Indication. Analgesic (pain killing tablets) can be used on a greatly limited scale to reduce pain in connection with minor injuries where this is a risk of aggravating the injury with continued activity (i.e. bleeding under the nail and the like). The treatment can naturally also be utilized in many other cases with pain present if the sports activity is discontinued (fracture, lumbago and the like). Some of the drugs within the “weak morphines” group are on the list of prohibited doping substances!

Mechanism of action. Weak morphines are pain killing tablets with a weak morphine-like effect. The effect is not substantially different from paracetamol. There are several different drugs within the “weak morphines” group, which are all absorbed via the intestines. The effect can be expected after approx. ½-1 hour, with a duration of 3-6 hours.

Side effects. The side effects are of the same character (although weaker) as morphine: nausea, vomiting, drowsiness, constipation and dizziness, and therefore extreme caution should be exercised when driving. The drugs present only a limited risk of dependence and addiction. Overdoses can be life threatening.

Contraindication. Pain killers should never be used to allow an athlete continue a sports activity which can bring about a risk of aggravating the injury. As there are different contraindications with all the drugs in the “weak morphines” group, the attending doctor should acquire a good knowledge of the patient before prescribing drugs from this group.

Dose. Dependent upon which drug is used in the treatment.

Conclusion. Weak morphines are almost never indicated in the treatment of sports injuries, as it is possible to achieve almost the same result with non-prescription drugs with considerably less risk attached.

Use of NSAID is widespread in sport as a painkiller, and as treatment to subdue inflammation. The pain-relieving effect is well documented, however, the documentation of NSAIDs effect of healing sport injuries is limited.

Indication. Over-load symptoms from tendons. A considerable number of scientific studies have been performed comprising NSAID treatment on acute tendon injuries. In the majority of studies, but not all, healing was achieved slightly quicker, and inflammation was slightly reduced compared with placebo treatment. Some studies have shown increased instability and reduced mobility in the joints after NSAID treatment. Acute muscle injuries. There are only a handful of animal studies dealing with NSAID treatment of acute muscle injuries. Increased muscle strength has been proven, however, also reduced healing of damaged tissue. Myositis ossifans (calcification in muscles after bleeding). One study shows that calcification in the muscles following a hip operation is reduced in patients who are treated with NSAID after the operation. Chronic muscle and tendon injury. There is no scientific evidence supporting use of NSAID on chronic muscle or tendon injuries.

Side effects. Side effects from the abdomen and intestines (heartburn, gastric ulcer and sour eructation) are frequent following treatment with NSAID. NSAID increases the risk for thrombosis (article). Allergic shock, kidney damage and bone marrow damage has been described, but are very rare events. Only moderate side effects are seen following localised treatment with NSAID (allergy).

Contraindications. Allergy is on the whole the only contraindication for NSAID treatment in healthy athletes. Patients with gastric ulcer, high blood pressure, liver, heart and kidney illnesses should be cautious with NSAID treatment.

Administration. Tablet treatment is recommended at the lowest dose if NSAID is indicated. Some placebo controlled studies show that local NSAID as gel is better than placebo on acute injuries, despite the concentration of blood following localised treatment constituting less than 10% of the level after tablet treatment or after injection in the muscles (article). There are no scientific grounds for using injection methods. There are no studies which document the ideal point in time to start NSAID treatment, or the length of duration.

Discussion. There is no conclusive clarification as to whether inhibiting the acute inflammation is an absolute advantage. Pain and discomfort are in any event partially conditional upon the inflammation. By reducing the inflammation the symptoms are reduced, thereby allowing rehabilitation to start at an earlier stage. On the other hand, the inflamed cells are responsible for the decomposition of the tissue which has been destroyed, which is necessary for removal of dead muscle fibre and the like.

Conclusion. It is recommended that NSAID is only used as a pain-reliever at the lowest dose at the acute stage, since it does not have a certain effect on healing of sports injuries. Since the treatment does have well documented and serious side effects (ulcers, blood clots) it is recommended to limit the treatment to a minimum. 
If NSAID is misused as a painkiller to continue a potentially damaging sports activity, the treatment will indirectly increase the risk of the chronic injury. It is for this reason that all NSAID treatment on athletes must be administered by a physician with knowledge of the basic rehabilitation principles.

Other medicaments treatments.

Systematical injection of heparin (anticoagulant) have been used to treat certain types of tendonitis. There is a general limited scientific documentation of the effect, and since the side effects can be serious, there has never been an indication for this treatment. Ultrasound guided injections of corticosteroids seems more effective and significantly less risky.

Garcia Rodriguez LA, Hernandez-Diaz S. Epidemiology 2001 Sep;12(5):570-6

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with an increase in upper gastrointestinal complications. There is no agreement, however, on whether all conventional NSAIDs have a similar relative risk (RR), and epidemiologic data are limited on acetaminophen. We studied the association between these medications and the risk of upper gastrointestinal bleed/perforation in a population-based cohort of 958,397 persons in the United Kingdom between 1993 and 1998. Our nested case-control analysis included 2,105 cases and 11,500 controls. RR estimates were adjusted for several factors known to be associated with upper gastrointestinal bleed/perforation. Compared with non-users, users of acetaminophen at doses less than 2 gm did not have an increased risk of upper gastrointestinal complications. The adjusted RR for acetaminophen at doses greater than 2 gm was 3.6 [95% confidence interval (95% CI) = 2.6-5.1]. The corresponding RRs for low/medium and high doses of NSAIDs were 2.4 (95% CI = 1.9-3.1) and 4.9 (95% CI = 4.1-5.8). The RR was 3.1 (95% CI = 2.5, 3.8) for short plasma half-life, 4.5 (95% CI = 3.5-5.9) for long half-life, and 5.4 (95% CI = 4.0-7.1) for slow-release formulations of NSAIDs. After adjusting for daily dose, the differences in RR between individual NSAIDs tended to diminish except for apazone. Users of H2 receptor antagonists, omeprazole, and misoprostol had RRs of 1.4 (95% CI = 1.2-1.8), 0.6 (95% CI = 0.4-0.9), and 0.6 (95% CI = 0.4-1.0), respectively. Among NSAID users, use of nitrates was associated with an RR of 0.6 (95% CI = 0.4-1).

Indication. Analgesic drugs (painkillers) can be used to a limited extent to reduce the pain with minor injuries where there are no risks of aggravating the injury through continued sports activity (i.e. bleeding under the nail, skin abrasions etc.). All forms of painkillers can naturally be taken if the sports activity ceases. Paracetamol is recommended due to the very modest side effects associated with its use.

Mechanism of action. Paracetamol provides both painkilling (analgesic) and temperature lowering (antipyretic) effects. The mechanism is partly unknown. 90% is absorbed from the intestines after ingestion of a tablet, with maximum concentration of paracetamol being achieved after ½-1 hour after ingestion. The duration of the effect is 4-6 hours. It should be noted that only approx. 60% is absorbed from suppositories.

Side effects. Paracetamol in normal doses has by and large no side effects, as opposed to weak morphine type drugs containing acetyl salicylic acid. Long term treatment with maximum dosage appears, however, to increase the risk of ulcers, especially if the treatment is combined with rheumatic pills (NSAID), (article). Relative risk of upper gastrointestinal complications among users of acetaminophen and nonsteroidal anti-inflammatory drugs.

Contraindications. Painkillers should never be used to enable the athlete to continue an activity which bears a risk of aggravating the injury. Paracetamol and other painkilling drugs with antipyretic effects must never be used to lower the body temperature of an athlete before starting sports activity. Serious virus infections can invade the (cardiac) muscle of the heart and cause myocarditis. The risk of myocarditis is increased under great physical exertion during virus infections, and some cases have been reported of fatalities amongst young, otherwise healthy athletes, under these circumstances. Increased body temperature indicates an infection, and all athletes should stop sports activity until the body temperature has returned to normal. Dose. 1 gram paracetamol 3-4 times daily.

Conclusion. Paracetamol can be recommended when needed as painkillers for conditions where pain is experienced without any suspicions of inflammation.