The issue of over-use, mis-use and prophylactic use of non-steroidal anti-inflammatory drugs (NSAIDs) in sports has been highlighted in various studies and articles for many years. The evidence would suggest that despite warnings and a growing understanding of the potentially harmful effects, the use of NSAIDs and particularly the culture of prophylactic NSAID use has grown within elite sport and is finding its way into the culture of non-elite sport and even that of recreational participants. ‘Shall we be discussing when is the best time to start taking (NSAIDs) painkillers in our marathon training’ was a question posed by a club runner at a recent marathon preparation seminar. A recent study (Rosenbloom 2020) highlighted the prevalence of NSAID use by Park-Run participants, along with the issues of side effects and lack of information provided regarding safe usage. In clinic, similar questions are asked regularly by patients which suggests that this practice has become common-place and there is still much work to be done to educate the public and also healthcare professions.

Why are NSAIDs so often used in sport? The answer to this would seem straightforward enough, they are known to have anti-inflammatory, analgesic and antipyretic effects. They are cheap and easily accessible, and it would seem logical for athletes to choose to take these as they often perceive pain and inflammation as their main symptoms. NSAIDs are fast acting and give significant pain relief (of mild to moderate pain) in a significant proportion of people (NNT ranging from around 2-3). Athletes train long and hard for many years with little time to recover and relentless demands to perform. They invariably experience musculoskeletal injuries but are under pressure to train and perform despite pain if they wish to succeed at the highest level. Elite sport often brings a more complex dynamic to managing injuries where a lack of congruency may exist between managers, medical staff and athletes which might create compromise or sub-optimal decision making with regards to the athletes overall long-term health and recovery. It’s not surprising then that studies have shown NSAID usage by elite athletes akin to 3.6 times greater than aged matched controls in the general population (Alaranta et al 2006).

However, NSAIDs are not benign agents. They work via cyclo-oxygenase (COX I and II) enzyme inhibition, thus blocking prostaglandin production from arachidonic acid. Prostaglandin inhibition will decrease the inflammatory response. This has the desired effect of reducing pain but may well reduce tissue adaptation to exercise and disrupt the healing process. This is also a rather unselective mechanism of action which has other widespread affects around the body. The inhibition of COX I in particular has the negative side effects of raising the risk of gastric trauma particularly in long term usage. This can range from relatively benign dyspepsia to potentially life threatening events such as upper GI bleeding. Prescribing COX II selective NSAIDs may reduce the risk of gastric trauma but increase the risk of potential cardiovascular side-effects. Use of NSAIDs are also linked with significant increase in the risk of thrombotic events such as myocardial infarction or stroke (Bally et al 2017, Kearney et al 2006). Cox isozymes are critical in maintaining renal blood flow and glomerular filtration rate – this may already be impeded by around 40-50% during strenuous exercise. Therefore, specifically in sports and endurance athletes NSAID usage may raise risks of dehydration and even life threatening hyponatremia (Page 2007, Wharam 2006), worrying when some 60% of Ironman Trials participants had taken NSAIDs in one 2008 study. Also, NSAIDs can cause serious exacerbate of asthma in around 10-15% of asthmatics.

The August 2017 issue of the BJSM featured an article relating to pain medications used in sports – ‘International Olympic Committee consensus statement on pain management in elite athletes’. Within this were highlighted the ‘Guiding principles for pharmacological pain management strategies in elite athletes’ which described much rationale and well evidenced advice and guidance. This paper once again repeatedly raised the issue regarding the potential mis-use and over-use of non-steroidal anti-inflammatory drugs (NSAIDs) in sports injury management. With regards to prophylactic usage within the guidelines is specifically mentioned the point ‘medications should not be prescribed to athletes for pain or injury prevention’. Although little accurate data exists directly with regards to prophylactic NSAIDs usage there is evidence that can be extrapolated from related studies along with much anecdotal evidence which suggests this has been a significant issue and growing trend.

Studies which have identified the extent of usage in elite sports include Philippe Tscholl’s (2015) excellent but equally worrying review article which presented data from 10 men’s, women’s and adolescent FIFA World Cups. The World Anti-Doping agency does not prohibit the use of NSAIDs as they are not considered performance enhancing. The review reveals NSAIDs were the most frequently prescribed medication accounting for 36% of all prescriptions. Interestingly paracetamol, which is considered to be far safer for most patients and of similar efficacy in soft tissue injury management, accounted for just 5.4% of prescribed substances. Also noted was no correlation between NSAID usage and players actually playing in games (versus substitutes) and also no correlation with injuries reported which might imply that much of the usage was indeed prophylactic. In total 54.5% of male, 50.9% of female and 43.3% of adolescent players in FIFA World Cups used NSAIDs at least once in the tournament. It was calculated that around 7 players per national team were using NSAIDs before every match. Worryingly 10% were using more than one NSAID at a time which would further increasing risks of side effects. Significant trends were seen within teams around choice of medications and rates of usage which may imply that the medical team may have a significant influence over the culture of medications usage. Comparative data between 2002, 2006 and 2010 FIFA World Cups show an overall trend of increasing NSAID usage. This came despite a campaign prior to the 2010 World Cup by the FIFA Medical Assessment and Research Centre (F-MARC) to highlight risks and advise against overuse and inappropriate prescribing of NSAIDs. Dr Jiri Dvorak, co-author, describes this as ‘a cultural issue, part of the game’.

Studies looking at medications use at Olympics and track and field events have noted some similar trends. Comparing the reported levels of NSAIDs use in elite sports across a number of studies, it was found that their use by elite athletes was 6-10 times higher than with age-matched groups in the general population. A further concerning finding is that usage appears to start at an early age and may become a form of preparation ritual. A study of American football youth academies found one in seven students (mean age 15.8 years old) were taking NSAIDs every day (Holmes et al 2013).

As noted above, these studies which have collected data regarding general rates of NSAID usage and potential over-use have concluded that prophylactic usage is likely to be common on the basis that overall use of NSAIDs seems independent of whether or not the player or athlete is actually registered as injured or complaining of musculoskeletal injury at that time. Reports in the literature suggest that players often use NSAIDs as a way of trying to prevent injury from occurring or to stop an injury becoming worse when they first start to feel pain. Also, from the literature, a number of other factors have been highlighted such as beliefs of reduced muscle soreness during and after an event, lack of confidence in self recovery, lack of awareness of potential harm (often linked to easy accessibility). Issues of peer pressure and psychological addiction have also been identified.

In essence, many involved in elite sport believe that NSAIDs have the ability to prevent injury, to speed the recovery process and prevent pain that hasn’t yet occurred. A further compounding factor is that they are regarded as low risk largely because they are freely available and, somewhat ironically, because they are seen being used so much.

However, many of these beliefs are most likely misguided. Whilst NSAIDs are effective for mild to moderate acute and sub-acute pain generally, NSAIDs analgesic action has been shown to provide only marginally greater pain relief than paracetamol in most circumstances whilst having significantly worse risks (Paolini et al BJSM 2014). A number of review articles have recommended against using NSAIDs in early soft tissue injury management because lack of indication over paracetamol and higher risks, along with the potential negative impact on healing (Paoloni and Orchard 2005). Where healing is required their affects may be counter-productive therefore their use in musculoskeletal injury remains controversial. NSAIDs have been shown to have a negative impact on the healing of most soft tissues. Studies have shown healing, recovery and poorer functional outcomes from muscle, bone and ligament healing. There is currently debate as to whether NSAIDs may possibly have a role in specific stages of tendinopathy management but currently there is no clear consensus or guidelines. There is also growing doubt about the appropriateness and rationale for use in long term injury management. Paoloni et al (2014) wrote an article ‘NSAIDs in sports medicine: Guideline for practical but sensible use’ concluding that the prescribing of NSAIDs should be with caution and both dose and duration should be minimised, using them in conjunction with alternative analgesics and non-pharmacological strategies where possible.

Whilst writing this article I thought it was important to also seek the opinions and feedback from a range of relevant parties including sports doctors, coaches and physiotherapists working within a range of professional sports as well as those of some athletes and ex-players. I’m hugely grateful to all those who agreed to contribute as their feedback was invaluable. All those who contributed were advised of the purpose and promised all comments would remain anonymous. For this reason, I believe the feedback to be frank and honest. Aspects of the feedback were actually quite varied, but it was overwhelmingly reported that NSAIDs are taken frequently and often in the absence of pain or injury. Some of main themes which emerged related to the constant pressure to be match fit and able to play, versus the heavy training and match schedules and lack of recovery time. Frequently reported by the players was the belief that NSAIDs, whilst possibly somewhat harmful, help to prevent injury or suppress small injuries from becoming more serious and allowing players to continue training and playing. There was a sense from players that this was all part of their expected lifestyle to stay fit, and one of the very many sacrifices they were expected to make. There was also a sense from some of the coaches and medical staff that because the first team players were taking NSAIDs frequently players in the academies would follow suit. Refreshingly, several reported that they had already seen a decline in recent years which they attributed to better awareness and education from medical staff. Almost universally there was a sense that more should be done to educate and advise not only about the potential harmful effects but also that NSAIDs could actually raise the risk of injury and impede recovery.

Much of the comments I received were echoed in an excellent and enlightening article published in The Times on 13th October 2017 by ex-professional footballer Gregor Robertson, highlighting the lengths many professional footballers would go to in order to be fit to play each week. He describes a number of cases where players had been reliant on painkillers for many years in order to be able to play and the realities of playing through injuries and the tough decisions players need to make on a regular basis regarding management of injuries and return to play which can damage careers. Hearing of players stating that ‘Anti-inflams are part of football and always will be’

is a sobering prospect. Also hearing descriptions of team physiotherapists with packets of NSAIDs walking around the dressing room indiscriminately offering ‘Anyone? Pill? Pill? Pill?’ is a very depressing image which sadly though reflects reports I’ve heard, ranging from professional football to Sunday league rugby, and from professional mixed martial arts to village cricket.

How might we change such behaviours? Education is surely the key. Stuart Warden, in his excellent article published in 2010 ‘Prophylactic Use of NSAIDs by Athletes: A Risk / Benefit Assessment’, writes that data from a range of sporting fields supports the hypothesis that prophylactic use is on the increase amongst athletes who often take anti-inflammatories in the belief that it will prevent pain and inflammation before it occurs. However, contrary to these beliefs, NSAIDs may actually have a negative impact on musculoskeletal resilience and paradoxically athletes are exposing themselves to a range of potentially harmful side effects, weakening the body’s natural defences against the higher loads and greater stresses experienced in sports. He writes that whilst there may be some evidence that exercise-induced muscle soreness may be reduced with NSAIDs, unfortunately there will also be a drug-induced reduction in tissue adaptation to exercise, compromising early healing processes within tissue, and may also risk dampening important signals to alert the athlete to early tissue injury. He concludes that, along with the mounting evidence for a range of gastric, cardiovascular and renal adverse effects, athletes should be advised against prophylactic NSAID usage. He concludes ‘(prophylactic) use of NSAIDs by athletes is not safe, there is no indication or rationale for prophylactic NSAID consumption in sport, and therefore constitutes misuse’.

In recent years we have witnessed the ‘calling out’ and challenges to many long standing, often unquestioned behaviours. It would seem that within sport the ongoing practice of overuse and prophylactic use of NSAIDs has worked its way into the culture to be seen as normal. In the ever-increasingly competitive world of elite sport, where marginal gains can be the difference between success or failure, it is important that players and athletes are made aware of the potential shortcomings and the real implications of NSAIDs usage. There would seem to be an opportunity for physiotherapists and all staff involved at all levels within sport (and with our patients generally) to help to educate and challenge behaviours where appropriate in the athletes’ (and patients’) best interests. I hope that in writing this commentary and further highlighting this issue it may encourage more medical staff and physiotherapists to disseminate this information to colleagues and to the athletes themselves.

Dave Baker
Clinical Director – Complete Physio

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