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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
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