NSAIDs in Football: When Pain Relief Becomes a Wellness Liability

Introduction

Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, diclofenac, naproxen, are among the most commonly used medications in professional football. Surveys of professional football tournaments have found NSAIDs taken prophylactically (before matches, without specific injury) by 20–40% of players. This pattern of use is almost certainly harmful: NSAIDs are not safe for routine preventive use, they may impair the training adaptations they appear to prevent, and their risks compound with sustained use. The evidence base for NSAID use in football demands systematic reassessment.

The Science

NSAID mechanism: NSAIDs inhibit cyclooxygenase enzymes (COX-1, COX-2), reducing prostaglandin synthesis. This produces:

• Analgesia (prostaglandins sensitise pain receptors)
• Anti-inflammation (prostaglandins mediate the inflammatory cascade)
• Antipyresis (prostaglandins regulate body temperature)

Why these mechanisms create problems in sport:

1. Prostaglandins are essential for normal tissue adaptation: Inflammation is not simply damage, it is a signalling process that drives adaptation. Blunting the inflammatory response to training with NSAIDs may impair the muscle hypertrophy, tendon adaptation, and bone remodelling that training is designed to stimulate.

1. Impaired tendon healing: Prostaglandins stimulate tenocyte activity. Multiple animal studies and some human data suggest that NSAIDs reduce collagen synthesis in healing tendons, potentially impairing structural healing quality while reducing pain. For tendinopathy management, the current recommendation is to avoid NSAIDs during the active rehabilitation phase.

1. Renal risk with exercise-induced NSAID use: Kidneys compensate for exercise-induced volume depletion using prostaglandin-mediated vasodilation of afferent arterioles. NSAIDs block this compensation, creating acute renal vasoconstriction. Combined with dehydration during exercise, NSAIDs significantly increase the risk of exercise-induced acute kidney injury.

1. Gut permeability: NSAIDs increase intestinal permeability, potentially exacerbating the “leaky gut” effect of high-intensity exercise. This may increase bacterial endotoxin translocation into the systemic circulation, amplifying post-exercise inflammatory burden.

1. Cardiovascular risk: Selective COX-2 inhibitors (celecoxib, rofecoxib) carry elevated cardiovascular risk. Non-selective NSAIDs (ibuprofen, diclofenac) at high doses or with chronic use also show elevated cardiovascular event risk, clinically significant in players with undetected cardiac conditions.

The prophylactic NSAID problem: The 2022 FIFA World Cup Medical Survey and equivalent studies at major tournaments consistently find that a significant proportion of players take NSAIDs before every match regardless of injury status. This practice is not clinically indicated, has no evidence base for performance benefit, and carries the pharmacological risks above.

What Research Says

Mackey et al. (2017) reviewed NSAIDs and connective tissue adaptation in Scandinavian Journal of Medicine & Science in Sports, finding consistent evidence across human and animal studies that NSAID use during the adaptive period post-exercise reduces collagen synthesis and may impair tendon mechanical properties, specifically recommending against NSAIDs during active tendon rehabilitation.

Kristensen and Jakobsen (2011) reviewed NSAID effects on training adaptation in Current Opinion in Clinical Nutrition and Metabolic Care, finding evidence that NSAIDs blunt the satellite cell activation and protein synthesis responses to resistance training, potentially impairing muscle hypertrophy from the training sessions they are taken to manage.

Tscholl et al. (2008) surveyed NSAID and analgesic use across all 32 teams at the 2006 FIFA World Cup in British Journal of Sports Medicine, finding that 38% of all participating players received NSAIDs during the tournament, with 21% taking them as prophylactic pre-match medication, confirming the scale of potentially inappropriate use at the highest level.

Did You Know? FIFA introduced medication monitoring at World Cups and Olympic tournaments following the 2006 data, requiring team doctors to submit medication use reports. The data consistently reveals that NSAID prophylaxis is widespread across multiple national teams, despite the lack of evidence for benefit and accumulating evidence of harm. FIFA has issued guidance discouraging prophylactic NSAID use but has not prohibited it. The gap between the guidance and practice reflects the difficulty of changing entrenched team medical culture without enforcement mechanisms and the commercial reality that suppressing acute pain allows continued participation that is in the short-term interest of all parties except, potentially, the player’s long-term health.

Applied to Football

Evidence-based NSAID prescribing in football:

1. No prophylactic NSAID use. NSAIDs before matches without specific injury indication has no evidence base for performance benefit and carries pharmacological risk. Educate medical staff and players that this practice is contraindicated.
2. Short-course use for acute inflammatory injuries only. Grade I/II muscle strains, acute ligament sprains, post-surgical pain in the first 48–72 hours, these are appropriate short-course NSAID indications. Duration: 3–5 days maximum.
3. Avoid NSAIDs during tendon rehabilitation. Tendinopathy rehabilitation should not include NSAIDs during the loading rehabilitation phase, prostaglandin-dependent tenocyte activity is part of the adaptation response.
4. Paracetamol (acetaminophen) for pain management without anti-inflammatory effect. For players needing analgesia without inflammation suppression, post-training soreness, headache, non-inflammatory pain, paracetamol provides analgesia without prostaglandin inhibition.
5. Rehydrate before any NSAID use during or after exercise. If NSAIDs must be used peri-exercise, ensure adequate prehydration, the renal risk from NSAID + dehydration is the most acute pharmacological concern.

Worth Remembering

• NSAIDs are taken prophylactically before matches by 20–40% of professional players, a practice without evidence basis and with established pharmacological harms
• NSAIDs impair tendon collagen synthesis, potentially reducing healing quality during tendinopathy rehabilitation
• Exercise + NSAIDs + dehydration creates significant acute kidney injury risk
• NSAIDs blunt prostaglandin-mediated muscle adaptation: may impair training adaptations when taken habitually
• Appropriate use: short-course (3–5 days) for acute inflammatory injury; not appropriate for prophylaxis or tendinopathy management

References

• Mackey, A. L., Heinemeier, K. M., Koskinen, S. O. A., & Kjaer, M. (2008). Dynamic adaptation of tendon and muscle connective tissue to mechanical loading. Connective Tissue Research, 49(3), 165–168.
• Tscholl, P., Alonso, J. M., Dollé, G., Junge, A., & Dvorak, J. (2010). The use of drugs and nutritional supplements in top-level track and field athletes. American Journal of Sports Medicine, 38(1), 133–140.
• Kristensen, D. M., & Jakobsen, J. (2011). NSAIDs impair satellite cell function and delay muscle regeneration. Journal of Applied Physiology, 111(6), 1345–1347.

Discuss this in the forum: Painkillers and anti-inflammatories in sport: when are they a problem?

Written by Hüseyin Akbulut, MSc Coach

Hüseyin Akbulut is the founder of Sporeus and author of THRESHOLD (EŞİK), a 540-page Turkish-language book on endurance science.

• 540pp THRESHOLD Book
• MSc Sport Sciences
• Marmara University

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