The Use of NSAIDS in the Healing Process

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for musculoskeletal injuries because the conditions are believed to be inflammatory in nature. However, because inflammation is a necessary component in the healing process, decreasing inflammation may prove counterproductive. Also, many tendon injuries called 'tendonitis' are, in fact, degenerative and not inflammatory conditions. An analysis of the pathophysiology and healing of musculoskeletal injuries questions the use of NSAIDs in many treatment protocols. Because NSAIDs have profound side effects, they should not automatically be the first choice for treating musculoskeletal injuries.

A major rationale for using NSAIDs in the treatment of musculoskeletal injuries has been their anti-inflammatory quality. The prevailing argument is that healthy tissue is not inflamed; therefore, if we stop the inflammation in an injured tissue, the tissue will be healthy. The problem with this viewpoint is that, in addition to being a sign of injury, inflammation is a necessary component of the healing process. “Inflammation can occur without healing, but healing cannot occur without inflammation.” (Leadbetter WB)

Whether the injured tissue is a ligament, tendon, or muscle, the body responds to injury with a sequence of events that begins with an influx of inflammatory cells and blood. The inflammatory cells remove debris and recruit cytokines (proteins for healing) and other growth factors toward the injury site. This inflammatory phase is partly mediated by the same prostaglandins that are blocked by NSAIDs. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase. The fibroblasts build a new extracellular matrix and persist into the final phase of repair, the maturation phase, where, if all goes well, functional tissue is laid down. The key point is that each phase of repair is necessary for the subsequent phase. By blocking the inflammatory phase, NSAIDs can, at least theoretically, delay the healing of musculoskeletal injuries.

When used properly, NSAIDs can be a useful, but limited, adjunct. They certainly play a key therapeutic role in the treatment of pathologic edema of bursa and synovial tissue (e.g., tenosynovitis). For most common sprains, strains, and overuse injuries, however, their therapeutic properties are unproven. It is crucial to keep a proper perspective regarding the role of NSAIDs, especially given their risk of side effects and their potential to blunt the normal healing response. Too many physicians and patients view NSAIDs as critical to recovery. Additional research is needed to define more explicitly the role of NSAIDs in interfering with or delaying healing and the role of other, potentially safer, means to control the pain of musculoskeletal injuries.

Drew Freedman