NSAIDs and Athletes

Are you a pill-popping athlete?

Athletes are often popping ibuprofen and other non-steroidal anti-inflammatory medications (NSAIDs) like they’re candy. 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-ld.

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. 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. 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 reddish 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 gobble up dirt and bacteria. The fluid accumulation results in swelling. The area becomes warmer from the increased blood supply and the swelling. Pain results from both the swelling and some of the chemical mediators released due to the injury. And now you’re also experiencing some loss of function in that ankle. This is the classic inflammatory response and can last from 1-4 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 (a sprain is a ligament tear)…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. 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.

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. Rats were sacrificed at 2,4, and 8 weeks and their tissues 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.”[Cohen DB, Kawamura S, Ehteshami JR, Rodeo  SA.: Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing, Am J Sports Med 2006 Mar;34(3):362-9. Epub 2005 Oct 6]. A nice overview of role of NSAIDs in athletics can be found in Maroon, JC, Bost JW, Borden MK, Lorenz KM, Ross NA.: Natural Antiinflammatory Agents for Pain Relief in Athletes. Neurosurg Focus. 2006;21(4) 2006 (American Association of Neurological Surgeons).

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?

In the general U.S. population it is estimated that 107,000 hospitalizations for gastrointestinal complications and 16,500 deaths are the result of NSAID use. Gastrointestinal symptoms include gastroesophageal 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.

Recent new releases reveal other undesirable side effects from NSAIDS. A 2006 article in the Journal of Urology concluded that regardless of the indication for using NSAIDs, their use doubled the risk of erectile dysfunction compared with nonuse.

Various studies have highlighted the increased risk for hypertension. All NSAIDs increased the risk, with COX-2 inhibitors less so than regular NSAIDs. All NSAIDS may also increase the rsik of myocardial infarction in peole with arthritis. Studies have found that in women both NSAIDs and acetaminophen (for example Tylenol) increase the risk for hypertension. Another study that looked only at post-menopausal women and was published in the International Journal of Cancer in 2003, showed that NSAIDs appeared to be a associated with an increased risk of non-Hodgkin lymphoma (NHL). A 2005 article in the Journal of the National Cancer Institute found that there is a small increase in NSAID users of breast cancer.

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.  

Healing can be promoted with modalities 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.

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