Do NSAIDs slow healing?

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Do NSAIDs slow healing?

Various studies indicate that the frequent use of NSAIDs can slow down the healing process of damaged ligaments, broken bones, and other tissues. If you are attempting to recuperate the harm done to a knee, shoulder, or other joint, utilizing NSAIDs can essentially protract the healing time. 

Unexpectedly this is because these medications do what exactly they show in promotions—for example, inflammation blockage. The issue is that inflammation is one of the essential steps of the healing process: a typical, essential, and valuable reaction. In advertisements, they show inflammation as something negative. However, it is an astoundingly positive, and vital step in the whole healing process. Obstructing the inflammation which accompanies injury is a part of the healing process as inflammation carries blood to the area to promote healing. 

However, further studies have shown that the use of NSAIDs delays the healing process after a muscle strain, knee ligament injury, and rotator cuff surgery. NSAIDs can be problematic in case of healing. However, healing eventually occurs anyway. Yet it will be disregarded, not as a result of the utilization of these medications.

Nonsteroidal Anti-inflammatory Drugs:

Most often, people administer these substances orally. Therefore, they pass through the digestive system, then into the circulation. Finally, they are metabolized according to their individual properties either by the kidney or by the liver. NSAIDs can also be delivered topically or by intramuscular injections. These routes of administration are less studied than the oral route.

In light of current knowledge, it seems more and more evident that taking NSAIDs results in a marked inhibition of the early inflammatory response. It can impair the natural healing of a lesion and harm the process—subsequent repair. The primary mechanism of action of NSAIDs is the inhibition of prostaglandin (PG) synthesis from arachidonic acid by blocking cyclooxygenase (Cox).

1. Nonsteroidal Anti-inflammatory And Ligament:

In humans and athletes, in particular, the most studied lesion is undoubtedly ankle sprain. Grade I or II. Moreover, the most used NSAID is ibuprofen 2400mg /d for seven to ten days. The results are relatively consistent. Compared to placebo, there is an early reduction in pain and swelling, an improvement in the range of motion of the ankle, and faster loading. These positive effects, when they exist, are generally observable until the seventh day, not beyond. 

2. Nonsteroidal and Tendon Anti-inflammatory:

Based on the observation of the absence of an inflammatory reaction during overload tendinopathy, the role of NSAIDs is, therefore, very uncertain and debated. A very recent meta-analysis identified randomized controlled clinical studies and systematic reviews. NSAIDs reduce only short-term pain for specific locations (shoulder in particular). There is no longer-term benefit, and the risk of side effects increases with the duration of treatment. One could even postulate that the analgesic effect of NSAIDs could allow the sportsman to increase too early the stresses on his tendon and, consequently, negatively influence healing. Also, NSAIDs never show any modification in the natural course of healing of tendinopathy. Only acute tendino-bursitis of the shoulder and De Quervain’s tenosynovitis appear to be potential indications for short-term treatments.

3. Nonsteroidal Anti-inflammatory and Bone:

Prostaglandins play a vital role in bone homeostasis. They stimulate both bone resorption by increasing the number and activity of osteoclasts and bone formation by increasing the differentiation and replication of osteoblasts. It is easy to understand that any substance which impairs their synthesis can be harmful. The inhibitory effects of NSAIDs on bone formation have led to their use in the prevention of heterotopic ossifications (abnormal growth of bone in non-skeletal tissues) after prosthetic surgery.

The harmful effects vary according to the NSAIDs chosen as well as according to the duration of taking. A delay in bone consolidation is quite noticeable in patients on NSAIDs. So patients must avoid their consumption during the first week after a fracture. After that, even in the absence of potentially harmful effects, their use is no longer justified, the analgesics should be sufficient. For stress fractures, for the same reasons, NSAIDs should not be used.

4. Nonsteroidal Anti-inflammatory and Muscle:

In a muscle injury, fiber breakage will be followed by necrosis of myofibers, the appearance of a hematoma, and an inflammatory reaction. A repair phase will generate along with phagocytosis of the necrotic material. Then it will produce fibrous tissues, a whole procession of cytokines, and secrete growth factors. The third and final phase that of remodeling will consist of the regeneration of newly formed muscle fibers, the contraction, and the reorganization of the fibrous scar.

Neutrophils and macrophages dominate the initial inflammatory response. The release of cytokines and free radicals could, for some, worsen the initial lesion. Their action of cleaning debris on the lesion site seems to be important to allow tissue remodeling.

The type of anti-inflammatory drugs, their selectivity Cox-1 or -2, the duration of intake, the doses used, and the schedule of intake about the occurrence of the lesion vary. 

Seven things to know before taking anti-inflammatory drugs:

Ibuprofen, diclofenac: at least one of these anti-inflammatories is always present in our medicine cabinets. But studies keep on highlighting their side effects and the Medicines Agency’s warning messages are increasing. Precautions to take.

  1. NSAIDs do not relieve back pain
  2. In self-medication, we start with paracetamol
  3. Some have cardiovascular risks
  4. Anti-inflammatory drugs can worsen infections
  5. They must sometimes be associated with a gastric protector
  6. During pregnancy, medical advice is essential
  7. Ibuprofen would disrupt the hormonal system

Often taken in self-medication for pain or fever, NSAIDs are nevertheless drugs to be used with caution and rarely as a first-line.

1. NSAIDs do not relieve back pain.

Osteoarthritis, arthritis, sciatica, painful periods, migraine, sprains, strains, and tendonitis: the pain of inflammatory origin is the first indication of these drugs. However, in case of low back pain, it seems unnecessary to rush to the ibuprofen box. In 2017, a study published by Australian researchers showed that it only relieved one in six patients. For the others, the placebo did as well.

2. In self-medication, we start with paracetamol.

The message from the health authorities is clear: always begin with paracetamol. If any individual uses it well, this pain reliever is very safe to be taken first in 500 mg doses and then one gram if necessary.

If the pain does not decrease after one or two days of treatment, we can then try to relieve it with an NSAID. Alone or alternately, with paracetamol. Ibuprofen is taken first in a 200 mg tablet, then 400 mg if necessary, without exceeding 1,200 mg per day.

3. Some have cardiovascular risks.

It would be particularly the case for diclofenac (Voltaren), available by prescription. A large Danish study shows that this molecule, taken orally, leads to an increased risk of serious cardiovascular problems (atrial fibrillation, stroke, heart failure). Even in people with no factor of risk. This risk was already known. The novelty is to have shown that diclofenac presents a 20 to 30% greater risk than other NSAIDs. This risk exists even in low doses (less than 100 mg per day), and for short durations. It is advisable to be cautious.

Ibuprofen taken above 2400 mg per day (maximum authorized dose), is not without cardiovascular risks. If you have hypertension or other cardiovascular diseases, it is prudent to limit the dose of NSAIDs to the minimum recommended and the duration of treatment to two to three days.

Avoid these drugs in case of renal or cardiac insufficiency, and after myocardial infarction.

4. Anti-inflammatory drugs can worsen infections.

Epidemiological studies carried out since 2002 suggest that these drugs increase the risk of infections like shingles, chickenpox, pulmonary infections, angina, or otitis. Excluding dental infections. The Medicines Agency confirmed a risk in April 2019. It shows that ibuprofen and Ketoprofen have been responsible for serious infectious complications. Such as neurological, pleuro-pulmonary infections, sepsis, etc. They even have led to hospitalization.

Suppressing inflammation also means suppressing a defense mechanism in the body, and this can promote infections.

Besides, relieving pain can mask the signs of a starting infection, delaying treatment. After two or three days of fever or persistent pain, stop using anti-inflammatory drugs, and consult a doctor as soon as possible.

Be careful if you suspect an infectious focus (dental abscess, angina, and otitis). You must not take an anti-inflammatory! It may mask the infection and delay the diagnosis.

5. They must sometimes be associated with a gastric protector.

Even at normal doses, taking them puts you at risk of heartburn, even ulcers, perforation, or gastric bleeding. This negative effect is very variable depending on the anti-inflammatory and its mode of action. Some like Ketoprofen is less harmful to the cardiovascular system, but they have gastrointestinal side effects. Ibuprofen, aspirin, and diclofenac are less dangerous to the stomach. Hence the importance of swallowing them with a glass of water is crucial. It prevents the tablet from sticking to the lining of the esophagus, and a snack or meal.

When NSAIDs are prescribed over several months and at a relatively high dose, for example, to treat the pain of chronic inflammatory rheumatism, 15 to 30% of users are at risk of having an ulcer disease. It is why the doctor most often associates them with a gastric protector such as a proton pump inhibitor, such as omeprazole. Despite the adverse effects listed or suspected, the gastric protectors keep all their interest in this co-prescription.

6. During pregnancy, medical advice is essential.

In January 2018, the National Medicines Safety Agency recalled never to use these drugs after the sixth month of pregnancy. The risk is that it will wound the heart of the fetus at the stage where the two cavities of the organ separate. It even happens with a single take. The ideal is to avoid any self-medication throughout the pregnancy.

If pain is to be relieved, use paracetamol as a priority, even on aspirin. As long as one is in the first two trimesters of pregnancy, but under medical supervision.

7. Ibuprofen would disrupt the hormonal system.

It is especially the case for athletes who use this molecule continuously to prevent muscle pain. However, taking ibuprofen at a dose of 1,200 mg per day for six weeks disrupts the secretion of sex hormones in the testes in young men. It usually occurs in 10% of older men. The long-term consequences are not yet known, especially for male fertility.


Nonsteroidal anti-inflammatory drugs (NSAIDs) can help in treating the painful episode in sports medicine. However, no scientific evidence has so far shown their effectiveness, and their side effects are not trivial. Inhibiting the early inflammatory response can affect the natural healing of a lesion and harm the subsequent repair process. In the case of ligament injuries, the administration of NSAIDs for a short course of treatment may be useful. In overload tendinopathy, if there is not, strictly speaking, an inflammatory phenomenon, NSAIDs are not recommended. One should also avoid taking these drugs after a fracture because of their effects on bone formation. There is no demonstrated evidence of the value of their use in muscle injuries.

The immediate measures taken in an emergency during sports trauma are known to all: ice, rest, elevation, compression (GREC). Even if it seems fair to continue to recommend their use, no scientific study has been able to demonstrate to date the interest of the application of these measures one after the other.

It is common to prescribe anti-inflammatory drugs (NSAIDs) or pain relievers to control the pain episode. These medications, especially the first, are not without side effects. They are, for some, over the counter, accessible without medical control.

Finally, among the side effects of NSAIDs, one should not overlook the possibility of post-traumatic hemorrhagic complications in all athletes involved in contact sports or “at risk.”


For many practitioners, medical knowledge of the harmful consequences of chronic NSAID uses limits to gastrointestinal issues, as well as that of kidney function. However, recent medical literature shows that the detrimental effects of NSAIDs also extend to the metabolism and growth of the primary tissues constituting the musculoskeletal system. An “ethical” problem therefore arises. Must we take into account the short-term analgesic effect of NSAIDs to favor immediate performance or to emphasize the potentially harmful long-term consequences of their use?

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