Introduction
My forte of knowledge is on bone recovery and healing (check out Master’s thesis page here ). What usually applies to bone, also applies to soft tissue. I want to address an important issue that people outside of the research world likely do not know about: the negative impact of NSAIDs, Cox-2 inhibitors, and corticosteroids on tissue healing and recovery.
NSAIDs
NSAIDs such as ibuprofen (~Advil), aspirin, and naproxen are taken to reduce inflammation and pain– they are considered catabolic. How? By inhibiting prostaglandin synthesis through both the Cox-1 and Cox-2 inflammatory pathways. While inflammation/swelling is viewed as a “bad thing”, it is very much a necessary process. Immune cells help get rid of the damaged tissue and biochemically signal the replacement with new tissue through growth factors (~IGF-1) and prostaglandin. Prostaglandin, of which there’s several different types and numerous functions (see to the left), plays a critical role for signaling tissue synthesis, esp. in the early phases of healing. By “blunting” this process, tissue healing is slowed, and the tissue may heal improperly. With bone, it’s well-established that taking NSAIDs lead to less bone callus formation, which means the bone isn’t as strong. I’ll include two review articles on the topic: bone healing and soft tissue healing .
Acetaminaphen/Paracetamol (~Tylenol) works through a different pain-reducing mechanism and is a weaker inhibitor of Cox-2/prostaglandin.
Unfortunately, most people will take ibuprofen or other NSAIDs at the onset of pain, which is the most critical step for tissue healing. I can’t stress to people enough– DO NOT TAKE NSAIDs! You should cope with the pain and accept it as a necessary part of healing. You will heal faster without NSAIDs. Moreover, being aware of when your musculoskeletal tissue is pain is a sign to back off– if you are not getting this feedback, what starts out as something minor could turn into something severe. The tissue that’s formed could also be malformed, which means tissue that isn’t as strong/stress resistant (think of it as tissue with microcracks/tears in it). If you read the links above, they talk about there being different effects depending on the type of NSAIDs, amount, duration, and time of application. The research shows that when you stop taking an NSAID, the healing process usually resumes.
Also, athletes may take NSAIDs before/during/after races for injuries, muscle soreness, or trying to prevent pain in the race. I have a friend who said she’d take it before races cause she thought not feeling the pain would help her to push harder, and then she’d take it after to prevent pain/swelling. I recently talked about taking Excedrin before and during the NYC Marathon, which has Caffeine, Acetamenophin (~Tylenol), and Aspirin– moreso took it for the caffeine, but it was also experimental to see how it impacted my pain and recovery (~of which I don’t believe my recovery was hindered- I only took two). Take at your own risk, and certainly not in excess. If it allows you to “push harder”, that might mean more muscle damage too.
Given the catabolic nature of NSAIDs, it’s suggested they may be beneficial in circumstances where there’s entrapment or impingement of nerves or soft tissue (see second link above on “soft tissue healing”). In particular, NSAID treatments that are localized (~sports rubs) and not systemic (~impacting the whole body) may be beneficial for certain conditions. However, as I’ll point out below, I believe there’s a better option for speeding up the inflammatory process to enhance tissue healing, reduce swelling, and improve range of motion.
Cox-2 Inhibitors
Doctors may prescribe Cox-2 inhibitors (ex. Celebrex, Vioxx, Bextra, Arcoxia) to deal with pain. These tend to be better for preventing GI problems, a possible downfall with taking traditional NSAIDs. However, being Cox-2 inhibitors, they will inhibit prostaglandin and slow tissue healing. They also have their own set of side effects.
Corticosteroids
Corticosteroids, such as cortisone and prednisone, are steroids that are highly catabolic to hard and soft tissue. Cortisone may be given locally to treat or diagnose a condition– as mentioned above, it may be of benefit for certain soft tissue conditions involving entrapment/impingement. Given the catabolic nature of cortisone, doctors are generally careful with it’s administration (dose/location/# of applications), esp. when given near cartilage, which has a limited ability to re-generate and heal itself. I’ve heard horror stories of people getting cortisone shots and it “eating away” their cartilage or leading to bone necrosis (~some bones having poor bone supply/slow-healing).
Professional athletes who are part of the national/international drug-testing pools should also be aware that you may need a therapeutic-use exemption (I believe it depends on the type/location of cortisone, so do your research if you receive this treatment).
Prednisone is usually taken in pill form and is systemic, meaning it’s non-specific and impacts the whole body. Given it’s systemic and catabolic effect, it’s usually prescribed only short term– absolutely do NOT take this long term! Better yet, try to avoid even taking prednisone.
Personal Experiences
I briefly talked about NSAIDs/Cox-2 inhibitors in my previous post about stress fractures . Back in high school when I had 3 metatarsal stress fractures in my left foot, I unknowingly was a human guinea pig on this topic. For my first metatarsal stress fracture (2nd metatarsal of left foot), I hate to acknowledge this, but our coach encouraged us to take ibuprofen to deal with daily aches and pains. I had just moved to a new high school, so before this season I wasn’t someone to ever take NSAIDs. I remember when I started feeling pain in my foot, I upped the dose of ibuprofen. Over a week’s time and 3 XC meets (~Pre-State, Conference, Chile Pepper), the pain got so bad that the ibuprofen no longer blunted the pain. What likely started out as a stress fracture, had completely fractured! My foot swelled up like a football. On top of it…. the doctor prescribed a Cox-2 inhibitor (don’t remember if it was Celebrex or Vioxx). I was never put in a boot either. It took 14 weeks to heal and be pain free. Additionally, the bone didn’t heal properly, and my foot is now malformed because of it.
I then went on to develop a stress fracture in the 3rd metatarsal in the spring. Before this, I had developed a hip issue (likely bursitis), and the doctor prescribed prednisone for 10 days. It definitely took care of the hip pain, but soon after I developed another stress fracture. Fortunately, I recognized the pain early and stopped before it completely fractured. Once again, I was naively given prescription pain killers. This time, it took 10 weeks to heal and be pain free.
The following fall, I developed my 3rd stress fracture, in the 4th metatarsal. I caught this one early as well. I did my research and learned how bad NSAIDs/Cox-2 inhibitors are for bone. I decided not to take anything, wore a boot for the first 2-3 weeks, and I got in the pool and cross trained so I could make a comeback for my final season of XC (won Regionals and made All-State once again).This time– it took only 7 weeks to heal and be painfree!
Flash forward many years to grad school, when I studied how to enhance bone recovery. A freak chain of events led to me fracturing a rib in the middle of training for my first marathon. Knowing what I know…. once again, I became a human guinea pig (oh, the irony!). I applied everything I had learned, which of course meant no pain killers (despite being in A LOT of misery!). What did I do? We taped up the rib cage to stabilize the area, and I kept running very easy, pitter patter. The light mechanical stress of my breathing and movement of the arms/torso significantly speeded up the healing process. Very quickly, the swelling and pain went away, and a huge knot formed (a great sign for bone callus formation!). Moreover, the endorphins released while running helped me overcome the pain– I would feel better after going for a run. Within 3 weeks, I was completely pain free (despite the big “bone knot”)! I was able to continue training, did a few minimal workouts, and ran my marathon debut at Eugene in 2:48.
Better Solutions
As illustrated by my story above (and because of what I learned from my research), I believe a better solution to enhance healing and deal with pain is to move. Light mechanical stress, whether a few days or even weeks of easy jogging or walking, or other cross training activities, is a great stimulus. It enhances blood flow to the area, which means growth factors and micronutrients needed for healing. The swelling will go away very quickly to enhance range of motion, and the healing of the tissue will be highly stimulated. As I mentioned, the body will also produce endorphins to help deal with the pain.
Additionally, I previously did a post about ice baths and icing . Unfortunately, the actual ice/ice baths does nothing to enhance tissue healing, but it will help deal with pain, without the negative effects seen by NSAIDs/etc.. Also, if there’s a mechanical component involved with icing, such as ice cupping or movement in an ice bath or pool, that mechanical component will enhance tissue healing. Therefore, if you can’t handle the pain of an injury, this is an better option to consider.
**Disclaimer** I am not a physician, so it’s best to seek out medical advice from a professional first. What I’ve shared above is purely my own experience and what I’ve learned through my research studies.
Very good post!
Thank you! Glad you like it.
Through my own experience with injuries this year, I was beginning to understand what you have said to be true. I am amazed at how my old (63) body can heal with just the right amount of stress and movement. I take very little medication. Coming off an injury, with inadequate training, I just ran a half marathon at the same time as a year ago at 1:54 and with less pain during and after. A most pleasant surprise. I find the ice bath speeds my healing process.
Wow, very cool!!! 1:54 Half at 63 is amazing!!! Running IS our “natural medicine” (and any exercise, really). The physiological impact is far reach. I have a lot of faith in the human body– it’s quite remarkable, if you understand how it works and how to upregulate/downregulate certain processes. Hope you enjoy following my blog! Good luck and Semper Salveo (“Always in good health”),
Camille
I am very much a believer in active recovery and am encouraged by the story of your rib fracture. Knowing what you know now, what type of activity would you suggest for a runner freshly diagnosed with a metatarsal stress fracture? And, how do you feel about The Boot? (I understand wanting to limit range of motion to lessen certain forces. But, it seems to me that walking in it is so convoluted that the disruption in natural gait might well confound the healing process and encourage harmful adaptations.)
Hi Liz! Great questions! I did a thorough post about my experiences with stress fractures: http://camilleherron.com/2011/05/11/overcoming-stress-fractures/
I think the boot is good short-term– the first few weeks. It will help protect and rest the foot, being stiff and not causing you to bend and push off excessively. Definitely, you’d want to have a shoe of comparable height on the other foot, so you’re not walking with a funny gait. I still think it’s good to bear some weight, as tolerated, as this will increase blood flow and healing of the bone. This may sound crazy, but I’ve heard of people training through metatarsal stress fractures– very easy, pitter patter running (lifting off the ground rather than pushing). It probably depends on the severity and what you can tolerate. That’s my best advice. Good luck and let me know if you have other questions!
Camille
Thanks for the reply, Camille! I’ve read that post (and most others here) – LOTS of great stuff! First heard about the idea of vibration promoting bone formation back in 1989 from a professor at University of Michigan… he warned me that I’d be hearing much much more about it! A progression in footwear – boot to stiff soles to supportive to minimal to bare (again) – sounds reasonable. And weight bearing – as tolerated/feasible – is a must (unless one enjoys a 14-week stint sitting back and eating bon-bons!). Can’t imagine running through this… unless truly barefoot (and even then, maybe not). But definitely believe in the power of barefoot running, walking and living. I seem to run into the most trouble when I don a very minimal shoe ,such as Vibram Five Fingers, Zem, or even Soft Star – I suspect it may be because they put full responsibility for all support on your feet while at the same time taking away the almost all of the feedback you’d otherwise get from the ground if barefoot. (Whereas a slightly cushioned shoe, such as the Inov-8 minimal lines, provides some support, leverage and [questionably] shock attenuation.)
Thanks again for your good work – I’m really enjoying your blog.
Hi Camille,
I have been making some ginger root tea to help with the common cold I just came down with a few days ago. I seem to remember that ginger root had other medicinal remedies (e.g., nausea, anti-inflammatory, etc.).
Since ginger root is a natural anti-inflammatory, I was wondering if it would inhibit prostaglandin synthesis and slow down the healing process?
Hi Dean, it looks like ginger is a Cox-2 inhibitor: http://www.ncbi.nlm.nih.gov/pubmed/20837112 It looks like ginger has several medicinal properties. I would have to study it more to understand the exact mechanisms. I’m a big believer in Theraflu and methol camphor on your nose/neck/chest. Fisherman’s friends too and hot toddy or a shot of whiskey. I haven’t had a cold in 4 years, but when I get hay fever with season changes, these are my go-to things. You need to be able to breath, get oxygen, and sleep well…. to heal. Get well soon!
Camille
Hi Camille,
I have been making some ginger root tea to help with the common cold I just came down with a few days ago. I seem to remember that ginger root had other medicinal remedies (e.g., nausea, anti-inflammatory, etc.).
Since ginger root is a natural anti-inflammatory, I was wondering if it would inhibit prostaglandin synthesis and slow down the healing process?
Hi Dean, it looks like ginger is a Cox-2 inhibitor: http://www.ncbi.nlm.nih.gov/pubmed/20837112 It looks like ginger has several medicinal properties. I would have to study it more to understand the exact mechanisms. I’m a big believer in Theraflu and methol camphor on your nose/neck/chest. Fisherman’s friends too and hot toddy or a shot of whiskey. I haven’t had a cold in 4 years, but when I get hay fever with season changes, these are my go-to things. You need to be able to breath, get oxygen, and sleep well…. to heal. Get well soon!
Camille
It looks like (after some quick research) that ginger does inhibit the prostaglandin synthesis. It is still good for the common cold …… btw.
Camille,
I love your website — thanks so much for sharing with us and congratulations on your run at the Trials! My experience with healing is very similar to yours. Last year, while training for the SF Marathon, I fell off my bike and broke my collarbone. I had been training well and was running faster than ever. I was really afraid that my race would be ruined. I took a week off, and then went for a run — slow, easy, careful not to bounce the shoulder too much. Guess what? — when I got back, I felt sooo much better — The area loosened up, the muscles that had been clenched tightly for a week started to relax. Bloodflow increased. I was able to get back to regular mileage — 50mpw — in just a couple of weeks. Without knowing any of the mechanics that you describe, I found the same thing that you did. Getting back out there and moving was the best medicine. Ten weeks after the injury, I PR’ed a week before my 43rd birthday. Based on what you describe, I probably took more ibuprofen and vicodin than was optimal for healing the bone — but the weight-bearing exercise really helped.
Hi Thomas! Glad you like my website! The ability to share my experiences…. while hearing stories like yours… is exactly why I started it!
Very cool story about the collarbone and congratulations on the PRs– sounds like what happened with me and my fractured rib (which I trained through and healed quickly, so I could run my debut marathon). Definitely, it’s about MOVING and getting the blood flowing to enhance the healing process. The endorphins from running are also their own “natural happy drug”– no need for ibuprofen/vicodin! It’s amazing you figured all this out, unknowingly… but you were motivated, and since it was your collarbone (and not your ~foot!) you figured it out by accident. Funny enough, I’ve heard of people training through stress fractures in their ~feet/fibula. If you run slow enough for long enough, I believe it’s possible.
Great, keep spreading the word about the benefits of mechanical stress!
Camille
Camille,
I love your website — thanks so much for sharing with us and congratulations on your run at the Trials! My experience with healing is very similar to yours. Last year, while training for the SF Marathon, I fell off my bike and broke my collarbone. I had been training well and was running faster than ever. I was really afraid that my race would be ruined. I took a week off, and then went for a run — slow, easy, careful not to bounce the shoulder too much. Guess what? — when I got back, I felt sooo much better — The area loosened up, the muscles that had been clenched tightly for a week started to relax. Bloodflow increased. I was able to get back to regular mileage — 50mpw — in just a couple of weeks. Without knowing any of the mechanics that you describe, I found the same thing that you did. Getting back out there and moving was the best medicine. Ten weeks after the injury, I PR’ed a week before my 43rd birthday. Based on what you describe, I probably took more ibuprofen and vicodin than was optimal for healing the bone — but the weight-bearing exercise really helped.
Hi Thomas! Glad you like my website! The ability to share my experiences…. while hearing stories like yours… is exactly why I started it!
Very cool story about the collarbone and congratulations on the PRs– sounds like what happened with me and my fractured rib (which I trained through and healed quickly, so I could run my debut marathon). Definitely, it’s about MOVING and getting the blood flowing to enhance the healing process. The endorphins from running are also their own “natural happy drug”– no need for ibuprofen/vicodin! It’s amazing you figured all this out, unknowingly… but you were motivated, and since it was your collarbone (and not your ~foot!) you figured it out by accident. Funny enough, I’ve heard of people training through stress fractures in their ~feet/fibula. If you run slow enough for long enough, I believe it’s possible.
Great, keep spreading the word about the benefits of mechanical stress!
Camille
Hi Camille – I just stumbled across your website (via Running Natural Center) last night – and can’t stop reading! Thanks for all your useful information on, well, everything pertaining to distance running. I was at the Natural Running Center website because I have been doing a lot of research on natural running. This is because I recently (10 weeks ago) sustained a bone bruise on my left knee (femoral condyle) or some bony damage in that area at the very least. The injury wasn’t due to an accident or fall but by the way I run. So besides getting physical therapy and patiently waiting for my bone to heal, I also have to teach myself to run in a way that won’t repeat this annoying injury. This injury occurred several weeks after I finally PR’d at the Jacksonville Bank Marathon (3:29). I’m a toe runner and supinate severely but am working on landing midfoot in low, flat and minimal shoes. Your site has been very helpful but I know I can’t mimic everything you do – because that works for you – and may not for me. However, I do notice that you aren’t afraid to try things to see if they work for you (like running slow on your recovery days and eating ice-cream every night) and refrain from doing things (like taking NSAIDS and running in cushioned shoes and orthotics) that don’t work for you. That’s what I have learnt from your site. To take control and execute a program that works for you, rather than what works for everybody else. Thank you for that! I look forward to reading more!!
Hi Lisa! Glad you like my website! Definitely, we’re each our own “human guinea pig”, trying to figure out what works for us! You’re absolutely right– we all are built differently and run differently. There is no wrong or right way to run. It took me many years of frustration with injuries before I finally decided to toss the orthotics and go with a basic shoe…. it seems like yesterday I did it, not knowing where it would lead me! Definitely experiment with different things, and pay attention to how your body feels.
Best wishes getting healthy and congrats on the PR!