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