Do NSAIDs Impair Fracture Healing?

There has been a theory that comes from looking at animal studies that NSAIDs like ibuprofen or Naproxen inhibit bone healing and may cause delayed unions or non-unions in fracture patients. Some doctors even go so far to say that you shouldn’t use NSAIDs in postoperative orthopedic case; but what is the truth?

A recent article in the Journal of Family Practice by Yates, Shah and Blackwell, showed NO, ALTHOUGH THE EVIDENCE VARIES. Nonsteroidal anti-inflammatory drugs (NSAIDs) don’t appear to impair clinical fracture healing. Even though animal studies show delayed healing and nonunion with NSAID use, evidence in humans doesn’t merit avoiding NSAIDs in patients with fractures who need the drugs’ analgesic and anti-inflammatory benefits.

NSAIDs are commonly prescribed to control pain in patients with fractures. Laboratory studies have found that their antiprostaglandin properties delay callus formation and subsequent healing.¹ However, human studies evaluating the effects of NSAIDs on fracture healing have found variable results.

BOTTOM LINE

Craziness! Earlier this week I was fortunate to carve out a 4 hour block of time for a long cycling workout. Being new to the sport of triathlon, 50 miles was the longest bike ride of my life! It was a really long, hot ride! The funny part was the only part of my body that hurt during and after the ride were my feet! Why is it that my feet hurt instead of my butt or legs? Turns out, I am not alone. Foot pain is much more common in cyclists than most of us realize. Biking is much gentler on my body than running, but your feet do take a pounding!

Let’s investigate foot pain in cyclists just a little. I experienced a burning pain in my forefoot after about 40 miles that did not go away until about 2 hours after I got off my bicycle. Why did this happen? In my case, I sized my cycling shoes too small for the training plan. My shoes fit well when I started, but as soon as my feet started to get hot; they swelled and literally got squished by the stiffness of the shoes. At 40 miles, the nerves in between my toes were pinched and all my toes went to sleep then started to burn like they were on fire! This is commonly called metatarsalgia, traumatic neuritis or parasthesias.

Foot pain like I experienced is actually not uncommon in cyclists. This can be caused by improper placement of clips, poorly sized shoes and certain foot deformities that require more support in the shoes. Luckily, most foot pain can be solved by bigger shoes, metatarsal padding, different socks or custom foot orthotics. Burning pain can be a sign of a Morton’s neuroma, an early stress fracture or lumbar radiculopathy (a pinched nerve in your back), so if your burning does not go away with simple solutions, quickly seek the advise of your podiatrist or sports medicine physician.

Other foot related problems seen in cyclist are plantar fasciitis and Achilles tendonitis, which in the early stages are usually solved by raising your saddle or turning it slightly askew. Often, we wait too long to address an injury because we think it will miraculously solve itself. Long standing foot pain often requires more aggressive treatments with custom orthotics, physical therapy, injections or even surgery in severe cases.

Thankfully my foot pain completely resolved with slightly bigger shoes, a thinner sock and a small metatarsal pad. My upcoming long rides on the way to a half-Ironman triathlon in the fall should be much more comfortable and pain free!

Cycle on....and keep tri-ing!

Houston Rocket's Yao Ming's career may be over due to a non-healing foot fracture. He was sidelined during the playoffs on May 8th with a hairline fracture of his navicular. As of today, this has not healed properly. The nature of his non-union and his prognosis is being kept quiet by the team physicians, but it is evident that there is a problem. Most stress fractures heal completely in 6 to 8 weeks. This is not the 7 foot 6 inch center's first fracture. He has been out portions of the last three seasons with stress fractures in his leg and foot. Perhaps his lanky frame just can' handle the stress of the NBA? Why is it that some fractures don't heal?

Looking at his present injury, stress fractures of the navicular (the cornerstone of your arch) are often slow to heal due to three factors, blood supply to the bone itself, underestimating the extent of the initial fracture so delaying aggressive treatment and too much abnormal stress on the healing bone. Other medical issues can delay bone healing like lack of Vitamin D, poor calcium uptake and many other systemic problems like diabetes, hypothyroidism and peripheral vascular disease. Many of these fractures are actually missed due to lack of specific x-ray findings. Many fractures are actually misdiagnosed for months. Plain film x-rays are often read as normal so the fracture is missed until symptoms increase. Early symptoms can be diffuse and non-specific so the index of suspicion is also low. A bone scan, MRI or CT scan can identify the specific fracture. CT scan is often the most helpful in identifying the extent of the fracture and guiding treatment. For a non-displaced stress fracture, cast immobilization is the first line therapy. Studies have shown that non-weight bearing immobilization in a cast for at least 6 weeks is usually around 80-86% successful. For those that do not heal this way, surgical fixation of the fracture can be helpful and a bone graft may be needed for long standing non-unions. New technologies like electronic and ultrasonic bone stimulators and injectable platelet rich plasma can help even the most stubborn fractures.

Follow up care for a navicular fracture often includes physical therapy and custom foot orthotics. Abnormal biomechanics of the foot often are one of the causes of these fractures, so biomechanical control is crucial to distribute the abnormal stress so an athlete can return to sports and have a lower risk of recurrence.

Yao Ming has had multiple stress fractures during his career increasing the likelihood of traumatic arthritis from avascular necrosis (not enough blood supply to heal so the bone crumbles) in his foot causing him to retire. The next few months will tell the tale for this multi-million dollar All Star. Can he heal his fracture and return to sport? The Rocket's fans are praying for divine intervention to cure their dominant center. 

A stress fracture is a tiny crack in the bone caused by overuse. Most stress fractures occur on your metatarsal bones in your foot but they can occur in any part of the body. Stress fractures develop over a long period of time and are often initially unnoticed. Your bones naturally break down bone and rebuild bone on a continual basis. If too much force in repeatedly applied to the bone, then the breaking down of bone will exceeds the rebuilding of bone. The bone is insufficiently repairing itself. This is called bone fatigue. Over time the bone becomes weaker and eventually cracks. The fracture is very small and is often unapparent on x-rays.

Physical activity is always encouraged, but working out too hard too fast puts your body at risk for injury. When starting to work out or changing your workout routine, make sure you give your body time to adjust to the new stresses. It takes time for your muscles and bones gain the strength necessary to absorb the impact of running, jumping, and jarring. When your muscles fatigue, they no longer distribute the forces along the entire bone and the bone has to carry an increase of load. This will lead to fractures. Sometimes even changing the surface you run on can lead to injuries. If you are used to running on the grass or a softer surface, changing to cement or concrete surfaces will force your body to absorb more of the impact. You may not notice the bone fatigue initially but over time, you may develop a small crack in the bone or stress fracture.

Stress fracture pain is usually experienced with increased activity. Therefore, one may notice the pain to get worse the more they work out. The pain also occurs earlier in the workout as the fracture progresses. Initially the pain will subside with rest, but as the fracture increases in size the pain will become more constant. The pain may also be elicited by palpating the area over the fracture. Sometime a doctor may use a tuning fork to elicit the pain. The fork causes vibrations in your bone, and if a fracture is present it will cause pain. If no fracture is present, the tuning fork will not cause pain. Your podiatric physician will also take x-rays to rule out any other complications. The stress fracture will often be unapparent on a x-ray because the crack is so small. Therefore, the physician may need to order an MRI or bone scan to further assess the injury.

The best treatment for a stress fracture is rest. Chen Lu, a professional figure skater, missed the Olympics due to a stress fracture, Scott Neidemayer missed his Hockey All Star Game, and Yao Ming had to sit out a large portion of the season to nurse his stress fracture. Whether you are a professional athlete or have sport hobbies, you need to rest if you have a stress fracture. The only way to fully recover and prevent the injury is to slow down and allow your body to heal. Changing your workout to less impact sports and slowly increasing your body’s demands is highly recommended. Athletic shoes lose their shock absorptive properties and should be replaced at least every 6 months. NSAIDS can be taken to reduce the pain but should not be taken for long periods of time. If you are experience any foot pain that is continually getting worse, you should see a podiatric physician to assess the injury.

This is a guest blog by Dr Peter Wishnie.....Run Happy! And with less stress :)