Men’s Fitness

THE SUFFERING ATHLETE'S
GUIDE TO PAIN RELIEF

By Michael Castleman

The gym wasn't too crowded. You nodded to some buddies and launched into the program the trainer had laid out for you six months earlier, a combination of cardiovascular work and weight training. You were making progress. You could feel it, see it in the mirror. You grabbed a pair of dumbbells. After a few reps, a sharp, burning pain stabbed your left elbow. Your first thought was: Ignore it. Work through it. It'll go away. But six reps later, it felt like someone had trained a blowtorch on the joint. You had to stop.

***
The Club Med offered beach volleyball. You'd played occasionally in gyms but never in sand. But how hard could it for a guy who worked out three times a week? You and your buddy played two other vacationers. You started out slow and friendly, but after a few volleys with various girlfriends cheering, things got serious. Before you knew it, you were diving into the sand to make plays--and searing pain kicked you in the groin. You had trouble hobbling off the court.

***
Tennis was never your game, but the new girlfriend played, so you figured what the hell. She was a decent player, but you had little difficulty keeping up. Tennis was fun. If the relationship went anywhere, you could see getting into it. You played for 90 minutes, then went to her place, where you showered, made dinner, and capped the evening with a horizontal workout. The next morning, you could hardly move. Your legs ached something fierce.

GOOD PAIN VS. BAD PAIN

An old proverb declares: "He who preaches patience has never known pain." Ain't it the truth. When you're hurting you want what that old pain-reliever commercial promised: fast, Fast, FAST relief.

But there's another side to pain, the side that tells us something is wrong. Poet David Seegal called pain our "messenger of harm, Nature's poignant alarm, often man's wily friend. To signal is to mend."

Just as there are two sides to pain--the suffering and the signal of injury--in athletics, there are two types of pain, bad and good. Bad pain is what happened to our weight lifter and beach volleyball player. The former developed tendinitis, specifically tennis elbow, one of several common overuse injuries marked by painful inflammation of the fibrous tissue that connects muscle bone. Tendinitis can strike any major joint, says Lynn Millar, Ph.D., P.T., a professor of physical therapy at Andrews University in Berrien Springs, Michigan, and a fellow of the American College of Sports Medicine (ACSM). It's a signal that the muscle attached to the affected tendon--in tennis elbow, the forearm muscle--is not strong enough to handle the demand placed on it. The tendon has to help out, but shouldn't, so it becomes overworked, inflamed--and very painful. Sprains cause similar pain and inflammation in ligaments, which attach bone to bone. Then there's bursitis, which also causes pain and inflammation--but of the bursae (singular, bursa), small fluid-filled sacs around the major joints.

Our volleyball player strained--or "pulled"--a groin muscle, a common traumatic injury caused by hyperextension, usually a quick move the affected muscle isn't conditioned to handle. Muscles are like cloth, Millar explains. They are made of fibrous tissue. Like the fibers in cloth, hyperextension can rip some muscle fibers. If a substantial number of the fibers in a muscle rip, you have a pulled muscle. If they all go, you have a "torn" muscle.

With tendinitis and pulled and torn muscles, the pain typically appears suddenly and feels sharp, severe, and weakening, says Scott Hasson, Ed.D., a professor of physical therapy at the University of Connecticut at Storrs. Such pain announces that something is very wrong, and requires immediate treatment.

Good pain is what happened to our tennis player. Many hours after his workout, he developed delayed-onset muscle soreness (DOMS). DOMS results from new workouts that tax muscles you haven't called on before, or from exertion a bit beyond what conditioned muscles are prepared to handle. When pushed somewhat beyond their conditioning, a small number of muscle fibers tear, Hasson says. These micro-injuries are not severe enough to cause the immediate pain of a pulled or torn muscle. But the body responds to any injury with inflammation. In DOMS, this inflammation causes dull, aching soreness 12 to 72 hours later.

If you develop DOMS, you've overdone it. But micro-injury is key to muscle development. After muscle fibers tear, they regenerate somewhat larger than they were to begin with. "To build large, well-defined muscles," Hasson explains, "you have to tear some fibers--ideally during carefully planned workouts that cause minimal DOMS and no other injuries. That's why you should increase your workout slowly. If you feel any pain or muscle weakness, stop. You're overdoing it."

FIRST-AID PAIN RELIEF

For the sudden, sharp pain of tendinitis, sprains, and pulled muscles, stop what you're doing and begin R.I.C.E. treatment: rest, ice, compression, and elevation.

Rest hangs up many workout enthusiasts. No doubt, you've heard the adage: No pain, no gain. You've seen pro athletes hobble out of the game then return moments later limp-free as the announcers banter about "playing with pain."

"Forget 'no pain, no gain,'" says Robert Moore, Ph.D., a professor of pharmacology at the McWhorter School of Pharmacy at Samford University in Birmingham, Alabama. "It's ridiculous. Playing hurt is stupid. Pain is the body's way of saying you need rest. Listen to your body. Take it seriously."

"Don't compare yourself to professional athletes," Millar advises. "The pros are in significantly better condition than even daily gym-goers. And they make so much money that they--and their coaches and trainers--are under tremendous pressure to keep them playing. For many injuries, they should stop playing. Instead, they get an anesthetic injection and keep playing. In the short run, they're doing their job. But in the long run, playing hurt is the reason why so many former professional athletes have chronic musculoskeletal problems."

After you've stopped doing what caused your pain, quickly apply ice to the affected area. Ice packs are especially important during the first 24 hours. "Icing constricts local blood vessels which minimizes swelling," says Richard Holm, R.Ph., a pharmacist in North Pole, Alaska, and a spokesperson for the American Pharmaceutical Association. To make an ice pack, place a few ice cubes or a commercial ice substitute in a plastic bag and wrap the bag in a clean cloth. If you want to wrap the ice pack around an injured area, Millar suggests using a large bag of frozen peas. Apply your ice pack to the affected area for 20 minutes, then remove it for 10 minutes before reapplying. Do not apply ice directly to the skin. It might cause frostbite.

Compression also helps keep swelling down. It's like squeezing a sponge, Hasson explains. Compression pushes excess fluid out of the affected area, minimizing discomfort.

The final anti-swelling measure is elevation. Elevating the injured body part above the heart, Hasson explains, restricts blood flow to the area. Less blood means less swelling. For leg injuries, put your feet up. For arm injuries, try a sling.

I.C.E. treatment minimizes swelling, but ironically, swelling is part of healing. "The extra blood promotes tissue repair," Millar explains. "But unchecked swelling becomes too much of a good thing, causing unnecessary pain and movement restriction."

After swelling has begun to subside--usually in 48 to 72 hours--try a heating pad or warm or hot water soaks. "Heat feels soothing," Millar explains, "and it promotes blood circulation in the area."

OVER-THE-COUNTER PAIN RELIEF

If you have any Extra-Strength Tylenol in your locker or gym bag, toss it in the trash now. "Tylenol (acetaminophen) works well to relieve things like headache pain," Moore explains, "but it has no anti-inflammatory action. Athletic pain--tendinitis, sprains, pulled muscles, and DOMS--all involve inflammation, so you want a pain reliever that also has anti-inflammatory action. Tylenol has none."

Fortunately, four other over-the-counter (OTC) pain relievers also have anti-inflammatory action: aspirin, ibuprofen, naproxen, and ketoprofen (see sidebar for brand names). Collectively, these medications are nonsteroidal anti-inflammatory drugs (NSAIDs).

Which one should you take? It's a matter of personal preference, Holm says. The standard dose of each (see sidebar) provides roughly equivalent pain relief. But they differ in duration of relief. Aspirin and ibuprofen must be taken more frequently than naproxen and keoprofen (every three to six hours vs. every six to 12).

They also differ in cost. "Go with a generic or store brand," Moore explains. "I buy the cheapest I can find." Pharmacologically, generics and store brands are identical to the big brand names. The only difference is that you don't subsidize their advertising costs. For example, at your author's local Wallgreens, Bayer Aspirin costs $6.99 for 100 tablets. Generic aspirin sets you back just $1.99 for the same number. Advil costs $5.99 for 50. Wall-Profen, the store brand of ibuprofen, costs just $3.99. Aleve goes for $9.99 for 100. Wall-Proxen, the store brand of naproxen, runs just $3.99.

Finally, people differ. You might feel that some of OTCs work better for you than others.

Side effects may also affect your choice. All the OTC pain relievers are safe enough to be available without a prescription. But they still may cause side effects. Aspirin is notorious for causing upset stomach. That's why some brands are "buffered," Moore explains. Buffered brands contain antacids to minimize stomach upset. Aspirin may also cause other gastrointestinal (GI) problems, notably bleeding. This usually occurs only with long-term use. But if you're sensitive, even short-term treatment of athletic injuries can cause GI problems. Aspirin also impairs blood-clotting. The effect lasts a few days. You might notice that shaving cuts to bleed longer than you'd like, and that you bruise easily. (Bruising is bleeding under the skin.) If you develop hives shortly after taking the little white pills, you're allergic to aspirin, and should stop using it. Finally, aspirin can aggravate kidney disease, and trigger asthma attacks.

Compared with aspirin, ibuprofen is generally considered less likely to cause GI problems. But stomach distress, heartburn, and nausea are still possible. Ibuprofen also impairs blood clotting but for only about half as long as aspirin. Ibuprofen can damage the kidneys. If you have kidney disease or diabetes, don't use it. If you're allergic to aspirin, you're probably allergic to ibuprofen as well.

Naproxen and ketoprofen have side effects similar to ibuprofen. In addition, they may cause constipation, diarrhea, and headache.

"The conventional wisdom is that aspirin causes more side effects than the other OTCs," Holm explains. "But I've seen plenty of people take large amounts of aspirin with no side effects, and others take standard doses of the other drugs, and suffer significant GI distress. My advice: Experiment to see how you tolerate these drugs."

If you take any other medication regularly (for asthma, high blood pressure, etc.), all the OTC pain relievers may cause problematic drug interactions. Consult your doctor or pharmacist about the advisability of mixing pain relievers with your other medication.

In addition to pain pills, for muscle strains and DOMS, Holm suggests such liniments as Ben-Gay and Tiger Balm. "They produce a feeling of warmth that helps relieve pain and soreness." Just rub them on, following label directions.

Beyond OTC treatments, Hasson advises, "Don’t veg out. Rest, but don't immobilize painful muscles or joints. That limits blood flow through them. You want blood flow to bring oxygen and nutrients to the repair the damage." He warns against attempting anything strenuous, but suggests light activity--gentle stretches and walking. "To the extent that you're able, gently move injured muscles and joints through their range of motion," Hasson says.

PRESCRIPTION PAIN RELIEF

If OTC drugs don't provide sufficient relief, a doctor can prescribe stronger NSAIDs. But their extra power comes with greater risk of side effects, Holm warns, particularly GI distress and bleeding.

A few years ago the Food and Drug Administration approved a new class of NSAIDs, the COX-2 inhibitors. These drugs--celecoxib (Celebrex) and rofecoxib (Vioxx)--provide the same pain relief and anti-inflammatory action as older prescription NSAIDs, but with far fewer GI side effects. As a result they have become wildly popular for treating chronic pain, notably arthritis. However, once a drug has been approved for any condition, physicians may prescribe it for others ("off-label use"). You might be able to talk your doctor into prescribing a COX-2 for a severe athletic injury.

COX-2 inhibitors are easy on the GI tract, but they may cause other problems--kidney damage and possibly even heart attack, though these side effects showed up in elderly people taking the drugs long-term for treatment of arthritis--not young men taking them occasionally for sports injuries.

For severe sprains, tendinitis or bursitis, a doctor might inject the inflamed area with corticosteriods and anesthetics. They provide rapid relief from severe pain and inflammation. "But they're a temporary fix," says Francis O’Connor, M.D., director of the sports medicine fellowship at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. "Steroids and anesthetics don't cure the problem. They just mask the pain for a while. To heal, you have to increase your flexibility and strength in the injured area." Physicians, trainers, and physical therapists can recommend specific exercises.

Some physicians are willing to inject corticosteroids many times. But O'Connor warns that repeated steroid injections weaken tendons and ligaments and retard healing. He limits injections to three times a year in the context of a good conditioning program.

ALTERNATIVE PAIN RELIEF

Acupuncture has been shown to be an effective athletic pain reliever. German researchers gave 48 people with tennis elbow one treatment of either real or sham acupuncture. Treatment was considered successful if the recipient reported at least 50 percent relief using a standard measure of pain. In the sham group, 25 percent reported treatment success. In the acupuncture group, the figure was 79 percent. On average, the placebo group experienced a 15 percent reduction in pain that lasted 90 minutes, while the acupuncture group reported pain reduction averaging 56 percent that lasted 20 hours.

This is just one of many studies showing that acupuncture is an effective treatment for pain. The National Institutes of Health considers it safe and effective.

The other alternative treatment for athletic pain is topical arnica gel, a homeopathic remedy available at many pharmacies and health food stores. Studies of arnica have been mixed. Some show benefit. Others do not. But it's very popular with athletes. "Personally," Holm says, "I think it works."

DON'T RUSH YOUR RETURN

After an injury, you want to return to the gym as quickly as possible. Bad idea. "Don't rush it," Dr. Millar advises. "That just sets you up for reinjury." Continue light, recuperative workouts--gentle stretching, walking, and range-of-motion exercise until you're fully recovered. How do you know when you are? "It's usually a two or three weeks after you think you are," Hasson says.

Whatever you do for painful injuries, don't be fatalistic about them. They may feel like they happened "out of the blue." But chances are that you overdid it in some way. And old Jewish proverb declares: "If you are visited by pain, examine your conduct."

Sidebar:
MANY NAMES FOR RELIEF
It's daunting to shop for OTC anti-inflammatory pain relievers. The shelves burst with more than two dozen brands. Relax. All of them boil down to just four drugs: aspirin, ibuprofen, naproxen, and ketoprofen.

Aspirin:
Arthritis Foundation Pain Reliever
Aspergum
Bayer
Emprin
Genprin
Norwich
St. Joseph
ZORprin

Buffered Aspirin:
Adprin-B
Ascriptin
Asprimox
Bufferin
Cama Arthritis Pain Reliever
Magnaprim

Aspirin-Caffeine Combinations:
Anacin
BC Powder
Excedrin (also contains acetaminophen)
Summit Caplets
Goody's Headache Powder

Ibuprofen:
Advil
Genpril
Haltran
Motrin
Nuprin

Naproxen:
Aleve

Ketoprofen:
Orudis


Sidebar:
How Much? How Often?

When taking over-the-counter medications, always follow package directions. But here are the standard dosages for aspirin, ibuprofen, naproxen, and ketoprofen.

Aspirin
325 to 500 mg every 3 hours, or 325 to 650 mg every 4 hours, or 650 to 1,000 mg every 6 hours, not to exceed 4,000 mg in 24 hours.

Ibuprofen
200-400 mg every 4 to 6 hours, not to exceed 1,200 mg in 24 hours.

Naproxen
220 mg tablets a day every 8 to 12 hours, not to exceed 660 mg in 24 hours.

Ketoprofen
12.5 mg every 6 to 8 hours, not to exceed 75 mg in 24 hours.


Sidebar:
Surprise: Caffeine Boosts Pain Relief

Chances are you take pain pills with water or juice. You'll get more pain relief if you wash them down with coffee, Coke, or Pepsi--anything that contains caffeine. Many studies have tested aspirin by itself head-to-head against aspirin-caffeine combinations. The combinations provided greater pain relief. In fact, to obtain the same relief provided by a combination of aspirin and caffeine, you'd have to take 40 percent more than a standard aspirin dose.

Caffeine boosts the pain-relieving power of ibuprofen even more. In one study of dental pain, compared with ibuprofen by itself, the drug plus caffeine more than doubled participants' relief.

There have been no studies of caffeine's effect on naproxen and ketoprofen, but Moore speculates a similar benefit: "Caffeine is a stimulant and mild antidepressant. Those actions appear to contribute to pain relief. Since caffeine boosts the pain relief of aspirin and ibuprofen, I'd expect it to have the same effect on naproxen and ketoprofen."


Sidebar:
Stretching for Injury Prevention: Newly Controversial

Few athletes doubt the value of stretching for injury prevention. But last year, a widely publicized Australian study showed that stretching had NO effect on injury risk. Researchers at the University of Sydney divided 1,538 young, male, Australian army recruits into two groups. One performed a single, 20-second, static stretch involving each of six major leg muscle groups during pre-exercise warm-ups under the researchers' supervision. The control group warmed up but did not engage in formal stretching. After 12 weeks of basic training involving 60,000 person-hours of strenuous exercise, 21.8 percent of the control group suffered injuries. In the stretching group, the figure was a nearly identical 21.5 percent. The researchers concluded that for injury prevention, stretching has "no effect" and is "futile."

Well, not quite, according to Glenn Gaesser, Ph.D., a professor of exercise physiology at the University of Virginia in Charlottesville and co-chair of the American College of Sports Medicine (ACSM) task force that developed the organization's guidelines for adult fitness, which include advocacy of flexibility training and stretching. Gaesser calls the Australian study misleading. Here's why:

* Both groups--the stretchers and controls--did warm-ups before exercise, several minutes of light jogging and side-stepping. While such warm-ups don't stretch the leg muscles as thoroughly as formal stretches, they do, in fact, stretch those muscles. As a result, the study did not really compare "stretching" with "no stretching," Gaesser explains. It compared formal and informal stretching.

* The formal-stretching group's 20-second stretches were within the 10- to 30-second duration advised by the ACSM. But based on research at the Orthopaedic Research Laboratories at Duke University, the ACSM recommends repeated stretches, up to four, per muscle group. In the Australian study, the stretching group stretched only once per muscle group, so their leg muscles may not have been stretched ENOUGH to affect their injury risk.

* Other studies have shown that stretching helps reduce injuries, which is why the ACSM fitness guidelines state: "Stretching programs have been shown to be effective in reducing both the severity and frequency of injuries." For example, Penn State University researchers studied five Pennsylvania high school football teams. Two made no changes in their training regimens, while the three others added an extra 90-second warm-up and 90-second stretch routine at the end of half-time. After 55 games, teams that stretched suffered fewer injuries. The researchers concluded: "An effective warm-up and stretching routine may reduce the most common injuries in high school football."

* Even if stretching does not reduce the NUMBER of injuries, some research shows that it decreases their SEVERITY. University of Alabama researchers studied 469 firefighters, 251 of whom augmented their routine training program with the kind of stretches runners typically use. After six months, the stretching group was significantly more flexible. Although the difference in the two groups' number of injuries was not statistically significant--52 in the control group, 48 among stretchers--the latter's injuries were significantly less severe, resulting in substantially lower medical costs and less loss of work time. Total medical and absence costs were THREE TIMES HIGHER in the control group--$235,131 vs. only $85,372 among the stretchers. The researchers concluded: "A flexibility program...can effectively increase joint flexibility and reduce the severity of musculoskeletal injuries with a concomitant decrease in costs."

* Injury prevention is not the only reason to stretch. The ACSM fitness guidelines cite "multiple benefits" including: increased range of motion, and enhanced muscle performance, in addition to injury prevention. The ACSM "recommends incorporating flexibility exercises into an overall fitness plan."

Finally, stretching feels good. What's the first thing you do when you wake up in the morning?

Despite the Australian study, the weight of the evidence suggests that stretching helps prevent athletic injuries. Just don’t expect it to magically immunize you against sprains, tendinitis, and pulled muscles. That would be a stretch.