Benefits and risks of using local anaesthetic for pain relief to allow

ORIGINAL ARTICLE

Benefits and risks of using local anaesthetic for pain

relief to allow early return to play in professional football

J W Orchard

.............................................................................................................................

Br J Sports Med

2002;36:209–213

Objective: To investigate the risks and benefits of the use of local anaesthetic in a descriptive case

series from three professional football (rugby league and Australian football) teams.

Methods: Cases of local anaesthetic use (both injection and topical routes) and complications over a

six year period were recorded. Complications were assessed using clinical presentation and also by

recording all cases of surgery, incidences of players missing games or leaving the field through injury,

and causes of player retirement.

Results: There were 268 injuries for which local anaesthetic was used to allow early return to play.

There were 11 minor and six major complications, although none of these were catastrophic or career

ending. About 10% of players taking the field did so with the assistance of local anaesthetic. This rate

should be considered in isolation and not seen to reflect standard practice by team doctors.

Conclusions: The use of local anaesthetic in professional football may reduce the rates of players

missing matches through injury, but there is the risk of worsening the injury, which should be fully

explained to players. A procedure should only be used when both the doctor and player consider that

the benefits outweigh the risks.

he use of local anaesthetic in professional football of vari-

ous codes is widespread, but has not been generally

discussed in the medical literature.

1–6

This discrepancy

represents a huge gap in the published sports medicine

knowledge base. The major explanation for the non-

publication of the use and complications of local anaesthetic

injections is that the practice is considered unethical by some

medical authorities, including FIMS.

The only major sporting

body known to have published guidelines on the use of local

anaesthetic is the National Collegiate Athletic Association

(NCAA) (guidelines available at www.ncaa.org), although

these do not list speciﬁc examples and leave the decision at

“the discretion of the individual treating physician”.

Various references in non-medical journals can be cited to

illustrate potential pitfalls of local anaesthetic injections.

3 5 9–11

These include cases where compensation has been obtained

through allegations of medical negligence.

Despite these risks generally being known, the use of local

anaesthetic is attractive because it is perceived that the risks

are often less than the potential beneﬁts.

This paper presents a case series from a single practitioner

working as team doctor for a professional football team. It is

appreciated that this form of medical presentation is science at

one of its lowest levels. It is nevertheless hoped that the study

will be the ﬁrst step towards ﬁlling the gap between “real

world” practice and published knowledge.

METHODS

The study was conducted over six years. For the ﬁrst two years

(1996 and 1997), I was team doctor to a professional Austral-

ian Football League (AFL) team, the Sydney Swans. For the

years 1998–2001 inclusive, I was team doctor for a professional

National Rugby League (NRL) team, the Sydney Roosters.

During 2000 and 2001, I was also the team doctor for the New

South Wales (NSW) Rugby League State of Origin team. In the

AFL and NRL competitions, teams play one 80 minute match

a week.

This case series includes all matches played in the

preseason, regular season, and ﬁnals by the ﬁrst and second

grade teams of the Swans (1996–1997) and Roosters

(1998–2001). It also includes the six State of Origin matches

played by the NSW team over 2000–2001. These are represen-

tative matches (similar to international or “All star” games)

that combine players from a number of different club teams.

All documented cases were recorded of local anaesthetic

topically applied or injected to reduce pain to allow players to

train or play matches with injury. Cases were not included

when the anaesthetic was used only to allow a procedure such

as suturing of a laceration to be undertaken or was given for

pain relief only and the player did not play or train.

The diagnosis, drug used, method and time of administra-

tion, and associated complications were all recorded in an

injury database. Verbal consent was obtained from the player

on every occasion; written consent was not obtained. For State

of Origin rugby league matches, consent was also obtained

from the club doctor of each player’s regular team.

A major complication was deﬁned as:

(1) degenerative arthritis of a major joint (knee, ankle, hip,

foot joint other than phalangeal, glenohumeral, elbow, ﬁrst

carpometacarpal, or radiocarpal) arising subsequent to intra-

articular injection or total block of that joint;

(2) rupture of a major tendon—for example, Achilles or other

foot and ankle tendon, patellar, quadriceps, adductor, proxi-

mal hamstring, rotator cuff, distal biceps, distal triceps—while

under local block;

(3) fracture or refracture of a major bone—for example, all

bones of lower limb other than phalanges, clavicle, scapula,

humerus, scaphoid, radius, and ulna—while under local

block;

(4) rupture of a major ligament—for example, the anterior,

posterior, or lateral cruciate ligament of the knee—or disloca-

tion of a major joint—for example, glenohumeral—while

under local block;

(5) inadvertent block of a major motor nerve that prevented a

player from being able to play—for example, femoral, obtura-

tor, common peroneal, sciatic;

(6) joint or other subcutaneous infection;

.......................

Correspondence to:

Dr Orchard, South Sydney

Sports Medicine, 111

Anzac Parade, Kensington,

NSW 2033, Australia;

[email protected];

www.johnorchard.com

Accepted 14 March 2002

.......................

209

www.bjsportmed.com

(7) damage to an important viscus—for example, pneumotho-

rax where intercostal block was performed;

(8) any injury that was possibly worsened by local anaesthetic

use that subsequently required surgery, although if surgery

was considered inevitable before the decision to use local

anaesthetic and the surgery also subsequently provided a

deﬁnitive cure, then the complication was considered minor;

(9) any injury that was possibly worsened by local anaesthetic

and had a role in limiting the duration of a player’s

professional football career.

A minor complication was deﬁned as:

(1) degenerative arthritis of a joint not considered above to be

a m ajor joint—for example, interphalangeal joint or acromio-

clavicular joint—arising subsequent to intra-articular injec-

tion or total block of that joint, and not requiring surgery;

(2) inadvertent sensory (but not motor) nerve block over a

wider range than planned;

(3) failure of the local anaesthetic procedure to block pain

enough for the player to participate meaningfully in the game;

(4) any injury that was possibly caused or worsened by local

anaesthetic use that caused the player to miss match playing

time (but is not listed under major complications) and which

eventually fully resolved.

The database was also used to record all cases of players

missing games through injury, players leaving the ﬁeld

through injury, players having surgery, and any reasons for

players leaving the team at the end of the season. These

records were used to help assess whether a player had suffered

a complication, as listed above.

RESULTS

The study covered 337 football games (221 Roosters, six NSW

State of Origin, 110 Swans). This included 10 NRL ﬁnals, four

AFL ﬁnals, and eight reserve grade ﬁnals (four rugby league

and four Australian football). During this period, I treated and

recorded in an injury database 2851 injuries (1521 for the

Roosters, 1256 for the Swans, and 74 for the NSW State of

Origin team).

Table 1 details the injuries that were managed with the

assistance of local anaesthetic (both topical and injectable).

The average number of players per team per match playing

with the aid of local anaesthetic injections was 1.7 in the

rugby league games (10.2% of all players) and 1.4 in the Aus-

tralian football games (6.8%). When topical application of

local anaesthetic is considered in addition, the average

numbers were 1.9 in the rugby league games (11.1%) and 1.6

in the Australian football games (8.0%). The usual drug used

for painkilling injections was bupivacaine (sometimes admin-

istered with a vasoconstrictor agent such as adrenaline, if the

injury was not to a peripheral structure such as a ﬁnger or

toe). The usual drugs used for topical (transdermal) adminis-

tration were a combination of lignocaine and prilocaine.

The proportion of players taking the ﬁeld with the aid of

local anaesthetic was signiﬁcantly higher in the rugby league

than the Australian football games (χ

= 15.1, p<0.001), and

was signiﬁcantly higher in ﬁrst grade games than reserve

grade games (χ

= 214, p<0.001). It was signiﬁcantly higher

in ﬁnals matches and State of Origin matches than regular

season matches (χ

= 76.2, p<0.001), and signiﬁcantly higher

in regular season matches than preseason matches ( χ

= 54.9,

p<0.001).

Most injections were given before the start of play. Some

injuries were injected on match day acutely, and therefore

without the use of imaging or time for the player to reﬂect on

the decision to use local anaesthetic (table 1).

There were six major complications (table 2) and 11 minor

complications (table 3).

No player had a career limiting injury associated with local

anaesthetic use. Only one player retired from football after

playing his last match with the aid of a local anaesthetic. He

had anaesthetic injected into his superior tibioﬁbular joint,

which had suffered a grade 2 sprain, for the last four games of

the season; he was able to run at training during the week

without requiring local anaesthetic. He did not suffer any

complication from this injection and the injury fully recovered

shortly after the season ended, but he was not offered a con-

tract by any professional team for the following season, and

elected to retire.

An injury commonly managed with local anaesthetic that

gave rise to two m ajor complications was sprain of the

acromioclavicular joint (table 2). Not all such injuries were

treated with local anaesthetic, because in some cases either

the doctor or the player decided that it should not be used.

There was one case in which local anaesthetic was not used,

and the player continued to play with an acromioclavicular

joint injury and developed osteolysis which required surgical

management (distal clavicle resection). Table 4 presents a

summary of the management of acromioclavicular joint inju-

ries. Although this is a non-randomised intervention with low

power, the relation between the use of local anaesthetic and

the development of symptomatic osteolysis appears to be

weak (χ

= 0.24, p>0.6). There also does not appear to be a

strong relation between number of injections used and risk of

osteolysis. Of the two cases of osteolysis after local anaes-

thetic, one player had received 16 local injections, and the

other had received only two. One player who received 24 local

Table 1 Injuries managed with local anaesthetic

Category

Number with

painkilling local

injections used

Mean number of

games using

injection per injury

Number where

injection was used

while a game was in

progress

Number with only

topical painkiller

used

Number with any

local painkiller used

Rib injuries 33 3.5 12 9 42

Iliac crest haematomas 32 2.3 24 1 33

Acromioclavicular joint injuries 27 5.7 14 1 28

Finger injuries (digits 2–5) 25 2.4 9 0 25

Thumb injuries 17 4.3 3 2 19

Ankle injuries 21 2.0 6 2 23

Metacarpal injuries 7 2.7 2 0 7

Sternum injuries 6 2.7 3 2 8

Toe phalangeal injuries (digits 2–5) 5 2.4 1 1 6

Prepatellar bursitis 4 2.8 1 1 5

Other injuries 44 2.0 11 28 72

All injuries 221 3.3 86 47 268

210 Orchard

www.bjsportmed.com

injections to the acromioclavicular joint had his symptoms

spontaneously resolve at the end of the season without

surgery.

A case of chronic plantar fasciitis was the one injury in this

series that appeared to be improved by the use of a local

anaesthetic injection during a game. In this case, the player

described feeling a tear while running which was only moder-

ately painful because of the local anaesthetic block. The next

mor ning, the pain he usually felt during his ﬁrst step had dis-

appeared, but was replaced by a dull ache when running; this

lasted for three weeks, after which he become almost

completely symptom free. In this case, I believe that the origi-

nal pain arose from a chronic tightness of the plantar fascia,

and that a rupture of the fascia at the region of tightness

occur red and effectively “cured” the original condition.

DISCUSSION

The use of local anaesthetic may allow players to return to

sport at an earlier stage. This may have enormous beneﬁts for

players of a professional sport.

This study shows that such

procedures are not without risk, but that these risks may be

acceptable for both the player and the doctor.

Only one previous study in rugby league has looked at the

use of local anaesthetic injections.

In this study, ﬁve injuries

(three acromioclavicular joint sprains, one rib fracture, and

one groin tendon tear) over three seasons were managed in

this way. Although these are similar injuries to those

presented in this study, the use of painkilling injections was

far less common. The rate of use of these procedures in other

teams in the past or present cannot be assumed by the rates

presented in this study. It is known that local anaesthetic

injections have been used in professional rugby league in

Australia since at least 1975, when a famous incident occurred

during the Grand Final: a player was unable to kick because of

inadvertent motor nerve block.

It is worth noting that in all

six seasons presented in this study, the ﬁrst grade team played

in the ﬁnals series and was a premiership contender. The

motivation for the players to return to the ﬁeld early was

Table 2 Major complications of the use of local anaesthetic to allow early return to play

Injury Complication

Acromioclavicular joint sprain (2) Distal clavicle osteolysis (2). In both cases this complication was somewhat expected and the two players were able

to delay surgery until the end of the season. Both made a full recovery. (Major complication no 8)

Chronic insertional Achilles

tendinopathy

Partial rupture of Achilles tendon at anterior portion insertion which required immediate surgery. This complication

was expected, with the decision to attempt a local block made on the eve of finals. The player was able to return to

play the following season after successful surgery. (Major complication no 2)

Adductor longus tendon partial tear This was an acute contact mechanism injury. Local anaesthetic was used to enable the player to play two games in

a finals series. The player developed chronic adductor tendinopathy and missed eight games the following season,

although eventually made a full recovery. (Major complication no 8)

Prepatellar bursitis Mild prepatellar bursa infection 2 days after game, which was successfully treated by aspiration and oral

antibiotics. The player was able to return to play the following weekend without local anaesthetic injection. Of

further note is that 2 weeks later, he suffered a partial tear of the quadriceps tendon in the same knee. This was a

contact mechanism injury and he was not injected for that game. He missed 5 weeks with this injury but did not

require surgery and made a full recovery. (Major complication no 6)

Scapholunate ligament tear This was an early season injury diagnosed as being likely to require surgery. The player elected to play the

remainder of the season and delay surgery. Local anaesthetic was used for three of these games during the

remainder of the season, but was not used in 21 games. After surgery (wrist reconstruction) he made a full functional

recovery. It is possible that he may suffer late degenerative changes related to this injury. (Major complication no 8)

Table 3 Minor complications of the use of local anaesthetic to allow early return to play

Injury Complication

Posterior ankle impingement Medial plantar nerve sensory block; player able to keep playing with numb sole of foot

Fractured 1st metacarpal Slight malunion with loss of full thumb span (anticipated and expected by player)

Posterior rib fractures Failed block; player could not take field for that game although successfully played with local anaesthetic the

following week

Sternoclavicular joint sprain Injury was worsened by a further contact mechanism injury; as a result the player needed to miss four games

Comminuted intra-articular fractured

base of 1st proximal phalanx

Osteoarthritis of 1st metacarpophalangeal joint (that was eventually almost asymptomatic), a complication

considered inevitable after the initial fracture but may have been worsened by playing for 6 weeks with thumb

blocks. The injury could not be treated surgically and the alternative treatment was plaster immobilisation, which

probably would not have prevented degenerative arthritis

Posterior ankle impingement Player elected to have surgery to remove os trigonum after playing one game with the assistance of local injection

Bruised iliac crest (3) Lateral femoral cutaneous nerve block (3)

Lateral ankle sprain Pericapsular injection causing superficial peroneal nerve block; player was able to play with numb dorsum of foot

Chronic plantar fasciitis Player ruptured his plantar fascia origin but was able to complete the game. He missed 2 weeks after this but

believed that this complication “cured” his injury.

Table 4 Risk of developing osteolysis of the distal clavicle after acromioclavicular (A/C) joint injury

Number of injuries

Total games missed

from these injuries

Number of cases requiring

distal clavicle resection at

end of season

A/C joint injuries treated with local anaesthetic injections 28 16 2

A/C joint injuries not treated with local anaesthetic injections 25 18 1

Total A/C joint injuries 53 34 3

Local anaesthetic use in professional football 211

www.bjsportmed.com

therefore probably higher than for teams not so competitively

placed, particularly towards the end of the season.

The players that were injected with local anaesthetic to play

State of Origin games came from eight different club teams,

and in all cases the club doctor for these teams approved the

use of injection. In some cases, the players were already being

injected to play w ith injury at club level. State of Origin

matches are the most important games of the season for the

players involved, so the beneﬁts of local injections are very

high.

In this case series, local anaesthetic was used more often in

rugby league than Australian football. This probably reﬂects

the relative injury proﬁles of the two sports. Contact

mechanism injuries that have a good prognosis for spontane-

ous healing but are very painful in the short term are the inju-

ries that are most amenable to the use of local anaesthetic.

Injuries of this type are more common in rugby league than

Australian football (which in contrast has more non-contact

lower limb injur ies).

In both of these sports, the use of local

anaesthetic is made more practical by the scheduling of only

one match per team per week. The nature of any individual

sport and player position within a sport should be considered

for each individual injury. For example, overhead throwing is

not used in either rugby league or Australian football, which

makes acromioclavicular joint degeneration a less serious

complication than in an American football quarterback, for

example.

A retired NFL team doctor recently claimed that local

anaesthetic use is common in the NFL.

He used local

injections for “painful contusions, bruised or cracked ribs,

intercostal muscle tears, fractured or dislocated ﬁngers, hip

pointers and isolated shin contusions”, but claimed to never

use the procedure for a “muscle pull” or inside the knee or

ankle joint.

Another recent anecdotal review of this topic

quoted another practising NFL team doctor as saying that

“blocking an acromioclavicular joint or injecting a rib injury is

reasonable at the professional level, not dangerous, and done

routinely”.

On the basis of cases presented in this paper and references

cited above, tables 5 and 6 present a list of examples of injuries

for which local anaesthetic injections could be considered

under routine (where beneﬁts will usually outweigh risks)

and extreme (where risks are high) circumstances respec-

tively. Injuries to ﬁnger and acromioclavicular joint when

managed with local anaesthetic may be more likely to lead to

degenerative changes, although these changes are common in

football players even when these procedures are not used.

Degenerative arthritis of the knee and hip are also common in

professional football players.

16–18

Although these conditions

(hip and knee degeneration) are far more disabling than

degenerative arthritis of a ﬁnger joint or acromioclavicular

joint, professional football players still knowingly accept these

risks when playing.

The ﬁndings and conclusions of this study should not be

seen as being deﬁnitive or representative of any group of doc-

tors, as the numbers of cases described are too few to present

an exhaustive proﬁle of the risks. Guidelines for anaesthetic

use in professional football are almost non-existent because of

“lack of scientiﬁc evidence”.

This situation can only be

remedied by publication of clinical case series (such as this),

followed by larger controlled studies with long term follow up.

ACKNOWLEDGEMENTS

I would like to acknowledge the teams in this survey and the doctors

who have assisted in medical coverage for the teams over the period of

the study, speciﬁcally Grace Bryant, Ameer Ibrahim, Katherine Rae,

Paul Annett, Maja Markovic, and David Thomas.

REFERENCES

1 Orchard J. The use of local anaesthetic injections in professional

football.

Br J Sports Med

2001;35:212–13.

Table 5 Injuries for which local anaesthetic could be used in professional football with routine caution—that is, where

the benefits will usually outweigh the risks

Injury Notes

Acromioclavicular joint sprain Block is usually very successful. There may be an increased risk of needing distal clavicle resection at

end of season, which is not usually a significant threat to a player’s career

Phalangeal injuries (toes and fingers)

and metacarpals 2–5

Block is easy to perform. Vasoconstrictors should not be used. Some injuries may lead to degenerative

arthritis of interphalangeal joints, although in most cases this is acceptable to a professional footballer.

The major factors to assess are loss of range of motion and whether the player has any pursuit outside

football that involves fine use of the hands, such as playing a musical instrument

Rib and sternum injuries Block is usually successful when rib injuries are lateral or posterior. Sternum, sternoclavicular joint, and

anterior injuries to high ribs are very hard to block adequately. Pneumothorax is a possible

complication, but usually occurs in conjunction with acute injury

Bruised iliac crest Block usually provides major relief from this very painful but self resolving injury. The only common

complication is sensory nerve block (lateral femoral cutaneous nerve)

Chronic plantar fasciitis Injection is very painful. Rupture of the plantar fascia origin is likely but this may, in fact, “cure” the

chronic condition

Table 6 Examples of injuries for which local anaesthetic should only be used in professional football, with extra

caution, when the rewards are very high (as risks are also high)

Injury Notes

Ankle sprains MRI scan is indicated to assess the state of articular cartilage, and injection (even extra-articular) is best

avoided if there is any significant articular damage

Tendon injuries Tendon ruptures are likely when a local block is performed to relieve pain arising from the tendon. In certain

circumstances (particularly tendons with many agonists) this risk may be acceptable

Prepatellar and olecranon bursa Infection is a likely complication of injection of these bursae. In the case of prepatellar bursa (or any other

extra-articular knee injury), documentation should be made, perhaps with a witness, to specifically note that

the injection was extra-articular, in case the player suffers a serious knee injury during the game

First metacarpal and radiocarpal injuries The thumb and wrist are more critical hand structures and degenerative conditions should not be accepted

lightly in these regions. Scaphoid fractures should always be excluded as this is a common missed diagnosis

that on occasion cannot be cured surgically

212 Orchard

www.bjsportmed.com

2 Green T.

The dark side of the game: my life in the NFL

. New York:

Warner Books, 1996.

3 Huizenga R.

You’re okay, it’s just a b ruise

. New York: St. Martin’s

Press, 1994.

4 Orchard J. The use of local anaesthetic in professional football.

JSci

Med Sport

1999;2:S108.

5 Polsky S. Winning medicine: professional sports team doctors’ conflicts

of interest.

J Contemp Health Law Policy

1998;14:503–29.

6 Sheahan M. Painkillers disturbing part of AFL culture.

Herald-Sun

Newspaper

(Melbourne) 1996 Feb 17.

7 FIMS Code of Ethics in Sports Medicine.

International sports medicine