Natural Antiinflammatory Agents for Pain Relief in Athletes

Joseph C. Maroon, M.D.; Jeffrey W. Bost, P.A.-C.; Meghan K. Borden; Keith M. Lorenz; Nathan A. Ross


Neurosurg Focus. 2006;21(4) 

In This Article

Lesser-Known Side Effects of NSAIDs

Besides the well-documented gastric side effects of NSAIDs and more recently discovered vascular side effects of selective COX-2 inhibitors, there are other less well-known but just as serious effects of NSAIDs, particularly in sports medicine. In this field of medicine, NSAIDs are still the most commonly used agent for the treatment of pain and inflammation arising from acute soft-tissue injuries, despite the wide recognition that there is no convincing evidence of their effectiveness in the treatment of these injuries.[22] In fact, by blocking the COX- 1 or -2 inflammatory pathway, healing may actually be hampered. Various studies have shown that such agents delay muscle regeneration and that their primary role is actually in relieving pain, which could be done just as well with other medications without the deleterious effect of reduced healing.[4,5] The use of NSAIDs has been shown to delay and hamper healing in all the soft tissues, including muscles (despite their tremendous blood supply), ligaments, tendons, and cartilage.[4,5,83,111,123,127] Similarly, in animal studies corticosteroid agents have been shown to delay resolution of hematomas and are well known to delay healing.

The mechanism for this effect is as follows: by taking powerful NSAIDs, the patient does not permit the body to mount any—or at best a very limited—inflammatory response, which is generally believed to be necessary as a prelude to healing because it draws the white blood cells into the injured area to start the repair process.[65] Specifically, NSAIDs are believed to wipe out the entire inflammatory proliferative phase of healing (Days 0–4). In Greene's study,[65] at Day 2 there were essentially no macrophages (cells that clean up the site) in the injured area, and by Day 4 after the muscle strain, there was very little muscle regeneration compared with that seen in the normal healing process. In 1992, Greene showed in adult patients that muscle strength at this time was only approximately 40% of normal.

Although NSAIDs have commonly been used for the treatment of muscle injury, recent research has provided evidence that these drugs have limited effectiveness when it comes to such injuries.[123] In an animal study, Rahusen, et al.,[132] obtained results that support this claim. These investigators evaluated the outcome after NSAIDs were used to treat acute muscle injury in 96 mice, and their findings agree with the statement Greene made earlier. In a study in which piroxicam was used on injured rabbits, researchers drew the same conclusion: NSAIDs did not help the healing process in muscle injuries.[118] A study of the effects of NSAIDs on acute hamstring injuries was done in humans by Reynolds, et al.,[136] and these investigators concluded that patients who used NSAIDs did not experience a greater reduction of pain and soft-tissue swelling when compared with the placebo group. Interestingly enough, the authors noted that the NSAIDs group had worse pain associated with severe injuries compared with the placebo group. Furthermore, in several other studies investigators have actually noted a degradation of muscle tissue in patients treated with NSAIDs. Almekinders and Gilbert[5] monitored the recovery of rats that received an injury in their tibialis anterior and were then treated with piroxicam. These researchers concluded that NSAIDs led to delayed recovery times and muscle growth. In yet another study in rats performed by Jarvinen,[89] it was noted that NSAIDs caused muscles to weaken during the later stages of healing.

The NSAIDs have also been found to have negative effects on skeletal muscle tissue when given to mice before rigorous exercise. Hung, et al.,[85] found that mice given NSAIDs before engaging in exercise showed an increase in the levels of lactate dehydrogenase as well as production of lactic acid in the muscles. This is a cause for alarm because the increase in lactic acid and lactate dehydrogenase levels will lead to increased production of creatine kinase, and that indicates increased necrosis of muscle cells.

The NSAIDs are known to have adverse effects on kidney function.[48,169] Situations resulting in stimulation of the renin–angiotensin system, such as dehydration or preexisting chronic renal failure or disease, may predispose athletes to acute renal failure through inhibition of prostaglandin synthesis, which can occur when taking NSAIDs.[48,169] The relevance of this became very public in the world of professional basketball when two premier National Basketball Association players, Alonzo Mourning and Sean Elliot, suffered significant renal complications when taking large amounts of NSAIDs.[173] While playing in the National Basketball Association, Mourning and Elliot often took NSAIDs daily to self-treat the pain and swelling associated with vigorous athletic activity. Both players suffered focal glomerulosclerosis and both subsequently required a kidney transplant. The National Kidney Foundation asserts that approximately 10% of kidney failures per year are directly correlated to substantial overuse of NSAIDs. Kenny Easley, an All-Pro safety of the Seattle Seahawks football team, claims that his kidney disease is closely related to the large amounts of NSAIDs he formerly ingested. Similar events have been reported in athletes competing in track and field at both the professional and amateur levels. In a recent study of high school football players, researchers have found that 75% of the players use NSAIDs, and 15% use them daily.


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