Muscle, Joint, and Shoulder Injuries
Page 1 Index
*Muscle and Joint Injuries (Care and Management)
*Should you Use Anti-Inflammatories (Article)
*Wrapping and Ankle Sprain
*Shoulder Problems Overview
*Shoulder Injury Rehab
Muscle and Joint Injuries
This article will focus on the soft tissue injuries that a bodybuilder or strength athlete may incur and the important first steps one should take to ensure a speedy recovery. It will not go into specific injuries and is not meant as a comprehensive guide or a replacement for professional medical advice.
Please keep in mind that asking “some dudes I know at the gym” does not constitute medical advice!
Also, it is important to note that injuries to the head, neck, face, or spinal cord; bone fractures, breaks, or injuries with excessive bleeding, are beyond the scope of this article and may require immediate medical attention.
First, some definitions:
Muscle: OK, so you know what a muscle is.
Tendon: Fibrous connective tissue serving for the attachment of muscles to bones and other parts.
Ligament: (Joint Ligament) A band or sheet of strong fibrous connective tissue connecting the articular ends of bones, binding them together and facilitating or limiting motion. It is important to note that ligaments have little if any flexibility. There are other parts of a joint that can be injured, such as the meniscus, but you don’t really want this article to be that long…
The two basic soft tissue injuries are strains and sprains.
Strain: A trauma, tear, or rupture to the muscle or musculotendinous unit from violent contraction or excessive forcible stretch. Can also be caused by a sudden blow. It can be difficult to know when you have strained a muscle or tendon. Bodybuilders and strength athletes are so used to pain and chronic injuries they find it easy to ignore discomfort in a muscle. You may feel something pulling loose or feel a ripping sensation. Or, you may just feel a mild pain in a muscle or tendon. It is best to take any unusual pain or discomfort seriously.
Strains are classified into one of three categories:
Grade I: overstretching of a few muscle fibers with less than 10 percent actual fibers tearing. No palpable defect in the muscle.
Grade II: a partial tear of the muscle fibers usually between 10 and 50 percent of the fibers. A definite palpable defect in the muscle belly.
Grade III: an extensive tear or complete rupture of the muscle fibers. From 50 to 100 percent destruction. Very large palpable depression in the muscle. The muscle may be torn away completely. There is no possibility of normal contraction.
Sprain: A trauma, tear, or rupture to a ligament or joint capsule. Many of us have suffered a sprain at some point and it is usually fairly obvious when you have sustained and Grade II or III. Sometimes even a “pop” is heard. A mild sprain can sometimes be easily overlooked so it is important to take even a mild sudden discomfort in a joint seriously.
They are classified similarly:
Grade I: mild injury caused by an overstretching or slight tear of the ligament with minimal pain, swelling and little or no loss of function. Weight can usually be put of the affected joint.
Grade II: a moderate injury that causes partial tearing of the ligament with bruising, moderate pain and swelling. There is some difficulty putting weight on the affected joint and there is some loss of function.
Grade III: a severe injury with complete tearing or rupture of the ligament. Pain, swelling and bruising are usually severe and the patient is unable to put weight on the joint.
If you experience this type of injury or even suspect you have there are some important first steps you can take to lessen damage and speed recovery. What you do in the period immediately following an injury is the most important part of your recovery. It can make or break you. I cannot stress this enough.
Step 1: Stop! Stop training. Stop moving around as soon as you can and try to asses the inury. Just don’t damage it further. If you hurt yourself somewhere in your upper body that doesn’t mean you should ignore it and switch to legs. The sooner you begin treatment, the better.
Step 2: R.I.C.E. This is still the most common and most effective treatment for strains and sprains. It has been shown to significantly reduce recovery time.
It will help alleviate the bleeding around the injury site and the resultant swelling and pain. It will help prevent further tissue damage and aid in the healing process.
Rest: This goes back to step one. A soon as possible begin keeping the injured area as still. Even moving it around while working other body parts can speed up the blood flow to the area and cause further damage. If it hurts even a little don’t do it. Use some kind of sling or brace to support the injured area if necessary.
ICE: This is the most important of all. Apply ice ASAP using crushed ice in a plastic bag, commercial cold packs or even frozen vegetables such as peas.Chemical ice packs are ok but some can be too cold or not cold enough. Real ice melting in water is best.
Use some kind of buffer between the skin and ice. A damp towel is best. It’s going to be slightly uncomfortable but not painful. You don’t want to get ice burns so only apply it for as long as is tolerable. Go for around 10 minutes but if this is too long then apply it for shorter times more often. Rotate it on and off every 30 minutes, several times a day for the first 24 to 48 hours. Avoid prolonged use of ice on the extremities such as hands and feet/toes and face.
Compression: Wrap snugly, but not to tight, with an elastic bandage. Begin wrapping area farthest from heart. You should be able to slip a finger underneath but even so make sure that it doesn't start to tingle or become numb. I have not been able to find consistent recommendations on whether strained muscles or tendons should always be wrapped. It should help with the bleeding and swelling and in some instances it may help to stabilize the injured area. In general I would say to use a bandage if it helps to reduce the pain. With joint injuries, especially those of the ankle, knee, or wrist it is generally recommended. It is best not to wrap the joint in a circle but to wrap over the joint in a zig-zag or figure eight pattern, anchoring below and above. I would recommend that you have your medical professional tell you whether this step is necessary or warranted based on your injury and have him or her instruct you in the correct method. They may provide you with a special wrap. Included below is specific instructions on wrapping an ankle.
Elevation: Raise the injured area above the level of the heart whenever possible. This will help further reduce the bleeding, swelling, and pain.
For the first 24 to 72 hours avoid any type of heat to the inured area. It would be best to even take lukewarm or cold showers. Avoid any massage or movement. There sould be NO STRETCHING AT ALL during this period.
The following is a cut and paste from here: http://www.thestretchinghandbook.com/archives/sports-injuries-pt2.htm.
Lets move on. What happens after the first 48 to 72 hours? Lets take a quick look at how your soft tissue (muscle, tendon, ligament, etc.) repairs itself.
When any sort of damage occurs to the soft tissues, like a strain or sprain, the body immediately goes into a process of repair. Where the individual fibres have been ruptures, or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen. Or, as it's more commonly known, scar tissue!
You see, when a muscle is torn, you would expect that the body would repair that tear with new muscle. In reality, this doesn't happen. The tear, or rupture, is repaired with scar tissue.
Now this might not sound like a big deal, but if you have ever suffered a soft tissue injury, you'll know how annoying it is to keep re-injuring that same old injury, over and over again. Untreated scar tissue is the major cause to re-injury, usually months after you thought that injury had fully healed.
Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged soft tissue fibres in an effort to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. In some cases it's even possible to see and feel this bulky mass under the skin.
When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished, but flexibility of the tissue is also compromised.
So what does this mean for the athlete? Firstly, it means a shortening of the soft tissues which results in a loss of flexibility. Secondly, it means a weak spot has formed within the soft tissues, which could easily result in further damage.
Lastly, the formation of scar tissue will result in a loss of strength and power. For a muscle to attain full power it must be fully stretched before contraction. Both the shortening effect and weakening of the tissues means that a full stretch and optimum contraction is not possible.
Now, if you've taken the advice from part 1, and used the R.I.C.E.R. regime to treat the initial reaction to a soft tissue injury, you're well on your way to a complete recovery. If however, you didn't use the R.I.C.E.R. regime, you're behind the eight-ball, so to speak. Let me explain.
From last months issue we learnt that when an injury occurs the body responds by sending large amounts of blood to the injury site. If this isn't controlled, with the R.I.C.E.R. regime, it will result in massive bleeding, swelling and pain. More importantly, it will also result in a large formation of bulky, painful scar tissue.
As we know from last month, the R.I.C.E.R. regime will help to control the bleeding, swelling and pain, but more importantly, it will also control the formation of scar tissue. When the R.I.C.E.R. regime is used correctly, there will only be a minimal formation of scar tissue, which allows for optimal return of flexibility and strength.
(The last R here means Referral to a qualified medical specialist.)
The Next 10 to 14 Days
So, how do we put the finishing touches on your recovery? How do we get rid of that annoying formation of scar tissue?
After the first 72 hours most of the initial swelling will have subsided and you can start with some gentle active rehabilitation techniques.
The most effective treatment at this stage is the use of heat and massage, but including light, gentle static and passive stretching exercises after your heat and massage treatment will help to dramatically speed up the recovery process.
Firstly, you must keep active! Don't listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity.
Light activity will not only promotes blood circulation, but it will also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system.
Before we move on, a quick word of warning. Never, Never, Never do any activity that hurts the injured area. Of course you may feel some discomfort, but NEVER, NEVER push yourself to the point where you're feeling pain. Listen to your body. Don't over do it at this stage of the recovery, you've come too far to blow it now.
To complete your recovery and remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is commonly used by physical therapists (or physiotherapists), and it primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.
Physical Therapists accomplish this aim by using a number of activities to stimulate the injured area. The most common methods used are ultrasound and heat.
Ultrasound, or TENS (Transcutaneous Electrical Nerve Stimulation) simply uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues.
Secondly, to remove the unwanted scar tissue it is vital that you start a course of deep tissue sports massage. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that.
Either find someone who can massage the effected area for you, or if the injury is accessible, massage the damaged tissues yourself. Doing this yourself has the advantage of knowing just how hard and deep you need to massage.
To start with, the area will be quite tender. Start with a light stroke and gradually increase the pressure until you're able to use deep, firm strokes. The more you massage the effected area the harder and deeper you will be able to push.
Use deep, firm strokes, moving in the direction of the muscle fibres. Concentrate your effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue.
So what is static and passive stretching?
Static stretching is performed by placing the body into a position whereby the muscle (or group of muscles) to be stretched is under tension. Both the opposing muscle group and the muscles to be stretched are relaxed. Then slowly and cautiously the body is moved to increase the tension of the stretched muscle group. At this point the position is held or maintained to allow the muscles to lengthen.
Passive stretching is very similar to static stretching; however another person or apparatus is used to help further stretch the muscles. Due to the greater force applied to the muscles, this form of stretching is slightly more hazardous. Therefore it is very important that any apparatus used is both solid and stable. When using a partner it is imperative that no jerky or bouncing force is applied to the stretched muscle. So, choose your partner carefully, they must be responsible for your safety while stretching.
The important point to remember during this phase of the rehabilitation process is light, gentle stretching. Never, never, never do any activity that hurts injured area. Of course you may feel some discomfort, but never push yourself to the point where you're feeling pain. Be very careful with any activity you do. Pain is the warning sign; don't ignore it.
The Next 2 to 5 Weeks
The aim of this phase of your rehabilitation will be to regain all the fitness components that were lost as a result of the injury. Regaining your flexibility, strength, power, muscular endurance, balance, and co-ordination will be the primary focus.
Without this phase of the rehabilitation, there is no hope of completely and permanently making a full recovery from your injury. A quote from a great book called "Sporting injuries" by Peter Dornan & Richard Dunn will help to reinforce the value of this phase of the rehabilitation process.
"The injury symptoms will permanently disappear only after the patient has undergone a very specific exercise program, deliberately designed to stretch and strengthen and regain all parameters of fitness of the damaged structure or structures. Further, it is suggested that when a specific stretching program is followed, thus more permanently reorganizing the scar fibers and allowing the circulation to become normal, the painful symptoms will disappear permanently."
So what type of stretching is best to use during this phase? Stick with the static and passive stretching exercises described above, but also include PNF Stretching.
PNF stretching, or Proprioceptive Neuromuscular Facilitation, is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted. PNF stretching was originally developed as a form of rehabilitation and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, (and range of movement) it also improves muscular strength.
If you're interested, you can learn more about PNF stretching here.
Looking Long Term
Once you're over your injury and have started to regain the fitness components that were lost during the injury process, it's time to focus on making the injured area stronger and more flexible that it was before the injury occurred. To do this, the best types of stretches to use are dynamic and active stretching exercises.
Dynamic stretching uses a controlled, soft bounce or swinging motion to move a particular body part to the limit of its range of movement. The force of the bounce or swing is gradually increased but should never become radical or uncontrolled.
Active stretching is performed without any aid or assistance from an external force. This form of stretching involves using only the strength of your opposing muscles to generate a stretch within the targeted muscle group. The contraction of the opposing muscles helps to relax the stretched muscles. A classic example of an active stretch is one where an individual raises one leg straight out in front as high as possible and then maintains that position with out any assistance from a partner or object.
Just a few final points before we finish up. Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body.
Also see: 0311's Pec Tear
There are some common tip-offs you should recognize as warning signs that you have an injury that needs your attention. While some sports injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop. The following list of six injury tip-offs comes from Anybody's Sports Medicine Book, written by James Garrick, M.D. and Peter Radetsky, Ph.D.
See also Giving Injuries the Cold Treatment
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]
1. Almekinders LC. Anti-inflammatory treatment of muscular injuries in sports. An update on recent studies. Sports Med. 1999;28:383-388.
2. Almekinders LC. The efficacy of nonsteroidal anti-inflammatory drugs in the treatment of ligament injuries. Sports Med. 1990;9:137-142.
3. Kennedy JC, Willis RB. The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. Am J Sports Med. 1976;4:11-21.
4. Cox JS. Current concepts in the role of steroids in the treatment of sprains and strains. Med Sci Sports Exerc. 1984;16:216-218.
5. Almekinders LC, Temple JD. Etiology, diagnosis and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998;30:1183-1190.
6. Astrom M, Westlin N. No effect of piroxicam on Achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand. 1992;63:631-634.
NSAIDs and Musculoskeletal Treatment
What Is the Clinical Evidence?
Steven D. Stovitz, MD
Robert J. Johnson, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 1 - JANUARY 2003
In Brief: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for musculoskeletal injuries because the conditions are believed to be inflammatory in nature. However, because inflammation is a necessary component in the healing process, decreasing inflammation may prove counterproductive. Also, many tendon injuries called 'tendinitis' are, in fact, degenerative and not inflammatory conditions. An analysis of the pathophysiology and healing of musculoskeletal injuries questions the use of NSAIDs in many treatment protocols. Because NSAIDs have profound side effects, they should not automatically be the first choice for treating musculoskeletal injuries.
Musculoskeletal concerns rank with upper respiratory illness as the most common reason patients seek medical attention in family practice.1 Treatment algorithms for musculoskeletal injuries tend to reflexively include the use of nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs). Currently, NSAIDs are among the most widely prescribed drugs in this country.2
Despite the widespread use of NSAIDs, we question their role in many treatment protocols for musculoskeletal complaints--in particular, the clinical value of their anti-inflammatory properties. Although originally marketed as the "safe" alternative to aspirin, NSAIDs are known to have serious gastrointestinal toxicity and other side effects. We review the pathophysiology and healing of musculoskeletal injuries and the clinical evidence regarding the efficacy of NSAIDs in treating a variety of nonrheumatic musculoskeletal injuries.
Mechanism of Action
NSAIDs are used for their analgesic, anti-inflammatory, and antipyretic properties. Their therapeutic actions are thought to stem primarily from their ability to block the formation of certain prostaglandins through inhibition of the cyclooxygenase (COX) enzymes (figure 1). In general, COX-1 catalyzes the production of several cytoprotective prostaglandins that coat the stomach lining with mucus and aid platelet aggregation, among other functions. COX-2 catalyzes the conversion of arachidonic acid into the inflammatory prostaglandins that are involved in three key biological functions: sensitizing skin pain receptors, elevating body temperature through the hypothalamus, and recruiting inflammatory cells toward injured body parts. (The delineation between COX-1 and COX-2 enzymes may be more complex, as described in the section on COX-2 inhibitors below.)
In addition to their effects on prostaglandins, NSAIDs exhibit other properties that have uncertain clinical relevance (eg, inhibition of neutrophil migration, oxidative phosphorylation, and lysosomal enzyme release).3
Inflammation and Healing
A major rationale for using NSAIDs in the treatment of musculoskeletal injuries has been their anti-inflammatory quality. The prevailing argument is that healthy tissue is not inflamed; therefore, if we stop the inflammation in an injured tissue, the tissue will be healthy. The problem with this viewpoint is that, in addition to being a sign of injury, inflammation is a necessary component of the healing process. As noted by Leadbetter,4 "inflammation can occur without healing, but healing cannot occur without inflammation."
Whether the injured tissue is a ligament, tendon, or muscle, the body responds to injury with a sequence of events that begins with an influx of inflammatory cells and blood. The inflammatory cells remove debris and recruit cytokines and other growth factors toward the injury site. This inflammatory phase is partly mediated by the same prostaglandins that are blocked by NSAIDs. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase. The fibroblasts build a new extracellular matrix and persist into the final phase of repair, the maturation phase, where, if all goes well, functional tissue is laid down. The key point is that each phase of repair is necessary for the subsequent phase. By blocking the inflammatory phase, NSAIDs can, at least theoretically, delay the healing of musculoskeletal injuries.
NSAIDs and Musculoskeletal Injuries
NSAIDs are commonly prescribed for the treatment of musculoskeletal complaints such as muscle injuries, ligament sprains, tendon injuries, low-back pain, and osteoarthritis. However, an examination of the pathophysiology and healing of such injuries, as well as a remarkable dearth of clinical trials supporting the efficacy of NSAIDs, raises questions about their use in many treatment protocols.
Muscle injuries. Whether caused by direct trauma or excessive strain, muscle injury is the most common sports injury.5 Although NSAIDs are commonly recommended in treatment protocols, clinical studies documenting their efficacy are notably lacking. We searched MEDLINE (1966 to 2002) using keywords "anti-inflammatories, nonsteroidal," "NSAIDs," "skeletal muscle," or "athletic injuries" and "randomized controlled trials" and found none involving oral NSAIDs. A recent review of studies on strains, contusions, and delayed-onset muscle soreness revealed minimal benefit at best when NSAIDs are compared with placebo.5
While some literature6,7 suggests that NSAIDs may delay the rate of muscle fiber regeneration, the clinical ramifications of this remain unclear. Clinical outcome studies of muscle injuries are difficult to conduct because the injuries tend to heal within days without intervention. Many clinicians in our sports medicine community are turning to short (24- to 48-hour) courses of NSAIDs, hoping to combine the benefits of pain relief and decreased swelling without affecting the regenerative phases of healing. Furthermore, several physicians in our community are now advocating the newer COX-2 inhibitors (discussed below) for muscle injuries with the idea that the drugs' lack of platelet inhibition might further diminish bleeding and swelling in the injured tissue. We are unaware of any studies to substantiate these claims.
Interestingly, users of anabolic steroids anecdotally report that these drugs--which actually increase inflammation--hasten the healing of muscle injuries. A recent animal study8 supports these claims. If anabolic steroids prove helpful for tissue healing in humans, the medical profession may be faced with some interesting ethical decisions.
Ligament injuries. Data on the efficacy of NSAIDs in the treatment of ligament sprains is extremely limited. In 1990, a review by Almekinders9 found only 15 studies that he felt were "carried out in a scientifically appropriate manner," and 8 of those focused on a single joint. NSAIDs were beneficial in half of these single-joint studies (2 of the 6 that examined ankle ligament sprains and the 2 that focused on knee ligament injuries). In 1995, a clinical review10 on treatment modalities for soft-tissue injuries of the ankle stated that "NSAIDs tended to offer significant improvement in recovery time and symptomatic relief over placebo." However, the authors do not state how the papers were selected for review or assessed for validity. Our own search of MEDLINE (1966 to 2002) using keywords "anti-inflammatories, nonsteroidal" or "NSAIDs," "ligaments," and "clinical trials" revealed no studies using oral NSAIDs in the outpatient setting. A 1997 study11 of 364 Australian army recruits who had ankle sprains showed that the group given NSAIDs returned to activity sooner, but had increased instability and decreased range of motion, compared with those given placebo.
The study of ligament sprains is limited, because sprains tend to heal with time and because the outcomes are subjective and favor NSAIDs, which are excellent analgesics. Controlled mobilization of injured ligaments assists healing,12 and, in this context, if NSAIDs decrease pain and thus encourage activity, they may provide some therapeutic benefit. It is unknown whether a similar effect could be obtained with other analgesics, including simply ice.
Tendon injuries. When it comes to tendinitis, the use of NSAIDs as anti-inflammatory agents becomes especially controversial. Contrary to what their name implies (the suffix "itis" denotes an inflammatory process), these injuries may not be inflammatory in nature. Indeed, several experts in this area have pointed out this misnomer and emphasized its unfortunate effect of furthering a false perception that an anti-inflammatory medicine should be used in treatment.13-15
Several large studies14,16,17 have looked at tissue biopsies from chronic injuries of the extensor carpi radialis brevis ("tennis elbow"), Achilles, patellar, and rotator cuff tendons. Results show the tendons to be degenerative and lacking in inflammatory cells. Thus, a more proper term would be either "tendinosis," meaning tendon degeneration, or "tendinopathy," signifying nonspecific tendon pathology. Some have argued that a poor inflammatory process is the precipitant that causes tendon degeneration.13,16
Controlled trials of NSAID use have not resolved this issue. A review15 of MEDLINE from 1966 to 1996 found only 9 prospective studies comparing NSAIDs with placebo. The review noted that NSAIDs provided better pain relief in 5 of the 9 studies. This result is hardly unexpected, given the potent analgesic effect of NSAIDs. The maximum study follow-up was only 1 to 4 weeks; therefore, the long-term effect of NSAIDs on these tendons is unknown.
Low-Back Pain and Osteoarthritis
NSAIDs are frequently used to treat common musculoskeletal conditions, such as low-back pain and osteoarthritis, though they are not classically sports-related injuries.
Low-back pain. The study of treatments for low-back pain is limited by its multiple and poorly understood causes. Two large meta-analyses18,19 were recently conducted, including a Cochrane review in 2000. Both searched MEDLINE for literature from the 1960s to the 1990s; the Cochrane study19 also included Embase studies from 1988 to 1998. Both found very few well-designed trials, and those that were found had small numbers of patients. There were some subtle differences in the reviews, but overall their methods and conclusions were similar.
Koes et al18 found 10 acceptable trials comparing NSAIDs with placebo and concluded that NSAIDs "might be effective for short-term symptomatic relief in patients with uncomplicated low-back pain." The Cochrane review19 identified 11 controlled studies of adequate design and concluded that there is "conflicting evidence that NSAIDs provide better pain relief than placebo for acute low-back pain." The Cochrane review found 5 "acceptable" studies comparing NSAID efficacy to that of acetaminophen and only 1 that was considered "high quality." This high-quality study included only 30 patients. It concluded that there is, at best, level 3 (ie, conflicting or limited) evidence that NSAIDs are more effective than acetaminophen for acute or chronic low-back pain.
Osteoarthritis. Eighty percent of individuals older than 65 have radiographic signs of osteoarthritis (OA), and a large percentage have symptoms.20 Given the chronic nature of the disease and the high incidence of medication side effects in the elderly, an understanding of the risks and benefits of NSAIDs in treating OA is crucial. The two main issues are pain relief and disease progression.
In reviews of clinical trials on OA of the hip and knee, NSAIDs perform significantly better as analgesics compared with placebo.21,22 Most studies comparing different NSAIDs have found no significant difference in their analgesic effects and provide no strong basis for recommending one NSAID over another. A recent randomized controlled trial23 comparing NSAIDs with acetaminophen found a significant benefit in using NSAIDs for moderate-to-severe OA. Previously, only two studies on OA had compared an NSAID with acetaminophen; neither supported a benefit for either medication. Given that the adverse effects of NSAIDs (see below) tend to disproportionately strike the elderly (hence, sufferers of OA), numerous guidelines, including those put forth by the American College of Rheumatology, recommend trying acetaminophen before an NSAID.24-26 An increasing number of small trials are being conducted that compare glucosamine and chondroitin sulfate with NSAIDs. The emerging evidence suggests a trend whereby pain relief during the first 4 weeks is superior with an NSAID, but then plateaus after 1 month.27,28
Whether NSAIDs hasten, attenuate, or have no effect on the progression of OA is unknown. In vitro studies are beginning to show evidence that certain NSAIDs stimulate the synthesis of glycosaminoglycan, whereas others either have no effect or degrade it.29,30 Given this variation in response among NSAIDs, their effects on articular cartilage are likely mediated by a mechanism other than prostaglandin inhibition. If certain NSAIDs prove beneficial to articular cartilage while others prove harmful, future treatment recommendations could change dramatically.
Weighing Side Effects
Although strong and consistent evidence is lacking that NSAIDs clinically benefit the healing of musculoskeletal injuries, they remain potent pain relievers. Their use in this capacity, however, is limited by notable side effects; gastrointestinal (GI) effects are the most common and serious.
GI bleeding secondary to NSAID use is the 15th leading cause of death in the United States.31 Unfortunately, dyspepsia cannot be used as a screening criterion, because only 40% of those who have NSAID-induced GI bleeding report abdominal symptoms before the bleed.32 This might be due to their analgesic effects. Perhaps as a result of their inhibition of platelet aggregation, individuals who have GI bleeding while taking NSAIDs have a significantly higher mortality than those with GI bleeds who are not taking NSAIDs.32
The renal and cardiovascular systems are also affected, because prostaglandins are necessary for renal blood flow and the secretion of sodium and chloride. Prostaglandin inhibition has been shown to raise mean arterial blood pressure by an average of 3 to 5 mm Hg, a small but potentially harmful amount.33 Endurance athletes are often hypohydrated as a consequence of prolonged training. NSAIDs can superimpose further decreases in renal blood flow through prostaglandin inhibition. This combination has been implicated in case reports of acute renal failure in marathoners.34,35 NSAIDs have historically been perceived to be either neutral or beneficial regarding cardiovascular occlusive events. However, a recent study36 suggests that the drugs' temporary platelet inhibition may limit the cardioprotective effects of aspirin by antagonizing aspirin's irreversible platelet inhibition.
Another potential complication for athletes involves the respiratory system. Blocking cyclooxygenase can shunt arachidonic acid toward the formation of the bronchoconstricting leukotrienes (see figure 1). It is estimated that 10% of patients who have asthma experience a decline in their respiratory function as a result of NSAID inhibition of cyclooxygenase.37
The new COX-2 inhibitors are being marketed as the safe alternative to other NSAIDs. Given the recent entry of COX-2 inhibitors into the market, little is known about their in vivo effects (either intended or adverse). Data from clinical trials suggest that their analgesic effects are similar to traditional NSAIDs.38
As their name implies, the COX-2 inhibitors preferentially block the COX-2 enzyme while allowing the pathways catalyzed by COX-1 to proceed. Theoretically, this inhibits the formation of the inflammatory prostaglandins while allowing the production of the homeostatic prostaglandins. Unfortunately, as Oscar Wilde said, "the pure and simple truth is rarely pure and never simple."39 In fact, increasing evidence indicates that the COX-2 enzyme also has some homeostatic functions.
Breyer and Harris40 suggest that the COX-2 enzyme plays an integral role in kidney function and will likely affect blood pressure to an extent similar to traditional NSAIDs. COX-2 inhibitors seem to cause fewer new GI ulcers, although this has not been definitively shown to decrease the number of complications from GI bleeds.41 Interestingly, this might be because the inflammatory pathway is necessary for healing preexisting ulcers.
A concern is that selective inhibition of antithrombotic prostaglandins might increase cardiovascular events. Patients receiving rofecoxib during the VIGOR study42 suffered cardiovascular events at a higher rate than those in the naproxyn group. This prompted a meta-analysis of trials with COX-2 inhibitors43 to state that "the available data raise a cautionary flag about the risk of cardiovascular events with COX-2 inhibitors." A more recent analysis44 suggests that the increased rate of cardiovascular events noted above was actually due to a cardioprotective effect of naproxen and not to increased events in the rofecoxib group.
The expense of COX-2 inhibitors is another major concern; treatment can cost as much as $70 or more than generic NSAIDs per month.45 Certainly, if this decreases other medical costs, this might prove beneficial. Finally, given their inhibition of the inflammatory pathway, all of the concerns regarding delayed healing of injured tissues remain the same when using COX-2 inhibitors.
Clarifying the Role of NSAIDs
Reviewing the most current updates on the use of NSAIDs in the treatment of musculoskeletal injuries is challenging. Although we mention randomized controlled trials, or lack thereof, this review is not intended to be a meta-analysis. Any attempt at a meta-analysis on this topic would be fraught with either a tremendous lack of data (if stringent criteria were used) or controversy (if criteria were loosened).
Given the paucity of data, we are unable to draw any definitive conclusion in support of or against the use of NSAIDs. We realize that many clinicians use anti-inflammatories for musculoskeletal conditions so routinely that any suggestion that little evidence supports their use is interpreted as a condemnation. This discussion is meant to clarify, not simply diminish, the role of NSAIDs. To effectively treat musculoskeletal injuries, the clinician must have realistic expectations about the capabilities of NSAIDs and convey them to the patient. NSAIDs are rarely a substitute for rehabilitation and activity modification.
When used properly, NSAIDs can be a useful, but limited, adjunct. They certainly play a key therapeutic role in the treatment of the crystalline and rheumatoid arthritides and may be beneficial in treating pathologic edema of bursa and synovial tissue (eg, tenosynovitis). For most common sprains, strains, and overuse injuries, however, their therapeutic properties are unproven. It is crucial to keep a proper perspective regarding the role of NSAIDs, especially given their risk of side effects and their potential to blunt the normal healing response. Too many physicians and patients view NSAIDs as critical to recovery. Additional research is needed to define more explicitly the role of NSAIDs in interfering with or delaying healing and the role of other, potentially safer, means to control the pain of musculoskeletal injuries.
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The authors thank Anne Marie Weber-Main, PhD, for her editorial assistance with this manuscript.
Dr Stovitz is an assistant professor and coordinator of sports medicine education in the department of family practice and community health at the University of Minnesota in Minneapolis. Dr Johnson is the director of primary care sports medicine in the department of family practice at Hennepin County Medical Center in Minneapolis and is president of the American Medical Society for Sports Medicine. Address correspondence to Steven D. Stovitz, MD, Smiley's Clinic, 2615 E Franklin Ave, Minneapolis, MN 55406; e-mail to email@example.com.
Disclosure information: Drs Stovitz and Johnson disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.
Wrapping an Ankle Sprain
Here is how to wrap a typical ankle sprain caused by inversion (ankle turned inwards):
1) Position the foot straight (in dorsiflexion), not pointed. You want the injury to heal in an unstretched position.
2) Wrap the elastic bandage around the foot several times for an anchor.
3) Coming from outside, bring the wrap over the ankle and around the back of leg just above the ankle, pulling the outer edge of the foot slightly upward (eversion, twisting outward, opposite of the injury), to counteract the inversion injury.
4) Complete several figure-8 wrapping patterns, again coming from the outside up and around the back of the leg, keeping the foot in dorsiflexion and slight eversion.Don't wrap too tightly. You want to slow the circulation, not stop it. Frequently check feeling, colour and temperature of areas beyond the injured portion; if they become numb, blue or cold, loosen the wrap.
Some further info at The Physio Room
Good stuff worth sticking for sure.
I drink alot :alcoholic: ...so I'll be using this quite a bit probably :owned:
good stuff...should be a sticky
Thanks everyone. Sorry for the frequent edits. I've had to use more sources then I could count to try to get the most consistent info as well as a few medical texts that I checked out from the city library. As I have found more information I have continued to revise it...most of the info I find is similar enough except for certain details. I think the above to be a pretty good consolidation.
I found this at Discussbodybuilding.Com:
As always, be careful and cross reference info from several sources. Some of the exercise threads may be useful but may just as well be harmful since they weren't written be trained proffesional. For instance there is a thread with Rotator Cuff rehab exercises that has isometrics but then goes on to describe methods that are NOT isometric, so take things with a grain of salt.
There are personal experiences there as well so that is good.
*Edit* I've been looking over the injury forums at several different sites and I have to say most of the advice sucks pretty bad. Definitely not how you should get most of your info. I'm seeing things like "I strained/pulled a muscle." Advice: "Start stretching it." Hmmmm. Right. I think what happens is that people recover (or think they do) from one or several injuries despite lack of professional advice and they think that makes them an expert.
I myself had a VERY bad sprained ankle once. My foot swelled up so badly my toes actually disappeared. My treatment consisted of, um, pretty much nothing. I started putting weight on it almost immediately despite the severe pain. It recovered. So there you go, I'm an expert. When you sprain your ankle my advice is to pretty much ignore it. Or you could be smart and ignore my advise!
:joke: (with a point)
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