Do anti inflammatory medications interfere with healing?

Ibuprofen impairs capsulolabral healing in a rat model of anterior glenohumeral instability

These authors used a rat model to determine the effect of nonsteroidal antiinflammatory drugs (NSAIDs) on the healing glenoid labrum and capsule after glenohumeral dislocation.

Sixty-six rats had surgically induced anterior-inferior labral tears and anterior glenohumeral dislocation. Postoperatively, the animals were assigned to either normal (n = 32) or ibuprofen drinking water (n = 31). Animals were euthanized at 2 and 4 weeks postoperatively for biomechanical testing and histologic analysis.

They found that the postinjury administration of ibuprofen resulted in decreased capsulolabral healing as indicated by decreased stiffness and maximal load to failure.

and delayed histologic evidence of healing

These authors point to a clinical study investigating the effect of NSAIDs on capsulolabral healing in 477 patients from the Norwegian shoulder instability registry with a primary arthroscopic Bankart procedure (see this link). The Western Ontario Shoulder Instability Index and the reoperation rate of the patients who received NSAIDs postoperatively were not statistically significant from those who did not.

Comment: There are substantial data suggesting that non-steroidal anti-inflammatory medications can interfere with the progress of healing of soft tissue injuries and repairs, fractures and surgical fusions.
On the other hand, these medications are effective non-narcotic analgesics with great utility in the postoperative period. They may also be effective in combatting stiffness after arthroplasty.

In situations where healing is likely to be robust (e.g. in healing the subscapularis repair after a shoulder arthroplasty) we use immediate postoperative NSAIDs because the benefit seems to outweigh the resk.
However, where healing is uncertain, for example in rotator cuff repair, there may be a consideration to avoid these medications, although again the evidence comes primarily from animal models (see this link).
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Cardiovascular safety of non-steroidal anti-inflammatory drugs for arthritis, NSAIDS

The British Medical Journal recently published a network meta-analysis to analyze the evidence on cardiovascular safety of non-steroidal anti-inflammatory medications. These are medications that are commonly used to manage the symptoms of arthritis. They looked at the rates of myocardial infarction (heart attacks), as well as strokes, death from cardiovascular disease, and death from any causes. They included 31 randomized controlled trials with data from over 100,000 patients. Patients included those taking naproxen (Aleve), ibuprofen (Advil), diclofenac (Voltaren), celecoxib (Celebrex), etoricoxib (Arcoxia), rofecoxib (Vioxx), lumiracoxib (Prexige), or placebo (a pill with no biological activity). Compared with placebo, rofecoxib was associated with the highest risk of myocardial infarction, followed by lumiracoxib. Ibuprofen was associated with the highest risk of stroke, followed by diclofenac. Etoricoxib and diclofenac were associated with the highest risk of cardiovascular death. However, none of these drugs appeared to be free of cardiovascular risk. Among them, naproxen seemed to be the safest. While this study does not indicate that these medications should be avoided, it does suggest that moderate and intermittent use may be advisable to minimize the risk.
See also Drugs for arthritis: the good and the bad and our post on the relative safety of these medications.

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Shoulder arthritis and rotator cuff articles from Sept issue of the Journal of Shoulder and Elbow Surgery

In the September issue of JSES a number of interesting articles appear.
Shidle et al sought evidence of inflammatory markers in tissue samples from shoulders with rotator cuff tears. They found that the amount of inflammation correlates with tear size and was greater in full thickness than in partial thickness tears. This finding of inflammation may help explain the achy pain at rest experienced by patients with full thickness cuff years as well as the relief of symptoms from anti-inflammatory medications as well as from a 'smooth and move' procedure that removes the inflamed bursal tissue, even if the cuff tear itself is not repaired.


Gulotta et al considered the prognostic factors for clinical and ultrasound determination of cuff integrity at five years after rotator cuff repair surgery. As Harryman et al demonstrared 20 years ago in a very similar study, larger tears in older patients are likely to fail to heal after repair. In fact, the risk of healing failure increased over five times when the tear involved more than one tendon. However, as Harryman et al pointed out previously, many patients were clinically improved even though the repair failed. These results suggest that an option for treating large tears in older patients may be the 'smooth and move' procedure, sparing the patient from the need to protect an attempted repair after surgery, especially if the prognosis for healing is unfavorable. This study points out that a 'successful' rotator cuff surgery needs to be carefully defined in clinical research: does 'success' refer to healing of the tendon verified by cuff tendon imaging or by improvement in the comfort and function of the shoulder?

Finally, Warrender et al reported that in patients having rotator cuff repair, obesity was associated with worse functional outcomes, longer operative times and longer hospital stays.

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Relative safety of non-steroidal anti-inflammatory medications

A recent study has made some important observations on the cardiovascular risk of different NSAIDs. The summary of this study is presented below.

For those patients with normal kidney function, who are not on anticoagulants, who do not have other contraindications, we commonly suggest naproxen (Aleve) used according to the manufacturer's specifications.


"Data from a study published online in the journal PLoS Medicine suggest that, among widely used non-steroidal anti-inflammatory drugs (NSAIDs), naproxen and low-dose ibuprofen are the least likely to increase cardiovascular risk. The authors conducted a systematic review of 30 case-control studies covering 184,946 cardiovascular events, and 21 cohort studies that described outcomes in more than 2.7 million exposed individuals. Of the most extensively studied drugs, the highest overall risks were seen with rofecoxib and diclofenac, and the lowest with ibuprofen and naproxen. In a sub-set of studies, risk was elevated with low doses of rofecoxib, celecoxib, and diclofenac, with risk increasing with higher doses. Ibuprofen risk was seen only with higher doses, while naproxen was risk-neutral at all doses."

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