Question: Should athletes take NSAIDs to combat muscle aches and soreness?
Athletes sustain a variety of muscle injuries throughout their careers. These injuries include, but are not limited to the following: strain- located at the myotendinous junction caused by unaccustomed explosive movements; contusion injury- vascular damage within a muscle caused by direct contact; myofiber injury- damage located in the muscle fibers caused by unaccustomed eccentric contractions; delayed onset muscle soreness (DOMS)- generalized pain that occurs during muscle lengthening 2-3 days post unaccustomed exercise (1). The healing time for these injuries varies from 2-12 weeks, depending on the location, severity, and other factors (1,2).
Unfortunately, athletes often do not allow their bodies sufficient time to fully heal before returning to play (2). Muscle regeneration is a multi-stage process that includes an inflammatory response that helps clear away damaged cells. This includes de-adhesion and disassembly of the muscle fiber matrix, followed by an anabolic response of the satellite cells (1,3). The satellite cells are dormant except when they are needed for muscle repair, but they are stimulated by stretch or contraction, damage to muscle fibers, and inflammation (3). Non-steroidal anti-inflammatory drugs (NSAID) inhibit satellite cells, thus decreasing some opportunity for muscle regeneration and hypertrophy post-exercise (1,3,4). Furthermore, NSAIDs also inhibit cyclo-oxygenase (COX)-2, an enzyme involved with the inflammatory response, which stimulates prostaglandins (PG) to help regulate protein metabolism and to help skeletal muscle tissue regeneration and hypertrophy (2). When COX-2 is inhibited, tissue repair and mechanical strength decrease following injury.
Many athletes ingest NSAIDs to reduce inflammation, pain, and swelling (1-3,5). Interestingly, in a double-blind randomized placebo controlled group study, Arendt-Nielson and colleagues (6) reported that systemic NSAIDs, such as Ibuprofen, do not have significant effect on muscle pain and soreness related to exercise. On the contrary, Al-Nawaiseh and colleagues (7) reported that NSAIDs can be beneficial when used as an anti-inflammatory and analgesic when used in combination with antioxidants, cold water submersion, and whey protein following high-intensity aerobic exercise (6). Despite conflicting evidence of the usefulness of NSAIDs, athletes continue using them for their anti-inflammatory and analgesic properties.
Although short term use seems to be beneficial, chronic use of orally ingested NSAIDs has many adverse effects. NSAIDs inhibit the adaptive response of skeletal muscle connective tissue to exercise, and thus prevent tendon strengthening, which could make an individual more prone to future injuries; decrease force production; and may cause damage to the central nervous system, renal system, and gastrointestinal system (1-3,5). Additionally, there is a common prophylactic misuse of NSAIDs in high school and college athletes who aim to block pain before it occurs (5). This misuse could lead to serious side effects; unfortunately, the negative side effects in youth may not become apparent until later (5).
Considering the risk-benefit ratio of ingesting NSAIDs could help athletes, coaches, and parents. Ingesting NSAIDs immediately post injury for a short duration could be beneficial for athletes to reduce injury-related inflammation, or for people, such as the elderly, who have systemically elevated inflammatory cytokines (3). However, in addition to the adverse effects previously listed, NSAIDs can mask pain, allowing athletes to return to play prematurely, thus risking more serious or additional injuries. The potential adverse reactions outweigh the benefits of these drugs, especially when a different pain reliever or topical anti-inflammatory could be used if necessary. If an athlete is persistent about using an NSAID, it is important to encourage the individual to use the smallest effective dose for the shortest duration possible, and only following an injury.
- Mackey, A., Mikkelsen, U., Magnussen, S., & Kjaer, M. (2012). Rehabilitation of muscle after injury – the role of anti-inflammatory drugs. Scandinavian Journal of Medicine & Science in Sports 22, e8-e14.
- Alaranta, A., Alaranta, H., & Helenius, I. (2008). Use of prescription drugs in athletes. Sports Medicine 38(6), 449-463.
- Mackey, A. (2013). Does an NSAID a day keep satellite cells at bay? Journal of Applied Physiology 115, 900-908.
- Mikkelsen, U., Langberg, H., Helmark, I., Skovgaard, D., Andersen, L., Kjaer, M., Mackey, A. (2009). Region specific prostaglandin blockade inhibits satellite cell proliferation in human skeletal muscle following eccentric exercise. Journal of Applied Physicology 107, 1600-1611.
- Warden, S. (2009). Prophylactic misuse and recommended use of non-steroidal anti-inflammatory drugs by athletes. British Journal of Sports Medicine 43(8), 548-549.
- Arendt-Nielsen, L., Weidner, M., Bartholin, D., & Rosetzky, A. (2007). A Double-blind placebo controlled parallel group study evaluating the effects of ibuprofen and glucosamine sulfate on exercise induced muscle soreness. Journal of Musculoskeletal Pain 15(1), 21-28.
- Al-Nawaiseh, A., Pritchett, R., & Bishop, P. (2016). Enhancing short-term recovery after high-intensity anaerobic exercise. Journal of Strength and Conditioning Research 30(2), 320-325.