An ER Doc Debunks 4 Common Inflammation Myths

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Mei Lin was out for a run when she unexpectedly rolled her ankle. She felt intense pain, was unable to continue her training, and made her way home gingerly. Later, she noted how her ankle was swollen, red, and warm.

Jordan had recently incorporated strength training into her training regimen but after a week or so during which she may have overextended herself lifting more weight too soon, she noticed a dull ache in her shoulder that made it difficult to lift her arm and awoke her from sleep.

James had been running since he was in his mid-twenties. Now in his mid-sixties, he found that his right knee was often stiff and sore in the mornings, and caused him a great deal of discomfort at night. He often noted swelling of this joint as well.

Michelle was in a groove with her training but was relishing her recovery week. After the latest block of hard work, she had seen some gains across all three disciplines, but she could feel some lingering soreness and fatigue in her legs and she was eager to have a few easier days to reset herself before the next training block.

Above, I have described four very disparate cases of athletes, each of whom is experiencing some kind of malady that will likely sound familiar to anyone who has been active for even a brief amount of time. Everyone has, at some point, sustained some kind of injury like Mei Lin, or experienced tendinitis like Jordan. Although you may not have osteoarthritis like James, you certainly know of someone who does, and like Michelle, we have all been at the point where we feel the almost pleasant sensation that the mixture of soreness and exhaustion that accompanies a recently completed hard training block can bring.

While each of these cases may seem very different on the surface, they are unified by the fact that they each share a common physiological pathway leading to the development of their symptoms: inflammation.

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Inflammation is often thought of as a dirty word among athletes, and it shouldn't be. The truth is that inflammation is a critical process by which our body responds to injury and illness. It is vital to keeping us alive and well. It is also an important contributor to how we respond to training overload and improve our overall fitness. When inflammation works properly, our bodies are well served.

Alas, there is a fine balance and when inflammation gets even slightly off-kilter, this process can become very destructive. All manner of chronic ailments results from inflammatory processes run amok, and in the worst cases, can even lead to death. So how does a process that is generally considered beneficial sometimes go off the rails?

Severe, systemic inflammation can occur in various clinical scenarios and can have devastating effects. Bacterial infections can lead to the systemic inflammatory response and chronic illnesses like lupus or rheumatoid arthritis are examples of this.

Conversely, low-level inflammation that is chronic tends to be seen with advanced age and can contribute to various ailments often associated with the elderly.

Tissue-level inflammation is a highly complex and coordinated series of events that is initiated by injury. It involves pro-inflammatory and immune cells working together towards a goal of tissue protection and repair. Unfortunately, if unresolved, inflammation can lead to ongoing tissue damage and chronic diseases.

How, then do we interpret all this information? Does this mean we should be tamping down inflammation at the earliest signs? Not quite. Let's take a look at a few myths surrounding inflammation, so we can better understand how manage it as part of our daily lives as athletes.

The primary response to injury is inflammation. Indeed, it is this inflammatory response that is critical to beginning the healing process. Consider the case of Mei Lin described above. When she rolled her ankle during a run, she tore a ligament. The response to that injury was complex and involved a rush of pro-inflammatory cells to the area that released a plethora of chemicals that resulted in local blood vessels becoming leaky among other changes. Fluid rushed into the area, causing the ankle to swell and become warm and pain receptors were stimulated. The result is that Mei Lin will stay off of the injury because it hurts and all of the cells and fluid in the area will facilitate healing and the restoration of normal function. In this case, inflammation is a very good thing.

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As we have just seen with the case of Mei Lin, inflammation can be very important to the healing process, so interfering with it might not be such a good idea. Still, controlling inflammation can have its benefits. The application of ice, in conjunction with pressure and elevation of an injured body part, can reduce swelling without completely obviating the beneficial effects of inflammation. But what about the use of anti-inflammatory medications, particularly in the form of non-steroidal anti-inflammatories (NSAIDs)?

NSAIDs have been around for more than a century since the discovery of acetylsalicylic acid (ASA). There are numerous other medications in this class and all work to inhibit one or more of the enzymatic processes critical to the inflammatory process. While NSAIDs can be helpful in decreasing pain and managing chronic inflammatory diseases, their use for acute injuries is a little more controversial.

NSAIDs inhibit bone growth, so their use to treat the pain related to fractures is not recommended. Even for sprains, NSAIDs should be used sparingly.

The case of Michelle, described above, is another example when NSAID use may need to be carefully considered. In that case, soreness from training is related to inflammation in the muscles from damage caused by pushing herself as hard as she did. This damage and the repair that comes about as a result is necessary for Michelle to become stronger. There is some evidence that the use of NSAIDs may interfere with this process and potentially negate some of the gains of training if these drugs are taken regularly (the evidence is compelling but not completely clear, still it should give athletes pause before using these medications regularly in training).

As we have just seen, NSAID use may have some negative consequences for training and performance, but this doesn't change the fact that this class of drugs remains among the most commonly used over-the-counter medications around the world. Ibuprofen, indomethacin, naproxen, and the previously mentioned ASA are all used to treat pain and inflammation from all manner of causes. It is a fairly common practice for athletes to use one of these agents before or during longer events to control soreness and pain and provide an ability to ‘push through’ based on the belief that these drugs are inherently safe.

Unfortunately, nothing could be further from the truth. Though NSAIDs have a good safety profile when used on occasion to treat mild to moderate pain or inflammation, their use on an ongoing basis or under certain circumstances can make them quite dangerous.

Consider the case of James that I described earlier. With his osteoarthritis, James may rely on NSAIDs to dull the ache in his knee so that he can continue to run. Taking that medication daily (especially at his age) puts him at risk for heart attack, stroke and gastrointestinal bleeding.

Even for Jordan, who had an acute tendinitis in her shoulder from overexerting herself in the weight room, NSAIDs could pose a risk if used in the wrong context. If she still had shoulder pain a couple of weeks later and took a high dose of naproxen because she wanted to be able to complete the swim in her 70.3, she could unknowingly be placing her body at serious risk. In the context of dehydration, higher doses of NSAIDs (and even normal doses) can lead to acute kidney injury or failure. For this reason their use is strongly discouraged before longer distance endurance events.

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While inflammation is clearly the issue in most acute injuries, and can even have a role in the development of many chronic processes, it is simply not true that all the things that can impair training are related to inflammatory processes.

For example, chronic tendinopathies, which affecting areas like the Achilles tendon, is a non-inflammatory process. Bursitis often results from injury, but has nothing to do with inflammation, despite the inclusion of the terminal ‘itis’ in its name that is pathognomonic for all inflammatory processes.

The reality is, that while inflammation is commonly underlying the pain from whatever ails you, it is not the only thing that might be responsible.

Clearly, inflammation has a bad rap. While in some ways it has justifiably earned its reputation, it has also been unfairly maligned. Understanding that inflammation is a normal and necessary response helps us see it in a better light and perhaps begin to accept it as a necessary part of our training and racing cycle. We push ourselves; we develop an inflammatory response and that response helps us get better. If we go too far and get injured, that inflammation becomes stronger but it is still a normal process of healing and getting us back to where we want to be. Rather than try to eliminate inflammation, we should learn to recognize its value and control it when we need to in ways that cause us the least harm.

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Dr. Jeffrey Sankoff is a Denver, Colorado-based emergency room physician, who produces the "TriDoc Podcast." Dr. Sankoff is also a triathlete himself and a USAT- and Ironman-certified coach.