Tendon injuries, which are very common among athletes as well as in the sedentary population, generally present symptoms of swelling and pain. Therefore, the prescription of anti-inflammatories is essentially inevitable. However, recent studies show that although anti-inflammatories aid in reducing pain and swelling, they hinder structural healing of the injury. In this article, it is stated that "together with the fact that all chronic tendinopathy cases received anti-inflammatory management, it is logical to assume that suppression of inflammatory responses may interact with the failed healing of degenerative tendon injuries." Failed healing is described by the authors as the "histopathological characteristics of tendinopathy [...] which exhibited traits of both active repair and degenerative injuries" (Chan, and Fu). Because nearly all cases of chronic tendon injuries have received non-steroidal anti-inflammatory drugs by their physician, the authors suggest that there might be a potential interaction in some cases in which a mild inflammatory tendon injury could turn into chronic tendinopathy in predisposed individuals (Chan, and Fu).
Non-steroidal anti-inflammatory drugs (NSAIDS) are the most common anti-inflammatories prescribed for tendon injuries. NSAIDS work by inhibiting the production of pro-inflammatory prostaglandins through the COX pathway. However, prostaglandin E2 (PGE2) is "essential for early tendon healing such as control of vascular flow" (Chan, and Fu), therefore the use of NSAIDS could have a deleterious effect on the structural healing of the tendon. Corticosteroids, which are a group of anti-inflammatories that are generally utilized to treat chronic pain in chronic injuries, "may increase risk of spontaneous ruptures of tendon cells.
The negative effects of corticosteroids were demonstrated on human culture tendon fibroblasts, which also included cell viability, proliferation and matrix synthesis.
The authors also discuss the use of physical therapies, such as pulsed electromagnetic fields, low level laser treatments, and extracorporeal shockwave therapy, to reduce inflammation in tendon injuries. "It appears that these biophysical interventions also exerted anti-inflammatory actions through modulation of pro-inflammatory mediators" (Chan, and Fu), such as the suppression of PGE2 by pulsed electromagnetic fields and low level laser treatments, and the modulation of nitric oxide production by extracorporeal shockwave therapy. However, there is not much research regarding the "efficacy and underlying mechanisms" (Chan, and Fu) of these therapies and they believe that "further exploration to consolidate their efficacies may yield a better clinical practice for anti-inflammatory management for chronic tendinopathy" (Chan, and Fu).
If disturbed prostaglandin levels as one of the causes of failed healing in tendinopathy could be identified, then, the authors believe, that the development of effective treatment strategies for tendon injuries could be improved.
Source:
Chan, Kai-Ming, and Sai-Chuen Fu. "Sports Med Arthrosc Rehabil Ther Technol.." Sports Med Arthrosc Rehabil Ther Technol.. 1.23 (2009): n. page. Web. 2 Dec. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770552/>.
I think this post brings up a very interesting point. We all take NSAIDS almost as if they were candy, whether it be for a headache, menstrual cramps or other muscle soreness but who would have ever thought that these common painkillers would actually be a harmful treatment! You mentioned that the anti-inflammatory component suppresses the inflammatory response thus causing a failed healing process within the tendon but does this problem arise in other areas of injury do you know? I feel like the mechanism of this is non-specific enough that it could very well be the case elsewhere in the body.
ReplyDeleteI like your post and you bring up a good point. I was wondering, how often would the lazer and other supplemetary treatments need to be done? What type of tendon damage occurs, a sprain, strain, and/or tear would?
ReplyDeleteThis post really surprised me just because I don't know a single friend who plays sports and wasn't recommended to take NSAIDS after a tendon injury. Even my friend who severely injured her tendon when her leg was asleep and she got up to resolve the issue. She was put on a few days of painkillers and then on NSAIDS for quite some time. It's kind of crazy to think about how many people, especially athletes, have actually done themselves more harm by taking these medications.
ReplyDeleteOn a sider note, after taking Immunology, I even started to not take anti-inflammatories when I'm sick, unless I really need to. Now that I understand why the body does what it does, I know I'm disrupting the immune response that is trying to rid my body of the problem, so I don't even want to interfere there. Even though I may not feel as well as I could if I took the medication, I know as long as my illness is not prolonged, this is the better way to recovery. Maybe people with tendon injuries need to start taking this route to recovery as well, if they want actual recovery from their injury.
@Nickk495, The authors suggest that physical therapies are simply another form of reducing inflammatory signs in tendon injuries, which do affect inflammatory pathways in the body. The difference is that the effect is induced physically rather than medicinally. They state that not enough research is available to prove the efficacy of such therapies at a structural healing standpoint, but since it is physical, it may eventually be proven that physical therapies are better resolutions than NSAIDS for tendon injuries.
ReplyDeleteBack to your question about how often you would need these physical therapy treatments- I believe it depends on the injury. Speaking from personal experience, I received pulse electromagnetic field therapy 1x a week for 3 1/2 months when I was in physical therapy for iliotibial syndrome in my hip, but I did that on top of taking Ibuprofen as well. I really enjoyed the therapy, I definitely felt as if it had a positive effect! However, because not enough research has been done in this field, whether the electrical therapy helped structurally heal the injury is unknown.
@Dina- I completely agree with you. The more I become knowledgeable of the immune system, the more I realize that NSAIDS and other medication are simply available to treat the symptoms, but not the cause, and could very well interfere with the natural process of healing in the human body. I have since stepped back from taking medicine as soon as I feel as if I 'need' it!
I totally agree with Carly, I used to take NSAIDs everyday when I injured my IT band as well, but I think that what many people forget is that tendon injuries tend to be slow to heal, and that PT, electromagnetic field therapy are just tools to ensure optimal healing, but ultimately your body is what carries out the healing process if we just give the time it needs.
ReplyDeleteThis is an excellent example of the extensive phases of research and follow up studies that are required to develop and distribute drugs in the present day. NSAIDS have been around for well over 30 years and are widely used, but we are still discovering adverse effects the drugs have on our immune system. It scares me to think about how new drugs that are released now could potentially have very harmful effects that are not seen until the patients get older.
ReplyDeleteI am often concerned about this when I feel sick, as a common effect of these drugs is the reduction of fever, which as we all know, your lymphocytes actually can function better at a slightly higher temperature while the bugs don't like it as much. In practice though, I will avoid it if possible, unless pain is hindering sleep, at which point we find ourselves doing a cost-benefit analysis - sleep or fever, which will help your immune system more? Not an easy question to answer, but one I would be very interested in!
ReplyDeleteI was interested to read the posts about NSAIDS, and this one in particular about the possible negative effects of NSAIDs on tendon healing following injury. I know that there is an ongoing debate about the value of NSAID therapy in treating pain after an orthopedic surgery. There is some evidence to show that controlling pain with scheduled NSAIDS, especially in a geriatric population, decreases the amount of narcotic necessary to control their pain. This subsequently decreases the number of cases of hospital acquired delirium which directly impacts how quickly these patients can leave the hospital and resume a meaningful quality of life.
ReplyDeleteOther studies (mostly animal) seem to indicate that NSAIDs taken after a broken bone or a joint surgery can prohibit bone healing. During the early stage of bone healing cytokines are released and prostaglandins help bone healing and formation (Li, Thompson & Paralkar, 2007). Recently some authors have conducted literature reviews and brought back into question this idea that NSAIDs should be avoided after surgery. That state that results from animal models are inconclusive and that the evidence in humans is not robust enough to adopt this clinical practice (Kurmis, Kurmis, O'Brien & Dalen, 2012; Pountos, Georgouli, Calori & Giannoudis, 2012).
Kurmis, A. P., Kurmis, T. P., O'Brien, J. X., & Dalen, T. (2012). The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. The Journal of Bone & Joint Surgery, 94(9), 815-823. doi: 10.2106/JBJS.J.01743
Li, M., Thompson, D. D., & Paralkar, V. M. (2007). Prostaglandin E2 receptors in bone formation. International Orthopedics, 31(6), 767-772.
Pountos, I., Georgouli, T., Calori, G. M., & Giannoudis, P. V. (2012). Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. Scientific World Journal, epub, doi: 10.1100/2012/606404
It is scary how much this post reminds me of athletics in high school. I recall a particular time I "rolled" my ankle 4 days before a big game. I was allowed to miss multiple classes a day to go hang out with the trainer and get ice baths for my ankle, then eventually heat over the three days to try and reduce the swelling. The entire time I was taking NSAIDs. It seemed clear I couldn't walk much less play on such a swollen ankle, so we had to get the swelling down! I was able to play the weekend game with a "wrapped" ankle (absurd amount of tape/etc to stabilize the joint), then I of course took NSAIDs that night for the pain I caused.
ReplyDeleteI think our mindset was always that the swelling was unnecessary. I recall thinking the swelling was an evolutionary remnant of the times prior to medical technology, where perhaps someone needed to be forced to not use the joint or needed the swelling to stabilize the joint since they didn't have braces. I had always considered the swelling to be a sign of the injury, and therefore if I could get it to go down, it was clearly getting "better". This course has certainly changed my perspective on soft-tissue injuries and associated symptoms...