Should You Use Anti Inflammatories?
Anti-Inflammatory Treatment of Acute and Chronic Soft-Tissue Sports Injuries
from Medscape Pharmacotherapy
Louis C. Almekinders, MD, Associate Professor, Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill.
Recreational and sports activities at any level have an inherent risk of injury. The majority of injuries affect the musculoskeletal system, which includes the bones, joints, muscles, tendons and ligaments. Several epidemiologic studies have shown that soft-tissue injuries comprise the largest part of all musculoskeletal injuries. The soft tissues include the ligaments, tendons, and muscles. Injuries to these soft tissues are classified as either acute or chronic injuries. Acute injuries include ligament sprains and muscle strains, whereas tendinitis is a common example of a chronic injury. All of these soft-tissue injuries are painful, and it is thought that, at least in part, the pain is due to the inflammatory response that the body generates following the injury. For that reason, treatment with anti-inflammatory medication is a popular choice of athletes and healthcare professionals. This article will review the current opinions on anti-inflammatory treatment of soft-tissue sports injuries.
Acute injuries are generally obvious to the athlete. They are caused by a sudden mishap such as a collision, fall, or twist. Pain is immediately present and medical attention is often quickly sought. The most common injuries are ligament tears or sprains and muscle tears or strains. The tears can range from a minor partial tear to a complete tear that may require surgical repair. In all cases, the body responds with a predictable inflammatory response. This response is, in essence, a physiologic reaction, as it is a necessary first step in the healing response. The inflammatory cells clear away injured debris and dead cells, paving the way for a proliferative phase as the next step in healing. The pain and swelling caused by the inflammation also keep the athlete from using the injured part and protect it from further injury. However, it is thought that the inflammatory response is generally excessive and prolonged. Therefore, anti-inflammatory medication is used to minimize this response. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for this purpose.
NSAIDs all have in common the inhibition of the enzyme cyclo-oxygenase (COX), which allows formation of certain inflammatory mediators — namely prostaglandins. Studies have shown that NSAIDs are effective in alleviating pain in acute soft-tissue injuries.[1,2] However, there is no convincing evidence that they are superior to analgesics that have no anti-inflammatory action, such as acetaminophen. The effects of NSAIDs on the inflammatory reaction following an acute soft-tissue injury are small and do not appear to change the natural history of these injuries to any great extent. NSAIDs may be most effective if they are used immediately following the injury, before the inflammatory response is fully established. Side effects, in particular gastrointestinal (GI) ulceration in elderly patients with other medical problems, remain a concern with most NSAIDs. However, in young, otherwise healthy athletes, short-term NSAID use is rarely associated with profound side effects beyond mild GI upset.
Recently, 2 new NSAIDs (celecoxib and rofecoxib) have become available. These selective COX-2 inhibitors have a significantly decreased incidence of side effects compared with the older NSAIDs. Research has shown that cyclo-oxygenase (COX) has at least 2 isoforms, COX-1 and COX-2. In addition it has been shown that inhibition of COX-1 results in some of the well-known side effects such as GI ulceration. Most traditional NSAIDs are nonselective inhibitors, inhibiting both COX-1 and COX-2. Selective COX-2 inhibitors have anti-inflammatory properties through their COX-2 inhibition but a marked decrease in their side-effect profile. There is no good reason to assume that their anti-inflammatory action is better than that of the traditional, nonselective inhibitors.
Corticosteroids belong to another class of drugs with anti-inflammatory properties. Derived from the hormone cortisol, corticosteroids are associated with much more pronounced and lasting anti-inflammatory effects compared with NSAIDs. Numerous studies have shown that they, in fact, can halt the healing process by virtually eliminating the inflammatory response. Inferior healing of ligament sprains and muscle strains has been observed in several animal models. For this reason, most healthcare professionals believe that corticosteroids have no role in the treatment of acute soft-tissue injuries.
Chronic soft-tissue injuries are often less obvious to the athlete. They may start as a mild pain but with few functional limitations. Athletes usually do not seek medical care until the pain progresses to a point of limiting performance. Evaluation at that point can reveal several different problems. Most of these injuries are classified as overuse injuries. It is thought that repeated microtrauma beyond the reparative abilities of the musculoskeletal system eventually can lead to a macroscopic injury. Tendinitis is probably the most common problem diagnosed at that point. Recently, it has become clear that mechanical overuse is not the only factor that allows these injuries to occur. Several studies have found an age-related degeneration that affects many of the large tendons in both the upper and lower extremity. This appears to predispose the tendon to painful lesions during athletic activity. Common examples are rotator cuff tendinitis, tennis elbow, and Achilles tendinitis. In addition, it has been shown that these lesions have mostly degenerative features rather than inflammatory changes. The term tendinopathy may therefore be more appropriate than tendinitis, which implies inflammatory changes.
Treatment of these chronic problems is traditionally through relative rest, physical therapy, and NSAIDs. Again, NSAID use can result in pain relief but does not appear to promote healing of these conditions. Several randomized studies have failed to show a significant advantage over other analgesics or even placebo. Other treatment modalities may be more important to stimulate healing in these conditions.
Corticosteroids also remain a popular choice in the treatment of chronic soft-tissue injuries. Often they are used in a parenteral form and injected directly on and around the affected tendon. A corticosteroid injection can result in quick and dramatic relief of the pain symptoms associated with tendinopathy. The exact mechanism through which this is accomplished remains unclear, as inflammatory features are often absent in these lesions. Problems associated with corticosteroid use include weakening of the tendon and the possibility of tendon rupture. Although the exact rupture risk has not been determined, many healthcare professionals avoid using corticosteroids in weight-bearing tendons such as the Achilles tendon. In the upper extremity, corticosteroids are more frequently used. In addition, the pain relief obtained from a corticosteroid injection can be temporary. Recurrence of the pain after several weeks is not uncommon.
Although anti-inflammatory medication remains popular in acute and chronic soft-tissue injuries, their efficacy is limited. Some pain relief is often obtained, but dramatic effects on the healing of the injury cannot be expected. On the contrary, corticosteroids have the potential to actually delay or halt healing, particularly in acute injuries.
Anti-Inflammatory Treatment of Acute and Chronic Soft-Tissue Sports Injuries
[Medscape Pharmacotherapy 2(2), 2000. © 2000 Medscape Portals, Inc]
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