Is Ramos risking an injury by playing with painkilling injections?

Sergio Ramos has turned out for Real Madrid in some vital games since injuring his shoulder a few weeks ago and it's common knowledge that he's been having pain-killing injections in order to do so.  Having injections in order to mask the pain has allowed Sergio to compete while still recovering from an acromio-clavicular joint (ACJ) sprain; however, the use of these injections remains controversial.  As an alternative to oral medication, injections administered before a game have been widely used in football for years and although not fully condoned by the game's authorities, their use is acknowledged.

Playing under local anaesthesia has been legal in football for the last ten years.  Before then, these injections would contravene anti-doping regulations.  Although they were still being used in football during that cross-over period when anti-doping regulations were becoming stricter, if too high a dose was administered then this would be easily detected.  The result was that many players were given such low dosages for that reason and the injections were frequently ineffective.  Once legalised, the club doctors became more adept at managing the required amounts to inject, but as a result their usage increased to the point where injections became commonplace.  Before injections were made subject to the control that they are today, players would often be given these routinely.  If they were carrying an injury such as a bony bruising or had an inflamed and swollen knee then the needle would be out and players rarely argued.  There are numerous stories of players having had repeated injections and many are now paying the price in terms of early joint degeneration and arthritic changes.

Correctly applied, the injections are used simply as an analgesic and are taken in order to reduce pain to manageable levels in order to allow players to compete.  They don't mask the pain completely and merely dull this to a point where the pain becomes tolerable.  By injecting the injured area, the medication is faster-acting than oral tablets and can be delivered accurately with almost immediate effects.  Such injections are generally considered safe although the evidence is limited as to both their effectiveness and reactions.  Painkilling injections can only be used when injuries are no longer at the acute stage and are normally administered when stronger pain relief is required.   However, they need to be used sparingly and there is little evidence enabling informed discussion about the recommended frequency with which they are used.

Although some of the substances used to inject have been widely debated and condemned, particularly with regards to the potential long-term damage often cited by medical professionals, the use of pain-killing injections remains common in sport.  It's not only doctors who regard the use of local anaesthesia as contrary to players' well-being either; it's a common topic regularly discussed on football websites worldwide.  The subject is particularly high-profile in American Football, and media stories regularly feature current and former players who have revealed that an overwhelming desire to make the starting line-up have led to them turning to injection therapy.  In many cases, the substance chosen has had a detrimental effect on their long-term careers through excessive and repeated use of pain-killing injections in order to allow them to play.

What pain-killing injections don't do, though, is help an injury to heal.  Anti-inflammatory injections delivered into a joint for the purpose of assisting the healing process are often confused with straight-forward local anaesthetics.  Injections of the type used recently by Sergio Ramos are purely pain killers and have no effect whatsoever on the healing tissues.  Additionally, they need to be delivered to areas where further damage is unlikely to take place as a result.  This usually means injecting into the joint space surrounding the injured area, such as the ACJ which is a common injury to be addressed via painkilling injections, or into the wrist.  General bony bruising to the shin or toes are also common areas for painkilling injections, but it's important to avoid injecting directly into the injured ligaments or tendons.  With bony bruising, ribs are perhaps the most painful in this category and the surrounding areas are often injected to allow someone to play; but the strength of the dosage is difficult to gauge and there's the risk of breathing problems to consider.  It's not appropriate to inject a thigh or a calf muscle strain for example, since this would mean directly masking the potential for worsening the injury.  The key factor needs to be that the risk of sustaining further damage through completely blocking any underlying pain from the injury must be avoided.

An obvious drawback with the injections, and not only to the ribs, is actually in getting the dosage right; pain killing injections frequently need to be topped up at half time and often the effects wear off quickly, leaving the player in more pain than before the injections were given in the first place.  Not all injuries are suitable to be considered for injection and the rule is to assess each case on it's own merits before going ahead.  From a legal standpoint, the use of certain substances has to be approved by the game's governing bodies via the World Anti-Doping Agency (WADA) and a document known as a Therapeutic Use Exemption (TUE) certificate has to be obtained prior to injecting; detailing what substance is going to be used and to where.  This ensures that all substances used are legal and appropriate; and although the substance used might be on WADA's prohibited list, it's use may be permitted for medical reasons.  However, most local anaesthetics of the type used to inject before games are not on WADA's prohibited list

Regular use of pain-killing injections is discouraged due to the risks involved with repeated use.  For Sergio Ramos to have injections before games will have been a collective decision taken between himself and the medical people at Real Madrid, and the risks and benefits will have been clearly explained.  It's not a good idea to have these on a medium to long term basis though, based on the lack of available evidence about the after effects.  Although painkilling injections are a lot safer nowadays than they used to be, further study is needed as to the safety and effectiveness of their use.  The main principle of tissue healing is to allow adequate, undisturbed, union of the damaged structures to take place and if this process is constantly being disturbed then you don't save anything in the short term and generally end up with the injury becoming chronic due to the disruption caused by repeatedly aggravating the injury.

Sergio Ramos isn't the first player to have had painkilling injections given before games and he certainly won't be the last.  Provided the injections given only dull the pain and not mask it completely then he's going to be aware of how his injury is feeling during the match.  It's still going to be a distraction though and there's always the risk that he could fall and aggravate the ACJ once again.  It's a big call, not only for himself as a player, but also for the medical people advising him.  He'll ultimately need to use his own judgement based on how the injury feels once the injection has worn off as to whether he intends to continue repeating this for much longer.