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SPORT-MED  October 2017

SPORT-MED October 2017

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Subject:

SPORTS MEDICINE : PRESCRIPTION DRUGS : SPORTS: PROFESSIONAL: FOOTBALL (NFL): Recommendations of the National Football League Physician Society Task Force on the Use of Toradol Ketorolac in the National Football League

From:

"David P. Dillard" <[log in to unmask]>

Reply-To:

To support research in sports medicine <[log in to unmask]>

Date:

Sat, 14 Oct 2017 18:35:06 -0400

Content-Type:

TEXT/PLAIN

Parts/Attachments:

Parts/Attachments

TEXT/PLAIN (285 lines)

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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

.

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.

.

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

.

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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