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Pain Relief for Acute Soft-Tissue Injuries

James S. Thornton

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 10 - OCTOBER 97


Treating the pain that accompanies a soft-tissue sports injury sometimes requires a delicate balancing act: making the patient comfortable enough to comply with rehabilitation—or, in some instances, to return to play—without nullifying pain's protective function. The first step is to minimize swelling and related discomfort by using rest, ice, compression, and elevation immediately after injury. In the postacute stage, the patient's symptoms and activity level will guide the choice of pain-control options.

From the sprained ankle of a recreational basketball player to the masticated ear of heavyweight boxer Evander Holyfield, sports and acute soft-tissue pain all too often go hand in hand. And the decision about appropriate pain control falls squarely to the physician.

In simplified overview, the soft-tissue pain process works this way: Trauma, either acute or chronic, ruptures cell walls. Enzymes such as cyclooxygenase then break down the spilled intracellular contents into prostaglandins, leukotrienes, and other components of the body's inflammatory process. The enzymatic activity mobilizes white blood cells and triggers other aspects of the innate healing response.

"Prostaglandins also sensitize nerve endings," says J. David Haddox, DDS, MD, director of the pain rehabilitation program at the Center for Pain Medicine of the Emory Clinic in Atlanta. "This makes nerve fibers fire more aggressively, and at a lower stimulus than would normally cause firing," he says. The pain response is also influenced by soft-tissue swelling that results from increased vascular permeability and vasodilation.

For the affected athlete, the net result of this complex molecular orchestration is pain. But for physicians who treat athletes, pain is hardly the enemy. "Pain is the body's way of saying something's wrong," says Thomas D. Rizzo, Jr, MD, a specialist in physical medicine and rehabilitation at the Mayo Clinic in Jacksonville, Florida, and a member of the editorial board of The Physician and Sportsmedicine. "It's important to listen to it."

Not that Rizzo believes an injured athlete should suffer needlessly. Rather, he suggests that any modality used to moderate pain should be chosen by the physician with the ultimate objective in mind—healing the injury, not just temporarily removing an obstacle to continued performance.

Start With RICE

In the classic 1978 volume that he cowrote, The Sportsmedicine Book (1), Gabe Mirkin, MD, an associate professor at Georgetown University School of Medicine, first coined the acronym RICE (rest, ice, compression, elevation), which has since become a mainstay of sports medicine practitioners the world over. Mirkin says this nonpharmacologic approach can be started immediately, whenever an athlete has suffered a soft-tissue injury and pain. When RICE is used during the "golden window" before swelling begins (immediately after injury), it can make a major difference in the amount of pain an athlete suffers.

"My favorite personal example of this," says Rizzo, "was a high school football player who got speared by a helmet on his thigh on the last play of the game." Rizzo and the team's orthopedic surgeon used RICE on the boy's thigh and knee and had him come in the next day for magnetic resonance imaging.

To his physicians' amazement, the scan revealed that the spearing had not only caused a deep bruise on the thigh, but had also torn both the medial collateral and anterior cruciate ligaments. That the boy felt some discomfort but little or no severe pain is testimony to the efficacy of RICE.

"I've found that RICE actually works quicker than medications, too," says Rizzo. "Say a patient has just sprained an ankle. Even the fastest-acting analgesics take 30 to 60 minutes to work. With RICE, an athlete can start feeling better in 20 minutes."

The regimen might also allow a quicker return to athletic participation. In his practice, Rizzo has found that a timely application of RICE often lets players with a grade 1 or 2 ankle sprain return in 1 week instead of in the 2 weeks usually cited in the literature. "From a study point of view," says Rizzo, "this might not seem to be a big deal. But it's a big difference to a kid to go from missing two games to not missing any."

To Medicate or Not?

Pain relief is more than a matter of comfort. Taking the edge off sports-related pain and inflammation can improve a patient's prognosis. Rehabilitation specialists have long understood that early return to motion can promote optimal healing. If a patient is in too much pain, however, he or she will avoid even passive stretching, which can lead to a host of long-term problems, from stiffness and adhesions to muscle atrophy and loss of proprioception.

"I think that in some ways, nature's inflammatory response is overkill," says Rizzo. "When you've got too much inflammation and swelling, it takes the body a long time to reabsorb it, and this can impede range of motion. Our goal is not to eliminate the body's response but to modify it." A 1992 meta-analysis (2) provides some support for this view. It concluded that moderate use of nonsteroidal anti-inflammatory drugs (NSAIDs) does not seriously affect healing of sports injuries, and that such use may enhance athletic performance.

Two caveats: Rizzo always warns his patients not to overdo activity when their pain is blunted by medications. And he rarely prescribes aspirin or other NSAIDs for the first day or two following an injury because of the theoretical risk that the drugs' blood-thinning properties will exacerbate initial swelling. Instead, he recommends using acetaminophen until the acute phase of the injury is over, advising his patients to switch over to an NSAID only if their pain continues.

Support for the use of anti-inflammatory medications, however, is not unanimous. To Mirkin, the use of anti-inflammatory drugs in addition to RICE is usually unnecessary and frequently counterproductive. "There are extensive data (3-5) showing that pain medicines that block prostaglandins actually delay healing," he says. Evolution has created a fine-tuned response to injury, Mirkin maintains, and any attempt to change this natural response with pharmaceuticals is usually misguided. "Whenever you try to change nature," Mirkin emphasizes, "you lose something."

But other physicians who treat athletes take a more moderate line. "It's true we have evolved a complex inflammatory response, but we've also evolved a complicated pyscho-social response to injury," says Rizzo. A rat with a broken leg is not worried about a job or supporting its family. "But these are real concerns for injured humans," he says, "and pain control does become important."

Drug Options

When the decision has been made to prescribe medication for a patient's pain, the physician has several medications and delivery systems to chose from.

NSAIDs. Billions are spent each year for prescription and over-the-counter NSAIDs, and brand marketing for such medicines is fierce. Patients and their physicians alike are often left wondering if one brand is better than another and if newer, higher-priced formulations are more efficacious than older medications.

"We know from years of treating arthritis and chronic pain patients that some individuals do respond better to some of these drugs than others," says Haddox. "The trouble is, you can't predict which one a given individual is going to respond best to. And there's no evidence that any of these drugs is consistently more efficacious across the board than any other ones."

Haddox and Rizzo recommend that physicians be both pragmatic and conservative when prescribing NSAIDs. "In picking which medication to use," says Rizzo, "I usually start with drugs that have been around for awhile because these tend to be the cheapest and the best studied."


Table 1. Categories of Frequently Used Nonsteroidal Anti-Inflammatory Drugs


Nonacids
Nabumetone

Carboxylic Acids
Acetic acids    Diclofenac potassium
   Diclofenac sodium
   Etodolac
   Indomethacin
   Sulindac
   Tolmetin sodium

Fenamates
   Meclofenamate sodium
   Mefenamic acid

Proprionic acids
   Fenoprofen calcium
   Flurbiprofen
   Ibuprofen
   Ketoprofen
   Naproxen
   Naproxen sodium
   Oxaprozin

Salicylates
   Aspirin
   Diflunisal
   Choline salicylate with magnesium
   Salicylate
   Salsalate

Enolic Acids
Oxicams
   Piroxicam

Pyrazoles
   Ketorolac tromethamine


But if the first medication doesn't work, a practitioner shouldn't hesitate to try another, preferably from another chemical family (table 1). Ibuprofen, naproxen, and ketoprofen, for example, are all proprionic acid derivatives. Etodolac, on the other hand, is an acetic acid. Other considerations include:

  • Dosage level. All NSAIDs have an analgesic ceiling. Patients should be advised to take the lowest dose that's effective for relieving their pain and inflammation. Taking more medicine won't relieve pain any better—but it will increase the risk of side effects.
  • Compliance. Patients who have a chronic injury may find that the longer-acting NSAIDs (effective for 8 to 12 hours per dose) are easier to remember to take than shorter-acting drugs with a 4- to 6-hour range. "On the other hand," says Rizzo, "it requires about five doses of a drug before it reaches a steady state in your body. Because of this, NSAIDs that allow more frequent dosing may be better for some cases of acute pain."
  • Expense. If aspirin or other nonprescription NSAIDs work well for a patient, it makes sense to go with these less expensive options. Note, however, that just because an NSAID is available over the counter doesn't mean it's always cheaper for patients to buy it this way. Depending on a patient's insurance plan, Rizzo sometimes finds that the same anti-inflammatory agent sold at "prescription strength" through the pharmacy costs less.
  • Side effects. Though these can occur in athletes of all ages, they are more likely in older patients because of changes in metabolism, renal function, and blood pressure. Generally speaking, NSAIDs should not be used by patients who have liver or kidney damage, an allergy to aspirin, or gastritis or peptic ulcer disease. In patients who truly depend on NSAIDs, such as rheumatoid arthritis sufferers, a potent H2 acid blocker such as famotidine or ranitidine hydrochloride can help prevent NSAID-associated ulcers. Hypertensive patients, says Rizzo, may be better off using one of the newer NSAIDs that don't contain sodium. Low-dose aspirin therapy for cardiovascular disease generally shouldn't affect NSAID treatment decisions, but the physician should nevertheless know about this and any other medicines a patient is taking.

Corticosteroid injections. Many athletes think of the "cortisone shot" as a miracle cure for pain associated with everything from plantar fasciitis to bursitis. In a sense they're right—a well-timed injection can quickly and effectively obliterate inflammation and its accompanying pain. But it's precisely because of this effectiveness that cortisone injections remain so controversial. "Giving athletes medicine to feel better," says Rizzo, "does not necessarily mean you're helping them get better." (See "Painkillers and Pro Athletes," below.) Though Rizzo and other practitioners acknowledge that corticosteroid injections have a place in sports medicine, they urge judiciousness in their use.

Prime candidates for injection therapy include patients who have the type of inflammation that can cause long-term problems. Examples include nerve compression injuries, where swelling can lead to nerve damage, and advanced shoulder tendinitis in which pain restricts movement and elevates the risk of adhesive capsulitis. Corticosteroids should never be injected into tendons, cartilage, or ligaments.

Muscle relaxants. When muscle spasm is a component of an acute injury, a muscle relaxant may provide pain relief. Muscles relaxants are also an option for treatment of painful muscle strains. Patients should be warned that these drugs may impair mental and physical abilities needed to perform hazardous tasks.

Narcotics. Narcotic pain relievers have a limited use for most sports injuries. To be sure, says Mirkin, injuries such as bone fractures are often extraordinarily painful, and there are occasions when short-term use of drugs like acetaminophen with codeine makes sense. Haddox says concerns about addiction to narcotics should be tempered by pragmatism, especially if a patient's pain cannot be managed by other means. "Worries about the 'habit forming' effects of opioids— ie, narcotic analgesics—reflect a view that is traditional and in many cases wrong," Haddox says. "Studies show that patients taking opioids for analgesia have a risk of developing addiction that is less than 0.5%. While opioids should not be prescribed indiscriminately, their use in legitimate pain problems should not be withheld."

Not prescribing a narcotic for severe pain might have an unintended effect, says Rizzo. "I believe—and I've discussed this with pain specialists—that you can induce drug-seeking behavior by undermedicating a patient who has significant pain," he says.

Other Therapeutic Modalities

RICE and medication are only part of the sports medicine doctor's armamentarium. When discomfort lingers following an injury, a variety of other options can provide relief.

Heat. Though heat should be avoided during the acute phase of an injury because it promotes swelling, it can be very helpful to patients suffering from pain associated with soft-tissue contracture or muscle spasm. Many athletes are instructed to use 20 minutes of heat before a workout, followed by 20 minutes of ice application afterward.

Counterirritants. Though most physicians don't prescribe counterirritants, patients often buy "heat" products for self-treatment. There are two main theories as to why balms containing skin irritants seem to work to block pain. The gate-control theory suggests that a spinal cord modulating mechanism exists in which one type of sensation (from a chemical irritant, for example) can impede transmission of another sensation, such as pain. A second theory suggests that counterirritants may stimulate the release of endorphins.

Transcutaneous electrical nerve stimulation (TENS) and interferential current. External electrical stimulation also appears to work on nerves that transmit pain signals. For his part, Rizzo has not found TENS effective for most soft-tissue injuries, though he has used it successfully to treat pain associated with fractures, surgery, and acute nerve injuries. For chronic knee, shoulder, ankle, or back pain, a deeper form of electrical stimulation—interferential current—can sometimes yield good results. Rizzo says he usually shows patients how to use the stimulator at his office, then prescribes units they can use at home as needed. "When you can give an athlete a sense of being in control of the pain," says Rizzo, "it hurts a lot less."

Massage therapy. Massage therapy may help relieve muscle spasm, facilitate stretching, and ultimately improve flexibility. This, in turn, may prevent future injuries.

Chiropractic manipulation. For many patients suffering pain associated with the spine, chiropractic manipulation can reduce symptoms, at least short term. "It's a lot like massage, heat, or ice: It provides pain relief," says Rizzo. "But it won't work for reestablishing proper range of motion or strength."

Ultrasound. This deep form of heat is usually not useful in treating acute pain, though it can often provide relief from soft-tissue contracture or muscle spasm. "I tend to use ultrasound on many of my masters and recreational athletes once the swelling is gone," says Rizzo. A typical scenario: A patient sprains her ankle, and a week or two later, it's still stiff and painful to stretch. "This is when I will have the patient see a therapist for ultrasound," says Rizzo. "It helps an athlete feel they are continuing to move forward in the rehab process."

Phonophoresis and iontophoresis. These systems reportedly drive topically applied cortisone deeper into underlying tissues. Phonophoresis uses ultrasound to deliver the corticosteroids, while iontophoresis uses electrical current. Though some physicians and patients have found these methods helpful, studies using radioactive-labeled steroids have failed to show these methods deliver steroids in greater quantity or more quickly than topical application.

When Old and New Converge

"State of the art" has different meanings in different medical settings. When treating the pain from acute soft-tissue injuries, the best treatment doesn't depend on a new drug or device. Rather, modern management of acute pain in athletics means swiftly applying a traditional treatment—RICE—and following it up with an individualized plan to relieve the patient's discomfort with medication and modalities.

References

  1. Mirkin G, Hoffman M: The Sportsmedicine Book. Boston, Little, Brown Co, 1978
  2. Weiler JM: Medical modifiers of sports injury: the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in sports soft-tissue injury. Clin Sports Med 1992;11(3):625-644
  3. Reynolds JF, Noakes TD, Schwellnus MP, et al: Non-steroidal anti-inflammatory drugs fail to enhance healing of acute hamstring injuries treated with physiotherapy. S Afr Med J 1995;85(6):517-522
  4. Almekinders LC, Gilbert JA: Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med 1986;14(4):303-308
  5. Altman RD, Latta LL, Keer R, et al: Effect of nonsteroidal antiinflammatory drugs on fracture healing: a laboratory study in rats. J Orthop Trauma 1995;9(5):392-400


Painkillers and Pro Athletes

High-profile pain medication scandals in professional football, such as Green Bay Packer quarterback Brett Favre's addiction to hydrocodone bitartrate in 1995, created a widespread impression that painkillers are overused in treating pro athletes' injuries.

Adding to this impression is a spate of lawsuits by former players who charge their teams' medical staff members with such misdeeds as promoting ibuprofen abuse and providing inadequate warnings about the disabling long-term consequences of a pro career.

To Mike Dillingham, MD, the orthopedic physician for the San Francisco 49ers of the National Football League, the issues involved in treating a pro player's pain are not as black-and-white as the mass media and legal community tend to depict them. "It's not wrong to play with pain," says Dillingham. "This is something that virtually every pro athlete will do at some point in their career. It's part of what these guys get paid huge amounts of money for, and we need to remove the concept of scandal from the debate."

Sports physicians should not be any more paternalistic in treating pro athletes than they are in treating other adults. "These guys aren't children," he says. "They have a right to self-determination."

In some cases, playing with some pain truly means the difference between earning millions and working for the minimum wage. Provided that players are fully informed about the consequences of treatment, Dillingham believes they should have a large, though not total, say in the matter.

"Before each season starts," Dillingham says, "I talk to the team and tell the players straight out that in this game, they risk being killed or paralyzed, and that they will in all probability suffer arthritis and disability later in life. I tell them they have to understand and accept these risks—and never come back and tell me they didn't think about it."

Not that Dillingham dispenses narcotics or cortisone injections to any player who asks for them. The two key issues are whether the pain medication will (1) remove protective sensation and potentially cause the player to suffer more serious injury, and (2) interfere with a player's ability to protect himself on the field by impairing either coordination or mental acuity.

Using these criteria, Dillingham says, can help physicians make the right decision. Case in point: a hip pointer (a bruise on the rim of the pelvis). Though this condition can be extremely painful to any athlete, it poses little risk to an athlete's long-term health, and Dillingham feels no compunction about numbing the area with lidocaine and letting the player return to play. "On the other hand," he says, "if I numb up an injured knee so the player can't feel the hurt, this can definitely lead to a permanent disability. It's wrong to do this, and I never once will."

Ultimately, Dillingham says, all athletes, from the pros to high school players, need to calculate their own risk-benefit ratio when it comes to playing with pain. And doctors need to bring some common sense to their deliberations. "My advice to someone who doesn't have a career in sports," he says, "is that it just makes sense to take less risk."


James Thornton is a freelance writer in Sewickley, Pennsylvania.


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