Is Treating a Running Injury with an Anti-inflammatory Medication Effectual or Obsolete? The Recent Research Explained
According to popular wisdom, inflammation is the main cause of pain in running injuries.
The suffix of many — plantar fasciitis, Achilles tendonitis, patellar tendonitis — also implies that the root cause is inflammation at the injured area. Even for injuries that do not end with an –itis, like shin splints, many experts would describe them as inflammatory conditions.
So it follows that the way to address these injuries is by reducing the inflammation, hence the prescription of ice, elevation, compression, and anti-inflammatory drugs like Advil and Aleve. But do these treatments do anything to actually speed the recovery?
This week’s article will hone in on the role of anti-inflammatory drugs. We’ll leave icing, compression, and elevation to another day.
Anti-inflammatory drug types
There are three main over-the-counter drugs that runners take for various aches and pains:
Ibuprofen and naproxen are both non-steroidal anti-inflammatory drugs, or NSAIDs. Advil is the most common brand-name of ibuprofen, and Aleve is likewise the most common brand name for naproxen.
In addition to interrupting the body’s inflammatory process, they also behave as pain relievers.
Acetaminophen, commonly sold as Tylenol, is not an anti-inflammatory; it only relieves pain. The efficacy of NSAIDs like Advil and Aleve at cutting down on inflammation is well-established—this is why they are commonly prescribed for chronic inflammatory conditions like rheumatoid arthritis.
But whether they speed recovery from running injuries, and whether they are even a healthy treatment at all, is not.
Injury and anti-inflammatory drug research
While there is a distinct lack of “gold standard” clinical studies comparing groups of injured runners who take anti-inflammatories post-injury to those who do not, there is still some evidence that NSAIDs may be interfering with the body’s ability to repair itself after an injury.
- A 2006 study, which evaluated the effect of ibuprofen on the Achilles tendon in rats, found that the drug inhibited the proliferation of tendon cells, which would not be good news in an injured area.1
- Another study that artificially stressed human tendon cells and examined their response when treated with NSAIDs also found that anti-inflammatories inhibited protein synthesis, the initial step in healing a damaged tendon.2
- A third study investigated the effects of specific anti-inflammatory drugs on the healing of an injured patellar tendon in rats. About 200 rats underwent an artificially-induced tendon rupture, then were split in to a control group and various experimental groups given different anti-inflammatory drugs—some over-the-counter types like ibuprofen and naproxen, and some prescription-strength drugs reserved for chronic conditions like arthritis.3 Two weeks after the initial injury, the rat tendons were removed and had their mechanical properties tested with the following results:
- Significant detrimental changes in tendon strength compared to the control group were seen among the tendons exposed to anti-inflammatories except for Ibuprofen.
- Ibuprofen, did not seem to have an effect on tendon healing and Acetaminophen, which is not an anti-inflammatory drug, had no effect on tendon healing either.
While the evidence for all of these inhibitory effects is rather weak, it’s worth noting that there isn’t much good evidence that NSAIDs have any positive effects on overuse injuries either.
Furthermore, new research is showing that many overuse injuries are not the result of inflammation; rather, they are the result of damage and degeneration of tendons or bone.
Tendon injuries: inflammation or degeneration
When analyzed with biological assays, samples of damaged tendons show little or no evidence of inflammation.
There’s even a push to replace the –itis suffix in many common injuries with -osis, which indicates a pathology or degeneration instead of inflammation.4, 5
Because of this, and because of the typically mild but notable side effects of NSAIDs, researchers and doctors are now starting to advocate avoiding prescribing anti-inflammatory drugs for overuse injuries.
As Merzesh Magra and Nicola Maffulli ponder in a 2006 article:6
“Can the continued use of NSAIDs for the treatment of tendinopathies be justified? The available literature would suggest that in the absence of an overt inflammatory process, there is no rational basis for the use of NSAIDs in chronic tendinopathy, because they are unlikely to change its still ill defined natural history. Despite this reality, many clinicians still anticipate a quicker and better recovery using these agents. There is no biologic basis for NSAID7; effectiveness in treating this condition, and no evidence of any benefit. NSAIDs appear to be effective, to some extent, for pain control. This causes patients to ignore early symptoms, and thus may lead to further damage of the tendon and delay definitive healing.”
This opinion is echoed by Steven Stovitz and Robert Johnson, both doctors at the University of Minnesota, who write:7
“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.”
While the evidence that anti-inflammatory drugs like ibuprofen and naproxen can inhibit tendon and bone healing is limited and mostly confined to studies of rat tendons and cells in cultures, there isn’t any better evidence that they do any good besides relieve pain.
And as Magra and Maffulli point out, pain relief may not necessarily be a good thing: it might cause you to ignore pain and cause further damage to an injured area.
Plus the consideration of the possible side effects (including nausea, indigestion, and gastrointestinal bleeding), suggests that anti-inflammatories should not be a part of your standard injury treatment regimen.
Inhibiting healing and delaying recovery aren’t a good trade for a bit of short-term pain relief.
1. Tsai, W.-C.; Tang, F.-T.; Hsu, C.-C.; Hsu, Y.-H.; Pang, J.-H. S.; Shiue, C.-C., Ibuprofen inhibition of tendon cell proliferation and upregulation of the cyclin kinase inhibitor p21CIP1. Journal of Orthopaedic Research 2006, 22 (3), 586-591.
2. Almekinders, L. C.; Baynes, A. J.; Bracey, L. W., An in vitro investigation into the effects of repetitive motion and nonsteroidal antiinflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine 1995, 23 (1), 119-123.
3. Ferry, S. T.; Dahners, L. E.; Afshari, H. M.; Weinhold, P. S., The effect of common anti-inflammatory drugs on the healing rat patellar tendon. American Journal of Sports Medicine 2007, 35 (8), 1326-1333.
4. Lemont, H.; Ammirati, K.; Usen, N., Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association 2003, 93 (3), 234-7.
5. Maffulli, N., Overuse tendon conditions: Time to change a confusing terminology. Arthroscopy: The Journal of Arthroscopic and Related Surgery 1998, 14 (8), 840-843.
6. Magra, M.; Maffulli, N., Nonsteroidal Antiinflammatory Drugs in Tendinopathy-Friend or Foe. Clinical Journal of Sports Medicine 2006, 16 (1), 1-3.
7. Stovitz, S. D.; Johnson, R. J., NSAIDs and musculoskeletal treatment: what is the clinical evidence? Physician and Sportsmedicine 2003, 31 (1), 35-52.