Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review

Abstract

Context: The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population. Objective: To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes. Data Sources: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies. Study Selection: A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed. Study Design: Systematic review. Level of Evidence: Level 5. Data Extraction: Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data. Results: Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events. Conclusion: Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.

Prevalence, frequency, adverse events, and reasons for analgesic use in youth athletes: A systematic review and meta-analysis of 44,381 athletes

“…37 Another systematic review including 163 individual studies showed that the proportion of adolescents reporting to have self-medicated analgesics ranged from 5.4 % to 93 % across 14 different prevalence measures. 38 While previous systematic reviews synthesizing the use of analgesics in sports have been published, 22,39,40 none have assessed the use in adult athletes only, thus hindering a direct comparison between youth and adult athletes. However, our meta-regression analysis showed no impact of age, suggesting that the prevalence of analgesic use was not significantly associated with age.…”

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play

“…3 By decreasing inflammation, locally injected corticosteroids help reduce pain in the athlete and can improve range of motion. 4 Percutaneous interventions that promote healing include dry needling of muscle, also referred to as trigger point injections, or of tendon, referred to as percutaneous tenotomy. These can also be performed with the use of a biologic agent such as platelet-rich plasma (PRP).…”

Drugs in Sports

“…Several articles in this issue of Sports Health can help physicians develop and implement safe pain treatment parameters. 3,5,7,8…”

“…Toradol (ketorolac) is currently the only injectable nonsteroidal anti-inflammatory agent approved by the Food and Drug Administration. Used widely on game day in college and professional sports, 5 it has a rapid onset and half-life of approximately 6.5 hours. 5 Its use in elite sports is declining and may be due to the fact that emergency department data on intramuscular ketorolac, oral ibuprofen, and placebo show that the analgesic effect is not statistically different.…”

“…Corticosteroids are very potent and used extensively both intra- and extra-articularly. 5 They are capable of preventing the accumulation of inflammatory cells and thus can slow the inflammatory response. 5 This inflammation inhibition can certainly relieve discomfort, but it can also slow the process of soft tissue healing and/or can weaken ligaments and tendons, increasing the risk of rupture.…”