Is There A Place For Topical NSAIDs In Podiatric Sports Medicine?

Jamie Yakel, DPM, FACFAS

   Diebschlag and colleagues compared ketorolac gel versus placebo gel and etofenamate gel in 37 patients with ankle sprains over 14 days.6 All had relief at seven and 14 days, but there was significant improvement in pain after four days with the ketorolac gel, specifically when it came to pain on movement and night pain. There was no difference in ankle swelling.

   Russell compared piroxicam gel to a placebo in 200 patients with acute soft tissue injures (Achilles versus supraspinatus tendonitis and ankle versus acromioclavicular sprains).7 They found that piroxicam was more effective for relief of pain, tenderness and range of motion, but this was only true in the tendonitis group and not the sprain group.

   In a meta-analysis of 26 double-blind, placebo-controlled trials consisting of 2,853 patients, topical NSAIDs were significantly better in 19 of 26 of the trials with ketoprofen being the most effective.8 In their study of 101 patients with minor sports injuries, Jenoure and colleagues found a 61 percent reduction in pain on pressure and a 60 percent reduction in spontaneous pain after two weeks of treatment with topical diclofenac.9 Limiting absorption should produce fewer systemic adverse effects with the absorption of a diclofenac patch having fewer adverse effects than other forms of the drug.10 Researchers found that topical ketoprofen was useful for acute tendonitis injuries over seven days of treatment.11

What You Should Know About Adverse Reactions

The incidence of adverse reactions with topical NSAIDs is low, thus making them a safe alternative.

   The most common adverse reaction is a cutaneous reaction occurring in 1 to 2 percent of patients with erythema, pruritus, irritation, a sensation of heat or burning, and contact dermatitis being the most common.12,13 The studies comparing oral versus topical NSAIDs concluded that topical NSAIDs demonstrated a decreased incidence of adverse events.14

In Conclusion

Topical NSAIDs have been in use in Europe for over 30 years but are in use sparingly in the United States. The evidence supports that topical NSAIDs are effective and safe, and should have a place in treatment regimens for sports-related injuries. There remains a lack of evidence as to which penetration enhancement method provides the best results. There is also a paucity of head-to-head studies of various topical NSAIDs.

   Currently, there are three approved topical NSAIDs available in the United States. They include diclofenac epolamine topical patch 1.3%; (Flector Patch, Pfizer); diclofenac sodium gel 1% (Voltaren Gel, Endo Pharmaceuticals/Novartis Pharmaceuticals); and diclofenac sodium topical solution 1.5% (Pennsaid, Covidien).

   Dr. Yakel is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified by the American Board of Podiatric Surgery. He is an Associate of the American Academy of Podiatric Sports Medicine. Dr. Yakel is in private practice in Longmont, Colo.

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