Does the Use of NSAIDs Affect Achilles Tendon Healing

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in soft-tissue disorders. Many different drugs exist within this category and their use is not without potential side-effects, such as gastrointestinal disturbances and renal damage. What is the evidence that they are helpful in the management of Achilles disorders, and is there any evidence that their use might be potentially harmful?

Physicians have frequently used nonsteroidal anti-inflammatory drugs (NSAIDs) in Achilles tendinopathy, especially in the clinically acute phases.49-51

Various forms of NSAIDs acted in a less-than-uniform manner when evaluated by Riley.52 Indo-

methacin and naproxen inhibited cell proliferation and glycosaminoglycan synthesis in the tendon, suggesting that they should be avoided in clinical situations where relief is required from pain and swelling after tendon trauma. Conversely, no such effects could be ascribed to diclofenac or aceclofenac.

However, the evidence from drug trials and histological examination of pathological tissue does not support their use in the more chronic situation.

Ástrom and Westlin53 undertook a randomized study on the effect of piroxicam in the management of Achilles paratendinopathy and could not detect a positive effect.

Histological specimens of Achilles tendon have failed to demonstrate an inflammatory cell infiltration in patients with chronic tendinopathies.54 Li55 reported that NSAIDs may exert a detrimental effect on the tendon by increasing the levels of leukotriene B4 within the structure and enhance the likelihood of a tendinopathy. Alme-kinders56 suggested that the effect of NSAIDs may be negative in the proliferative phase of healing by their inhibition of DNA synthesis, while acting in a more positive fashion later as the tissue matures and remodels by stimulating protein synthesis.

Medico-Legal Implications

• In the acute phases of Achilles tendinopathy, a short course of NSAIDs may help relieve symptoms.

• In chronic tendinopathy, NSAIDs are of little benefit, and may prove harmful.

• It seems likely that the only secure indication for the use of NSAIDs in patients with chronic Achilles tendinopathy is when it is associated with an underlying inflammatory arthropathy.57,58

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