 Is it safe to use local anaesthetic painkilling injections in professional football?Click to read the .pdf version John W. Orchard, MBBS BA PhD FACSP FACSM FASMF Short running title: Local anaesthetic
use in professional football Revised version: August 19, 2003. Major
changes in boldface. Abstract The use of local anaesthetic painkilling
injections in professional football can counter the performance-reducing impact
of injury and lower the rate of players missing matches through injury. In the
majority of cases these injections are probably safe, although scientific
evidence in this area is scant, particularly with respect to long-term
follow-up. The known long-term injury sequelae of professional football, such as
increased rates of osteoarthritis of the knee (in particular), hip, ankle and
lumbar spine, do not generally relate to the injuries for which local
anaesthetic is commonly used. The most commonly injected injuries - A/C joint
sprains, finger and rib injuries and iliac crest haematomas – are probably the
safest to inject. There are risks of worsening injuries and known specific
complications when local anaesthetic is used, and players requesting injections
should be made aware of these. Local anaesthetic injections as painkillers
should only be used when both the doctor and player consider that the benefits
clearly outweigh the anticipated possible risks. Intraarticular injections to
the knee, ankle, wrist, joints of the foot, and to the pubic symphysis and major
tendons of the lower limb are best avoided. To enable to benefit and risk
profile of local anaesthetic injections to be better understood, it is
recommended that professional football competitions make local anaesthetics
legal only with compulsory notification. Key terms: retirement, chronic injury,
local anaesthetic, rugby, football 1. Introduction The use of local anaesthetic in
professional football of various codes is reported to be widespread, but is not
adequately covered in the medical literature [1-10]. In the era of
evidence-based medicine, this represents a major dilemma for team physicians.
The International Rugby Board, which administers the sport of Rugby Union, has
officially banned local anaesthetic use for painkilling purposes[1]. The only
major sporting administrative body known to permit local anaesthetic use and to
have published guidelines is the National Collegiate Athletic Association (NCAA)
(guidelines available at www.ncaa.org), although these are vague and do not list
specific examples, leaving the decision at “the discretion of the individual
treating physician” [5]. Although official policy is not generally stated for
other sporting bodies, most adopt the NCAA approach of leaving the decision to
the athlete and treating doctor. The acknowledges that there is a place for
the use of local anaesthetic agents in professional sport;recognises the use of
local anaesthetic agents in the professional sporting environment is principally
a matter between doctors and their patients; recognises that the use of local
anaesthetic agents in professional sport requires discussion between doctors and
their patients and informed formal consent of the patient given in an
appropriate environment prior to the planned intervention; acknowledges the lack of scientific
information regarding the use of local anaesthetic agents in the sporting
environment and recommends that research be undertaken to increase the body of
scientific knowledge; recommends that education and training
of medical practitioners in their use of local anaesthetic agents in sport is
appropriate; does not endorse the use of local
anaesthetic injections in the sporting environment for children under 16 of age. This policy is somewhat in contrast to
the International Federation of Sports Medicine (FIMS) policy which states that:
“[The physician may not]….in any way mask pain in order to enable the
athlete’s return to practicing the sport if there is any risk of aggravating
the injury”. Despite the presence of largely
unquantified risks, the use of local anaesthetic is attractive because it is
perceived that the risks for injecting certain injuries are probably less than
the potential benefits [2]. 2. Assessing the risks and benefits of
local anaesthetic use The benefits of local anaesthetic use
are easy to outline, although they are somewhat subjective. The most common
symptom of injury is pain, and for certain injuries, local anaesthetic is a
method of reducing this symptom. For the injuries that are most amenable to
local anaesthetic use, a pain block can be achieved without affecting motor
function. The magnitude of this benefit is subjective and dependent on the
importance of performance in a given game to a particular player. Whilst most
neutral judges can appreciate the benefits to a player at the highest
professional levels (e.g. National Football League (NFL), World Cup soccer and
rugby), for an individual player the benefits at a lower level can still be
substantial (e.g. College football player trying to impress to become drafted by
an NFL team). The risks of local anaesthetic use are
far more difficult to quantify, as there are very few studies with descriptions
of complications, particularly with long-term follow-up [1,2,5-7]. Orchard has listed some possible
complications of local anaesthetic use [1] as including: (1)
Degenerative arthritis of a joint arising or worsening subsequent to
intra-articular injection or total block of that joint.(2)
Rupture of a tendon whilst under local block.(3)
Fracture or re-fracture of a bone whilst under local block.(4)
Rupture of a ligament or dislocation of a joint whilst under local
block.(5) Inadvertent block of
a major motor nerve that prevented player from being able to play (e.g. femoral,
obturator, common peroneal, sciatic).(6)
Joint or other subcutaneous infection.(7)
Damage to an important viscus (e.g. pneumothorax where intercostal block
was performed). This list, whilst not exclusive,
indicates the extent to which playing whilst under local anaesthetic block may
theoretically cause complications. A fairly exhaustive list of possible
complications for injection of each individual injury can be readily compiled.
The difficulty for doctors and hence players is in assessing the likelihood for
each individual complication. For example, what is the increase in risk (if any)
of suffering a pneumothorax if local anaesthetic is used to numb the pain of a
broken rib? What is the increase in risk of a tendon rupture if local
anaesthetic is used to block the pain caused by tendinopathy? In situations
where the benefits are obvious and the risks are difficult to quantify, it is
understandable that players are in favour of using local anaesthetic and doctors
are under pressure to comply with this expectation. Nelson has illustrated that opinions
vary as to how this dilemma should be approached given the lack of scientific
evidence regarding the long-term safety of local anaesthetic injections [6]. On
the one hand, he quotes Spindler as saying “It’s passing the buck [for the
doctor] to ask the athlete to make the decision, because the athlete usually
decides to play [with the aid of local anaesthetic]”. In contrast, Bracker is
quoted as saying that, “if there is no evidence [that local anaesthetic
injections cause long-term damage] it’s not wise simply to be
paternalistic”. Nelson noted that medicine is evolving away from paternalistic
decisions in which the doctor ordains what is best for the patient, to shared
decision-making in which patients are counselled so they can make their own
decisions. In this context, treating doctors should not necessarily ignore the
consistent observation of most authorities that “professional athletes will
usually decide that they want to play with the aid of local anaesthetic
injections”. A middle ground position would be that the doctor should respect
the wishes of the athlete but also has the responsibility of preventing the
athlete from making a reckless decision with respect to local anaesthetic use.
The difficult remains in determining – when is the use of local anaesthetic
injections reckless? 3. Documented cases of local anaesthetic
use There are few publications documenting
incidence of local anaesthetic use, particularly in the peer-reviewed sports
medicine literature. Local anaesthetic has been used as a painkiller to allow
early return in professional football since at least the 1970s in the The only large case series in the sports
medicine literature has been published by Orchard [1]. This detailed cases from
two professional sports teams in Nelson has collated the most substantial
body of anecdotal recommendations regarding local anaesthetic use [5-7]. For
example, Nelson quotes Herring, an NFL team physician, as saying that
“blocking an A/C joint or injecting a rib injury is reasonable at the
professional level, not dangerous, and done routinely”. His (Nelson’s)
sampling of collegiate and professional team physicians found many who be
comfortable using blocks for low grade A/C joint injuries, hip pointers, ribs or
iliotibial band injuries, but that most felt that it was inappropriate to numb a
knee or ankle joint [5]. Nelson reported that non-medical considerations,
particularly player earning capacity, were taken into account by doctors when
deciding whether injections were justified. For example, a foot and ankle
consultant was quoted as saying that injecting an ankle sprain or a chronically
painful subtalar joint could be justified in a professional athlete, but that in
a high school or college athlete the same injection would constitute
“malpractice” [5]. A recent book written by a retired NFL
team physician (Scranton) claims that local anaesthetic use is common in this
competition [19], which is consistent with a previous book by another retired
NFL physician (Huizenga) [4]. Scranton used local injections for “painful
contusions, bruised or cracked ribs, intercostal muscle tears, fractured or
dislocated fingers, hip pointers and isolated shin contusions”, but claimed to
never use this procedure for a “muscle pull” or inside the knee or ankle
joint [19]. He also claimed that the players “although they hated the blocks,
invariably requested them…understanding that playing with pain is part of the
professional game. A game-day check [payment], a starting spot on the roster,
playoff hopes, and professional pride were factors that figured into the
decision [to take local blocks]. When the team was completely out of the playoff
picture, very few players took a block” [19]. One previous study in rugby league has
discussed the use of local anaesthetic injections [20]. In this study, five
injuries (3 A/C joint, 1 rib fracture and 1 groin tendon tear) over three
seasons were managed in this way. 4. Documented cases of complications
from local anaesthetic use Various non-medical-journal references
can be cited to illustrate potential pitfalls of local anaesthetic injections
[4,9,14,17,21]. These include cases where compensation has been obtained through
allegations of medical negligence. In Krueger v San Francisco 49ers, the
player (Charlie Krueger) was treated for ‘years’ from 1963 onwards with
local anaesthetic injections into his left knee, despite the loss of his
anterior cruciate ligament (p.43, 94) [14]. In this case, it appears that it was
not simply the use of local anaesthetic itself that was considered negligent,
but the combination of local anaesthetic use and failure to inform the player of
his diagnosis and prognosis. Dick Butkus, a former Chicago Bears linebacker,
successfully sued his team doctor after suffering degenerative changes in his
knees, which were considered to have been worsening by repetitive injections of
cortisone and local anaesthetic over a two year period [13]. Bill Walton, a
former NBA center, received an out-of-court settlement in a case where his feet
suffered permanent damage from repeated pre-game local anaesthetic injections
[13]. Mark Siani, an NFL wide receiver, successfully sued his team doctor for 16
injections into his broken toes in a single season [7]. One of the most famous
cases of damage secondary to the use of local anaesthetic and cortisone
injections affected former NFL player Curt Marsh. Marsh had a degenerative
chondral injury of the ankle joint which was injected for the last two years of
his career. An ankle fusion when he retired failed to relieve his pain and he
eventually had his foot amputated [21]. Marsh incidentally chose not to sue his
team physician, in part as he felt that he knowingly participated in the
decision to continue to playing and worsening the injury. An investigation by an Australian
football magazine interviewed former players about cases in which they were
injected for injuries with local anaesthetic (with incidentally none of the
cases being the subject of medicolegal claims) [17]. One player regretted the
decision to receive local anaesthetic injections into a left navicular stress
fracture as he only played seven games of professional football before the foot
injury forced his retirement. He claimed that eight operations since the injury
first presented had failed to cure the injury, which still gave him pain ten
years later. However, other players with similar histories interviewed for the
same article defended the procedures and the doctors who injected their
injuries. One player described receiving injections for a ruptured finger
tendon, chronic groin pain and foot stress fractures over the course of his
career. Subsequent to his career finishing, he also suffers from chronic foot
pain (whenever he stands for longer than an hour), yet was “adamant that
players knew exactly what they were getting on the day” and that he was always
the one in the end saying “let’s just put a shot in it” [17]. These two
cases highlight the difference in perspective for a similar injury and outcome
(chronic foot pain) where a player has had a successful (and financially
lucrative) professional career compared to one who was forced to retire
prematurely due to injury. Authors from the United States in
particular have cautioned about conflicts of interest in the team physician
role, particularly where the team physician is a part owner, receives bonuses
for team performance or in arrangements where large medical organizations can
‘buy’ the rights to provide medical services to a professional team and then
advertise this provision [9,13,22]. As
financial considerations may affect a player’s own judgement regarding
accepting local anaesthetic injections, it would appear to be judicious advice
that teams should try to minimise any financial inducements to the physician to
keep players on the field, so that the physicians can remain as objective as
possible. There have been some notable cases where
star players have suffered short-term complications from local anaesthetic
injections which have prevented them from taking the field and/or performing in
key games. Jerome Bettis, a running back for the Pittsburgh Steelers, was forced
to pull out of an NFL playoff game in 2002 after receiving an inadvertent nerve
block from a painkilling injection for a groin injury [18]. In the 1975 There is no study that has examined the
long-term disability associated with local anaesthetic use. Understanding of the
scope of disability suffered by retired football players in general is a further
area of sports medicine in which research is lacking. Some conditions, such as
degenerative arthritis of the knee and hip, are known to be common in retired
professional football players [27-30]. However, despite some of the medicolegal
case histories presented previously, injections of local anaesthetic are rarely
used for the knee and hip joints. There is very little documentation of the
incidence of long-term pain and dysfunction in the regions where local
anaesthetic is commonly used, such as the fingers, ribs and A/C joint. A survey of the causes of delistment
(finishing playing career at the top level) for AFL players showed that knee
injuries were the most common cause of player retirement through injury, which
itself affected 28% of players [31,32]. Other common causes of retirement were
unlikely to be related to local anaesthetic use (lumbar spondylosis, recurrent
shoulder instability, leg fractures, hip osteoarthritis and multiple recurrent
muscle strains) (Table 1). However, chronic groin injuries, ruptured tendons,
stress fractures, ankle degenerative changes and scaphoid fractures were all
injuries that could lead to retirement, and for which local anaesthetic use may
have been an issue [31,32]. In soccer, the rate of players retiring
through injury has been reported to be 47% [27]. The knee, lower back, hip and
ankles are the most common areas of arthritis in ex-soccer players and also the
most common causes of retirement [27]. The rate of knee osteoarthritis in
previously elite level soccer players may be as high as 15% [33]. Permanent
disability in ex-soccer players is very high, with the majority of cases
involving the knee (Table 1), particularly the ACL (which was associated in 628
of the 746 cases of permanent disability in the knee reported by the Folksam
insurance company) [34]. It is worthy of noting that wrist and hand injuries do
represent a small proportion of permanent disability in the Folksam records,
although the disability percentages are usually minor. Records from S. W. Taylor
& Co. from the 1970s, who insured the English Football League, show a
predominance of knee injuries (Table 1) [12]. Soccer does not appear to be
associated with a great increase in hip osteoarthritis compared to other sports
or controls [35]. In the NFL, 41% of players retired from
the game due to injury, whilst 47% of players are afflicted with arthritis later
in life [15]. As with other football codes, the knee is the major location for
arthritis and surgery both during and after a player’s NFL career. 6. The option of banning local
anaesthetic use in football One major football body – the
International Rugby Board – has officially banned the use of painkilling
injections in rugby union. This is an option available to administrative bodies
that decide that there is insufficient evidence regarding the safety of local
anaesthetic injections to allow them to be legally performed. There is no doubt
that the existence of such a law in a sport would result in a decrease of the
use of painkilling local anaesthetic injections. The administrators who oversee
such a law may feel as though they have contributed to player safety by passing
it. However the downside of outlawing the
process of local anaesthetic use is that it is almost impossible to police in a
fair manner. The IRB regulation (21.6.2), as it must, makes an exception for the
common case of a rugby player suffering a laceration who leaves the field to
have the laceration sutured. In this case, it is legal for the player to receive
a local anaesthetic injection. However, this common exception removes the
ability for the regulatory bodies to police their law on the basis of a positive
drug test for a local anaesthetic agent. If a professional rugby player ever
tested positive for a local anaesthetic drug, the player and his doctor would
almost certainly cite that the anaesthetic had been legitimately used for a
laceration (irrespective of whether this was true or not) to save both of them
from a doping offence. This law provides an incentive for rugby players to try
to suffer from bleeding wounds, as this gives the doctor and player a legitimate
reason for using local anaesthetic. For example, it is illegal to use local
anaesthetic for a closed rib cartilage injury, but would be legal to use it
(incidentally) for a rib cartilage injury with a superficial abrasion overlying
it. It is illegal to use local anaesthetic to reduce a closed dislocated finger
during a rugby union match, yet it would be legal to use it in the case of a
compound dislocated finger, in order to assist with the laceration closure.
Sending a player back on to the field with a blocked finger after a compound
dislocation is a far riskier proposition than with a block after a closed
dislocation, yet the laws of rugby union permit only the more dangerous of these
two situations. There are no documented cases of rugby
union players – or their doctors – having been sanctioned for committing
doping offences with respect to local anaesthetic injections. Given the
loopholes illustrated above, it is almost impossible that a conviction could
ever be made without a player or doctor making a public statement confessing to
the illegal use of local anaesthetic. Players and doctors in this sport are
therefore in a terrible dilemma if confronted with a situation of an apparently
minor but painful injury standing in the way of participation in an extremely
important game (e.g. a grade 1 A/C joint injury prior to a World Cup rugby
final). Do they decide to play using the illegal method, knowing that it is
legal in other football competitions and that they have almost no chance of
being caught, or do they decide to stick to the rules, knowing that it is quite
possible that opponents are breaking them and getting away with it?7. The option
of compulsory notification of local anaesthetic use in football Although the International Rugby Board
option is highly impractical, the status quo for the other football codes is
also unsatisfactory. In professional soccer, American football, rugby league and
Australian football, it is apparent that because of the lack of regulation of
local anaesthetic use, complications probably occur more often than would be
desirable. The major criticism of the status quo should be that it prevents the
missing scientific-evidence base from being discovered. Administrators are
probably more interested in transferring medicolegal liability from the
competition controlling bodies onto the individual team physicians for the cases
where complications occur, than in taking overall responsibility for a central
register of local anaesthetic use and complications. This latter course of
action is probably threatening to administrative bodies as the documentation
itself could be seen in a court of law as constituting vicarious liability for
any mishaps. Given the failings of the tort law system in most Western
countries, the legal defence of “we know nothing about the problem and do not
believe it is our concern” is unfortunately stronger than “we are aware of
the complication rates of local anaesthetic injections and are undertaking
regular reviews of best practice in order to reduce them”. Yet the later
approach is ethically – as opposed to legally – far more sound. The advantages and disadvantages of each
policy regarding local anaesthetic injection use are detailed in Table 2.
Although the option of compulsory notification and monitoring is probably the
best approach to this topic in the future, it may take a memorandum of
understanding to be signed between a professional sport’s controlling body,
the players’ association and the physicians’ association to successfully
establish a framework under which compulsory notification could take place
without generating an increase in medicolegal liability.8. Recommendations for
safety of local anaesthetic use There is a conservative body of opinion
based on the premise that doctors should never allow patients to harm
themselves, which believes that local anaesthetic injections as painkillers to
allow continued performance are never justified in sport at any level. This
viewpoint appears to be the basis for the IRB ruling against these procedures
and FIMS policy. It arises from beliefs similar to those published by McKeag
asserting the following basic principles about whether athletes can safely
re-enter or continue to participate in sport [36]:The diagnosis has tentatively
or definitively been made. The injury will not be worsened by
continued participation. The injury or condition will not place
the athlete at increased risk for other injuries or reduce the athlete’s
capability to protect himself. Whilst these principles are
idealistically sound, they are practically useless in professional football, as
not only would they preclude all use of local anaesthetic injections, they would
exclude the majority of football players from participation. Any football player
who has had any knee meniscal damage, lumbar disc damage, joint instability of
any kind, articular cartilage damage of any kind or even a history of muscle
strains would be forbidden to return to football for life under criteria 2 and
3. All of these injuries can recur (worsen) with continued participation, and
the increased risk of re-injury for many of these injuries, once suffered once,
is permanent. It is known that osteoarthritis of the
knee is increased in players who have undergone ACL reconstruction [37].
Osteoarthritis of the knee is a far more permanently disabling condition for a
football player than osteoarthritis of a 5th finger distal interphalangeal
joint, for example. It would be inconsistent to argue that a doctor should not
allow a player to play a game with local anaesthetic for a distal phalanx
fracture of the 5th finger, for fear that he may one day suffer from
osteoarthritis of the distal interphalangeal joint, yet that the doctor can
allow the same player to return to play after ACL reconstruction, knowing of the
increase of knee osteoarthritis. It seems to also be inconsistent for the
International Rugby Board to ban local anaesthetic injections as painkillers,
yet persist with scrummaging laws that result in rugby union having a greater
incidence of catastrophic spinal injuries than other football codes [38-40]. A ‘safe’ injection for a particular
player is defined by the risk profile that this player is comfortable with. As
football codes have known high risks of injury, players who are given the
autonomy to choose to play football (and subject themselves to this high risk)
should also be given some autonomy regarding acceptance of risks of local
anaesthetic injections. It is impossible to create a list of ‘safe’
injections that apply to all players equally. A football player who plays a
musical instrument may not consider a finger block to continue playing football
to be safe, whereas the average football player may. Notwithstanding these issues, Tables 3-5
present a list of examples of injuries for which local anaesthetic injections
could be considered under routine circumstances (where benefits will usually
outweigh risks), extreme circumstances (where risks are high) and areas that
under most circumstances should not be injected. The inclusion of injuries in
each of these tables is based on suboptimal evidence, although references (even
where anecdotal) to support the inclusion in each of the relevant tables are
included. These lists, whilst not definitive, provide an important framework for
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