Pharmacological treatment of soft-tissue injuries.

Publisher Website
Google Scholar
Abstract
Few people engage in recreational or sports activities or physical work without ever sustaining an acute sprain, strain, or overuse injury of a tendon, muscle-tendon junction, ligament, or joint capsule. Many individuals who sustain such an injury seek treatment from an orthopaedic surgeon. Although most of the injuries heal uneventfully, they can cause considerable pain, limit mobility, and compromise the ability of the patient to work or to participate in sports or recreational activities. Partial suppression of the inflammation that is caused by a soft-tissue injury decreases the pain. It may also allow earlier resumption of normal activity by decreasing the pain, tenderness, stiffness, and swelling as well as by limiting changes in the tissues from disuse and by reducing the secondary tissue damage from the release of degradative enzymes and other events that occur during inflammation [16]. For these reasons, when patients seek treatment for acute injury of musculoskeletal soft tissue, physicians commonly prescribe modification or restriction of activity and anti-inflammatory medications -- usually oral administration of non-steroidal anti-inflammatory drugs and less commonly injections of corticosteroids [2,16,36,57,98]. Some physicians also recommend the topical administration of non-steroidal anti-inflammatory drugs and corticosteroids or short courses of orally administered corticosteroids [21,43,49,64]. In addition, some patients choose other drugs, including anabolic steroids and dimethyl sulfoxide, to treat the injuries [5,12,72,74,91,99,112,146,171,183]. The use of medications has become so widely accepted as part of the routine treatment of soft-tissue injuries that few physicians or patients question the efficacy of the commonly used drugs or carefully consider their potential adverse effects on the musculoskeletal tissues or their potential systemic toxicity. In addition, because inflammation may have a role in initiating and promoting the repair of vascularized tissues [37] and because the pain that is due to inflammation may limit activity that can cause additional injury, it is reasonable to question whether the suppression of inflammation adversely affects healing. For these reasons, physicians and patients should understand the potential benefits and risks of the drugs that are commonly used in the treatment of injuries of musculoskeletal soft tissue, including the effects of these drugs on articular cartilage, tendons, ligaments, joint capsules, and muscle-tendon junctions. Also, they should understand how these medications affect the healing of soft tissue. This is especially important as most of these drugs were developed and are marketed primarily for uses other than the treatment of acute soft-tissue injuries. Yet, despite the large number of patients who are managed with medications for soft-tissue injuries either by themselves, by physicians, or by other health-care providers, there have been few prospective, randomized, controlled studies of the pharmacological treatment of soft-tissue injuries. The current article is a review of the use of non-steroidal anti-inflammatory drugs, corticosteroids, anabolic steroids, and dimethyl sulfoxide for the treatment of injuries of musculoskeletal soft tissue. The clinical efficacy of these drugs and the evidence concerning their potential effects on normal as well as injured soft tissues are discussed. Non-steroidal anti-inflammatory drugs have been recommended primarily for the treatment of chronic musculoskeletal disorders, including rheumatoid arthritis, ankylosing spondylitis, and osteoarthrosis. However, physicians frequently prescribe them, and patients purchase them without prescription, for the treatment of soft-tissue injuries [1,2,51]. (Currently, acetylsalicylic acid, sodium salicylate, magnesium salicylate, choline salicylate, ibuprofen, and naproxen are available without prescription in the United States.) Non-steroidal anti-inflammatory drugs that are commonly used include aspirin (acetylsalicylic acid), diclofenac, diflunisal, fenoprofen, ibuprofen, indomethacin, ketoprofen, nabumetone, naproxen, piroxicam, salsalate, sulindac, and tolmetin. All of these chemically heterogeneous drugs have analgesic, antipyretic, and anti-inflammatory activity.