Necessary Inflammation in the Early Healing Response
Necessary Inflammation in the Early Healing Response
Abstract & Commentary
Synopsis: Early use of celecoxib reduced the biomechanical strength of a healing ligament injury in a rat model.
Source: Elder CL, et al. A cyclooxygenase-2 inhibitor impairs ligament healing in the rat. Am J Sports Med. 2001;29(6):801-805.
Celecoxib is one of a few medications in the class of cyclooxygenase-2 (COX-2) inhibitors, which block inflammation but have less side effects then other traditional nonsteroidal anti-inflammatory medications (NSAIDs). The indications for its use in musculoskeletal injury include pain and inflammation control. The purpose of this study was to determine if the short-term biomechanical properties of a healing rat medial collateral ligament (MCL) were altered by use of a COX-2 inhibitor.
The study included 50 Sprague-Dawley rats that underwent surgical transection of the right MCL. Half were given celecoxib for the first 6 days postoperatively and the other half were not treated. All animals were sacrificed at 14 days and the transected MCLs were biomechanically tested to failure in a tension mode. The rats treated with celecoxib were found to have a significantly lower load at failure than the untreated animals. Elder and associates conclude that the study does not support the use of celecoxib in the treatment of acute ligament injury.
Comment by James R. Slauterbeck, MD
NSAID medications are the mainstay of treatment for musculoskeletal injuries. As a class of medications they are useful in treating pain and inflammation. These medications are usually prescribed in younger athletes for short courses without concern for significant consequences. But wait—should we reconsider?
The early inflammatory response is a key step in the healing process as the body begins to remove necrotic tissue and initializes the reparative response. The basic science of ligament healing indicates that the first stage of healing begins at the time of injury as the blood clot forms at the site. The second phase begins as the monocytes migrate to the injured area at the end of 24 hours. The third or proliferate phase begins as the cellular matrix begins to proliferate at 1-3 weeks and extends into the remodeling phase which lasts for up to 1 year. It would seem that the major effect of NSAIDs on ligament healing would be in the early phases of tissue repair and would have the greatest effect during the first 1-2 week period. This study brings to light that the early inflammatory response may be necessary for sufficient healing of the injured tissue to establish early biomechanical integrity following ligament injury.
Although this study does not determine if long-term biomechanical properties of the ligaments are altered, it does raise early concern in sports medicine patients because our main priority is to return an athlete to sport as early and safely as possible. An early return on a painless but biomechanically weakened ligament may lead to further and more significant injury.
So will I change my treatment of an athlete with an acute ligament injury? Maybe! I might consider alternative, short-term pain medications like Tylenol and Ultram. For more significant injuries I might consider prescribing Tylenol 3 for a very short course. So when would I start to use NSAIDs? In my opinion, the ideal time to start an NSAID would be around 1-2 weeks, or after the initial and necessary inflammatory process was well underway. More studies are needed in this area to determine if what is presented here is mostly theoretical rather than clinically relevant. However, one should think twice about the necessary inflammatory process that occurs after injury and one may want to consider delaying the use of NSAID medications if early return to sport is important to the athlete.
Dr. Slauterbeck, Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, is Associate Editor of Sports Medicine Reports.
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