Pain, Sports, and Your Options

Written by Adam Freeman, DC, CCSP®

An information piece for athletes, desk jockeys, weekend warriors, parents, coaches, or anyone else who doesn’t know where to turn when aches and pains appear. The culture of pain management is changing. Here is what you need to know to protect yourself and your loved ones:

Hurt vs Injured

Recognizing when you need to reach out to a qualified physician can be a tough hurdle. In general, if you have pain first thing in the morning, during or after an activity (like playing sports, working out or even putting your shoes on), pain that wakes you up at night, pain that is always there, or simply pain that is decreasing your enjoyment of life; you should ask for help.

As a young child some of my first experiences playing competitive sports were tainted with pain or injury. Some of those experiences have led me to the work I do now. More specifically, I remember my first time being asked by a coach, “Are you hurt or are you injured?” The first time you hear that it rattles your brain a little. How are you supposed to know? Do even know now?

Pain teaches you things. It teaches you what not to do, what to avoid, and sometimes it teaches you strength. I see pain on a regular basis in the clinic; typically nothing serious, but the question is always there. Are they just hurting or are they injured? And can I help?

The debate about pain has intensified over the last few years as more and more research is done on how pain is perceived in the brain. Pain is more subjective than you may be aware. For instance, your culture relates directly to the expression of pain. Our upbringing and social values influence how we express pain and its nature, intensity, and duration. (1) So, while pain is part of the human experience, it isn’t the same for everyone.

Pain Basics

When you experience pain, your nerves carry messages from the area to your brain, which allows you to feel the pain. This is actually a protective mechanism so that you can know that your body is in danger and take action. Reaction to that pain is innate, or something you body does without you thinking about it. One such reaction may be to find a way to move differently so as to protect the area. Think about the last time you sprained your ankle. Nearly instantly you started to limp. If that ankle goes untreated for a period of time, you develop an entirely new movement pattern. These new movement patterns can force certain muscles to do more than their fair share and potentially lead to overuse injuries.

Sport and Pain

Engaging in sports is a risky activity. The amount of risk, however, varies based on several factors. Those factors can include, physical conditioning, understanding of the game and the rules, playing conditions, skill level, technique, and many more. One of the more important aspects this day and age is sport specificity. If you only play one sport, and play it throughout the year, you are more likely to be injured due to overuse. Research reported in 2013 by Jayanthi and colleagues, found that young athletes who played a single sport for more hours a week than years they were old — such as a 10-year-old who played 11 or more hours of soccer — were 70% more likely to experience serious overuse injuries. (2)

For some athletes the only answer is to cover it up. During the season there is high pressure from coaches, parents, and teammates to play through it. Though this culture has made some changes, we are still seeing high reoccurrence rates in many injuries. Approximately 50% of sports medicine injuries in kids and teens are overuse in nature. (3)

A small sample study on potential overuse injuries vs acute injuries by Yang et. al in the Journal of Athletic Training (2012) gives you an idea for occurrence of injuries in college sports. The study reports 60% of back injuries in college sports were related to muscle strains (potentially from overuse) while only 6% were due to disc injuries. (4)

Study sample on 573 male and female collegiate athletes from an NCAA Division I institution participating in 16 team sports found that participants reported 1,317 injuries during a three-year period. Of those injuries, 386 (29.3 percent) were overuse injuries and 931 (70.7 percent) were acute. A total of 319 male athletes sustained 705 injuries, and 254 female athletes sustained 612 injuries.

The long-term consequences of overuse injuries include loss of playing time, reduced function and psychological exhaustion. Overuse injuries also are associated with a gradual increase in symptoms, which means athletes may go undiagnosed and untreated for longer periods of time leading to long-term residual symptoms and chronic health consequences, including deformities and arthritis.

What will you do?

Other than using Google to find the nearest sports physician or specialist, using Dr. Google for an injury is not your best long-term option. Some even argue that a trip to the ER is happening far too often for sport related injuries. You are much more likely, however, to end up in your primary care physician’s office. This can be a good thing if you physician knows whom to turn to for musculoskeletal pain and injuries. If, however, they just simply prescribe you pain medication, you may be in the wrong office. Moreover, pain medication prescribing should be cautious and both situation and pathology specific.

First, understand what you are taking or prescribed. Ask questions.

NSAIDS (non-steroidal anti-inflammatory drugs) – The 4 most common include Aspirin (Bayer is a common one), Ibuprofen (Advil or Motrin), Naproxen (Aleve), Celecoxib (Celebrex). These drugs have known anti-inflammatory, analgesic (pain relief), antipyretic (fever reducer) and antithrombotic effects (blood clot formation reduction), though in-vivo (whole living organisms) effects in treating musculoskeletal injuries in humans remain largely unknown. NSAID work to block inflammatory factor production. While, inflammation is generally thought of in a negative light due to soft tissue edema (swelling) and local cell death. The opposite is true when managed correctly. Inflammation is what initiates much of the healing needed in soft tissue injuries. Research even shows us that with regular NSAID use, the soft tissue repair process is delayed and can cause the tissue to become more rigid with incomplete healing. (5) Further adding to the disability. 

The side effects are well documented however, and should be considered contraindicated to those with predisposition to the following. These include asthma exacerbation, gastrointestinal (intestines) damage, liver and renal (kidney) damage, hypertension and other cardiovascular complications. (6) Over prescription and toxicity in the US is rampant as well. Wolfe et al. studied gastrointestinal toxicity and published in The New England Journal of Medicine in 1999 that the numbers of hospitalizations in the US range from 100,000 to 200,000 hospitalizations from serious toxicity to these drugs. The number of deaths from 1990 to 1999 climbed from about 6,000 to more than 17,000. (7) This is significant.

The benefits from taking NSAID are generally limited to use in early rehab scenarios (postoperatively) where mobilization and pain relief is a key component to return to play. The early and aggressive use of NSAIDs to treat acute musculoskeletal injuries including sprains and strains has been common in the past, in order to halt the inflammation that leads to pain, swelling and loss of joint mobility. However, during the first 24-48 hours following injury, the inflammatory response is crucial for the recruitment and activation of inflammatory mediators that act to remove tissue damage and begin the process of tissue repair and regeneration. This process reaches its maximum at 48 hours, as mentioned in NZ Journal of Physiotherapy in 2007. (8) Other indications could be impingement conditions, tenosynovitis, chronic joint inflammation, degenerative joint conditions, or ligament strains. Caution should be noted with most acute conditions.

Paracetamol (acetaminophen) – Most commonly branded as Tylenol. Paracetamol can be used to ease mild to moderate pain. It is most commonly used in cases of musculoskeletal injury, general aches and pains, as well as conditions such as headaches and toothache.

No one knows exactly how paracetamol works, but scientists think that it works mainly in the central nervous system (the brain and the spine). Paracetamol is thought to reduce the intensity of pain signals to the brain. It may also prevent the release of substances, called prostaglandins, that increase pain and body temperature.

Paracetamol has similar warnings or side effects. If you have problems with kidney or liver function you may want to consider other options. One review, by Machado et. al in 2015, reported of 13 randomized trials reports that, "paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis." (9) Also, reports show that ingesting acetaminophen and alcohol at the same time results in liver death. This is a very serious and toxic combination. More reports show use during pregnancy and during childhood have serious implications on brain function, as reported in the online Toxicological Sciences Journal by Uppsala University. (10)

Lastly, if you’re prescribed something stronger (like morphine, oxycodone, fentanyl, tramadol, opioid or other narcotics) than previously mentioned, understand the risks and side effects. One major concern is the risk of dependency and addiction. These are serious and widely documented throughout everyday use and professional sports.

Other Options for Pain Relief

It was mentioned before that NSAID are a popular and moderately potent analgesic. This has been challenged by a recent article by Machdo et. al. in 2017 stating, "NSAID reduced pain and disability, but provided clinically unimportant effects over placebo." (11) Additionally, is it worth the risk and side effects to you or your young athlete? Consider too, that you haven’t really solved the problem. Just covered up the pain. For athletes, this can be a massive error.

You will hear some doctors liken covering up pain, to a leak in the roof. You haven’t fixed anything if you just mop up the floor. Those aches and pains that seemingly just go away can eventually catch up to you.

So what can you do?

As mentioned previously, find someone who diagnoses and treats the underlying issue. For many aches and pains the problematic area is elsewhere and that needs to be treated. To use the previous example; the headache was the puddle on the floor, but the problem was a hole in the roof.

Prevention is key. Some tips for preventing an overuse injury include:

• Cutting back the intensity, duration, and frequency of an activity
• Adopting a hard/easy workout schedule and crosstraining with other activities to maintain fitness levels
• Learning about proper training and technique from a coach or athletic trainer
• Performing proper warm-up activities before and after
• Using ice or self treatment modalities (like foam rolling and stretching) after an activity for minor aches and pain
• If symptoms persist, a sports medicine specialist or physician will be able to create a more detailed treatment plan for your specific condition. This may include a thorough review of your training program and an evaluation for any predisposing factors. 

Modalities that many physicians may use to effectively treat the underlying issues include approaches like:

• Chiropractic care, which has a wide range of benefits and research to back it up. Chiropractors detect and treat dysfunction of the joints in the spine and extremities. Dysfunction in these joints is termed subluxations. These subluxations can create abnormal wear and tear of the surrounding tissues. Correcting the subluxation opens up the body for more optimal and complete soft tissue appraisal and corrective exercises. Searching for a Chiropractor with board qualified sport specific training is going to typically be more effective, as they have more education on the matter (DACBSP®, CCSP®, or some will have a CSCS).
• Soft tissue treatments, as applied by Chiropractors and Physical Therapists, are very effective for long term recovery and pain management (including things like massage, cupping, ART® (Active Release Technique), instrument assisted soft tissue mobilization (Graston Technique®), mechanical percussion (Theragun G1® and Erchonia®), stretching, mobilization, etc.) that improve the health, healing, and pain of muscles and ligaments. Other modalities may include kinesio tape, laser, electric stimulation, ultrasound, topical analgesics and more.
• Nutrition advice is a great way to improve the environment of which the tissues of the body operate. Proper nutrition has wide ranging benefits that should always play an important role in the recovery from surgery, injury, or strength training.
• Acupuncture, which has been shown to directly activate specific parts of the brain by He, Tian, et al. in "Neural mechanisms of acupuncture as revealed by fMRI studies," published by Autonomic Neuroscience in 2015, in order to manage pain among other outcomes.
• Massage research continues to find massage as an incredibly effective tool, especially if you are able to group together treatments. 

As you can see the list can get quite extensive. The point being, many of these interventions have very limited side effects, especially as compared to the prolonged use of pills.

In Summary

The use, access, and news coverage of pain medication is growing. Too many people are relying on pills to cover up their pain instead of getting the underlying issues treated. In taking these pills, that are basically as clinically effective as placebo, you set yourself up for potential serious adverse side effects. Treatment of the cause of pain can prevent a more serious injury from occurring and offer long term relief.

What you do about pain and injury should largely rely on the diagnosis of a qualified physician. The more specific diagnosis you get the more likely you are to be on a fast and full recovery. The earlier you intervene in the pain cycle the more likely you are to have a full and complete recovery without the added destruction from pills.

Living with pain and just getting by day to day there is lowering your quality of life. The long-term implications of taking medications and playing while injured just aren't worth it. You may want to consider how your pain today, is effecting your enjoyment of tomorrow.

Resources

1. Peacock, Sue, and Shilpa Patel. “Cultural Influences on Pain.” Reviews in Pain1.2 (2008): 6–9. PMC. Web. 22 July 2017.
2. Jayanthi, Neeru A., Cynthia R. Labella, Daniel Fischer, Jacqueline Pasulka, and Lara R. Dugas. "Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes." The American Journal of Sports Medicine 43.4 (2015): 794-801.
3. Brenner, J. S. "Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes." Pediatrics 119.6 (2007): 1242-245.
4. Yang, Jingzhen et al. “Epidemiology of Overuse and Acute Injuries Among Competitive Collegiate Athletes.” Journal of Athletic Training 47.2 (2012): 198–204.

5. Almekinders, L. C. (1999). "Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies." Sports Med 28(6): 383-8.

6. Australian Acute Musculoskeletal Pain Guidelines Group (AAMPGG). Evidence based management of acute musculoskeletal pain, 2004. Australian Academic Press. Brisbane. http://www.nhmrc.gov.au 

7. Wolfe, Michael M., David R. Lichtenstein, and Gurkirpal Singh. "Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs." Survey of Anesthesiology 44.3 (2000): 180-81.

8. Braund, Rhiannon, and J. Haxby Abbott. "Nonsteroidal antiinflammatory drugs (NSAIDs) and paracetamol for acute musculoskeletal injuries: Physiotherapists understanding of which is safer, more effective, and when to initiate treatment." Physiotherapy Theory and Practice 27.7 (2011): 482-91.

9. Machado, Gustavo C et al. “Efficacy and Safety of Paracetamol for Spinal Pain and Osteoarthritis: Systematic Review and Meta-Analysis of Randomised Placebo Controlled Trials.” The BMJ 350 (2015): h1225. PMC. Web. 22 July 2017.

10. Henrik Viberg, Per Eriksson, Torsten Gordh, Anders Fredriksson; Paracetamol (Acetaminophen) Administration During Neonatal Brain Development Affects Cognitive Function and Alters Its Analgesic and Anxiolytic Response in Adult Male Mice. Toxicol Sci 2014; 138 (1): 139-147. doi: 10.1093/toxsci/kft329

11. Machado GC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases 2017;76:1269-1278.