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The No Pills, No Pain Program

What Does No Pills, No Pain Mean?

This is the name of a program of treating injuries that states that your fastest rate of healing will occur if you:

  1. do not take any medications which can mask symptoms or directly interfere with healing (NO PILLS), and
  2. do nothing that causes pain to the injured area (NO PAIN)

When I discuss this with patients in my office who are injured they usually state, once it is explained to them, that it is so obvious that it is amazing that we treat injuries any other way. The reason why we do, as will be explained below, is the mistaken belief that we have medications which can hasten healing (we don’t), that the medicines we take are harmless (they’re not) and that ignoring pain to an injured area is OK (it isn’t)

Why Do We Feel Pain When We Are Injured?

Pain signals us that damage or death has occurred to the cells in the affected area. For example bone cells in a fracture, tendon cells in a tendon rupture, or muscle cells in a torn muscle. It is also our body’s way of telling us not to use the affected area. It is remarkably specific in telling us not to do certain activities that will aggravate the given area but letting us do others that will not aggravate the affected area. For example if you have “tennis elbow” (lateral epicondylitis) you will have pain if you lift with your palm facing downward because in that position the damaged tendon (the ECRB tendon) is called into play. But if you lift with your palm facing upward you will not have pain because you are not using the damaged tendon but rather other tendons in your elbow which are uninjured. Our bodies are amazingly good at telling us what is ok to do with an injury and what is not. All we have to do is be good listeners to what our bodies are telling us. Avoiding pain allows healing. Persisting in painful activities causes more damage and slows healing. What could be simpler?

The problem is that we tend to want to heal even faster and attempt to provide treatments or medications to improve on Mother Nature – and we can’t. This basic natural healing rate is, in fact, the best we can do. We have nothing that can accelerate it, but we can – and do – slow our down our recoveries in misguided attempts to improve it. This is all well established in the scientific literature. However the popularity of these treatments is not about science. Instead it is about giving people what they want, even if it doesn’t really exist. The business of selling treatments and medications to hasten healing from musculoskeletal injuries is a gigantic and very profitable industry. Often the treatments and medications are wrapped in complicated medical jargon. These treatments usually make us “feel good” (pain relieving pills, massages, braces, sports creams etc.) even though they are not helping us get better. The claims of success are not lies, just carefully worded inferences of success, which are nonetheless misleading. However, patients are looking for something that works and there is no end of sources to satisfy this desire even though none are effective. Below we will explain why such strategies are useless at best and often harmful.

The Role of Sleep

Every day cell death occurs. During deep sleep cells are replenished. If you are physically active, you will incur more cell death during the day. If you do not get sufficient sleep at night you will suffer a net cell loss and eventually injury. Such injuries commonly manifest as tendinitis, muscle strains, or stress fractures. If you have an acute injury, you have a sudden large loss of healthy tissue to cell death that must be replenished. Almost everyone needs at least 7 hours of sleep a night to function at their best and stay healthy, and most adults need 8 or more. Adolescents need at least 9 hours. In the 1960s in the United States the average American slept more than 8 hours per night. Now, however, the average American sleeps only 6.9 hours per night. This decreased sleep worsens health in a number of ways: including increased obesity and insulin resistance. However in the current context it is most noteworthy for causing injuries to occur more easily and take longer to heal.

What Pills Does “No Pills” Refer To?

NSAIDs (non-steroidal anti-inflammatory medications)

NSAIDs are a class of drugs that all function in similar ways. Biochemically, they block the synthesis of a class of chemicals called prostaglandins. NSAIDs can relieve pain, decrease inflammation, reduce fever, and act as an anticoagulant (blood thinner). The group includes the common over the counter drugs Ibuprofen (also called Advil and Motrin), Naproxen (Aleve), and aspirin (Excedrin, Bayer, etc). There are also numerous prescription strength NSAIDs including Indomethacin (Indocin), Ketorolac (Toradol), Oxaprozin (Daypro), diclofenac (Voltaren) and diflusinal (Dolobid). Additionally, there is a new subclass of these drugs called COX-2 inhibitors. This subclass, which contains the drug celecoxib (Celebrex), shares many of the characteristics of general NSAIDs, although they also have some unique characteristics and problems. COX-2 inhibitors do not act as blood thinners and do not reduce fever, but they do reduce pain and decrease inflammation. They also cause less problems in the gastrointestinal (GI) track but can cause cardiac problems. The newest subclass is a COX-3 drug called Limbrel. This also relieves pain but does not thin blood.

Why Taking NSAIDs Can Be Bad

NSAIDs block pain

When you take an NSAID, you feel better because the drug blocks the feelings of pain that your body is producing. However, NSAIDs do not get rid of the pain; they only keep you from feeling it for awhile. Pain is you body’s way of telling you that something is wrong and damage is being done to some part of your body. When you don’t feel the pain, you may use the injured area more and actually hurt it more because you are not feeling the pain. When the medication wears off, the pain is worse than before. Or, if you keep taking the pain pills, eventually the pain gets so bad that you can feel it even while you are still taking the drugs. If treated promptly, many pains can be resolved and the damage reversed. If you wait until the pain (and therefore the damage) is much worse, it may be much more difficult to eliminate the pain. For example, a patient with a partially torn rotator cuff in the shoulder can usually heal if they rest their shoulder. However taking pain medications or getting cortisone shots will diminish their pain and allow greater use of the arm. This results in an increased chance that they will tear the tendon completely and require surgery – which could and should have been avoided.

NSAIDs can cause gastrointestinal and other problems

NSAIDs can cause stomach and intestinal ulcers. Therefore, at the first sign of stomach upset, they should be discontinued. Continued use can lead to severe and sometimes fatal GI bleeding. While the most serious problems usually occur after symptoms have started, in some cases severe GI bleeds and death have occurred after only short term use. In fact, it was estimated in a New England Journal of Medicine article that 16,500 deaths occur in the U.S. every year from NSAID use, primarily from GI bleeding. This is a frighteningly high number and points out the danger in using these drugs indiscriminately. I have also had patients develop both kidney and liver failure from their use.

NSAIDs can slow healing

Multiple studies have shown that using NSAIDs can slow the healing of broken bones, damaged ligament and other tissues. If you are trying to heal the damage done to a knee, shoulder or other joint, using NSAIDs can significantly lengthen the healing time.

Ironically this is because these drugs do exactly what they are advertised to do: i.e. block inflammation. The problem is that inflammation is part of the necessary steps in healing: a normal, necessary and useful response. In advertisements inflammation is somehow inferred to be a negative thing. Instead, it is a remarkably positive and necessary step in healing. Blocking the normal inflammation that accompanies injury is blocking part of the normal healing response. Inflammation brings blood to the area to help healing. Platelets and natural growth factors are also brought in. The area swells because healing factors are filling the area. The injured area also produces pain which is critically important to let the injured party know not to use the injured area. For example some diabetic patients who have lost the ability to feel pain in their feet can develop a condition called Charcot’s joint disease. Damage causes broken bones within a joint that never heal because the pain is not felt so it remains untreated. Amputation is a common ultimate outcome. So using NSAIDs to block swelling, inflammation and pain diminishes the nutrient supply to the injured area and allows increased deleterious use of the affected area. 

In cases where the normal inflammatory mechanism is not working properly, such as in auto immune diseases like rheumatoid arthritis or lupus, interfering with the inflammatory cascade is beneficial. In these situations, the body’s immune system is attacking itself and blocking inflammation diminishes this self destruction. It is for diseases such as these that NSAIDs are a good treatment. However in injured patients with normal immune systems, blockade of the inflammatory cascade is only interfering with a step in what is otherwise a remarkably effective self healing mechanism. This mechanism has been honed over millions of years of evolution to heal us with maximum speed and efficacy. 

One recent study looked at the effect of Toradol (ketorolac) on the results of ACL reconstruction surgery. They found that one injection of Toradol given before the surgery to help control post-operative pain resulted in significantly greater laxity in the repaired knee six weeks after the surgery.  Addition studies have found NSAID use has resulted in delays in healing after rotator cuff surgery, knee ligament injury, and muscle strain.  The message is that if healing is desired, then NSAIDs can be problematic. Healing will, usually, but not always, occur eventually anyway, but it will be in spite of, not because of, the use of these drugs.

Other Pain Killers (Analgesics)

The following are the main pain killers in use besides NSAIDs. Unlike NSAIDs they do not directly interfere with healing nor do they have the serious ulcerogenic and GI bleeding side effects. However, they all still can interfere with healing by masking pain and thus allowing you to continue to hurt yourself without know it. And both Acetaminophen (liver damage) and narcotics (constipation, nausea and addiction) have their own serious side effects.

Acetaminophen (Tylenol)

Tylenol is not an NSAID but it is a good pain killer. Used in moderation it is a safe drug, but in too high doses it can cause liver damage. If an over-the-counter pain killer must be taken, it usually is a better choice than an NSAID. Since acetaminophen is found in a number of over the counter formulations it is particularly important to not combine acetaminophen by itself with another drug (such as many cold remedies) that may contain acetaminophen. This is a leading cause of acetaminophen poisoning. Acetaminophen toxicity is the second leading cause of liver damage in the United States after alcohol use.

Tramadol (Ultram)

Tramadol is another non-narcotic analgesic available by prescription that is commonly prescribed for musculoskeletal injuries. It is a relatively safe drug often combined with acetaminophen.

Narcotics

All narcotics are prescription drugs. Ones that are commonly prescribed for musculoskeletal problems include hydrocodone (Vicodin), and codeine (Tylenol 3). The most common side effects with narcotics are nausea and constipation.

How About Sports Creams, Pain Patches & Braces?

Sports creams are “liniments” that work by causing a mild chemical burn of the skin. This does nothing to treat the underlying problem but merely “distracts” the pain fibers of the nervous system from sensing the pain due to tissue damage. Pain patches work by supplying a local anesthetic to the local area. Again they do not help healing in any way. Braces (for the knee, elbow or elsewhere) apply local pressure to the painful area. They also do not in any way help healing. They do not “support” the affected part in a way that improves healing. They do diminish the feeling of pain and thereby also encourage increased use of the affected part and increased damage.
What all of these methods – sports creams, pain patches, and braces – have in common is that they do not help the injury heal, but do mask pain symptoms and thus encourage overuse. This is the same thing that happens with pain pills. People may well heal in spite of these pain killers but they will not heal faster. And often they will heal more slowly, sometimes needing more extreme treatment such as surgery that could have been avoided had they simply let the body heal itself without interfering with the healing process

What About Ice or Cold Therapy?

It may surprise you to know that there is no evidence that cooling an injured part helps it heal. Cold has two effects. It can decrease blood flow to an area and decrease swelling. But our bodies specifically increase blood flow to an area to bring nutrients there to help healing. So why do we think it is useful to diminish this natural response to injury? The answer is that there is no reason to think that it is useful except that it gives patients something to do to feel that they are helping the area to heal; and it gives practitioners something to prescribe. There is no reason to think that cold is harmful either (except for the occasional skin ice burn) but you should be aware that all the trouble of keeping an area cold is probably not helping. Actually I think it is somewhat imprudent to initiate a treatment that counters part of our natural healing response – the swelling that brings nutrients to the injured area – without a good reason to do so. So if you like using ice packs go right ahead, but realize that there is no evidence that it helps healing.

The second effect of ice is analgesic – it is a pain reliever. If pain is severe, then cold is probably a better and safer alternative to medications that can have side effects. Just make sure that ice in not applied directly to the skin. This can result in cold burns that can be severe. In fact, in my surgical practice I use sophisticated cold pads with pumps after knee surgery. This diminishes pain and allows patients to use less narcotic pain medicine. For the less severe pain of sprains and strains it is usually not necessary to use ice, as long as the person stays off or doesn’t use the injured part.

What About Immobilization?

Say you severely sprain your ankle. You want to avoid pills for the reasons enumerated above. Crutches have been recommended but are inconvenient. How about just applying a rigid immobilizing walker boot and going about your business? Immobilizing the ankle will not prevent use of the joint resulting in pain and slowing your healing response. But more importantly, it turns that a certain amount of – painless – motion is essential to allow maximum healing. The normal joint motions produce “piezoelectric fields” that are sensed by your body. These electric fields have an orientation relative to the affected joint that serve as a roadmap for the body to orient healing tissue. Ligaments, tendons, and bones are all composed of tissue that has structural orientation like the cables of a suspension bridge. A given amount of structural tissue (like a given amount of steel cable) produces greater structural rigidity and strength if it is oriented along the natural lines of stress that the joint experiences. If the joint is immobilized, these piezoelectric fields are weakened or eliminated. The body will deposit the healing structural tissue in a more random and less ordered fashion. The net result is a weakened healing construct relative to what would have occurred if the joint had been allowed to move normally. When a bone is broken, immobilization for a time is unavoidable. In all other cases, decreased weight bearing with no pain but continued motion will maximize the strength and speed of healing.

How About Night Pain: If Sleep is Useful, Shouldn’t I Take a Pain Pill at Night to Allow Me to Sleep?

You can take a pain pill if you must to get to sleep but try to avoid it. Night pain is almost always caused by excessive activity during the day. We feel pain more at night because our nervous system has less other sensory input to distract us from our pain. But it is easy to fall into a vicious cycle of excessive activity during the day causing pain at night which is then masked with a pain pill allowing you to continue the excessive – and destructive – activity during the next day. Not taking a pain pill forces you to take it easy on yourself resulting in the elimination or at least diminution of the night pain. The night pain is your body’s way of telling you to take it easy during the day. If you do you will feel better; you will sleep better naturally, and you will heal more quickly because you are not continually aggravating the injured area. If instead, you continue to abuse your body, then the pain and inflammation will continue to increase as your body tries ever harder to signal you that you should take it easy.

Why are the Above Described Non-Helpful Treatments so Popular?

The reason that all these methods stay popular is twofold. First, people, understandably, want to avoid pain and get back to doing everything they were before the injury as quickly as possible. The big reason however, is that clever marketing has left consumers with the impression that these medications help them heal faster. The ads don’t come out and say this directly. They can’t because it is simply not true. But the impression is implied. In my experience most patients do not like taking pills or using other treatments that are only pain killers. The appeal of these treatments is that patients believe they speed up healing. Once they are told that faster healing does not occur, they usually want to stop taking the medications. This is particularly true once they realize how these products can actually interfere with healing, and have severe side effects as well.

What To Use Instead of NSAIDs or Other Pain Medication

Woman with crutchRelative Rest

If something causes pain, it is a sign that you are doing damage to that area. Stopping the activity and giving the area time to heal is essential and usually enough to resolve the problem. If you are not causing pain and not taking pain pills (so that you really know that you are not causing pain and damage), then it is unlikely that you are causing further damage. If the problem is in your leg, using a crutch, cane, wheelchair or brace can help lessen your body weight on the joint and give it an opportunity to heal. If the problem is in your shoulder, modifying your activity so that you keep your elbows near your body instead of reaching away from your body can help. Every musculoskeletal injury can be helped in this way. The trick is finding ways to put the body part at rest while keeping your whole body functioning.

How about Physical Therapy?

Physical therapy can be helpful, but be aware that it should not be painful. The one exception is when therapy to stretch a contracted joint is necessary. This may be painful, but is nonetheless beneficial. However pain from strengthening or other physical therapy treatments should not occur. If it does, it is a signal that, although you are strengthening muscles, you are also causing damage. And this is a bad trade off. Strengthening may be useful. But strengthening in and of itself does nothing to help an injured joint heal. And it is never worth the price of causing tendinitis or muscle strain. If physical therapy is causing pain, then it should be modified so that it does not. The same holds true for “deep tissue massage.” Kneading or probing injured tissue despite pain is simply causing further injury. You will probably heal anyway eventually, but if the treatment is painful, you are hurting not helping the healing process. The oft cited rationales that such treatment increase circulation or remove scar tissue have no basis in scientific fact. Go ahead with these treatments if you like. While they won’t help you heal faster, perhaps they will help you become more functional sooner. But stop if they cause pain.

Conclusion

No one knows your body better than you. If you listen to what it tells you, you can respond in ways that help, instead of hurt. As mentioned above, we have a fantastic natural healing mechanism honed over millions of years of evolution to heal our wounds. When you reduce, modify, or eliminate activities that cause pain, you give your body’s natural healing abilities the chance to work. This is your absolute best opportunity to heal. Pushing through pain or taking potentially toxic and non-helpful medications will only get in the way of your body’s natural healing powers. And, caveat emptor, beware of false claims of accelerated healing.  One day such treatments may exist – indeed the nascent field of tissue engineering shows great promise in this regard – but as of now none do. Learn to be a skilled interpreter of what your body is telling you; be aware that pain is a necessary signal to be heeded, not muffled and masked. If you avoid pills and avoid activities that cause pain (“no pills, no pain”) you will optimize your chances to heal. And you will also save time and money.

See These Published Papers for Additional Information:

Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs. New England Journal of Medicine, Wolfe, et al. 1999

The Effect of Ketorolac on Anteroposterior Knee Laxity After Anterior Cruciate Ligament Reconstruction. Orthopedics. Mehta, et al, 2008.

Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing. Am J Sports Med. Cohen, et al. 2006.

Low-intensity pulsed ultrasound accelerates and a nonsteroidal anti-infammatory drug delays knee ligament healing. Am J Sports Med. Warden, et al. 2006.

Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med. Almekinders & Gilbert. 1986.