The role of NSAIDs to treat sports injuries is questionable

  There is growing research evidence to suggest that NSAIDs may have adverse healing effects on tendons (1,2), muscles (3), ligaments (4) and bone fractures. At the very least, their use remains unsubstantiated (5-7). Consequently, many of our elite athletes / cyclists are being discouraged against their use for sports-injuries i.e. muscle, tendon and ligament injuries.  

What are NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most prescribed medications for treating conditions such as arthritis and sports injuries. Most people are familiar with over-the-counter, non-prescription NSAIDs, such as aspirin and ibuprofen. Anti-inflammatory medicines are drugs with analgesic and antipyretic (fever-reducing) effects - with higher doses of anti-inflammatory effects. NSAIDs are a widely used class of medication that has three main uses:

• to relieve pain
• to reduce inflammation
• to bring down a high temperature (fever)

Research findings

Although the widespread use of NSAIDs is frequently cited to treat sports injuries, and as such,  frequently prescribed by medical doctors, there is growing evidence of their potentially detrimental effects to healing of muscles, tendons and ligaments (8). This is additional to the well documented adverse effects of gastrointestinal, renal and cardiovascular risks. Consequently, some authors suggest automatic use (prescription) be reassessed, since they have, at best, a mild effect on relieving symptoms and are potentially deleterious to tissue healing (9). Examining ‘best practice’ for management of muscle strains in elite athletes, Orchard et al (10) found that NSAIDs may possibly predispose to recurrence of injury due to pain masking - and before the tissue has appropriately healed . Pain represents the body’s natural warning system / defense mechanism.

How NSAIDs work

NSAIDs work by preventing an enzyme (a protein that triggers changes in the body) from doing its job. The enzyme is called cyclooxygenase, or COX, and it has two forms. COX-1 protects the stomach lining from harsh acids and digestive chemicals. It also helps maintain kidney function. COX-2 is produced when joints are injured or inflamed. Traditional NSAIDs block the actions of both COX-1 and COX-2, which is why they can cause stomach upset and bleeding as well as ease pain and inflammation.

Types of NSAIDs

There are two main types of NSAIDs:

• non-selective NSAIDs – such as ibuprofen, which block the effects of both COX-1 and COX-2 enzymes

• COX-2 inhibitors – such as celecoxib, which only block the effects of COX-2 enzymes

COX-2 inhibitors were designed to treat chronic conditions that cause pain and inflammation without affecting the stomach. Although COX-2 inhibitors have less effect on the stomach, they may be more likely to cause side-effects on the heart compared with traditional NSAIDs. This means that they may be more suitable for someone who is at risk of developing stomach or intestinal problems, but less suitable for those with a heart or circulation problem.

The most commonly prescribed NSAIDs in the UK are:

• diclofenac
• ibuprofen
• naproxen
• celecoxib
• mefenamic acid
• etoricoxib
• indometacin

References

1. Cohen et al. (2006). Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing. American Journal of Sports Medicine 34(3), 362-9.
2. Tsai et al. (2004). Ibuprofen inhibition of tendon cell proliferation and upregulation of the cyclin kinase inhibitor p21CIP1. Journal Orthopaedic   Research 22, 586-91.
3. Reynolds et al. (1995). "Non-steroidal anti-inflammatory drugs fail to enhance healing of acute hamstring injuries treated with physiotherapy." South African Medical Journal. 85(6), 517-522.
4. Warden et al. (2006). Low-intensity pulsed ultrasound accelerates and a nonsteroidal anti-inflammatory drug delays knee ligament healing. American Orthopaedic Society for Sports Medicine. 34(7), 1094-1102.
5. Clarke, S. & F. Lecky (2005). Best evidence topic report. Do non-steroidal anti-inflammatory drugs cause a delay in fracture healing? Emergency Medical Journal, 22(9), 652-653.
6. Wheeler, P. & M. E. Batt (2005). Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. British Journal of Sports Medicine 39(2), 65-69.
7. Bhattacharyya et al. (2005). Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures. Arthritis Rheum, 53(3), 364-367.
8. Watson, T. (2011). NSAIDs and tissue healing. http://www.electrotherapy.org/modalities/nsaids.htm
9. Paolini, J.A. & Orchard, J.W. (2005). The use of therapeutic medication for soft-tissue injuries in sports medicine. MJA Practice – Sports Medicine, 183, 384-388.
10. Orchard et al. (2008). The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. British Journal of Sports Medicine, 42,158-159