NSAIDs

Many older athletes are often popping ibuprofen and other non-steroidal anti-inflammatory medications (NSAIDs) like they’re candy. These are sold under the names of Motrin, Advil, Naprosyn, Aleve, and others. And why not? These drugs are some of the most heavily marketed drugs around. The advertisements would have a person believe that the NSAID being marketed is good for any ache or pain and can make you feel like you’re a care-free 20 year-old.

Do we need to curb inflammation in swimming or other sports-related injuries? Advertisers and the media would have us believe that inflammation is bad and must at all costs be contained. However, inflammation and repair are essential to survival. Except in cases such as autoimmune diseases (for example rheumatoid arthritis), or inflamed arteries, inflammation is a healthy response to an injury. If we stomp out the response, the injury won’t heal. Where inflammation is chronic, we want to get to the root cause and eliminate the cause, not the response.

Let’s say you slip on the pool deck and sprain your ankle (which means you just tore a ligament). The first reactions in your body are from the nervous system and the release of chemical mediators from the damaged tissue and the blood. The chemical mediators, two of which are prostaglandins and histamines, instigate the body’s inflammatory response. The inflammatory response includes redness, swelling, heat, pain, and loss of function. Your ankle will get a little red at the painful area. This is the increased blood to the area. Some of the fluid from the damaged cells will leak out. The blood vessels will become more permeable so that plasma proteins and white blood cells can leak out. These white blood cells and the later-arriving white blood cells will gobble up any debris from the injury. If the skin is open, these cells will also absorb dirt and bacteria. The fluid accumulation results in swelling. The area becomes warmer from the increased blood supply and the swelling. Pain results from swelling and some of the chemical mediators. And now you’re also experiencing some loss of function in that ankle. This is the classic inflammatory response and can last from 1 to 4 days.

The repair process involves replacing damaged tissues and restoring function. This is triggered by the inflammatory response and overlaps with it. It may last up to a year or longer, depending on the injury. In the repair process fibroblasts, which have wandered into the injured area due to signals from various elements of the inflammatory response, will lay down a matrix of connective tissue. This connective tissue consists primarily of collagen fibers and ground substance. It will become scar tissue which will be remodeled along the lines of stress over the course of a couple of months.

Back to your ankle that you’ve just sprained. If you compromise the inflammatory response by taking an anti-inflammatory medication, you are affecting not only the immediate inflammatory response, but the entire repair process. NSAIDs work by blocking COX-1 and COX-2 enzymes (cycloxygenase-1 and cycloxygenase-2) and thus the formation of prostaglandins, the chemical mediators we just discussed. These are part of a group of chemical mediators of inflammation. Note that most NSAIDs block both COX-1 and COX-2. Blocking COX-1 prevented the production of prostaglandins that help coat the stomach lining. As a result, patients taking these NSAIDs are at an increased risk for upper gastro-intestinal ulcers. The newer COX-2 blocking NSAIDs (Celebrex, Vioxx, Bextra) were supposed to solve this problem, but had their own set of problems, such as an increased risk for heart problems.

What has research shown?

There is no convincing evidence that NSAIDs are effective in treating sports-related injuries. Various human and animal studies have shown that NSAIDs hinder the healing of muscles, ligaments, tendons, bone, and cartilage. One of my favorite studies was done by a group of researchers including Scott Rodeo, M.D., an orthopedic surgeon, who did the surgery on Brooke Bennett’s shoulders. He has been involved with USA Swimming. In this study 180 rats underwent rotator cuff surgery. 60 then received 14 days of celecoxib (Celebrex), 60 received indomethacin (a traditional NSAID), and 60 were controls, who received nothing. The rats’ tissues were examined at 2, 4, and 8 weeks and were inspected under the microscope and tested for strength. Over the course of the study, “the controls demonstrated progressively increasing collagen organization.” Neither of the NSAID groups showed collagen organization, a sign of tissue strength and healing, with the result being “significantly inhibited tendon-to-bone healing.”

Many athletes take NSAIDs after a heavy workout in the belief that it will help prevent muscle soreness. Studies have shown either no effect or a miniscule effect when compared to a placebo. What the NSAID will do, however, is prevent your body from healing properly after the hard workout. Training involves stressing the muscles to the point of micro-tears, which the body then heals using the same inflammatory pathways. The trained muscle should be stronger than the untrained muscle, unless it’s healing has been inhibited.

What are the side effects of NSAIDs?

It is estimated that NSAID use causes 107,000 hospitalizations for gastrointestinal complications and 16,500 deaths in the United States. Gastrointestinal symptoms include gastro-esophageal reflux (GERD), nausea, abdominal pain, ulcers, and gastric perforation. Bleeding ulcers can occur with no warning and don’t have to be the result of massive doses.

Athletes need to be aware that dehydration or underlying kidney disease may predispose them to acute renal failure when taking large doses of NSAIDs. This is what happened to two NBA players in 2002. Alonzo Mourning and Sean Elliot often took NSAIDs daily to self-treat for workout-related aches and pains. They both suffered kidney failure and ultimately needed kidney transplants. The National Kidney Foundation estimates that 10% of kidney failures per year are related to NSAID overuse.

Perhaps not directly related to swimming, but particularly distressing to some is the conclusion in an article in the Journal of Urology that the use of NSAIDS doubled the risk of erectile dysfunction. In addition, all NSAIDs increase the risk of hypertension. Both NSAIDs and acetaminophen (for example Tylenol) increase the risk for hypertension in women. All NSAIDS may also increase the risk of myocardial infarction in people with arthritis. NSAID use in post-menopausal women appears to be associated with an increased risk of non-Hodgkin lymphoma. Finally, a 2005 article in the Journal of the National Cancer Institute found that there is a small increase of breast cancer in NSAID users.

Why does my doctor prescribe NSAIDs for musculoskeletal injuries?

That is a very good question. Pain can be controlled with acetaminophen, ice, or herbal remedies. Corticosteroids, while excellent at stopping pain and inflammation that causes pain, completely stop the healing process. For some reason many medical doctors are now prescribing prednisone, a corticosteroid, as a first treatment for patients with musculoskeletal pain, primarily back pain. It doesn’t make sense and certainly doesn’t help the underlying problem.

NSAIDS not only don’t promote healing but actually inhibit it. There are alternative which actually do promote healing such as ultrasound, myofascial release and massage, laser therapies, and many herbal remedies. Underlying joint problems can be treated with chiropractic adjustments, mobilizations, and other exercises and movement therapies.

Jessica Seaton, D.C.

11022 Santa Monica Blvd.

Suite 440

Los Angeles

CA 90025

Phone: (310) 470-0282

E-mail: jseaton@aol.com