Sports
Medicine Commentary
Therapeutic agents injuries
in musculoskeletal
JAMES M. GLICK, MD
&dquo;Muscle relaxants and
prescribed principally
to
tranquilizers
are
lend the small
of comfort they provide to encourinjured athlete in the belief that his physician is using all modalities of therapv amount
age the
that will permit his early re-entrv into
competition.&dquo;
It
is well for the consider the
physician serving athletes
make-up of his patient. Generally speaking the athlete is young and in good or excellent health and has excelto
lent musculoskeletal attributes. The athlete is highly motivated to achieve excellence in his particular sport,-hence his mental attitude is good and he is generally cooperative. He, or she, does not require much urging to participate in preventive or therapeutic measures advised by the physician. Understandably, treatment of athletes for immediate injuries or during longer periods of rehabilitation takes a different pattern than that of the patient regularly seen by a physician in general practice. The great desire of an injured athlete to return to competition is an inducement to the therapist for he can count on a large degree of cooperation in the relatively slow process of rehabilitation. Here progress may be steady but not as readily apparent to a patient as recovery from an infection. As a rule the physician treating athletes is Dr. James M. Glick is Assistant Clinical Profesof Orthopedic Surgery, University of California Medical Center, San Francisco; and Associate Professor of Physical Education and Team Physician, San Francisco State University, San Francisco, California. sor
136
concerned largely with traumatic injuries centered on the musculoskeletal system and less frequently, injuries to internal organs. Such considerations as outlined above will govern the physician in his choice of drugs. Drugs are used for &dquo;curing&dquo;, &dquo;controlling&dquo; and &dquo;comforting&dquo; in therapeutic situations ; they should not be used to increase the quality of athletic performance. The basic underlying problem for which the drug is to be given should be diagnosed. The drugs commonly used for musculoskeletal conditions in athletics will be discussed. TO CURE
Drugs do not prevent injury. Likewise no drug (including vitamins, calcium and iron preparations) will speed up the healing of fracture, strain or sprain in the healthy individual. TO CONTROL
Anti-inflammatory drugs and
muscle
re-
laxants control inflammation and muscle spasm. Anti-inflammatory agents may be divided thusly: l. Proteolytic enzymes 2. Steroids 3. Others (salicylates, phenylbutazone and indomethacin) Their primary function is to reduce inflammation. Enzymes and steroids injected directly into musculoskeletal regions may delay healing. The rationale for the use of proteolytic enzymes is based on their fibrinolytic activity in vitro. Reports from unbiased sources’ do not support the claims of their proponents that they are effective in preventing swelling. The claim that enzymes
such
as
streptokinase-streptodornase (Vari-
verse
changes in the blood. Salicylates
are
preparations (Papase~) liable to depress the blood-clotting mecha11 may be administered locally or systemically nism and cause bleeding.9, They have been with good results and no untoward reactions shown however, to protect against cartilage is not borne out by my experiences. Local degeneration following a joint injury,.&dquo; In injections frequently cause alarming allergic the exceptional cases of older persons enreactions. When given orally or systemi- gaged in strenuous athletic activity, who cally their dangers are few but their useful- may be prone to acute attacks of gout, ness is nil. salicylates should not be given because of Cortisone, a natural product of the adre- their uricosuric action. In the experience of nal glands, and its cogenors produced syn- this observer, indomethacin is not as effec-
dascR)
and papaya
thetically are designated corticosteroids and tive as phenylbutazone but its side effects are less. Therefore, indomethacin is reversed are frequently used to control inflammation. The corticosteroids have multiple actions. for patients who cannot tolerate phenylbutaWhen given in large amounts over a long zone or salicylates. Tranquilizers such as diazepam (Valium) period of time, suppression of adrenal gland activity may occur. If it becomes necessary as well as the so-called muscle relaxants such as methacarbamol (Robaxin) or carisoto give corticosteroids in high doses over a long period of time, the physician should be prodol (Soma) are claimed to relieve muscle alert to the occurrence of untoward re- spasm. However, they have little effect with sponses. Therefore, steroids, however ad- the recommended doses. Many, especially the tranquilizers, give some sedation and ministered, should be limited. &dquo;Repository steroids&dquo; are relatively insol- therefore aid in this fashion. uble esters which are slowly absorbed from the joint cavity or tendon sheath.2Systemic effects are minimal when only one joint or one tendon has received an injection. Undesirable local effects may occur if the steroid is injected repeatedly into a joint or tendon. Joint destruction and an increased incidence of tendon rupture have been reported. 3.4, 5~ 6 The etiology of these complications is unknown; it has been suggested that steroids reduce pain to such an extent that the patient then exceeds the mechanical tolerance of the part.* It has been shown experimentally that corticosteroids soften the bone in the vicinity of a joint,~and reduce the tensile strength of a tendon.e Despite these facts the majority of athletes who receive intra-articular corticosteroids should derive considerable benefit as long as treatment is approached with caution. The hazards of corticosteroids infiltrating around a tendon may be greater than the benefit. Salicylates, phenylbutazone and indomethacin are used widely in athletic medicine. They are most helpful in the more chronic cases of tendinitis and arthritis. If used injudiciously, these drugs can cause troublesome complications such as gastric irritation, peptic ulcers, bleeding and ad-
COMFORT
The aforementioned drugs, except for salicylates, give comfort primarily by relieving inflammation and spasm. The primary goal of the administation of analgesics is to obtain comfort for the injured athlete. Analgesics for systemic use may be divided into those used for severe pain, for which morphine is the prototype and those used for mild pain, for which salicylates are the prototype. In between these lies codeine. The strong analgesics may be preferred for the injured athlete who cannot return to play. Obviously a narcotic should be given cautiously at all times, but should never be administered before an athletic event. The sedative effect of these strong analgesics will also hamper performance. Some football teams are reportedly giving mild analgesics prior to game time, to those players who bruise easily. Since these mild analgesics have never been shown to prevent the pain of acute injury, it is a meddlesome therapeutic endeavor. Procaine and lidocaine, which are usually used for local anaesthetic action, have an analgesic effect when injected locally. These act on the sensory nerve endings and have little to no central nervous system effects.&dquo; 137
Their use can be hazardous depending on the time of injection. Injections into any major joint or tendon prior to participation can cause immediate severe injury to that part while performing. Pain is a warning sign and if this protective device is destroyed, further injury can occur under stress. DISCUSSION
The therapeutic use of some of the drugs discussed above is open to question. My experience suggests the following: Oral enzymes seem to give no benefit. The use of injectable enzymes is not advisable; they have little to recommend them. Corticosteroids are instilled by injection to relieve inflammation in an injured joint or in an acute muscle strain. They are rarely used for tendinitis. A reasonable rule is to inject corticosteroids into a joint three times at two week intervals; if there is no improvement one should resort to other methods. Weight bearing tendons are injected once, after all other forms of treatment have failed and only after the athlete is warned of the increased risk of rupture. A single steroid injection is helpful in reducing inflammation of a muscle strain where bleeding is well localized. Corticosteroids may be injected more frequently into areas such as the epicondylar region of the elbow for tennis elbow, the acromioclavicular joint for a strain or in the back for trigger areas of tenderness. In most instances a local injection of a
&dquo;pain killer&dquo;, immediately prior
to
a
game,
is to be avoided. However, this general rule may be breached; minor areas may be injected if there is a pinpoint spot of tenderness. These so-called minor areas are m the trunk (iliac creast, sacro-iliac joint) and the acromioclavicular joint (acromioclavicular strain or contusion). Analgesics mask pain and should never be injected into any area of the lower extremities. I follow a cardinal rule: A player with neck pain and stiffness should not be allowed to participate in a contact sport until the signs and symptoms of the injury are no longer apparent. Systemic administration of corticosteroids is rarely used. It is reserved for such chronic conditions as tennis elbow or tendinitis of the shoulder when other therapeu138
tic measures have failed. The prescribed dose should be given daily for 7 to 10 days and then reduced slowly over 3 to 4 days. Salicylates and phenylbutazone are given more frequently. The dosage of salicylates is 2 five-grain tablets, 4 times a day with meals for 3 to 6 weeks. A 100 mg. phenylbutazone tablet is given four times daily with food for one week. If it is necessary to utilize indomethacin it is given as a one 25-mg. tablet 3 times a day for 2 to 3 weeks. If these do not produce the desired response in the usual period of time, then other forms of treatment should be considered. References 1. Bennett JE, Zook EG, Ashbell TS, Hugo NE: The Spreading Enzymes and Localized Edema: A Study of Wringer Crush Injury in the Rabbit. Journal of Trauma 10: 240248 ; 1970 2. Hollander JL: Disabling Osteoarthritis of Hip—Surgery or Steroid Therapy? Questions and Answers. JAMA 222: 841, 1972 3. Bentley G, Goodfellow JW: Disorganization of the Knees following Intraarticular, Hydrocortisone Injections. Journal of Bone and Joint Surgery 51 B 498-502, 1969 4. Chandler GN, Wright V. Deleterious Effect of Intraarticular Hydrocortisone Lancet 2 661 663, 1958 5. Ismail AM, Balakrishnan B, Rajakumar MK: Rupture of Patellar Ligament after Steroid Infiltration. Report of a Case. Journal of Bone and Joint Surgery. 51B 503 505, 1969 6. Lee HB. Avulsion and Rupture of the Tendocalcaneus after Injection of Hydrocortisone Brit. Med. Journal. 2: 395, 1957. 7. Cohen H (First Baron of Birkenhead), Neuropathic Joints. Journal of Bone and Joint Surgery. 43B 219-221, 1961 8. Wrenn RN, Goldner JL, Markee JL An Experimental Study of the Effect of Cortisone on the Healing Process and Tensile Strength of Tendons Journal of Bone and Joint Surgery 36A: 588-601, 1954 9. Chrisman DO, Snook GA, Wilson TC. The Protective Effect of Aspirin against Degeneration of Human Articular Cartilage. Clin Orthop 84 193-196, 1972 10. Evans G, Packman MA, Nishizawa EA. The Effects of Acetylsalicylic Acid on Platelet Function J Exp Med 128 877-894, 1968 11. Quick AJ, Celscen L: Influence of Acetylsalicylic Acid and Salicylamide on the Coagulation of Blood. J Pharmacol Exp Ther 128: 95-98, 1960 12. Goodman LS, Gilman A: The Pharmacological Bases of Therapeutics. ed. 2. New York, The MacMillan Co., 1955, pp 364-366
Medicine Commentary
Therapeutic agents injuries
in musculoskeletal
JAMES M. GLICK, MD
&dquo;Muscle relaxants and
prescribed principally
to
tranquilizers
are
lend the small
of comfort they provide to encourinjured athlete in the belief that his physician is using all modalities of therapv amount
age the
that will permit his early re-entrv into
competition.&dquo;
It
is well for the consider the
physician serving athletes
make-up of his patient. Generally speaking the athlete is young and in good or excellent health and has excelto
lent musculoskeletal attributes. The athlete is highly motivated to achieve excellence in his particular sport,-hence his mental attitude is good and he is generally cooperative. He, or she, does not require much urging to participate in preventive or therapeutic measures advised by the physician. Understandably, treatment of athletes for immediate injuries or during longer periods of rehabilitation takes a different pattern than that of the patient regularly seen by a physician in general practice. The great desire of an injured athlete to return to competition is an inducement to the therapist for he can count on a large degree of cooperation in the relatively slow process of rehabilitation. Here progress may be steady but not as readily apparent to a patient as recovery from an infection. As a rule the physician treating athletes is Dr. James M. Glick is Assistant Clinical Profesof Orthopedic Surgery, University of California Medical Center, San Francisco; and Associate Professor of Physical Education and Team Physician, San Francisco State University, San Francisco, California. sor
136
concerned largely with traumatic injuries centered on the musculoskeletal system and less frequently, injuries to internal organs. Such considerations as outlined above will govern the physician in his choice of drugs. Drugs are used for &dquo;curing&dquo;, &dquo;controlling&dquo; and &dquo;comforting&dquo; in therapeutic situations ; they should not be used to increase the quality of athletic performance. The basic underlying problem for which the drug is to be given should be diagnosed. The drugs commonly used for musculoskeletal conditions in athletics will be discussed. TO CURE
Drugs do not prevent injury. Likewise no drug (including vitamins, calcium and iron preparations) will speed up the healing of fracture, strain or sprain in the healthy individual. TO CONTROL
Anti-inflammatory drugs and
muscle
re-
laxants control inflammation and muscle spasm. Anti-inflammatory agents may be divided thusly: l. Proteolytic enzymes 2. Steroids 3. Others (salicylates, phenylbutazone and indomethacin) Their primary function is to reduce inflammation. Enzymes and steroids injected directly into musculoskeletal regions may delay healing. The rationale for the use of proteolytic enzymes is based on their fibrinolytic activity in vitro. Reports from unbiased sources’ do not support the claims of their proponents that they are effective in preventing swelling. The claim that enzymes
such
as
streptokinase-streptodornase (Vari-
verse
changes in the blood. Salicylates
are
preparations (Papase~) liable to depress the blood-clotting mecha11 may be administered locally or systemically nism and cause bleeding.9, They have been with good results and no untoward reactions shown however, to protect against cartilage is not borne out by my experiences. Local degeneration following a joint injury,.&dquo; In injections frequently cause alarming allergic the exceptional cases of older persons enreactions. When given orally or systemi- gaged in strenuous athletic activity, who cally their dangers are few but their useful- may be prone to acute attacks of gout, ness is nil. salicylates should not be given because of Cortisone, a natural product of the adre- their uricosuric action. In the experience of nal glands, and its cogenors produced syn- this observer, indomethacin is not as effec-
dascR)
and papaya
thetically are designated corticosteroids and tive as phenylbutazone but its side effects are less. Therefore, indomethacin is reversed are frequently used to control inflammation. The corticosteroids have multiple actions. for patients who cannot tolerate phenylbutaWhen given in large amounts over a long zone or salicylates. Tranquilizers such as diazepam (Valium) period of time, suppression of adrenal gland activity may occur. If it becomes necessary as well as the so-called muscle relaxants such as methacarbamol (Robaxin) or carisoto give corticosteroids in high doses over a long period of time, the physician should be prodol (Soma) are claimed to relieve muscle alert to the occurrence of untoward re- spasm. However, they have little effect with sponses. Therefore, steroids, however ad- the recommended doses. Many, especially the tranquilizers, give some sedation and ministered, should be limited. &dquo;Repository steroids&dquo; are relatively insol- therefore aid in this fashion. uble esters which are slowly absorbed from the joint cavity or tendon sheath.2Systemic effects are minimal when only one joint or one tendon has received an injection. Undesirable local effects may occur if the steroid is injected repeatedly into a joint or tendon. Joint destruction and an increased incidence of tendon rupture have been reported. 3.4, 5~ 6 The etiology of these complications is unknown; it has been suggested that steroids reduce pain to such an extent that the patient then exceeds the mechanical tolerance of the part.* It has been shown experimentally that corticosteroids soften the bone in the vicinity of a joint,~and reduce the tensile strength of a tendon.e Despite these facts the majority of athletes who receive intra-articular corticosteroids should derive considerable benefit as long as treatment is approached with caution. The hazards of corticosteroids infiltrating around a tendon may be greater than the benefit. Salicylates, phenylbutazone and indomethacin are used widely in athletic medicine. They are most helpful in the more chronic cases of tendinitis and arthritis. If used injudiciously, these drugs can cause troublesome complications such as gastric irritation, peptic ulcers, bleeding and ad-
COMFORT
The aforementioned drugs, except for salicylates, give comfort primarily by relieving inflammation and spasm. The primary goal of the administation of analgesics is to obtain comfort for the injured athlete. Analgesics for systemic use may be divided into those used for severe pain, for which morphine is the prototype and those used for mild pain, for which salicylates are the prototype. In between these lies codeine. The strong analgesics may be preferred for the injured athlete who cannot return to play. Obviously a narcotic should be given cautiously at all times, but should never be administered before an athletic event. The sedative effect of these strong analgesics will also hamper performance. Some football teams are reportedly giving mild analgesics prior to game time, to those players who bruise easily. Since these mild analgesics have never been shown to prevent the pain of acute injury, it is a meddlesome therapeutic endeavor. Procaine and lidocaine, which are usually used for local anaesthetic action, have an analgesic effect when injected locally. These act on the sensory nerve endings and have little to no central nervous system effects.&dquo; 137
Their use can be hazardous depending on the time of injection. Injections into any major joint or tendon prior to participation can cause immediate severe injury to that part while performing. Pain is a warning sign and if this protective device is destroyed, further injury can occur under stress. DISCUSSION
The therapeutic use of some of the drugs discussed above is open to question. My experience suggests the following: Oral enzymes seem to give no benefit. The use of injectable enzymes is not advisable; they have little to recommend them. Corticosteroids are instilled by injection to relieve inflammation in an injured joint or in an acute muscle strain. They are rarely used for tendinitis. A reasonable rule is to inject corticosteroids into a joint three times at two week intervals; if there is no improvement one should resort to other methods. Weight bearing tendons are injected once, after all other forms of treatment have failed and only after the athlete is warned of the increased risk of rupture. A single steroid injection is helpful in reducing inflammation of a muscle strain where bleeding is well localized. Corticosteroids may be injected more frequently into areas such as the epicondylar region of the elbow for tennis elbow, the acromioclavicular joint for a strain or in the back for trigger areas of tenderness. In most instances a local injection of a
&dquo;pain killer&dquo;, immediately prior
to
a
game,
is to be avoided. However, this general rule may be breached; minor areas may be injected if there is a pinpoint spot of tenderness. These so-called minor areas are m the trunk (iliac creast, sacro-iliac joint) and the acromioclavicular joint (acromioclavicular strain or contusion). Analgesics mask pain and should never be injected into any area of the lower extremities. I follow a cardinal rule: A player with neck pain and stiffness should not be allowed to participate in a contact sport until the signs and symptoms of the injury are no longer apparent. Systemic administration of corticosteroids is rarely used. It is reserved for such chronic conditions as tennis elbow or tendinitis of the shoulder when other therapeu138
tic measures have failed. The prescribed dose should be given daily for 7 to 10 days and then reduced slowly over 3 to 4 days. Salicylates and phenylbutazone are given more frequently. The dosage of salicylates is 2 five-grain tablets, 4 times a day with meals for 3 to 6 weeks. A 100 mg. phenylbutazone tablet is given four times daily with food for one week. If it is necessary to utilize indomethacin it is given as a one 25-mg. tablet 3 times a day for 2 to 3 weeks. If these do not produce the desired response in the usual period of time, then other forms of treatment should be considered. References 1. Bennett JE, Zook EG, Ashbell TS, Hugo NE: The Spreading Enzymes and Localized Edema: A Study of Wringer Crush Injury in the Rabbit. Journal of Trauma 10: 240248 ; 1970 2. Hollander JL: Disabling Osteoarthritis of Hip—Surgery or Steroid Therapy? Questions and Answers. JAMA 222: 841, 1972 3. Bentley G, Goodfellow JW: Disorganization of the Knees following Intraarticular, Hydrocortisone Injections. Journal of Bone and Joint Surgery 51 B 498-502, 1969 4. Chandler GN, Wright V. Deleterious Effect of Intraarticular Hydrocortisone Lancet 2 661 663, 1958 5. Ismail AM, Balakrishnan B, Rajakumar MK: Rupture of Patellar Ligament after Steroid Infiltration. Report of a Case. Journal of Bone and Joint Surgery. 51B 503 505, 1969 6. Lee HB. Avulsion and Rupture of the Tendocalcaneus after Injection of Hydrocortisone Brit. Med. Journal. 2: 395, 1957. 7. Cohen H (First Baron of Birkenhead), Neuropathic Joints. Journal of Bone and Joint Surgery. 43B 219-221, 1961 8. Wrenn RN, Goldner JL, Markee JL An Experimental Study of the Effect of Cortisone on the Healing Process and Tensile Strength of Tendons Journal of Bone and Joint Surgery 36A: 588-601, 1954 9. Chrisman DO, Snook GA, Wilson TC. The Protective Effect of Aspirin against Degeneration of Human Articular Cartilage. Clin Orthop 84 193-196, 1972 10. Evans G, Packman MA, Nishizawa EA. The Effects of Acetylsalicylic Acid on Platelet Function J Exp Med 128 877-894, 1968 11. Quick AJ, Celscen L: Influence of Acetylsalicylic Acid and Salicylamide on the Coagulation of Blood. J Pharmacol Exp Ther 128: 95-98, 1960 12. Goodman LS, Gilman A: The Pharmacological Bases of Therapeutics. ed. 2. New York, The MacMillan Co., 1955, pp 364-366
