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. . Recommendations of the National Football League Physician Society Task Force on the Use of Toradol Ketorolac in the National Football League Matthew Matava, MD,* D. Craig Brater, MD, Nancy Gritter, MD, Robert Heyer, MD, Douglas Rollins, MD, PhD, Theodore Schlegel, MD, Robert Toto, MD, and Anthony Yates, MD Sports Health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435943/ . . Abstract Ketorolac tromethamine (Toradol) is a non-steroidal anti-inflammatory drug that has potent analgesic and anti-inflammatory properties. It can be administered orally, intravenously, intramuscularly, or via a nasal route. Ketorolac injections have been used for several years in the National Football League (NFL), in both the oral and injectable forms, to treat musculoskeletal injuries and to prevent post-game soreness. In an attempt to determine the appropriate use of this medication in NFL players, the NFL Team Physician Society appointed a Task Force to consider the best available evidence as to how ketorolac should be used for pain management in professional football players. These treatment recommendations were established based on the available medical literature taking into consideration the pharmacokinetic properties of ketorolac, its accepted indications and contraindications, and the unique clinical challenges of the NFL. The Task Force recommended that 1) ketorolac should only be administered under the direct supervision and order of a team physician; 2) ketorolac should not be used prophylactically as a means of reducing anticipated pain either during or after participation in NFL games or practices and should be limited to those players diagnosed with an injury or condition and listed on the teams injury report; 3) ketorolac should be given in the lowest effective therapeutic dose and should not be used in any form for more than 5 days; 4) ketorolac should be given in its oral preparation under typical circumstances; 5) ketorolac should not be taken concurrently with other NSAIDs or by those players with a history of allergic reaction to ketorolac, other NSAIDs or aspirin; and 6) ketorolac should not be used by a player with a history of significant gastrointestinal bleeding, renal compromise, or a past history of complications related to NSAIDs. . Keywords: Toradol, Ketorolac, NFL, Football . Beginning with the introduction of ibuprofen in the 1950s, nonsteroidal anti-inflammatory drugs (NSAIDs) have been prescribed for athletic injuries in an attempt to blunt the bodys inflammatory response to injury, control pain, and aid in the return to sports.26 There are a variety of both prescription and nonprescription medications in this class of drugs. Among athletes using prescription medication, NSAIDs have been found to be among the most frequently prescribed (8.1%).1 Unfortunately, these agents are not without complications (see the following). Adverse events were reported in 20% of athletes using NSAIDs for a variety of musculoskeletal complaints.1 . Athletes may even take NSAIDs as a preventive measure. For example, during the 2000 Olympic Games in Sydney, Canadian athletes used NSAIDs more than any other medication.17 Similarly, a survey of American football players showed that 1 out of 7 high school athletes took NSAIDs daily and that 29% of college athletes took them as a preventive measure on the day of a game.30 Warner et al31 found a similar occurrence in their study of athletes; independent of their analgesic effect, the athletes mentioned a potential performance improvement to justify taking these medications. . Ketorolac tromethamine (Toradol) is an NSAID that has potent analgesic and anti-inflammatory properties. It can be administered orally, intravenously, intramuscularly, or via a nasal route. Ketorolac has been used principally for its analgesic properties following acute strains and sprains, overuse injuries, and as an adjunct to narcotic medication following surgery. Ketorolac injections have been used for several years in the National Football League (NFL), in both the oral and injectable forms, to treat musculoskeletal injuries and to prevent postgame soreness. The only study, to date, examining the prevalence of ketorolac use in professional sports was performed by Tokish et al in 2002.29 These authors investigated the use of injectable ketorolac in NFL teams during the 2001 season. Their study revealed that 28 of the 30 teams that responded to their survey used intramuscular ketorolac. Game-day usage was reported at 93% with pain relief of 1 to 2 days noted in 50% to 75% of players. There were 6 adverse reactions reported, including 4 muscle injuries, 1 gastrointestinal (GI) complaint, and 1 case of postinjection soreness. Anecdotally, some NFL medical staffs felt that ketorolac injections were considered more powerful than other NSAIDs because of the route of administration in that many players felt that getting a shot was an intrinsic sign that they were getting a more powerful medicine.29 Overall, these authors found ketorolac to be safe and effective when used in the pregame setting of the NFL. However, they were careful to recommend further study to develop standardized guidelines for ketorolac use in athletes to protect both players and medical staffs from potential complications. Since the publication of this study, it is widely believed by NFL team physicians that the use of ketorolac has increased in prevalence not only in the NFL but also in NCAA Division I football. However, we are unaware of any objective documentation proving this hypothesis. . Sports medicine specialists often use injections to deliver the intended medication directly to the site of injury (anesthetic or corticosteroid) or to provide a medication when oral dosing is not possible. Sterile preparation may reduce the risk of infection, but this can be challenging in the game-day training room or hotel setting. In addition, injections clearly pose a risk of bleeding and injury to adjacent structures. As with the administration of any other form of invasive treatment, informed consent has been recommended prior to administering injections to athletes.27 . Injections are typically perceived as a more aggressive form of treatment that has recently garnered attention from the lay media as a result of ketorolac injections used prior to competition in the NFL. Injection of medication to treat sports-related conditions is not unheard of, but there is no evidence of increased effectiveness owing to this route of administration. Orchard24 published the results of a case series involving professional Australian Rules football and rugby players treated with local anesthetic injections to facilitate a quicker return to play. This study showed an 8% complication rate associated with the use of injections in these players and was an important first step in trying to adequately define the risks and complications associated with injections following athletic injuries. Public perception of team physicians administering various therapeutic (or pain killing) injections to allow athletes to return to competition likely varies depending on the level of competition and public visibility of the athlete. Moreover, the literature is deficient in terms of the ethical considerations implicit with the administration of injectable medications in the athletic setting solely for the athlete to return to competition. . . The complete article may be read at the URL above. . . 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