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Recommendations of the National Football League Physician Society Task
Force on the Use of Toradol Ketorolac in the National Football League
Matthew Matava, MD,* D. Craig Brater, MD, Nancy Gritter, MD, Robert Heyer,
MD, Douglas Rollins, MD, PhD, Theodore Schlegel, MD, Robert Toto, MD, and
Anthony Yates, MD
Sports Health
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435943/
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Abstract
Ketorolac tromethamine (Toradol) is a non-steroidal anti-inflammatory drug
that has potent analgesic and anti-inflammatory properties. It can be
administered orally, intravenously, intramuscularly, or via a nasal route.
Ketorolac injections have been used for several years in the National
Football League (NFL), in both the oral and injectable forms, to treat
musculoskeletal injuries and to prevent post-game soreness. In an attempt
to determine the appropriate use of this medication in NFL players, the
NFL Team Physician Society appointed a Task Force to consider the best
available evidence as to how ketorolac should be used for pain management
in professional football players. These treatment recommendations were
established based on the available medical literature taking into
consideration the pharmacokinetic properties of ketorolac, its accepted
indications and contraindications, and the unique clinical challenges of
the NFL. The Task Force recommended that 1) ketorolac should only be
administered under the direct supervision and order of a team physician;
2) ketorolac should not be used prophylactically as a means of reducing
anticipated pain either during or after participation in NFL games or
practices and should be limited to those players diagnosed with an injury
or condition and listed on the teams injury report; 3) ketorolac should be
given in the lowest effective therapeutic dose and should not be used in
any form for more than 5 days; 4) ketorolac should be given in its oral
preparation under typical circumstances; 5) ketorolac should not be taken
concurrently with other NSAIDs or by those players with a history of
allergic reaction to ketorolac, other NSAIDs or aspirin; and 6) ketorolac
should not be used by a player with a history of significant
gastrointestinal bleeding, renal compromise, or a past history of
complications related to NSAIDs.
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Keywords: Toradol, Ketorolac, NFL, Football
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Beginning with the introduction of ibuprofen in the 1950s, nonsteroidal
anti-inflammatory drugs (NSAIDs) have been prescribed for athletic
injuries in an attempt to blunt the bodys inflammatory response to injury,
control pain, and aid in the return to sports.26 There are a variety of
both prescription and nonprescription medications in this class of drugs.
Among athletes using prescription medication, NSAIDs have been found to be
among the most frequently prescribed (8.1%).1 Unfortunately, these agents
are not without complications (see the following). Adverse events were
reported in 20% of athletes using NSAIDs for a variety of musculoskeletal
complaints.1
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Athletes may even take NSAIDs as a preventive measure. For example, during
the 2000 Olympic Games in Sydney, Canadian athletes used NSAIDs more than
any other medication.17 Similarly, a survey of American football players
showed that 1 out of 7 high school athletes took NSAIDs daily and that 29%
of college athletes took them as a preventive measure on the day of a
game.30 Warner et al31 found a similar occurrence in their study of
athletes; independent of their analgesic effect, the athletes mentioned a
potential performance improvement to justify taking these medications.
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Ketorolac tromethamine (Toradol) is an NSAID that has potent analgesic and
anti-inflammatory properties. It can be administered orally,
intravenously, intramuscularly, or via a nasal route. Ketorolac has been
used principally for its analgesic properties following acute strains and
sprains, overuse injuries, and as an adjunct to narcotic medication
following surgery. Ketorolac injections have been used for several years
in the National Football League (NFL), in both the oral and injectable
forms, to treat musculoskeletal injuries and to prevent postgame soreness.
The only study, to date, examining the prevalence of ketorolac use in
professional sports was performed by Tokish et al in 2002.29 These authors
investigated the use of injectable ketorolac in NFL teams during the 2001
season. Their study revealed that 28 of the 30 teams that responded to
their survey used intramuscular ketorolac. Game-day usage was reported at
93% with pain relief of 1 to 2 days noted in 50% to 75% of players. There
were 6 adverse reactions reported, including 4 muscle injuries, 1
gastrointestinal (GI) complaint, and 1 case of postinjection soreness.
Anecdotally, some NFL medical staffs felt that ketorolac injections were
considered more powerful than other NSAIDs because of the route of
administration in that many players felt that getting a shot was an
intrinsic sign that they were getting a more powerful medicine.29 Overall,
these authors found ketorolac to be safe and effective when used in the
pregame setting of the NFL. However, they were careful to recommend
further study to develop standardized guidelines for ketorolac use in
athletes to protect both players and medical staffs from potential
complications. Since the publication of this study, it is widely believed
by NFL team physicians that the use of ketorolac has increased in
prevalence not only in the NFL but also in NCAA Division I football.
However, we are unaware of any objective documentation proving this
hypothesis.
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Sports medicine specialists often use injections to deliver the intended
medication directly to the site of injury (anesthetic or corticosteroid)
or to provide a medication when oral dosing is not possible. Sterile
preparation may reduce the risk of infection, but this can be challenging
in the game-day training room or hotel setting. In addition, injections
clearly pose a risk of bleeding and injury to adjacent structures. As with
the administration of any other form of invasive treatment, informed
consent has been recommended prior to administering injections to
athletes.27
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Injections are typically perceived as a more aggressive form of treatment
that has recently garnered attention from the lay media as a result of
ketorolac injections used prior to competition in the NFL. Injection of
medication to treat sports-related conditions is not unheard of, but there
is no evidence of increased effectiveness owing to this route of
administration. Orchard24 published the results of a case series involving
professional Australian Rules football and rugby players treated with
local anesthetic injections to facilitate a quicker return to play. This
study showed an 8% complication rate associated with the use of injections
in these players and was an important first step in trying to adequately
define the risks and complications associated with injections following
athletic injuries. Public perception of team physicians administering
various therapeutic (or pain killing) injections to allow athletes to
return to competition likely varies depending on the level of competition
and public visibility of the athlete. Moreover, the literature is
deficient in terms of the ethical considerations implicit with the
administration of injectable medications in the athletic setting solely
for the athlete to return to competition.
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The complete article may be read at the URL above.
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Sincerely,
David Dillard
Temple University
(215) 204 - 4584
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