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Document Title: Warden-AJSM-Jul06.shtml
Article Title: Low-Intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing
Authors: Stuart J. Warden, BPhysio (Hons), PhD, Keith G. Avin, MS, Erin M. Beck, PTA, Marie E. DeWolf, ATC, Molly A. Hagemeier and Kristin M. Martin
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: July 2006
Volume 34, pages 1094-1102
Keywords: Low-Intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing
(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)
Comments: This intriguing study, done on rats, shows that ultrasound accelerates medial-collateral-ligament healing and NSAIDs (non-steroidal anti-inflammatory drugs, such as Advil) delay it. However, the quality of the actual healing apparently remained unaffected. Still, it might be advisable to avoid excessive use of anti-inflammatory drugs (which have been heavily marketed by the drug companies) and instead rely on more traditional anti-inflammatory means such as icing. This is something to discuss with one's orthopedist and physiotherapist. (The authors quote Provenzano, who researched the effects of different flexion angles and loadings on knee ligaments and healing.) As with any laboratory-only study, keep in mind that the results have not yet been confirmed clinically in humans. Remember, too, that the human knee is far more highly stressed that the knee of a rat. Not only do humans have much longer legs (both in absolute terms and proportionally in terms of overall body size), but human walk on two legs and thus exert vastly higher forces (including torques and dynamic loadings) on their knees. But in any case, the worrisome side effect of NSAIDs (in this case, slower graft incorporation, hence more opportunity for the graft to be damaged) remains. In short, please remember that there is no such thing as a drug without side effects! Note that even though this study looked at MCL "self-healing" (remember that the MCL is the only knee ligament capable of meaningful self-healing via scarring-over), the NSAID-healing-inhibition effect would be expected to apply to any ligament injury, including ligament reconstruction (ACL, PCL, LCL, etc.).
ABSTRACT
Background: Low-intensity pulsed ultrasound and nonsteroidal anti-inflammatory drugs are used to treat ligament injuries; however, their individual and combined effects are not established.
Hypotheses: Low-intensity pulsed ultrasound accelerates ligament healing, a nonsteroidal anti-inflammatory drug delays healing, and the nonsteroidal anti-inflammatory drug inhibits the beneficial effect of low-intensity pulsed ultrasound.
Study Design: Controlled laboratory study.
Methods: Sixty adult rats underwent bilateral transection of their knee medial collateral ligaments. Animals were divided into 2 drug groups and treated 5 d/wk with celecoxib (5 mg/kg) mixed in a vehicle solution (NSAID group) or vehicle alone (VEH group). One to 3 hours after drug administration, all animals were treated with unilateral active low-intensity pulsed ultrasound and contralateral inactive low-intensity pulsed ultrasound. Equal numbers of animals from each drug group were mechanically tested at 2 weeks (n = 14/group), 4 weeks (n = 8/group), and 12 weeks (n = 8/group) after injury.
Results: Ultrasound and drug intervention did not interact to influence ligament mechanical properties at any time point. After 2 weeks of intervention, ligaments treated with active low-intensity pulsed ultrasound were 34.2% stronger, 27.0% stiffer, and could absorb 54.4% more energy before failure than could ligaments treated with inactive low-intensity pulsed ultrasound, whereas ligaments from the NSAID group could absorb 33.3% less energy than could ligaments from the VEH group. There were no ultrasound or drug effects after 4 and 12 weeks of intervention.
Conclusions: Low-intensity pulsed ultrasound accelerated but did not improve ligament healing, whereas the nonsteroidal anti-inflammatory drug delayed but did not impair healing. When used in combination, the beneficial low-intensity pulsed ultrasound effect was cancelled by the detrimental nonsteroidal anti-inflammatory drug effect.
Clinical Relevance: Low-intensity pulsed ultrasound after ligament injury may facilitate earlier return to activity, whereas non-steroidal anti-inflammatory drugs may elevate early reinjury risk.
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