Tendon healing and COX-2 inhibitors

[injuryupdate]

Interesting paper from the AJSM. Suggests that COX-2 inhibitors (such as Celebrex, Mobic, Dynastat and the recently removed Vioxx) and other NSAIDs might be bad for tendon healing in the early stages after injury, but useful for chronic tendinopathy.

This version was published on October 1, 2004

The American Journal of Sports Medicine 32:1743-1747 (2004)
© 2004 American Orthopaedic Society for Sports Medicine
Parecoxib Impairs Early Tendon Repair but Improves Later Remodeling
Olena Virchenko, MD, Björn Skoglund and Per Aspenberg, MD, PhD*
From the Section for Orthopaedics and Sports Medicine, Department of Neuroscience and Locomotion, Faculty of Health Sciences, Linköping, Sweden

* Address correspondence to Per Aspenberg, MD, PhD, Section for Orthopaedics and Sports Medicine, Department of Neuroscience and Locomotion, Faculty of Health Sciences, SE-581 85 Linköping, Sweden (e-mail: per.aspenberg@inr.liu.se).

Background: Cyclooxygenase-2 inhibitors inhibit bone repair.

Hypothesis: Cyclooxygenase inhibitors might also have a negative effect on early tendon repair, although a positive effect on late tendon repair previously has been shown.

Study Design: Controlled laboratory study.

Methods: Achilles tendon transection was performed on 80 rats. Sixty rats were given daily intramuscular injections of either parecoxib (6.4 mg/kg body weight) or saline for the first 5 days after surgery and sacrificed either at 8 or 14 days. The remaining 20 rats were given intramuscular parecoxib or saline injections from day 6 until sacrifice at 14 days.

Results: At 8 days, early parecoxib treatment caused a 27% decrease in force at failure (P = .007), a 25% decrease in maximum stress (P = .01), and a 31% decrease in energy uptake (P = .05). Stiffness and transverse area were not significantly affected. At 14 days, early parecoxib treatment caused a decrease in stiffness (P = .004). In contrast to early treatment, late parecoxib treatment caused a 16% decrease in cross-sectional area (P = .03) and a 29% increase in maximum stress (P = .04).

Conclusions: During early tendon repair, a cyclooxygenase-2 inhibitor had a detrimental effect. During remodelling, however, inflammation appears to have a negative influence, and cyclooxygenase-2 inhibitors might be of value.

Clinical Relevance: The results suggest that cyclooxygenase-2 inhibitors should be used with care in the early period after tendon injury.


Key Words: nonsteroidal anti-inflammatory drug (NSAID) • tendon repair • ligament • rat • remodeling

[hhh]

Is there much supportive clinical evidence for any form of NSAID for muscle/tendon injuries (short term more than long term) - Cochrane smashes them and virtually says their main effects are analgesic, therefore should have over the counter medication? I know clinical experience and anecdotal experience shows positive results. When does good science overide clinical experience and how long does this process chage (if it occurs?)

[injuryupdate]

A recent study (not published yet) from the AFL on hamstrings shows higher recurrence rate if NSAIDs taken in the first 72 hours.

I like the study published at the start of this thread, as it fits in with my experience and other papers I have read:

Structural injuries with significant damage (fractures, ligament ruptures, tendon tears, big muscle strains) - AVOID NSAIDs
Injuries with mild or no structural damage (DOMS, gd 1- muscle injuries, impingement injuries) - USE NSAIDs
First 48-72 hours after injury - AVOID NSAIDs
Chronic injuries - USE NSAIDs

Avoid NSAIDs when trying to bulk up, and in the off-season. Use them when trying to get through the season with a painful injury.

Basically NSAIDs will break down painful scar tissue and some normal tissue like muscle and connective tissue. A serious injury, particularly early in its recovery, needs to lay down a lot of new connective tissue to repair, so stay off the NSAIDs. A chronic injury with little damage that is painful may be helped by getting rid of inflammed scar tissue that is doing little else but causing pain.

An advantage that cortisone injections and NSAID gels have is that the anti-inflammtory effects can be put where you want them and not taken everywhere else.

[hhh]

Who are the authors of that study, has the paper been accepted yet, if so where? Please list the details

Have you seen this paper??

Reynolds JF, Noakes TD, Schwellnus MP, Windt A, Bowerbank P.
Non-steroidal anti-inflammatory drugs fail to enhance healing of acute hamstring injuries treated with physiotherapy.
S Afr Med J. 1995 Jun;85(6):517-22.

The effects of two non-steroidal anti-inflammatory drugs (NSAIDs), meclofenamate and diclofenac, in combination with physiotherapy modalities on the rate of healing of acute hamstring muscle tears were studied in a double-blind, placebo-controlled trial. Fourty-four of the 75 patients with this injury recruited were assessed and randomly allocated to one of three treatment groups: meclofenamate (100 mg 3 times a day), diclofenac (50 mg 3 times a day) and placebo. All patients received the same intensive physiotherapy treatment over the 7-day treatment period. Patient assessments were performed on days 1, 3 and 7 of the 7-day study period and included pain assessment (visual analogue scale), swelling measurement (thigh circumference measurement at the site of the muscle tear) and isokinetic muscle performance testing. Treatment produced a significant improvement in all measurements in all groups, but there was no difference in any measurement between groups. However, when only the more severe injuries were analysed, the reported pain score at day 7 was significantly lower in the placebo group than in either the meclofenamate group or the diclofenac group (P < 0.05). Hence this study did not find any additive effect on the healing of acute muscle injuries when meclofenamate or diclofenac was added to standard physiotherapeutic modalities. The study therefore does not support the use of NSAIDs in the treatment of acute hamstring muscle injuries.

[morris1]

Hello everyone,
I am very new in this forum and joining the discussion related to the Parecoxib medication .Well this is well known that in the surgery there will be very good and fine instruments has been used .Gelfilm Sterile Film is also the film which is used in the surgery and this is very special type of film because this can be cut in any shape .

Please go through the link below for more...

http://www.drugdelivery.ca/s3533-s-GELFILM.aspx

[injuryupdate]

The NSAID finding was presented at ACSMS by Price Warren as part of his hamstring abstract. Not sure if he is in-press yet anywhere, but sure to be accepted somewhere eventually. For the time being the ACSMS abstracts in JSMS could be quoted.

Recent review of Paoloni & Orchard in MJA discourages NSAIDs for soft tissue injuries not involving impingement.

http://www.mja.com.au/public/issues/183_07_031005/pao10246_fm.html