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Pearls and Pitfalls

Intramuscular Ketorolac Injections

The Pregame Toradol Parade

Eichner, E. Randy MD, FACSM

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doi: 10.1249/JSR.0b013e31826029ef
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Introduction

The use of pregame injections of ketorolac (trade name, Toradol) may be common in some college and professional sports, especially football. The pros and cons of this pregame practice have been recently debated (1,13). A New York Times article raises concern about Toradol in sports, focusing on professional football and baseball (2). The article notes that Toradol is central in a lawsuit by 12 retired National Football League (NFL) players who say NFL teams repeatedly and indiscriminately gave the drug before and during games, thus worsening injuries like concussions. The players even call the pregame Toradol line the “cattle call.”

The NFL disputes these claims. But according to a recent article in Sports Illustrated, nearly 1,800 retired NFL players have joined in 68 lawsuits against the NFL, relating mainly to head trauma and concussions and their aftermath (11). Although I see no clear reason to tie Toradol to concussions, it seems to me, in light of the times, we should continue to ponder whether pregame Toradol does more good than harm.

Studies on the Use of Pregame Toradol

Few studies exist on pregame Toradol, a practice few seem eager to discuss. In a survey of the NFL 2000 season, 28 of 30 teams gave intramuscular (IM) injections of Toradol on game day, to an average of 15 players, with few and minor adverse effects and no clinically important bleeding. Some teams worried about psychological dependence by players, noting that players perceived “getting a shot” as more powerful medicine (9).

In a recent study, 6,950 sports medicine physicians were polled by a questionnaire and 1,100 responded (60% were orthopedic surgeons and 40% were nonsurgical physicians). Bearing in mind the low response rate (16%), nearly 50% of the respondents gave Toradol injections, mostly at the college or professional level, most frequently in football, basketball, and soccer, respectively. About 75% of the time, the Toradol was given in the hours before the game. Bleeding was noted as an “adverse reaction” in 3%, but the questionnaire was not designed for clinical details (10).

The Bleeding Question

Like other nonsteroidal anti-inflammatory drugs, Toradol has an antiplatelet action. In a study of 20 young healthy volunteers, IM injection of 60 mg of Toradol increased bleeding time an average of 50% at 4 h after injection. Although this longer bleeding time was generally still within the normal range and its clinical relevance is uncertain, some worry that pregame Toradol could increase bleeding complications from head trauma (1).

Clinical studies show mixed results on the postsurgical bleeding risk from Toradol. Some studies of tonsillectomy show increased bleeding risk, but others do not. A recent meta-analysis of seven studies concludes that, because of bleeding risk, Toradol should not be used after tonsillectomy (6). Other studies on Toradol find little or no increased risk of clinically important bleeding after cholecystectomy, congenital heart surgery, scoliosis surgery in children, or diverse orthopedic operations in adults.

I know of one lawsuit against physicians who gave oral Toradol to a high school football player for headaches after a concussion. He apparently stopped taking the Toradol 1 to 2 d before he played football again, 3 wk later, where he sustained a second head impact that caused or increased a subdural hematoma that led to lasting clinical problems.

Other potential toxicities of Toradol exist, especially perhaps with long-term or repeated use. These include gastrointestinal, renal, and cardiac concerns, which are discussed elsewhere (1,10).

How Good a Pain Reliever?

Conflicting results come from the scores of studies of Toradol as a pain reliever. Several key studies are briefly discussed elsewhere (10). A recent meta-analysis of 13 studies concludes that, in the postoperative setting, 60 mg (but not 30 mg) of Toradol injected IM has an opioid-sparing pain relief benefit (3).

In settings more relevant to pregame Toradol, however, the picture is murky. In one study of 82 patients with acute musculoskeletal pain from trauma, 60 mg of Toradol injected IM plus a placebo pill gave no better pain relief than 800 mg of ibuprofen orally plus a placebo IM injection of saline (12). In another study with the same “needle placebo” design, among 119 patients with major pain, most from musculoskeletal injury, in the emergency department, IM injection of Toradol worked no better than ibuprofen did orally, and 40% of all patients had inadequate pain relief from either ibuprofen or Toradol (8).

In other words, no good reason exists to believe that, before a game, a “shot” of Toradol will work any better than a pill or two of ibuprofen, or maybe even acetaminophen (7). The magic is not in the Toradol but in the shot — or in the doctor behind the shot. Expectations count in pain control: Inert injections work better than inert pills and visible injections work better than hidden ones (4). As one savvy sports medicine physician said: “The needle is mightier than the pill” (2).

Debate Points

We are taught: First, do no harm. But in medicine, some calls can be close. In college, if we give a shot to mask pain before a game, are we helping athletes thrive and aim for their dreams? Or are we putting them at risk of further injury? Are we encouraging them to play through pain that otherwise would force them to rest and heal? Some team physicians do not give Toradol IM to their own athletes but are asked to give it to visiting athletes. This is a dilemma (10).

I worry about the potential bleeding risk from pregame Toradol IM in a collision sport, especially when much of the analgesia is from the “needle placebo” or the expectations of the physician and athlete. Some say the intensity of game day itself is a pain reliever (5). Others argue that pregame acetaminophen, 1,000 mg orally, would work almost as well for pain as Toradol and would be safer (1).

I also worry about the lethal scourge of opioid abuse sweeping our nation, with some of the overdose deaths in football or hockey players. Do some young “warriors” begin to perceive pain shots or strong pain pills as requisite to playing the game? If so, does the pregame Toradol parade feed this perception? You tell me.

The author declares no conflict of interest and does not have any financial disclosures.

References

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2. Belson K, Pilon M. Concern raised over painkiller’s use in sports. The New York Times. [Internet]. 2012 [cited 2012 April 14]; Available from: www.nytimes.com/2012/04/14/sports/wide-use-of-painkiller-toradol-before-game-raises-concerns.html.
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13. Valentine V. Pro: use of ketorolac injections in sports medicine. The Sideline Report. 2012; 1, 4.
© 2012 American College of Sports Medicine