Local anesthetic use in sport for early return to play – should we be offering these jabs?

The use of local anesthetics in sports injury management is a bit of dark art – often practised, but not so often talked about. Certainly, there is a paucity of medical literature on the subject, with perhaps more articles in the lay press.

Statistics on the use of local anesthetics in different sports are not widely available, but it is likely that they are most widely used in the contact sports including the football codes (American football, soccer, and rugby league and union).

When they are used, the aim is usually to eliminate or diminish pain caused by an injury which may be acute or chronic, or another condition such as an ingrowing toenail, significantly enough in order for a player to return to play.

Some questions remain about their use, however –

– Are they safe for players in the short and long term?

– Are we currently using them in an ethically-sound manner?

The World Anti-doping Agency currently places no restrictions on the use of local anesthetics in sport, although there is a debate about whether the elimination of pain constitutes a performance enhancing intervention. Most governing bodies leave the decision as to whether use local anesthetics to the team physician and patient. The NCAA, for example, mentions that ‘use is medically justified only when permitting the athlete to continue the competition without potential risk to his or her health.’ (see section 31.2.3.4.1 of NCAA drug policies).

The assessment of potential risk to health from using local anesthetics in order to assist a player to return to play is a difficult one. To a large extent, the risk depends upon the nature of the injury. Most of us would, I suspect, be reluctant to administer a local anesthetic to a player with an acute grade 1 medial collateral ligament injury of the knee in order for them to attempt to play, but may be less concerned about blocking a toe with an undisplaced phalangeal fracture.

Orchard and colleagues reviewed a case series of 268 injuries over a 6 year period in which local anesthetic was administered to allow an early return to play. In this series, around 10% of players competing did so with the assistance of a local anesthetic. The most common injuries for which local anesthetics were administered were rib injuries, iliac crest hematomas, acromioclavicular joint injuries, and finger and thumb injuries. A total of 6 ‘major’ complications were noted, including two cases of distal clavicle osteolysis (questionable as to whether this was a true complication), a partial tendoachilles rupture, an adductor longus tendinopathy (again, causality is questionable), prepatellar infected bursitis and a scapholunate ligament tear, with 11 ‘minor’ complications.

Orchard and colleagues went on to publish a retrospective survey of 100 players over ten seasons who had been injected with local anesthetic on 1023 occasions for 307 injuries. There was an average of 5 years’ follow-up. They found that 98% of players stated they would have had the procedure in the same circumstances again, although nearly a third felt that there were side effects associated with the use of the local anesthetic. 22% of players thought that the anesthetic had delayed their recovery and 6% thought that their injury was worsened due to playing on with a local anesthetic block.

The authors concluded that ‘the most commonly injected injuries – acromioclavicular joint sprains, finger and rib injuries, and iliac crest contusions appear to be quite safe (in the context of professional sport) to inject at long-term follow up.’

They conceded that ‘a few injuries may have been made substantially worse by playing after an injection,’ and also mentioned that there was ‘still insufficient evidence to completely determine the safety of local anesthetic injections in the majority of potential circumstances,’ calling for further studies to assess long-term safety.

There is good evidence that local anesthetic injections are both chondrotoxic and myotoxic when administered during both in vitro and in vivo studies. Given that the long-term safety of local anesthetic injections is unknown, can we safely recommend and administer these to our patients in order to allow them an early return to play?

Perhaps even more important are the ethical and safeguarding issues surrounding the use of local anesthetics in sports injury. What happens if a player chooses not to have an injection following  an injury when it is common practice amongst the team for other players to have this intervention in order that they may be able to play with a similar injury? Will they be discriminated against by the team manager or other players, or be subject to coercion?

Should there be an independent assessment of the appropriateness of using these injections prior to administration?

Do we need a review and a consensus opinion from WADA or individual governing bodies ?

CJSM would like to hear your thoughts

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Abuse, Harassment and Bullying in Sport

 This month marks the publication of an important article in CJSM, the Canadian Academy of Sport and Exercise Medicine Position Paper on Abuse, Harassment and Bullying in Sport, and highlights the issue of safeguarding within the sporting environment.

I am sure that if we reflect on our own experiences whilst working within sport, most of us will be able to recollect incidents highlighting the important issue of safeguarding within the sporting environment. The problem of unacceptable behaviours is probably more widespread than we realise due to the likely under-reporting of events, longstanding cultural precedents, and the fine line that exists between acceptable strategies aimed at getting the best out of sports participants and unacceptable behaviours.

There have been some recent important claims and disclosures of unacceptable behaviours from prominent sporting personalities, including the legendary American boxer Sugar Ray Leonard,  UK Olympic diving hopeful Tom Daly, and Australian umpire Daryl Harper amongst others.

The CASEM paper highlights the definitions of the terms abuse, harrasment and bullying, citing the paper by Stirling published in the BJSM in 2009 ‘Definition and constituents of maltreatment in sport: establishing a conceptual framework for research practitioners.’  Risk factors and signs and symptoms of unacceptable behaviours are discussed together with recommendations for healthcare professionals working in sport, and practical advice on what to do in the event of disclosure and suspicion is given. In addition, there is advice on primary prevention, and on protecting oneself from spurious allegations of unacceptable behaviours.

There are a wide range of resources available for those working in sport on safeguarding issues including the following :

1) Respect in Sport

Sheldon Kennedy, former NHL player with Detroit Red Wings, Calgary Flames and Boston Bruins, is perhaps as famous for his disclosure of sexual abuse by his former coach and his work as a spokesperson for the prevention of unacceptable behaviours as he is for his fame as an NHL star. Sheldon founded Respect in Sport in 2004 together with Wayne McNeil, and their website provides an online certification program, together with links to other resources.

2) The UK-based National Society for the Prevention of Cruelty to Children website has a section devoted to safeguarding children and young people in sport, although the general principles and issues highlighted are equally applicable to adults. The NSPCC child protection in Sport Unit (CSPU) was founded in 2001 to work with UK Sports Councils, governing bodies and others to reduce risk to children of abusive behaviours during sporting activities. The website has a number of excellent resources including a series of videos of scenarios highlighting unacceptable behaviours to raise awareness.

3) The Bullying UK website, has a section devoted to the issue of bullying in sport and discusses amongst other things, important issues to consider when introducing a sports club anti-bullying policy.

4) The youth sports psychology website blog has a section devoted to bullying in sports, and offers an opportunity for parents and others to share their experiences of unacceptable behaviours within the sporting environment and for mutual support.

5) Women Sport International’s sexual harrasment task force discuss sexual harassment and signpost to resources on their website. They also offer support for victims and for those who require further information.

6) The UK Government charter for action against homophobia and transphobia in sport, with signatories including the UK Football Association, Rugby Football League, Rugby Football Union and Law Tennis Association have their own facebook page which seeks to raise awareness of issues particularly relevant to these forms of unacceptable behaviours within sport.

The responsibility for safeguarding individuals within the sporting environment rests on the shoulders of all of those who are involved in sport, and this month’s CASEM position paper in CJSM acts as an significant resource and a reminder of this important issue. It’s free, so please signpost your colleagues to it as raising awareness is one of the most important steps we can all take. Awareness, planning, vigilance and effective action when necessary are key when it comes to preventing and dealing with unacceptable behaviours within the sporting environment.

CJSM would like to hear your views on safeguarding, and your experiences.

Keep safe.

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