory drugs, (NSAIDs), are a class of medications with
analagesic (anti-pain), antipyretic (anti-fever) and anti-inflammatory effects. The most
well known drugs of this class are aspirin, ibuprofen, motrin, advil, alleve, and naprosyn.
NSAIDs inhibit tissue inflammation by repressing cyclooxygenase (COX) activity, with a
reduction in the synthesis of pro-inflammatory prostaglandins. Acetominophen (tylenol)
another well known analgesic and antipyretic is NOT an NSAID.
Since 1829, with the isolation of salicylic acid from willow bark, NSAIDs have become an
integral treatment of pain (at low doses) and inflammation (at higher doses). NSAIDs
are available by prescription and over-the-counter. Readily available and prescribed
often, they have been accepted as a popular treatment of athletic injuries. They were
the most common medicine used by the Canadian Olympic team during the past two
games (and that can be an entire topic in itself). But do they really treat injuries? Or
may they be doing harm?
In acute ligament injuries, such as an ankle sprain, the healing progresses through 3
stages: (1) an initial inflammatory phase to remove damaged tissue; (2) a proliferative
phase during which new collagen is formed; and (3) a remodeling phase, which may
continue for 1 year.
In a 1997 randomized controlled study of army recruits with ankle sprains (ligament
tear), subjects treated with NSAID (Piroxicam) had less pain and were able to resume
training more quickly than the placebo group. At the time of the initial injury, ankle laxity
in the NSAID group and the control group were exactly the same. At days three, seven,
and fourteen, however, the NSAID treated group demonstrated greater ankle laxity
(ligament looseness or weakness). This difference may have resulted from a direct
effect of the NSAID impeding nature’s inflammatory phase of healing or could have
occurred indirectly by its analgesic (anti-pain) effect, allowing the athlete to return to
play prior to complete healing. Either reason, laxity in a joint often leads to recurrent
injury, more severe injury, and over time arthritis. (Slatyer, M. A randomized controlled
trial of Piroxicam in the management of acute ankle sprain in Australian regular army
recruits. American Journal of Sports Medicine. 1997; 25:544-553.)
One of the biggest myths and errors in sports medicine has been the erroneous blame
and classification of tendon injuries as ‘tendonitis’. One of the key marks of
tendonopathy is absence of any inflammatory cells in the painful tendon. Disorganized,
haphazard healing, with frayed and disrupted collagen fibrils are the key features of
what should be termed ‘tendinosis’. Our misunderstanding of ‘tendonitis’ is so
engrained in parents, coaches, and athletes, NSAID use has become a rapid reflex
when an athlete complains of musculoskeletal pain.
Ironically, the pain relieving effect of NSAIDs allow athletes to mask symptoms, which
may further damage the injured tendon and delay definitive healing. Recent studies on
rats with acute tendon injuries showed that NSAID administration caused loss of tensile
force (strength) in tendons.
In bony injuries, an initial inflammatory response leads to a series of biochemical
processes that ultimately lead to fracture repair. Prostaglandins (PGs) play a major role
in bone formation and bone repair. NSAIDs block the formation of PGs and several well-
designed studies in animals have shown NSAIDs to negatively impact fracture healing.
Studies on humans have associated NSAID use with delayed healing in tibia fractures
and increased risk for nonunion in long bone fractures. Researchers have also found
delayed union and nonunion in fractures requiring surgical fixation. One noted study
found that patients given Ketorolac after spinal surgery demonstrated a significant
increase risk of nonunion.
Summary:
In spite of the ubiquitous use of NSAIDs in sports injuries there is no scientific
evidence as to their effectiveness in the treatment of sports injuries and
substantial evidence that they actually hinder healing.
A child or adolescent should NEVER be given an NSAID to treat pain so that they can
participate in sports. NSAIDs are not recommended in the treatment of completed
fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle
injury. An alternative pain medication should be used in the setting of fractures and
acute ligament, muscle, or tendon injury. NSAIDs have no role in the treatment of
chronic tendon injury, as inflammation is NOT a component of such an injury.
NSAIDs should NOT be taken by athletes who are engaged in contact sports that put
them at major risk of traumatic injuries, as these drugs have the potential to seriously
exacerbate post-traumatic bleeding. NSAIDs should NOT be taken by endurance
athletes prior to participation as serious kidney and metabolic complications may arise
in the setting of dehydration or underlying medical condition.
If you are injured, seek care from a qualified SPORTS MEDICINE physician, as specific injuries
require specific treatments, some do better with rest, some better with activity, some better with
immobilization, some better with movement, some better with strengthening, some better with
stretching. Most importantly, the sports medicine physician will be able to analyze your technique and
training, the actual cause of your injury and then treat accordingly.
References:
Clinical Journal of Sport Medicine: Volume 16(2) March 2006 pp 170-174
Practical Management: Nonsteroidal Antiinflammatory Drug (NSAID) Use in Athletic Injuries
Non-steroidal anti-inflammatory drugs, (NSAIDs), are a class of medications with
analagesic (anti-pain), antipyretic (anti-fever) and anti-inflammatory effects. The most
well known drugs of this class are aspirin, ibuprofen, motrin, advil, alleve, and naprosyn.
NSAIDs inhibit tissue inflammation by repressing cyclooxygenase (COX) activity, with a
reduction in the synthesis of pro-inflammatory prostaglandins. Acetominophen (tylenol)
another well known analgesic and antipyretic is NOT an NSAID.
Since 1829, with the isolation of salicylic acid from willow bark, NSAIDs have become an
integral treatment of pain (at low doses) and inflammation (at higher doses). NSAIDs
are available by prescription and over-the-counter. Readily available and prescribed
often, they have been accepted as a popular treatment of athletic injuries. They were
the most common medicine used by the Canadian Olympic team during the past two
games (and that can be an entire topic in itself). But do they really treat injuries? Or
may they be doing harm?
In acute ligament injuries, such as an ankle sprain, the healing progresses through 3
stages: (1) an initial inflammatory phase to remove damaged tissue; (2) a proliferative
phase during which new collagen is formed; and (3) a remodeling phase, which may
continue for 1 year.
In a 1997 randomized controlled study of army recruits with ankle sprains (ligament
tear), subjects treated with NSAID (Piroxicam) had less pain and were able to resume
training more quickly than the placebo group. At the time of the initial injury, ankle laxity
in the NSAID group and the control group were exactly the same. At days three, seven,
and fourteen, however, the NSAID treated group demonstrated greater ankle laxity
(ligament looseness or weakness). This difference may have resulted from a direct
effect of the NSAID impeding nature’s inflammatory phase of healing or could have
occurred indirectly by its analgesic (anti-pain) effect, allowing the athlete to return to
play prior to complete healing. Either reason, laxity in a joint often leads to recurrent
injury, more severe injury, and over time arthritis. (Slatyer, M. A randomized controlled
trial of Piroxicam in the management of acute ankle sprain in Australian regular army
recruits. American Journal of Sports Medicine. 1997; 25:544-553.)
One of the biggest myths and errors in sports medicine has been the erroneous blame
and classification of tendon injuries as ‘tendonitis’. One of the key marks of
tendonopathy is absence of any inflammatory cells in the painful tendon. Disorganized,
haphazard healing, with frayed and disrupted collagen fibrils are the key features of
what should be termed ‘tendinosis’. Our misunderstanding of ‘tendonitis’ is so
engrained in parents, coaches, and athletes, NSAID use has become a rapid reflex
when an athlete complains of musculoskeletal pain.
Ironically, the pain relieving effect of NSAIDs allow athletes to mask symptoms, which
may further damage the injured tendon and delay definitive healing. Recent studies on
rats with acute tendon injuries showed that NSAID administration caused loss of tensile
force (strength) in tendons.
In bony injuries, an initial inflammatory response leads to a series of biochemical
processes that ultimately lead to fracture repair. Prostaglandins (PGs) play a major role
in bone formation and bone repair. NSAIDs block the formation of PGs and several well-
designed studies in animals have shown NSAIDs to negatively impact fracture healing.
Studies on humans have associated NSAID use with delayed healing in tibia fractures
and increased risk for nonunion in long bone fractures. Researchers have also found
delayed union and nonunion in fractures requiring surgical fixation. One noted study
found that patients given Ketorolac after spinal surgery demonstrated a significant
increase risk of nonunion.
Summary:
In spite of the ubiquitous use of NSAIDs in sports injuries there is no scientific
evidence as to their effectiveness in the treatment of sports injuries and
substantial evidence that they actually hinder healing.
A child or adolescent should NEVER be given an NSAID to treat pain so that they can
participate in sports. NSAIDs are not recommended in the treatment of completed
fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle
injury. An alternative pain medication should be used in the setting of fractures and
acute ligament, muscle, or tendon injury. NSAIDs have no role in the treatment of
chronic tendon injury, as inflammation is NOT a component of such an injury.
NSAIDs should NOT be taken by athletes who are engaged in contact sports that put
them at major risk of traumatic injuries, as these drugs have the potential to seriously
exacerbate post-traumatic bleeding. NSAIDs should NOT be taken by endurance
athletes prior to participation as serious kidney and metabolic complications may arise
in the setting of dehydration or underlying medical condition.
If you are injured, seek care from a qualified SPORTS MEDICINE physician, as specific injuries
require specific treatments, some do better with rest, some better with activity, some better with
immobilization, some better with movement, some better with strengthening, some better with
stretching. Most importantly, the sports medicine physician will be able to analyze your technique and
training, the actual cause of your injury and then treat accordingly.
References:
Clinical Journal of Sport Medicine: Volume 16(2) March 2006 pp 170-174
Practical Management: Nonsteroidal Antiinflammatory Drug (NSAID) Use in Athletic Injuries
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Copyright 2004, New Jersey Sports Medicine and Performance Center LLC. All rights reserved. Disclaimer.
Copyright 2004, New Jersey Sports Medicine and Performance Center LLC. All rights reserved. Disclaimer.
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| Get Better. Faster. |
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