Many Distance Runners Use Analgesics Indiscriminately. The Consequences Could Be the Ultimate Overuse Injury

Los DISTANCE running is associated with pain—the pain of a maximal race effort, the pain of interval training, the pain of the long run. There is also the devastating pain of injury.

The marathoner and ultrarunner trains on the edge, balancing ona tightrope between optimal performance and overuse (overload) injury. The insidious nature of the overuse injury feeds the athlete’s tolerance of training-related pain. The distance runner typically deals with pain in one of two ways: by tolerating it or by medicating it. Both practices are readily accepted by the runner as occupational hazards.

The most popular drugs used by endurance athletes for pain are a group of analgesics (pain relievers) commonly known as “nonsteroidals” or “NSAIDs” (Non-Steroidal Anti-Inflammatory Drugs). Ibuprofen, Motrin, Advil, and Aleve are the most common NSAIDs. Aspirin is also considered an NSAID.

The use of NSAIDs by athletes has reached astronomic proportions, exceeded only by the marketing budgets and retail sales of the manufacturers of these drugs. Their availability over the counter at convenience stores, pharmacies, and grocery stores has only increased their use and overuse with little regard for efficacy or risk. In fact, I’ve often referred to these medications as “Vitamin N” because of their ubiquitous and haphazard use in the athletic community.

This careless and indiscriminate use of NSAIDs with potentially serious consequences became woefully apparent to me when I became the medical director of two ultramarathons. Each aid station literally had a bowl of ibuprofen on the table. Runners coming by would take a cup of water, a cup of electrolyte replacement drink, a piece of banana, and a handful of “drugs.” I quickly removed the ibuprofen and advised that it be replaced with a different analgesic.

The reasons for this recommendation are included in the following discussion of what we know about NSAIDs and aspirin, their therapeutic limitations, and the risk to runners who use them indiscriminately.

THE INSIDIOUS USE OF IBUPROFEN

Ibuprofen and its related medications were initially developed as “safe” alternatives for the treatment of rheumatoid arthritis, especially for those who experienced adverse side effects from aspirin, which has long been first-line therapy for rheumatoid arthritis.

Rheumatoid arthritis is an inflammatory arthritis with well-known chemical processes that cause serious alteration of the joint cartilage and, ultimately, destruction of the joint. Somehow, over the years, physicians began to prescribe these NSAIDs to treat non-rheumatoid conditions that were thought to be inflammatory in character.

Since inflammation is assumed to be involved in athletic injuries (both acute and overuse), NSAIDs are used for treatment, even though there isn’t any proof that NSAIDs will be effective for treating such injuries. Scientific proof of efficacy still lags far behind popular clinical use.

No studies yet show that the use of NSAIDs speeds recovery or improves outcomes in treating training aches and pains and overuse injuries.

The effective marketing practices of the pharmaceutical companies using anecdotal reports or the testimonies of recognizable professional athletes have further fueled the use (or overuse) of this group of drugs.

Scouring the scientific literature for evidence of the efficacy of these drugs in acute sports injuries is not rewarding. Though many studies have been conducted, few meet the rigorous criteria usually applied to well-conducted medication evaluations. The NSAID research accepted by medical experts does not clearly show that NSAIDs are an effective treatment for acute sports injuries such as an ankle sprain.

Most of the studies using NSAIDs in the treatment of acute injuries show that most of the benefit comes in the first one to two days following the injury,

when compared to a placebo. But no differences in final outcome or return to practice or play have been convincingly demonstrated. Currently, most experts who have researched this subject agree that the early benefit of NSAIDs in acute injuries is likely due to their potent analgesic effect rather than any significant impact on the inflammatory process of the injury.

Why is this? First of all, the inflammatory response in acute injury has never been shown to be identical to the inflammatory process of rheumatoid arthritis. Thus, the effects of NSAIDs on reducing the inflammation of acute injuries are not predictable or proven.

Secondly, while NSAIDs reduce inflammation by affecting the prostaglandin pathway, inflammation of soft tissue is not solely dependent on this pathway but on other factors as well that are not affected by NSAIDs. There are many other mediators of inflammation. Consequently, these processes remain unaffected by the medications.

Another important hypothetical consideration raised by experts is the actual role of inflammation in the healing process. The natural healing process is aided by the process of inflammation. As yet unknown is whether the use of NSAIDs actually inhibits the contribution of the natural healing effects triggered by the injury and inflammation. Animal studies have shown slower bone healing rates in animals with bone fractures that were given NSAIDs compared to those that received a placebo. Clinically, then, the inappropriate or prolonged use of NSAIDs may actually retard the healing process they were meant to enhance.

NO PROOF OF IMPROVED OUTCOMES

There are no studies yet that show that the use of NSAIDs speeds recovery or improves outcomes in those using them to treat their training aches and pains and overuse injuries. This news may come as a surprise for those who have treated their own injuries or have been treated by the medical community for running injuries with “ice and nonsteroidals,” a treatment mantra for many medical practitioners. Any perceived benefit is most likely due to the very effective pain-relieving capabilities of these medications.

There is also very scant information regarding the effects of NSAID on the postmarathon muscle soreness (or any delayed-onset muscle soreness) that afflicts us all for several days after an event. Again, any benefit is probably because NSAIDs effectively, very effectively, relieve pain.

I have also heard reports of some endurance athletes “loading” up with NSAIDs prior to an event. I assume this is done to build a “bank” orreserve of antiinflammatory effect to be released in a massive quantity when pain and inflammation begin. A nice thought, but the human organism doesn’t function this way.

The body continuously metabolizes and excretes any medication after it is ingested. We have no means of “storing” the drug or its effects.

SIDE EFFECTS AND RISKS OF NSAIDS

We must also bear in mind that every medication has side effects. Most of the time the side effects are extremely infrequent, or the potential benefit of the medication far outweighs the risk. NSAIDs are no different. Their availability without prescription should not imply little or no risk. The most common targets for side effects are the stomach and kidneys.

Aless significant effect of NSAIDs involves platelets, those tiny circulating particles that help blood clot when we bleed. They are rendered inactive in the presence of NSAIDs. As soon as the drug clears the body, however, normal function of the platelet is restored. Blood in the urine and bleeding from the gastrointestinal tract are known occurrences in long-distance running, but incidences are usually minor. However, if the clotting effects of the platelets are compromised by the use of NSAIDs, the body’s natural clotting of this blood is shut off, and the threat from bleeding can be increased significantly.

Potential Problems with the Stomach

The occurrence of side effects on the stomach from taking NSAIDs is estimated to be 15 to 25 percent of all users. In studies of the adverse effects on the stomach, NSAIDs have caused visible erosions of the lining of the stomach (gastric mucosa) in as many as 60 percent of those who use NSAIDs, even though the user may have no symptoms of abdominal pain. In fact, cases of life-threatening bleeding from the stomach caused by anti-inflammatory medications have been reported where severe bleeding was the very first sign of a problem.

The cause of these stomach problems occurs through two distinctly different mechanisms. One is a direct effect of the medication, which causes local irritation when the tablet or capsule makes contact with the stomach lining. This can be minimized by taking the medication with a meal or a snack. The second problem occurs because NSAIDs block the release of a chemical that normally protects the stomach lining. The absence or reduction of this protective chemical increases the risk of irritation and breakdown of the stomach lining. Taking the medicine with food has no protective effect in this instance.

Potential Problems with the Kidneys

Uncommon but possible kidney problems related to NSAIDs include allergic interstitial nephritis and vasomotor nephropathy. I use these terms not to impress you but to inform you that direct kidney damage can occur in some users.

Of more concern to me is the potential for catastrophic kidney failure as a combined effect of dehydration (low fluid volume) related to inadequate fluid replacement during training and competition and the effect of NSAIDs on a prostaglandin that affects blood flow to the kidney. Prostaglandin is a chemical in the kidney that aides dilatation of the blood vessels to the kidney. NSAIDs block this hormone, which results in constriction of the kidney’s blood vessels.

Consider this scenario: Start with a runner who is inadequately rehydrated, or even dehydrated, following a training run or long-distance event. Add a few NSAIDs for muscle pain or injury and you have an athlete who is primed for a kidney problem. The volume of blood flowing through the kidney is already diminished by the event. This low blood volume to the kidney is compounded by the inhibition of the kidney prostaglandin, which results in kidney blood vessel constriction with an even lower volume of blood delivered to the kidney. If the kidney blood flow is drastically reduced, the kidneys can shut down, resulting in kidney failure.

Indeed, cases of acute kidney failure during ultradistance events have been reported (with scenarios like the one just described). Fortunately, kidney dialysis successfully reversed the problem in these individuals by restoring their normal kidney function. At the risk of understatement, dialysis seems more than an unfortunate, inconvenient circumstance most of us would like to avoid.

ASPIRIN: THE WONDER DRUG?

Aspirin is an effective analgesic, but probably not as potent when compared to other NSAIDs. It has been proven effective in reducing the risk of heart attacks and strokes and effective in rheumatoid arthritis. | would consider using aspirin and ibuprofen interchangeably. Ibuprofen may be a more potent pain reliever.

Regrettably, aspirin has similar adverse effects in the body to those discussed regarding NSAIDs. Aspirin may be a little more toxic to the stomach and a lot less toxic to the kidney, but the potential to damage the stomach is still there. The aspirin effect on platelets is more profound: The platelets are rendered useless for their 10- to 12-day lifespan if exposed to aspirin.

OTHER RISKS OF ANALGESICS

Another hypothetical risk to consider is the effect these medications have to control fevers. During an illness that is accompanied by a fever, NSAIDs and aspirin lower temperatures. To lower body temperature, aspirin and NSAIDs have to exert some effect on the hypothalamus (our body’s thermostat). Does this temperature control help or hinder optimal athletic performance in the healthy runner? How does this affect athletic performance on a very hot or very cold

day when the body has to adjust to temperature extremes? Is the body more or less efficient at temperature control in the presence of NSAIDs and aspirin? I have no answers to these questions. I raise them only to emphasize a possible deleterious effect on internal temperature control during endurance activity. My intuitive hunch is that aspirin may blunt a normal physiologic response or confuse the hypothalamus, thereby affecting the body’s ability to withstand temperature extremes while exercising. But no studies have been conducted to support this hypothesis.

One other seldom discussed risk is financial. The range of treating yourself with over-the-counter or doctor-prescribed NSAIDs can range from $10 to $100 per month if used regularly. If you use them, choose wisely, especially since the risks and benefits may not justify their expense.

SHOULD YOU USE ANALGESICS?

After this apparent condemnation, the question is why use NSAIDs and aspirin at all? I still find a role for the judicious use of NSAIDs in my sports medicine practice. Just because NSAIDs haven’t been proven conclusively to speed the healing process and return athletes to competition faster doesn’t mean they don’t have some benefit.

For the acute injury, such as an ankle sprain, I use maximum doses of NSAIDs for two to four days in the chance they might inhibit an exaggerated inflammatory reaction, but I limit the duration to minimize the theoretical risk of blocking or delaying a normal healing response. At worst, the medications will give some pain relief, which will permit the athlete to begin the all-important rehabilitation.

If I need further analgesia, I turn to nonaspirin drugs such as acetaminophen or extra-strength acetaminophen. These are very safe in healthy individuals and are quite inexpensive if generics are used. Since they exhibit little or no antiinflammatory effect, I needn’t worry about inhibiting healing.

If NSAIDs are to be used in someone who has stomach problems or kidney problems, I use a group of prescription medications in the family of nonacetylated salicylates. These seem to have little toxic effect on the kidney, stomach, or platelets. Again, I use them for brief periods in the acute injury.

For the more common overload or overuse injury in the endurance athlete, I suggest up to two weeks of NSAID therapy, realizing that if a benefit is perceived by the injured athlete, it may only be relief of a symptom: pain.

Iam uncomfortable leading athletes to believe that I am curing inflammation in their injuries; rather, I am treating a symptom and possibly treating some of the cellular chemical changes that occur with the tendinitis or fasciitis or whatever “itis” | might have diagnosed. Furthermore, I never want to convey to the

Robert Johnson, MD ANALGESICS: CURE OR CURSE? 47

athlete that the cure is in the pill. This permits a passive approach to treatment, which only serves to retard recovery. I still feel that judicious use of ice after training, stretching and strengthening the injured part, and commonsense training alterations are far more critical to the success of the treatment plan than a silly little pill.

SUMMARY

I liken NSAIDs to an oft-used expression describing the quarterback in football: “They get too much credit when they win [work] and too much blame when they lose [don’t work].” Part of the reason for this Jekyll and Hyde evaluation of NSAIDs is due to the unrealistic expectations physicians and athletes place on these drugs. Too much is expected. I view NSAIDs as extremely effective pain relievers. I don’t see them as great anti-inflammatory drugs for athletic injuries and aches and pains.

Therefore, my therapeutic goals are usually accomplished when I include NSAIDs as a part, albeit a small part, of my treatment regimen. If NSAIDs are used indiscriminately and without respect, the wrong edge of the proverbial two-edged sword may strike. PH

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