Ibuprofen and NSAIDs: The Grand Deception

The following statement comes from a well-known sports medicine book that has gone through five printings. "In spite of the widespread use of NSAIDs there is no convincing evidence as to their effectiveness in the treatment of acute soft tissue injuries." (Bruckner, P. Clinical Sports Medicine. New York City, NY: McGraw-Hill Book Company, 1995, pp. 105-109.)

In spite of the widespread use of NSAIDs there is substantial evidence that they hamper soft tissue healing.

• NSAIDs have been shown to delay and hamper the healing in all the soft tissues, including muscles, ligaments, tendons, and cartilage
• Anti-inflammatories can delay healing and delay it significantly, even in muscles with their tremendous blood supply
• In one study on muscle strains, Piroxicam essentially wiped out the entire inflammatory proliferative phase of healing (days 0-4). At day two there were essentially no macrophages (cells that clean up the area) in the area and by day four after the muscle strain, there was very little muscle regeneration compared to the normal healing process. The muscle strength at this time was only about 40% of normal.

(Green, J. Cost-concious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis. Archives of Internal Medicine. 1992; 152: 1995-2002.)

Another study confirmed the above by showing that at day 28 after injury the muscle regenerative process was still delayed. The muscles of the group treated with Flurbiprofen (NSAID) were significantly weeaker. The muscle fibers were shown under the microscope to have incomplete healing because of the medication. (Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123.)

Asking the Right Questions

• The key question regarding the healing of sports injury is, "What exactly does any therapy do to the fibroblastic cells that actually grow the ligament and tendon tissue?"
• Treatments that stimulate fibroblast proliferation will cause ligament and tendon repair and will help the athlete heal.
• Therapies that kill or hamper fibroblastic growth will be detrimental to the athlete.

Functional Medicine

In 1993 at the University of North Carolina School of Medicine, Division of Orthopaedic Surgery, Sports Medicine section, Dr. Louis Almekinders and associates studied human tendon fibroblasts to determine the effect of exercise and the NSAID Indomethacin on fibroblasts. Group 1 was the control in which no treatment was done; Group 2-the tendons were exercised; Group 3-the tendons were just anti-inflamed with the Indomethacin. All the tendons underwent injury through repetitive motion, similar to what would happen to an athlete in training. Seventy-two hours after the injury, it was noted that compared to controls the only group that showed increased levels of prostaglandins was the exercised group. The group that was exercised and received the NSAID, as well as the NSAID group, had statistically significant lower levels of prostaglandins (specifically Prostaglandin E2) in the tendons. THis showed that the NSAID blocked the inflammatory healing of even the tendon injuries that were exercised or rehabilitated. The tendonitis that was treated with just the NSAID had almost no prostaglandins in the sample, signaling a complete inhibition of the inflammatory healing process. The effect was even more pronounced at 108 hours.

Why interrupt the repair?

The researchers also measured DNA synthesis in the fibroblasts. This showed which fibroblasts were proliferating. Again, the exercised group was the only group that exhibited elevated levels of DNA synthesis in the fibroblasts. Compare to the control group there was 100 percent more growth of fibroblasts in the exercise group. The tendons treated with Indomethacin had no DNA synthesis noted.

Counter Culture

This showed there was no fibroblastic growth occurring. The group that exercised and took the NSAID showed a little bit of growth. The authors concluded, "Motion and prostaglandin release in Group 2 were associated with increased DNA synthesis. Inhibition of prostaglandin by Indomethacin also coincided with a decrease in DNA synthesis. Inhibition of prostaglandin synthesis, and thereby DNA synthesis, may not be desirable during the proliferative stage of a soft tissue injury, when DNA synthesis for a cell division of fibroblasts is needed to heal the injury to the tendon.The paper also stated a fact that many researchers in this field are wondering, "Despite the lack of scientific data, NSAIDs are widely used, often as the mainstay treatment.(Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123.)

All Making Sense

Another study was done on the use of perhaps the most popular anti-inflammatory medication used in sports medicine, ibuprofen, in the treatment of tendon injuries. It was found that the only thing the ibuprofen doses used in the study caused the strength of the flexor tendons to decrease. A decrease in strength of the flexor tendons of 300 percent was observed at 4 weeks. The peak force of the flexor tendons of controls was 12.0 newtons, whereas in the Indomethacin group it was an average of 2.5 newtons. Extensor tendon analysis showed similar results, with controls having a breaking strength of 12.0 newtons and the tendons treated with the NSAID, 3.5 newtons. The authors noted, "Examination of the data reveals a marked decrease in the breaking strength of tendons at four and six weeks in the ibuprofen-treated animals...This difference was statistically significant." (Kulick, M. Oral ibprofen: evaluation of its effect on peritendinous adhesions and the breaking strength of a tenorrhaphy. The Journal of Hand Surgery. 1986; 11A:100-119.)

From the above studies, it is clear that NSAIDs inhibit the fibroblastic growth process and thus diminish an athlete's chance of healing. NSAIDs are used because they decrease pain, but they do so at the expense of hurting the healing of the injured soft tissue.

This is True in the All Tissue Repair

Do you see the difference between pain relief and healing? The athlete needs healed tissue. Up until the present, too many studies were advocating NSAID use when it came to ligament injuries, because they were such great pain-relievers, when in fact the were stopping the healing mechanisms of the body. Any technique or medication that stops the normal inflammatory process that helps heal the body must have a long-term detrimental effect on the body.