Abstract
“Your pain is the breaking of the shell that encloses your understanding.”
–Kahlil Gibran (1883–1931). The Prophet.
Knees may lock, shoulders dislocate, and ankles give out, but pain is the symptom most likely to bring an athlete to the doorstep of an orthopaedic sports medicine specialist. Pain is as integral to sports participation as it is inimical to it. Athletes may ignore it, tolerate it, even glorify it, but it remains a lurking threat to their fluid movement and maximum achievement. Physicians try to objectify it, quantify it, and modify it, but it persists, ubiquitous yet elusive.
Pain may be the ultimate subjective experience, but that does not stop us from trying to measure it. According to legend, a famous orthopaedic surgeon incorporated algometry, the measurement of pain, into his office's normal intake procedure. After filling out the usual questionnaires and insurance forms, each patient was asked to insert a finger into a simple testing device that resembled a small guillotine. Instead of a massive, razor-sharp blade, however, a modest blunt weight was dropped from a fixed height on the proffered digit. The patient's response to the impact was carefully recorded. If the reaction was too demonstrative, the patient was allegedly advised to seek the care of another practitioner. Presumably, such patients were judged to have an unacceptably low pain tolerance.
A high tolerance for pain is traditionally considered a virtue among athletes. The world of sports is rife with clever mottos depicting pain as a normal part of the athletic experience, from the weightlifters’ “No pain, no gain” to the swimmers’ “Pain is just the feeling of weakness leaving the body.” Such epigrams to the contrary, at some point pain becomes a solid obstacle blocking the path to athletic excellence. This fact is starkly demonstrated by the widespread use of analgesics in sports, a practice explored in the provocatively titled article “The Use and Abuse of Painkillers in International Soccer” in this issue of AJSM.
In this study by Tscholl and colleagues, team physicians were asked to record all medications given to their players in the 72 hours preceding each match in 6 FIFA World Cup tournaments between 2003 and 2007. Under-17 males, under-20 males, and adult women were studied. Among the 3 groups, women had the highest prevalence of medication use per match, even when oral contraceptives were excluded: 46.7%, compared with 34.2% and 33.2% for the 2 classes of male youths. The overall prevalence for the tournament, however, was comparable among the 3 groups (56.7%-62.5%).
Nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics were the most common class of drugs recorded by the team physicians, constituting almost 40% of all reported medications. About 17% of under-17 males, 21% of under-20 males, and 31% of women consumed NSAIDs before a match. In a similar study conducted during the last 2 men's FIFA World Cups, adult men were found to have a prevalence of NSAID use comparable to the adult women in the current investigation. 19 Tscholl et al acknowledged that these numbers might actually be a low estimate, as their figures did not include unreported self-medication. In fact, in another study, 92.6% of a cohort of 743 Italian professional soccer players reported that they had used NSAIDs in the previous year. 17
A pattern of frequent analgesic use is not confined to soccer players. In personal interviews, about 47% of the Canadian Olympic Team at the 2000 and 2004 Games admitted to taking NSAIDs or other analgesics. 8 In another study, Alaranta et al 1 compared 446 elite athletes supported by the Finnish National Olympic Committee with an age-matched sample of 1503 controls from the general populace. Among the athletes, 48.6% of women and 49.4% of men had used physician-prescribed NSAIDs during the previous 12 months. In the 7 days prior to the survey, 8.1% of athletes had used such drugs, a Figure 3.63 (95% confidence interval, 2.25–5.84) times higher than the general controls.
Self-administration of analgesics begins as early as adolescence. In a study of 681 American high school football players, Warner et al 21 found that 75% had used NSAIDs in the preceding 3 months; 15% used them daily, often to block pain before it occurred. In another study of junior high school students not limited to athletes, Canadian researchers found that 79.2% of respondents had taken a pain killer in the preceding 3 months, 36.3% of them for musculoskeletal pain. 5 Most respondents had started administering analgesics to themselves between ages 11 and 12.
Because the primary effects of NSAIDs are seen as anti-inflammatory and analgesic, the most logical reasons for an athlete to take them would be to relieve inflammation or pain. The underlying motivation of athletes and their physicians is likely to be a desire to accelerate healing, permit an earlier return to competition, and possibly improve performance. In fact, there is evidence that brief courses of NSAIDs can hasten the clinical resolution of a number of acute athletic injuries.9,10,12,13,16 This may be a direct effect of their anti-inflammatory properties or simply the facilitation of early motion through analgesia. As inflammation is a normal part of the healing process, however, the net effect of NSAIDs at the tissue level, at least as commonly used, is less clear. 4 , 20 In fact, they have been implicated as interfering with normal bone and soft tissue healing.2,7,20,23 Beyond that, their potential systemic side effects are well-known. 3 , 22
Athletes themselves are usually less concerned with cellular processes and potential side effects than they are with symptoms that inhibit their performance. Analgesics may be taken to suppress pain sufficiently to permit the resumption of sports. 18 Few physicians would condone a practice that might expose an athlete to the risk of greater injury, but analgesic use may be deemed acceptable in the case of acute injuries that are considered likely to heal regardless of continued activity or for chronic conditions for which pain suppression is similarly not perceived as prejudicial to ultimate recovery.
In such cases, the assumption is usually that NSAIDs do not produce analgesia powerful enough to mask pain that would reflect progressive injury. In fact, there is some evidence that continued sports activity may not inhibit the recovery of a chronically painful condition. In a randomized trial designed to address the safety of continued sports activity with monitoring of pain levels during rehabilitation for Achilles tendinopathy, Silbernagel et al 15 found no difference in the rate of recovery between subjects who were allowed to exercise during treatment and those who were prohibited from doing so. The applicability of this study to the question at hand is uncertain, however, since the authors did not permit the use of NSAIDs during the trial.
Although Tscholl et al were not able to report detailed reasons for the widespread use of NSAIDs and other analgesics in their subjects, they felt that the discrepancy between the frequency of drug use and the rate of acute injury indicated “a level of pharmaceutical substance use that is not justifiable based upon the medical diagnoses and current best evidence.” Certainly, their study and others indicate that some athletes or their physicians are engaging in questionable practices, such as analgesic prophylaxis, overdosing, underdosing, or polypharmacy. 6
As I have noted before on this page, 14 many athletes will gladly ingest substances much more hazardous than analgesics if they perceive that doing so will maximize their performance. Indeed, an important facet of sports medicine is helping athletes achieve optimum function, including a timely return to competition. When an athlete appeals to a team physician for help, both have a compelling motivation to institute potentially effective treatment. The athlete may have already tried an over-the-counter medication to no avail. In some cases, the progression to a prescription medication may thus be entirely appropriate. In other cases, a strong desire to try anything that might help may drive the physician's decision-making, even when the pharmacologic rationale is questionable. Clearly, the motivation for such behavior is most powerful at the highest level of competition, such as during a world championship.
The research cited above 5 , 21 suggests that, by the age of adolescence, there is already widespread use of analgesics in the general population, at least in North America. This high background level of consumption makes it difficult to look at absolute use in athletic populations and know how frequently analgesics are prescribed inappropriately. The findings of Tscholl et al nevertheless serve as a timely reminder for team physicians to exercise due judgment when considering treatment options for their patients.
When confronted with a sick or injured athlete, a physician should carefully consider the underlying pathophysiology and available evidence before deciding whether the proposed medication, or any treatment, is likely to help. The possibility that a treatment may actually interfere with the healing process, produce systemic side effects, or increase the risk of injury progression should always be considered and, if pertinent, reviewed with the athlete. 11 The healing process is a complex sequence of events, and its intricacies are still being revealed. Future research may yield information on the optimal dosing and timing of pharmacologic interventions, allowing physicians to target their therapy and maximize the chance of a positive outcome.
