As a sideline observer, I have frequently witnessed coaches, first aid providers, and anxious parents reaching into their training bags and purses, and medicating the acutely injured athlete. As an orthopedic surgeon interested in sports medicine I treat athletes who were initially prescribed medications by their primary care physicians, emergency room personnel, or have self-medicated with over-the-counter (OTC) medications or those found left over in their medicine cabinets. It is important to understand the role of medication in the treatment of sports related injuries, particularly in regards to their efficacy, and most importantly, their potential side effects. The purpose of this article is to review the classes of medications commonly used in this environment and to provide guidelines for their rational usage. While other classes of medication may be mentioned, this discussion will be focused on the most commonly used classes of drugs, pain relievers (analgesics) and anti-inflammatory medications.
Analgesics: Analgesics are used specifically for their pain relieving property. Two sub-categories exist, narcotic and non-narcotic preparations. Narcotics exist in both injectable and oral forms. Injectables include Morphine, Demerol, and Dilaudid. These are almost exclusively used in emergency rooms and hospitals for the treatment of moderate to severe pain associated with acute musculoskeletal injuries or following surgical treatment. The oral forms commonly prescribed are Tylenol with codeine, Vicodin, Norco, and Lortab. Each is combined with acetaminophen to enhance its pain relieving properties. They should likewise be reserved for the treatment of moderate to severe pain. Side effects of narcotics include GI upset, nausea, and altered consciousness. They also have the capacity for recreational drug abuse and physical addiction. Acute injuries and chronic musculoskeletal conditions requiring their usage under almost all circumstances should preclude the athlete from returning to his or her sport until the medical condition has evolved to the point where these medications are no longer necessary. One particular injury requiring special consideration is the treatment of head trauma. Because of narcotics effect on the central nervous system, including sedation and potential mental status changes, they may interfere with the need for monitoring an injured player who has sustained this type of injury, including even minor concussions. This is particularly important in the first 24 to 48 hours following injury.
The most common non-narcotic analgesic is acetaminophen. This is marketed under its generic name, as well as the popular Tylenol brand. It has long been recognized as safe and effective in the treatment of mild to moderate pain. It is usually well-tolerated and has minimal side effects or interactions with other medications. It can be safely used to supplement the pain relieving properties of nonsteroidal anti-inflammatories. Available in a liquid form, it may be useful in youth athletes who have difficulty swallowing tablets or pills. It does, however, have the potential for causing liver damage when used in dosages which exceed the maximum recommended daily dosage. In an adult, the maximum dosage should not exceed 4,000 mg (4 grams) in a 24 period. When used in children, parents should follow the recommended dosages included on the product’s packaging. As noted above, acetaminophen is frequently combined with oral narcotics. Therefore, the patient needs to be careful that this be figured into their maximum daily dosage. As will be discussed in more detail below, acetaminophen has no effect on blood clotting. Whether or not an injured athlete using acetaminophen should continue to compete ultimately depends on the specific condition requiring its use.
Anti-inflammatory Medications: The other class of drugs commonly used in the treatment of athletes are the anti-inflammatory medications. These exist as steroid and nonsteroidal anti-inflammatories (NSAIDS). Anti-inflammatory steroids, however, should not be confused with the anabolic steroids recently publicized as being abused by athletes. Anti-inflammatory steroids are available only through prescription. They include the commonly prescribed oral form, prednisone, and the various preparations that are the main ingredient of “cortisone shots”. Neither form has much value in the treatment of acute athletic injuries with the possible exception of severe head or spinal trauma. They may be utilized in such conditions as exercise-induced asthma, or allergic reactions to environmental substances or insect bites. When used in the proper setting under a physician’s care, anti-inflammatory steroids can be extremely beneficial in the treatment of chronic athletic conditions involving inflammation such as tendinitis, bursitis, and low back pain.
Non-steroidal anti-inflammatory medications (NSAIDs) have been available for decades. All initially came to market as prescription medication. As they lose patent protection, many are sold over-the-counter (OTC). The only difference between those prescribed and those sold OTC is that of dosage. The most recognized NSAIDS are ibuprofen and naproxen sodium. Ibuprofen is marketed under its generic name, as well as, various brand names
including Advil and Motrin. Naproxen sodium is the main ingredient of Aleve and Naprosyn. Additionally, they are commonly included in OTC cold and allergy preparations. These medications have two properties which make them useful in the treatment of sports injuries. Much like acetaminophen, they provide a direct analgesic effect. As their name implies, they are also useful in reducing inflammation most commonly associated with non-traumatic or more chronic musculoskeletal conditions. Their frequent use, therefore, in the treatment of acute athletic injuries is worth some additional attention. While soft tissue swelling is often times associated with chronic inflammatory conditions, the swelling associated with acute injuries will probably be little affected by anti-inflammatory medication.
The majority of anti-inflammatory medications have an influence on the body’s blood clotting system. This side effect has been publicized as being useful in the prevention of heart attacks in adult patients. While a benefit in this instance, the “blood-thinning” side effects of anti-inflammatory medications may have negative consequences in many acute sports-acquired injuries by increasing the risk of additional bleeding. This is particularly the case in those injuries such as fractures, significant muscle tears, contusions often acquired in contact sports, and even the more severe ligament sprains about the knee and ankle. In fractures and deep contusions, bleeding may cause potentially limb- threatening complications because of the build up of excessive pressure within the tissues involved. In contusions, most notably those sustained by soccer players to the lower leg, excess bleeding may result in the formation of hematomas, localized areas of blood accumulation which the body may have difficulty resorbing, ultimately requiring surgical drainage. At the very least, excessive bleeding following these types of injuries will certainly lengthen the athlete’s recovery period and prolong the time prior to return to sports. Their use following head injury is also potentially dangerous in causing additional cerebral bleeding. It is important to remember that the anticoagulation effects of anti-inflammatory medications will persist for a period of seven to ten days following discontinuation of their use. If an athlete has been taking these medications, it is possible sustaining an acute injury during that time frame might lead to undesirable increased bleeding and bruising.
When used in the proper setting, oral anti-inflammatory medications can be of great benefit in the treatment of specific sports related injuries and other conditions affecting the musculoskeletal system. Aside from the specific side effect involving blood coagulation, other common side effects include
gastrointestinal upset, gastrointestinal bleeding, fluid retention, and for those patients on high dose long term usage, the risk of liver or kidney damage. Patients using these medications chronically need to be monitored. Remember that these side effects are present in both over-the-counter and prescribed forms.
Recently the lay press has highlighted the potential complications of increased risk of heart attack and stroke in patients being prescribed the newer generation of anti-inflammatory medications referred to as Cox-2 inhibitors. These include the highly marketed Celebrex, Vioxx, and Bextra brands. These complications have primarily been seen in older patients with a history of pre-existing cardiac disease, taking higher doses over longer periods of time. They may still be a beneficial in patients who are at high risk for gastrointestinal complications. Of note is that the Cox-2 inhibitors do not share the increased bleeding risk associated with the earlier generations of NSAIDs. Their use may therefore be of benefit in the treatment of certain athletic injuries where additional bleeding would be detrimental. This, however, must be an informed decision made between patient and physician.
Antibiotics: Antibiotics may be required in the treatment of sports-sustained lacerations and abrasions which become secondarily infected. Recently there has been concern raised over the growing incidence of infections caused by an antibiotic resistant strain of the very common bacteria, Staphylococcus aureus. This is referred to as Methicillin-resistant Staphylococcus aureus (MRSA). Infections caused by this bacteria apparently can develop without an obvious open skin wound. Many times it will be mistaken for an infected hair follicle, “pimple”, insect or spider bite. It can appear rather innocuous in the first several days following its presentation but can quickly develop into a more significant infection which can be limb and even life-threatening. While often seen in athletes participating in close contact sports such as football and wrestling, it has been reported in almost every sport and its incidence seems to be growing at an alarming rate. Any athlete who exhibits such a condition should seek immediate medical attention. When antibiotics have been prescribed they should be continued for the full treatment course. If an infection does not seem to be responding or certainly worsening while under treatment, this should be reported to the treating physician.
Miscellaneous OTC Medications: These include the highly publicized glucosamine and chondroitin sulfate, MSM, a large variety of herbal based medications, as well as nutritional and
mineral supplements. Athletes should be aware that these are poorly monitored and controlled substances. Despite the fact that they are sold OTC and marketed as containing “natural” ingredients, many of these are substances can have significant side effects and drug interactions. It is important to remember that their efficacy, content, and purity are not monitored by the FDA. Their value in the treatment of acute and chronic sports injuries is usually anecdotal and rarely supported by investigational or clinical studies.
Conclusion: In summary, medications can be an important part of treatment programs designed for the management of both acute and chronic sports injuries and musculoskeletal conditions. Their use and value must, however, be considered on a case by case basis. Potential side effects must be recognized and understood.
Analgesics are valuable in the management and control of pain associated with injury. They should not, however, be used to allow an athlete to return to sports participation prematurely. This is especially true when narcotic analgesics are required. The use of narcotic analgesics should also be avoided in acute head trauma under most circumstances, especially in the critical first 24 to 48 hours. Non-steroidal anti-inflammatory medications are of considerable usefulness, particularly in the treatment of those conditions associated with inflammation or chronic in nature. They are probably over-prescribed, however, in the acute injury setting. Because of their potential for increased bleeding, they should be used with caution in injuries where significant bleeding may occur. Athletes and parent care providers for younger sports participants need to be aware that even OTC medications have potential side effects that can be detrimental and even dangerous when used in an improper fashion. Aside from the minor bumps and bruises that most athletes sustain during their playing careers, the utilization of medications in the treatment of athletic injuries should be discussed with physicians familiar and comfortable with their management.