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Anti-Inflammatories: To Take Or Not To Take?! (Get out of pain now!)

inflammation medication pain Nov 22, 2022

pill bottle getting dumped out with the words

It's fairly common practice, honestly, to pop some Ibuprofen for aches and pain, whether it be a headache or a muscle spasm or an injury. Hell, I grew up being tossed a few 200mg pills if something started naggin me during soccer or whenever. But is that really the answer? Is there an action that would be better that would still get you the desired result of dampening the pain?!

The answer is not only yes, but an emphatic YES!

And that, my friend, is movement and maybe some manual work. But let's unpack that a bit because (1) it's not just any movement and (2) I bet you have a lot of questions about why.

Let's start with why NSAIDs (non steroidal anti inflammatories - the category that Ibuprofen, Asprin, Aleve, Voltaren, and the likes fall under) are NOT the answer:

Quick side note: Did you know that there are over 90 million presciptions for NSAIDs filled in the US every year?! And that's not even getting into the over-the-counter options that account for several extra millions of dollars in sales. Despite how common they are, there are several risks that might be bigger than you think...

One of the biggest (and most well known) risks is gastrointestinal (GI) issues. Specifically, GI ulcers or hemorrhage. In fact, if you're taking NSAIDs, your chance of a gastric ulcer is 10-20% (up to 10x higher risk than if you're not taking NSAIDs). Ulcers can lead to hemorrhage or perforation, which can be fatal. (Couldn't find the risk/rate of that occuring, but it does seem like in cases that were fatal, up to 80% were in people on NSAIDs) (ref: Savaas et al 1991, Babb et al 1992)
Another risk is cardiovascular issues and even stroke. Most NSAIDs can increase your risk of stroke. To note, a study by Garcia-Posa et al did not find a link to stroke with naproxen or ibuprofen (though they did with others). Barthelemy et all in 2011 did find that long term (2 year) use of all NSAIDs, including naproxen and ibuprofen, increased your risk of stroke by 64%
There are a ton of negative drug interactions to be considered with taking NSAIDs that, unless you're getting prescription strength ones where MAYBE a pharmacist might realize it's connection with other drugs you're on and warn you, you may not be aware of. (Chart below from Wongrakpanich et al, 2018, A Comprehensice Review of Non-Steroidal Anti-Inflammatory Drug...)

Ok, the LAST thing that I want this information to do is intill a ton of fear around anything. I simply want you to think twice about why you're popping pills to take the edge off. I myself have taken prescription strength Ibuprofen after each of my knee surgeries because, well at the time I didn't know the options that I'm about to get into and 800mg of Ibuprofen was far better than popping Oxy or Loratab at age 11 (or 15 or 19 - my other 2 surgeries). There are times where it's the "better evil" and warranted. But for the vast majority of the time when it's a relatively minor ache/pain (ankle sprain, tweaked back/neck, pulled shoulder, etc), think about trying movement and muscle activation first! Seriously. Let's dive into it:

Probably not a shocker if you've been following me for awhile that I'm gonna have a "movement is medicine" approach here!

Did you know that isometrics (where a muscle acts against a non moving object, causing a static activation) can be analgesic, especially for tendon issues?! Which is the exact outcome that someone is poppin ibuprofen for. Except isometrics don't come with any of those nasty side effects. Win-win. Ok, so how do you do them in a way that causes that desired decrease in pain?

You perform 5 sets, each time holding 45" and then resting 2 min (or doing exercises for unrelated musculature during that time).

How do you chose the exercise?

Well, the effect is going to be local to what's active during the isometric, so you wanna do something that isolates out the muscle/tendon that's painful. Sounds counterintuitive, I know, to work the tissue that's in pain in order to decrease pain. But when it's done in this way, it really works! Think of what movement that muscle does, and then you wanna perform an isometric of that movement at a partial range point. Here are some examples:

Bicep tendonopathy: isometric bicep "curls" at 90 deg performed against the bottom of a table
Patellar tendonopathy: knee extension isometrics performed at about 45 deg flexion (can be into a bench or using a knee extension machine set there with enough weight that you can't actually move it)
Adductor tendonopathy (often shows up as groin pain. Possibly medial knee pain): Copenhagen planks (Note that the full leg itteration is tough and may be too much just yet...stabilize above the knee to start and progress accordingly)

Ok, hopefully that gives you some ideas for the isometric! And then here's my favorite thing to do for the 2 min rest as well as for literally any pain: Cardio. Get the blood pumping in order to get a full body fluid flush, aka flush out the inflammatory chemicals piling up in the area causing pain. Now, the trick here is to not involve the painful area. Pain in your leg? Hit the arms-only bike. Shoulder pain? Hit the bike using only your legs. Back pain? Arms-only bike and then standing or sitting will depend on what feels best (during and after). And I don't mean just piddling around on the bike. If you put it with isometrics, it'll look something like this:

15' EMOM (every minute on the minute - ie minute 1 you do the 1st, min 2 the 2nd, and then keep rotating through for 15 min to get 5 rounds):

30" bike sprint (80% effort if you're on an Echo or Assault bike. You can also crank the resistence up on something like a Peleton to get the effect here. Otherwise, make this a 45" all-out effort)
45" isometric
Rest

You should be breathing pretty heavy getting off the bike and wanting that rest in the 3rd minute! You will also be amazed at how much better you feel after doing this! Legit every person I've worked with and had do this has noticed significat pain reductions. And the best part? They now have a formula for something to try first if anything pops up down the road! #autonomy WIll this solve every issue? Absolutely not. But it will help calm pain down enough to be able to get to the work (aka loading) that those tissues need to really recover and become more resilient.

Outside of acute tendon issues, the cardio/blood flow is still a go-to to dampen pain for just about everything. Even headaches! But that's something we can really dive into another time...

Give it a shot and let me know what you think! Please comment or DM me with any questions about this. And of course, if you have something going on that you'd like a little more in depth personalized help with, jump on a call with me or book a session!

Because I have to put this. This is not individualized medical advice or diagnostic information. This is purely educational.

"Your knees are shot and if you keep up all the activity you're doing, you won't walk at 30"- what I was told by medical professionals at age 18 after my 3rd knee surgery. Fast forward to today, and I'm 32 and not only do I Crossfit 4-5 days a week, but my off days are usually spent trail running and/or hiking. And the only time I have knee pain is when I take 4 or more days off from activity. You see, the stronger the muscles around a joint are, the more they can unload the joint - i.e. the ligaments, meniscus, and cartilage in the knee don’t have to absorb quite as much force as they would otherwise. And less pressure = less risk of damage or pain.

For years, I avoided squatting below parallel, catching heavy weight in a squat such as full cleans and snatches, and had a crazy wide squat stance. I also avoiding running and would get nervous hiking downhill. Why? Because I let the nocebo (negative thoughts) given to me medical professionals dictate my movement. You see, I've had three knee surgeries, with the 1st one being in 5th grade and the last being a cartilage graft during college. Most of my knee injuries have been due to Osteochondritis Dissecans (Rare condition. Lack of blood flow to bone causing cracks to form in the cartilage and underlying bone. Cause unknown). Though one surgery was an ACL reconstruction where they took out part of my patellar tendon and put it where the ACL should be.

With each of these instances (a few others didn't require surgery), I was told yet again that I should stop doing any high impact activity, never run on hard ground, that I should never do heavy squats, and definitely don't go below parallel even without weight. This is devastating news to a very active and athletic fifth grader. And let's be real, still devastating to an active college student. Thankfully, I'm stubborn. I agreed to quit all hard court sports like basketball (though to be fair, as soon as everyone else hit their growth spurt, I probably wouldn't have lasted) and gymnastics. But I refused to give up soccer. And with that came weight training once I got to high school.

I still lift and do Crossfit 4 days a week and trail run or hike in the off days. I honestly LOVE heavy squats and deadlifts, and I am constantly challenge myself! And you know what I realized once I left soccer but was still in the gym doing weightlifting? My knees only bothered me when I did one of 2 things: wayyyyy overdid it or skipped the gym and hiking several days in a row.

Two main takeaways from this bit:

1. Don't let a doctor's opinion dictate your own opinion or your life.

Every profession has it's bad and good apples. And a certain degree does not make one infallible.

2. Heavy squats fix everything (read: your body wants to be loaded. Strength training has countless benefits and should definitely be a part of your life)

So I bet you’re like “Sweet, so strength is important. Got it. But what are some ways to build up strength?” Here ya go:

First, I should explain that it’s not always as simple as “get stronger.” Mobility and technique also need to be considered when figuring out the cause of knee pain. And it’s almost never directly the knee. Typically, if a mobility issue is at play, it is either from the hips or ankles, though it could be from further up as well. This will be it’s own blog (or maybe Eboko!) soon

As far as technique goes, it really kind of depends on when you’re having pain. For example, if it’s just with running, maybe you’re not keeping enough bend in your knee throughout the gait cycle, causing increased stress on the knee. If it’s just at the transition point at the bottom of a squat, maybe you’re only going to parallel, which is actually the knee angle with the highest amount of pressure on the knees. Or maybe you’re letting your knees come inward even just slightly with squats or sumo deadlifts and causing undue stress. If you are having pain with a certain lift/movement and want it assessed, or just want to dial in technique, I do offer movement assessments. Ok, gonna get nerdy and dive a bit deeper to include some research on technique for the next few paragraphs...(if you don’t care about research and just want the takeaways…skip to the next bolded line)

Research by Bloomquist et al showed that deep squats improved strength throughout the range of motion while shallow squats did improve strength a little more at shallow depth, but minimal strength increase at deeper positions. In other words, if you constantly squat above parallel, you;ll get stronger in that position, but not really improve strength for things like getting up and down from the floor, squatting down to pick up heavy items off the ground, catching nd standing a clean or snatch at full depth. Squat jump strength also improved only with full depth squats, not quarter squats according to research by Hartmann et al.

Hartmann et al also found that the compressive forces in the knee are highest at 90 degrees and have little quad tendon support, yet when you squat deeper, there is actually a protective wrapping effect around the knees! My mom can attest to that. One of my biggest recent “wins” is finally getting my mother to listen to me (seriously, it’s like pay back for not listening as a child) about squats. She does not have ACLs in either knee and then retore an MCL about 10 years ago while waterskiing. She has at least listened to me for awhile that the best thing she can do for her knees is keep up strength to create the extra support needed in lieu of those ligaments. About a month ago, I finally got her to start doing a few exercises I wrote including some goblet squats with increased weight. However, she’s been scared to squat below parallel. So she called me up and told me her knees were achy. I explained the above research and told her to just give going below parallel a shot for a few days and call me back. Guess what?! Her knee pain was GONE!

The other major lie that we’ve all heard is that your knees can’t past your toes. Absolute BS. In fact, I can personally say that the first time I really felt my quads fire during a squat was when I finally let my knees go past my toes. It’s also the first time I didn’t end of having soreness in my low back after a bunch of squats. Here’s why: Fry et al did some research looking at joint forces at the hips and knees when knee movement is restricted to avoid going past the toes or allowed to do so. They found that if it is restricted, there’s a 1000% increase in hip forces. One thousand y’all! It also caused your torso to come more forward since the hips had to stay back. This then places more pressure on your back. Between those factors, it’s no wonder my back was getting sore with back squats! Some of whether or not your knees need to come forward and the degree to which they do is definitely dependent on your specific anatomy.

Okay, now for the fun stuff. Strength. Note that this is specific for the person dealing with knee pain with squatting…

As I mentioned earlier, if you have strength surrounding the joint, it will unload it and you won’t deal with pain that comes from pressure on the internal structures (for example, osteoarthritis bone changes won’t cause pain) But…how do you build strength if you’re dealing with knee pain already?? The following exercises will be a great start!!

Even better if you mix in things to spike your heart rate like a 30” arm only bike sprint…gets your heart rate going, thereby increasing fluid circulation to the legs/knees which will drastically help “flush out” any inflammatory chemicals. Therefore, decreased swelling and pain!

There are plenty of great drills not listed here, but this is a great start:

-Knee Gapping.

Ok this one is for you if you just feel a lot of pressure in your knee when you squat and feel like it limits you. You know that feeling when your knee is even a little swollen and it won’t quite bend all the way back into full flexion? Yea, this helps with that. A ton. You can use a small ball, like a lacrosse ball, or a tightly rolled up towel like I am here. This helps glide the tibia (the lower leg bone) forward as you go into end range motion, which is what’s needed, and increase the joint space so it doesn’t get as much of that pressure feeling. Help yourself into end range flexion by grabbing your lower leg and pull it in, as shown. Make sure to get some calf motion in by moving your ankle around as the gastroc does cross up over the knee and assist in this motion. (side note: please ignore the squeeky ball in the background from the pups)

- Spanish squats.

Easily my favorite exercise to not only get a quick solid quad burn, but to unload the knee and allow better movement. I’ve used this countless times with acute knee pain, chronic arthritis, post surgical, and a whole host of other people (and myself) to be able to squat sooner and build/maintain strength. The band is placed directly behind the knees. You want to make sure there is solid tension in the band throughout the movement - as you can see in this video, the band can hold my weight. Unlike a normal squat, you keep your shins perpendicular to the ground. The kettlebell is mostly to counterbalance and help me keep my chest upright. Shoutout to Zach Long, PT, DPT (aka @thebarbellphysio) for introducing me to these several years ago while we were at a course together.

- Copenhagen Planks.

So it may not be readily obvious how these help your squat, but the truth is the inner thigh muscles play a HUGE role in full depth squats, and if their capacity isn’t adequate, it can cause knee pain, particularly on the inside of the knee. Now, this exercise is MUCH harder than it looks, so I highly recommend starting it where you have the top knee supported on the bench (or couch or whatever you’re using). If that’s still too much, you can leave the bottom leg on the ground and allow it to help support as much as needed, but as little as possible (don’t cheat yourself!)

- Bulgarian Split Squats.

Not just for lifters. This is a fantastic exercises for hikers and trail runners as it not only works on the muscles you use in your sport, but it also challenges single leg and trunk/core stability which are very important. Get into a lunge position with the back leg up on a box/bench/couch/whatever and then drop your trunk straight down while both knees bend. I’m using a kettlebell in a goblet hold here, but you can also do a barbell in the front/back/Zercher position

- Hip Thrusters

Yes, I know, this is a butt exercise. But without strong glutes, your knees will be trying to compensate for lack of stability. No bueno. Besides, lets be real, is there a downside to having a nice ass? No.

In this video, my fiancé is demonstrating with both legs, but going single leg is a great option as well! Please note, he’s also going absurdly light with the weight here. You want to go HEAVY on this exercise. You’ll probably surprise yourself with how heavy you can go…I have multiple patients over 65 that do this one well over 100, if not 200 pounds for reps. Just make sure you can actually hit full extension at the top (meaning your hips finish in line with your knees and shoulders)

No barbell? That’s fine! Use a super heavy dumbbell or kettlebell…just know you’ll be limited by getting the weight on/off your lap and will need to up the reps to have any benefit.

Ok, hopefully these exercises are helpful!

One last quick note that I’d be remiss if I didn’t mention: When discussing knee pain, you have to consider lifestyle factors. All too often, knee pain is due to any increase in the body’s inflammatory response. And I’m not just taking about the injury response. If our diet, our sleep, and/or our stress is trash, it affects our entire system. So while I don’t wanna vilify the occasional cup of ice cream (that would make me a hypocrite), I do want to point out that if you’re crushing a whole pizza, McDonalds, and M&Ms every day, then it’s not entirely surprising that you feel lie you have “bad knees”…but if you take away the inflammatory-inducing foods, get 8 hrs of sleep, and move your body regularly, I bet you would find that you actually have good knees! They were just mad at you and letting you know they were mad…