Anti-inflammatory Medication and Sport

Before we kick off, I should point out I’m not a pharmacist or GP! I am not qualified to prescribe medicine and the aim of this article is not to make recommendations. What I will do though is feedback the findings of a fairly recent article by Paolini et al. 2009 in the British Journal of Sports Medicine. I’ve also had some help from Pharmacist Vaggelees Zachos who has very kindly advised me on this topic. Look him up on Twitter @vaggeleeszachos.

The article, which is currently freely available online on the link above, gives a nice overview of current thinking in the use of Non-Steroidal Anti-inflammatory Drugs (NSAIDS) in sport. Use of NSAIDs in runners appears fairly common and in elite athletes is reported to be as high as 25-35%, so it’s well worth reviewing if we are using them correctly.

When are NSAIDs contraindicated?

With some clinical conditions NSAIDs are contraindicated – this means they can’t be used. The risk of side effects in these conditions far outweighs the potential benefits. Contraindications are detailed nicely here. Some of the contraindications listed there may be fairly unlikely in runners – such as heart failure or impaired liver or kidney function but others are certainly more common. Asthma is seen as a potential contraindication but your GP may offer you a trial of the medication to see if you can tolerate it. Gastrointestinal problems are also a contraindication and are fairly common. If the problem is mild (such as indigestion like symptoms rather than peptic ulcer or gastrointestinal bleeding) the GP may provide NSAIDs with additional medication to protect the stomach. NSAIDs cause a gradual destruction of the protective mucosa of the stomach lining. As a result treatment may be limited to 5-7 days and Lansoprazole is commonly prescribed with NSAIDs, especially for athletes who are on 5 or more days of treatment. Vaggelees tells me that Fast-Tab Lansoprazole is especially effective with NSAIDs.

NSAIDs, such as Ibuprofen, are available without prescription, if you have any questions regarding whether they are safe for you to take make sure you discuss them with your GP.

When are NSAIDs most likely to help?

In inflammatory pathologies. No great surprise there – they work best when inflammation is present this includes;

  • Impingement conditions – including nerve and soft tissue impingement
  • Tenosynovitis – inflammation of the fluid filled sheath that surrounds the tendon. Acute bouts of tendon pain (e.g. From the Achilles,Tibialis Posterior and Patella tendons) are more likely to involve inflammation so NSAIDs will probably be more effective in acute tendon pain than chronic.
  • Inflammatory arthropathy – this includes things like Rheumatoid Arthritis and Psoriatic Arthritis. These are systemic conditions that can effect the whole body, not to be confused with Osteoarthritis which tends to effect individual joints.
  • ??ITBS – several studies I’ve read have suggested NSAIDs for ITB problems. Paolini et al. 2009 don’t mention it specifically. As the condition is reported to involve inflammation of the tissues around the ITB you might expect NSAIDs to be helpful.

With some conditions NSAIDs are a viable option but their usage would depend on clinical findings;

  • Ligament and joint sprains – there is evidence that NSAIDs can delay healing of ligament and bone and so probably should not be used in treatment of joint or ligament injuries. However sometimes the use of NSAIDs allows early movement and mobilisation which encourages healing. Usage would depend on the situation and whether an alternative medication might provide pain relief without adversely affecting healing.
  • Osteoarthritis and other joint conditions
  • Haematomas
  • Post operatively – be guided by your consultant on appropriate medication

What about muscular injuries?

Paolini et al. 2009 concluded that use of NSAIDs in muscular injuries was controversial and should be used with caution. There was some suggestion that NSAIDs could be used in the sub-acute stage after the initial inflammation had settled, however there was concern that NSAID could have adverse effects on healing. A suggestion has emerged from the research (although not from this article) that NSAIDs should not be used at all in the first 48 hours after a soft tissue injury, due to their effects on healing. Like anything in medicine this is not set in stone and there may be some situations where NSAIDs in this time frame may be helpful.

In what conditions are NSAIDs contraindicated because they may compromise healing?

  • Chronic tendinopathies – these are common in runners, especially Achilles Tendinopathy and Patella Tendinopathy. Research has found that chronic tendinopathies are more of a degenerate process than an inflammatory one.
  • Fractures – be guided by your consultant or GP when managing pain post fracture.

What’s the alternative?

According to Paolini et al. 2009 paracetamol has similar pain relieving effects to NSAID’s and yet has fewer risks. They suggest paracetamol should be chosen if the main aim is to reduce pain. Although generally considered a fairly mild drug and widely available with prescription paracetamol does have contraindications. Over the counter medications also combine paracetamol with caffeine (such as Panadol Extra) which may be more effective (although the research doesn’t comment on this). Anti-inflammatory creams, especially those containing Nimesulide or Diclofenac (both NSAIDs) can prove helpful for those athletes having gastrointestinal problems.

The article also mentions that medications should be combined with PRICE (Protection, Rest, Ice, Compression and Elevation) to optimise healing. I’ve recently done a piece on acute pain management here which details an update on PRICE – POLICE.

There are a multitude of different pain relieving medications available. Typically as the drug’s strength increases so do it’s potential side effects. Opioid pain relief (Codeine, Tramadol, Dihydrocodeine etc) are quite commonly prescribed but patients often complain of constipation or drowsiness.

If you are struggling to manage your pain for any reason, or struggling with side effects from medication always discuss this with your GP.

 

 

 

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Sub-acute injury management

A lot of guidelines exist for management of acute injury. Most people will have heard of RICE, PRICE or, more recently POLICE. But what do you do when the acute phase ends? Continue with the ice? Stick your running shoes on and hit the road? This blog is to help you manage the next part, the sub-acute stage.

This advice is most useful for actual injury management, rather than a tight hamstring or a flare up of an old problem. As ever with this blog, it is not designed to replace medical advice – if in doubt get it checked out!

When does the sub-acute stage start?

There is no definitive timescale for healing as different things heal at different speeds but the sub-acute stage starts when the initial stage of swelling and pain has started to settle. There is usually a lot of bleeding in the first 6-8 hours post injury and a lot of inflammation for 2-3 days so the sub-acute stage usually starts between 3 and 7 days post injury and lasts until around 3-4 weeks.

What healing is taking place at this stage?

After the initial bleeding and inflammation your body starts the repair work. It does this by laying down new tissue usually in the form of collagen. This collagen starts off disorganised and “immature” and is not very good at managing load. If you place too much stress on this healing tissue it will breakdown and cause more swelling and pain. At around 3 weeks post injury the collagen has usually matured to a level where it is more efficient at dealing with some load but it takes 6-8 weeks to fully mature. Even beyond this stage tissue is being “remodelled” and strengthened further. Some structures will continue to heal in this way over a year after the initial injury. That said, we often consider things to be healed when they have reached a level where they can manage normal load and are without pain. Bone and muscle injuries take around 6-8 weeks to reach this level, ligament and tendon takes around 12 weeks. Areas with poor blood supply can be significantly longer.

What affect will the injury have on surrounding tissues?

Some injuries have immediately obvious effects. Injure a muscle and you would expect that muscle to be weak, but what if you injure a ligament or a bone? The resulting swelling and pain from an injury usually affect muscle strength, tissue flexibility, joint range of movement, balance and control of movement. An ankle ligament sprain, for example, usually causes a lot of swelling. The ankle joint stiffens as a result, the calf muscle may tighten, the muscles around the ankle become weak and it becomes very difficult to balance.

It is these issues that need to be addressed post injury to allow a problem free return to running. It often boils down to The Big Three movement control, range of movement and strength.

In the sub-acute stage you need to be guided by your pain, don’t push through pain and if you have specific instructions from your consultant or Physio stick to those.

Rehab of movement control

Part of movement control is something called “proprioception”, it’s how our bodies know the position of joints, muscles etc in space. It tends to be reduced after injury as described above. Movement control and proprioception work can be started as soon as comfortable after an injury, as it can be done very gently. Start with non-weightbearing exercises, this could be sitting with a ball under your foot, rolling it side to side, back and forwards, in circles etc or keeping a wobble board level (again in sitting). Some people do “alphabets” with their feet – drawing each letter of the alphabet in the air. A pool is a great place for balance exercise, bare in mind that if you are chest deep in water you reduce your weightbearing by about 80%. If it’s comfortable you could try single leg balance in the water, walking on your tip toes or heels and sideways walking. To gradually increase the amount of weight you take through an injured limb go progressively shallower in the pool. This is a great way to prepare for weightbearing work.

When comfortable you can progress to exercises in standing (out of the pool). You could start with 2 leg activities like gentle squats or wobble board balance and progress to single leg work balance work (detailed here). Use as much or as little support as you can manage, your aim is restore balance without causing pain or placing too much stress on healing tissue.

Restore range of movement

It’s important not to be overly aggressive in this area, find which movements are stiff and gently work into them. Common problem areas are ankle dorsiflexion (the upward movement), ankle inversion and eversion (turning the foot in and out) and knee flexion. Again, start in non weightbearing e.g. simply moving the foot up and down and in and out or bending and straightening the knee. You can try a static stretch as long as it’s comfortable, gradually build up towards a 30 second hold. When you feel ready progress to assisted stretching e.g. Using a towel or resistance band to add to the stretch, then add weight bearing stretches when able. Restoring range of movement isn’t just about stretching muscles, it’s about moving the joint. For example, simple squats and lunges can be very effective to loosen an ankle that’s stiff into dorsiflexion (I.e. won’t bend up) even though there may be little stretch on the calf muscles.

Restoring strength

Common muscles to be weak post injury are calf, quads, hamstring and glutes.

Try to gently work the muscles around the injured area as soon as it’s comfortable to do so. Start with isometric exercise. This means contracting the muscle without change in joint angle or muscle length. It’s a fairly static exercise so there is little stress on healing tissue, with the exception of the muscle you are working. One way to do this is to push against an immovable object, like a wall or the floor. You can even resist it with your good leg/arm. An isometric contraction can also be at the joint’s end of range where the joint itself prevents movement, for example static quads (sit on the bed with the leg straight and tighten the quads muscle). Muscle contraction also has the added benefit of improving swelling as it has a pumping action that helps move fluid from within the tissues. For other isometric exercises see the table below.

When comfortable you can progress from isometric strength work to working through range. Often it’s best to allow 7-10 days post injury to make this transition, after all, we need to allow the area to heal and there is little to gain in pushing things too quickly. Just the weight of the limb can offer enough resistance, e.g. with a straight leg raise exercise for quads. Body weight can also be used e.g. with squats or calf raises. Additional weights or resistance bands can be used if needed. It should remain pain free. Just work in whatever range is comfortable. Strength can also be gained by using equipment, like a static bike. Start with a low resistance and gradually increase. Keep movement comfortable and controlled.

How many, how often?

While the healing continues the priority is protecting that process, so if in doubt do less rather than more. Think of it as gently keeping things ticking over to prevent deconditioning (muscle weakness, joint stiffness etc.) rather than working hard to build strength. These exercises are best done little and often rather than all at once. I usually suggest that patients pick 3 or 4 exercises and do those about 3 times per day (morning, noon and evening) just doing as much as comfortable of each exercise. This might be as little as 4 or 5 reps. Which exercise you choose depends on what problems you are having following your injury. If you have no range of movement problems but feel very weak you would focus on strength work. If the muscles feel strong but the joints are stiff you would focus on improving range of movement. If strength and range are good but you struggle to balance you’d focus on that. Usually with injuries you’d also have guidance from a Physio or health professional on what exercises to do.

What else might help?

Ice remains useful as long as the area is continuing to swell. After 2-3 weeks if swelling remains you may want to replace ice with heat or contrast bathing. Both will improve the blood supply to the area to help clear swelling. Contrast bathing is using heat for 1 minute, then ice for 1 minute and continuing for 10-15 minutes finishing with heat. In theory this helps to cause blood and lymph vessels to dilate and then contract to pump fluid from the area.

Massage may help by reducing inflammation and pain, avoid aggressive painful massage around healing tissues. A compression bandage or supportive taping can also be used to manage swelling and support the area. Ultrasound may also help the healing process in soft tissues.

Closing thoughts

Gentle exercise can be used in the sub-acute stage following an injury but it should be done in a pain free manner with a gradual progression and respect to the healing structures. Loading tissues in this way can reduce deconditioning following an injury and help stimulate the healing process and development of collagen.

Injuries that create pain and swelling need to be assessed by your GP, Physio or health professional. Their guidance always supersedes that of general advice on this and other blogs.