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
- 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.