- Email: [email protected]
Survey of Orthopaedic and Sports Medicine Physicians Regarding Use of Medrol Dosepak for Sports Injuries
Survey of Orthopaedic and Sports Medicine Physicians Regarding Use of Medrol Dosepak for Sports Injuries Phillip Langer, M.D., Paul Fadale, M.D., Michael Hulstyn, M.D., Braden Fleming, Ph.D., and Mark Brady, B.S.
Purpose: To study the use of a methylprednisolone taper (Medrol Dosepak; Pfizer, New York, NY) short-term oral corticosteroid treatment modality by sports medicine physicians; included is discussion on indications, perceived efficacy, and complications. Methods: A survey specific to Medrol Dosepak (MDP) use was mailed to all members of the Arthroscopy Association of North America (AANA) and the American Orthopedic Society for Sports Medicine (AOSSM). Surveys were collected and data were collated and analyzed. Results: Total response rate was 41% (1,290/3,167), US response rate 43% (1,247/2,906), and international response rate 16% (43/261). Prescribing of MDP for sports injuries was significantly associated with average patient age ⱕ40 years ( square; P ⫽ .001), but it was not associated with years in practice or patients seen per year. It was found that 47% of members (603/1,290) prescribe MDP. Postinjury disease was the most common indication. The most frequent complication was glucose intolerance (37%; 222/603). Of members who prescribe MDP, 8.5% (51/603) reported that they had seen 101 total cases of osteonecrosis, predominantly in the hip. Results revealed that 52% of members (672/1,290) do not prescribe MDP. The most frequent reasons for not prescribing included fear of osteonecrosis (30%; 201/672), fear of complications in general (27%; 183/672), lack of proven efficacy (27%; 180/672), and fear of malpractice (4.5%; 30/672). Of nonprescribing members (171/672), 25% had seen 500 cases of osteonecrosis, most often in the hip. Conclusions: The responding membership of AANA and AOSSM is evenly split regarding MDP use. Average patient age ⱕ40 years was associated with a greater likelihood that MDP would be prescribed for sports injuries. Postinjury disease is the most common indication; lack of proven efficacy and osteonecrosis are deterrents to prescription. Level of Evidence: Level V, expert opinion. Key Words: Sports injuries—Methylprednisolone—Oral corticosteroids.
T
he routine use of anti-inflammatory medications, including corticosteroids, for the treatment of patients with athletic injuries is controversial. Anti-inflammatory medications have gained
From the Department of Orthopedic Surgery, Brown University Medical School, Providence, Rhode Island, U.S.A. Supported by outside funding or grants from University Orthopedics, Inc., and Rhode Island Orthopaedic Foundation. The authors report no conflict of interest. Address correspondence and reprint requests to Phillip Langer, M.D., Department of Orthopedic Surgery, Brown Medical School/ Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2212-0684$32.00/0 doi:10.1016/j.arthro.2006.08.020 Note: To access the supplementary table and figure accompanying this report, visit the December issue of Arthroscopy at www.arthroscopyjournal.org.
widespread acceptance by athletes, athletic trainers, and physicians as a treatment adjunct during rehabilitation for sports-related musculoskeletal problems. Although these medications effectively reduce inflammation and pain, concern has been expressed about the scarcity of published clinical trials, unclear indications, potentially serious adverse effects, and even inhibition or delay of normal healing after injury.1-4 Corticosteroids, the most potent inhibitors of inflammation, have been particularly scrutinized because of untoward effects that have been documented with long-term high-dose systemic use. Reports on adverse effects associated with low-dose corticosteroid use have shown that few commonly held beliefs about their incidence are supported by clear evidence.5 Nichols6 searched medical literature that described the risks and complications associated with corticoste-
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roid treatment given for athletic injuries. This investigation failed to identify a single article that addressed the use of systemic oral corticosteroids or complications resulting from their use for the treatment of patients with sports-related musculoskeletal injuries. The author concluded that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids for the treatment of patients with athletic injuries. In a more recent survey of head team physicians for the National Football League (NFL),7 83.9% of 31 respondents (29 orthopaedic surgeons and 2 primary care physicians) reported that they had prescribed oral corticosteroids, most commonly for intervertebral disc herniations. The oral corticosteroid most commonly used was methylprednisolone, at a starting dose of 12 to 24 mg given over 1 week. Of these physicians, 25.8% reported serious complications, most commonly osteonecrosis (16.1%). In another recent report,8 primary care physicians were surveyed during a national sports medicine meeting. The 99 respondents were sports medicine clinicians who had undergone varied training and who had different types of practices. Of these providers, 58.6% reported that they had prescribed oral corticosteroids for musculoskeletal injuries. Prednisone was the most commonly prescribed corticosteroid (82%). Usual starting dose was 60 mg, and average prescription length was 7 days; 57.1% tapered the dose over the duration of treatment. Although these surveys have enhanced our understanding of the prescribing practices of sports medicine physicians who use oral corticosteroids as a treatment modality for patients with athletic injuries, the descriptive data that have been generated are limited by the small sample size of respondents and by the failure of investigators to gather information on specific oral corticosteroid treatment regimens. Thus, the need remains for additional descriptive data that specifically reflect the orthopaedic sports medicine community. The purpose of the present study was to survey the collective membership of the Arthroscopy Association of North America (AANA) and the American Orthopedic Society for Sports Medicine (AOSSM) to gain insight into the use of, indications for, perceived efficacy, and complications associated with the Medrol Dosepak (MDP, methylprednisolone; Pfizer, New York, NY) used in the treatment of patients with athletic musculoskeletal injuries.
METHODS A survey was designed by the authors to explore the use of MDP as a treatment modality for patients with routine musculoskeletal sports-related injuries (Fig 1, online only, available at www.arthroscopyjournal.org). The survey was mailed to members of AANA and AOSSM. Mailing lists, obtained upon request from each respective organization, included all current international and national members as of June 2005. Over a 2-week period during the end of June 2005, surveys were mailed out in university envelopes with postage paid return envelopes. A personalized cover letter written on university letterhead with the signatures of each author was included. Survey responses were collected over a 7-week period extending from June to August 2005. Data were collated and entered onto a spreadsheet, and descriptive results were generated. square tests were used to determine whether prescribing of MDP for sports injuries was statistically related to years in practice, average patient age, or number of patients seen per year. RESULTS The survey was mailed to 3,167 active members of the AANA and the AOSSM. Total response rate was 41% (1,290 of 3,167). Of US members, 43% (1,247 of 2,906) responded, as did 16% (43 of 261) of those from various other countries. square tests showed no significant association between prescribing of MDP for sports injuries and years in practice (P ⫽ .19) or total patients seen per year (P ⫽ .25). The square test showed that respondents with an average patient age ⱕ40 years exhibited a significantly higher frequency of prescribing MPD for sports injuries than did respondents whose patients were ⬎40 years old (P ⫽ .001). Members Who Prescribe MDP Of current members, 47% (603/1290) prescribe MDP. Table 1 (online only, available at www.arthros copyjournal.org) shows data for time in practice, average patient age, and number of patients seen per year for those who prescribe MDP. Responses showed that 49% (295 of 603) had prescribed MDP for longer than 10 years, 26% (157 of 603) between 5 and 10 years, 22% (133 of 603) between 1 and 5 years, and 2% (12 of 603) for less than 1 year. When questioned about the total number of times they had prescribed MDP for athletic injuries
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FIGURE 2. Reasons for not prescribing or for restricting MDP use in respondents who do not prescribe it.
over the course of their entire clinical practice, 14% (84 of 603) reported less than 10 times, 27% (163 of 603) between 10 and 50 times, 20% (121 of 603) between 50 and 100 times, 21% (127 of 603) more than 250 times, and 18% (109 of 603) between 100 and 250 times. Respondents reported that total use of MDP in their practice each year was as follows: 41% (247 of 603) ⬍10 times per year; 42% (253 of 603) 10 to 50 times per year; 11% (66 of 603) 50 to 100 times per year; 4% (24 of 603) 100 to 250 times per year; and 2% (12 of 603) ⬎250 times per year. When questioned about whether they had prescribed MDP multiple times for an individual patient over a 1-year interval, 58% (350 of 603) of members responded no, and 41% (247 of 603) answered yes. Of these members, 75% (455 of 603) have an age limit below which they will not prescribe a MDP (10 to 40 years; mean, 17 yr of age; standard deviation [SD], 3 years). A total of 23% (139 of 603) reported that they do not have an age threshold. All reasons listed by these 603 members for restricting MDP use are shown in Fig 2. Postinjury disease was the most common indication given by respondents for prescribing a MDP; specific reasons for its use included postinjury swelling (55%; 332 of 603), postinjury stiffness (48%; 289 of 603), and postinjury pain (59%; 353 of 603) (Table 2). Regarding perceived efficacy, 82% (492 of 603) reported improved patient function, 92% (556 of 603) decreased pain, 70% (421 of 603) improved motion, and 52% (313 of 603) an accelerated return to activity. Specifically, time to return to play was believed to be
decreased by a mean of 7 days (SD, 4.5 days; range, 0.5 to 30 days). Several members wrote in additional comments regarding use and postoperative and postinjury timeline recommendations (Table 3). The most commonly reported complication was glucose intolerance; this had been seen by 37% of members (222/603) (Table 4). Other complications cited were facial flushing, insomnia or sleep disturbance, shingles, weight gain, gastrointestinal disturbance, hypertension, and behavior disturbances, such as anger, brief manic-depressive episodes, anxiety, and hyperactivity. In all, 8.5% (51 of 603) reported that they had seen a total of 101 cases of osteonecrosis, predominantly in the hip, as a complication of MDP use. Notably, of these 51 physicians, 67% (34 of
TABLE 2. Common Indications Given by Those Respondents Who Prescribe MDP for Sports Injuries (n ⫽ 603)
Postinjury pain Postinjury swelling Postinjury stiffness Postsurgical stiffness Accelerated recovery (return to play) Postsurgical swelling Postsurgical pain Delayed onset of muscle soreness MDP, Medrol Dosepak.
Yes %
No %
Blank %
59 55 48 32 31 27 24 6.5
41 44 51 67 68 73 75 92
0.8 0.8 0.8 0.7 1.5 0.7 0.8 1.5
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TABLE 3. Other Uses for MDP Cited by Respondents Who Do and Do Not Use MDP for Sports Injuries Do Not Use MDP for Sports Injuries
Do Use MDP for Sports Injuries
Poison ivy Severe allergic reactions Sinusitis Seasonal allergies Arthritis flare-ups Hip bursitis Sciatica HNP Cervical/lumbar radiculopathy Neurogenic acute inflammation Chronic LBP Acute tenosynovitis Spinal stenosis
Alternative to cortisone shots Frozen shoulder (adhesive capsulitis) Postinjury/postsurgical arthrofibrosis, knee Acute inflammatory event Tendonitis Ligament sprains AC joint sprain SA bursitis RSD/CRPS MO prevention (after severe soft tissue injury) Concussions Peripheral neuropathy Acute neurologic injury Burners/stingers Brachial plexus traction injuries Low back pain/spasms Discogenic pain Herniated discs, cervical/lumbar Radiculopathy, cervical/lumbar
MDP, Medrol Dosepak; HNP, herniated nucleus pulposus (disc); LBP, low back pain; RSD, reflex sympathetic dystrophy; CRPS, complex regional pain syndrome; MO, myositis ossificans.
51) reported that they had never prescribed a MDP multiple times to a single patient in a given year; only 31% (16 of 51) reported the contrary. Members Who Do Not Prescribe Medrol Dosepak Of current members, 52% (672 of 1290) do not prescribe MDP. A demographic profile of these patients is presented in Table 1. A total of 97% (649 of 672) provided explanations for why they did not use MDP as a treatment modality. The reasons most frequently cited included fear of osteonecrosis (30%; 201 of 672), fear of complications in general (27%; 183 of 672), lack of proven efficacy (27%; 180 of 672), and fear of malpractice (4.5%; 30 of 672) (Fig 3). The least important reasons in decreasing order were as follows: fear of malpractice (61%; 409 of 672), lack of proven efficacy (25%; 167 of 672), fear of complications in general (17%; 112 of 672), and fear of osteonecrosis (14%; 95 of 672). Of 672 (25%) nonprescribing physicians, 171 reported that they had seen a combined total of 500 cases of osteonecrosis as a complication of MDP use (Table 5). Most of these cases reportedly occurred in the hip. In all,
5% (31 of 672) reported that they had observed osteonecrosis but did not provide a number of cases; 41% (275 of 672) did not respond to this question. DISCUSSION For the athlete, musculoskeletal injuries that manifest with pain, swelling, stiffness, atrophy, dysfunction, and loss of athletic fitness are the leading cause of training room visits and of missed practices and games.9 Potential benefits of anti-inflammatory medications for the treatment of patients with an injury include analgesia and prevention of an excessive inflammatory response, diminished swelling and stiffness allowing for early restoration of motion and strength, and a rapid return to functional exercise and sports. Detractors argue that rates of healing and return to sports are not influenced by anti-inflammatory medications, and that such pharmacologic modalities may cause harm by interfering with normal healing, by masking symptoms and allowing premature return to activity (which may lead to reinjury), and by producing serious adverse effects. Corticosteroids are potent inhibitors of the inflammatory response. Macrophage and leukocyte adhesion, migration, and activation are inhibited, and levels of cytokines, prostaglandins, kinins, and histamine are diminished.10 Nichols’ review of 3 databases—MEDLINE, CINAHL, and Cochrane Clinical Trial Register— was performed with use of the OVID interface for all years between 1966 and 2003 to determine the risks and complications associated with corticosteroid treatment of patients with athletic injuries.6 Studies were included if subjects were human, treatment was provided for athletic TABLE 4. Complications Observed in Decreasing Frequency for Respondents Who Do Prescribe MDP for Sports Injuries (n ⫽ 603)
Glucose intolerance Behavior disturbances GI disturbance/ulcers Hypertension Osteonecrosis Infection Impaired wound healing Other Tendon/ligament rupture Myopathy Growth inhibition
Yes %
No. of Cases
No %
Blank %
37 26 26 9.6 8.5 4.0 4.0 2.8 2.3 0.5 0.5
1,149 559 630 247 101 31 25 — 30 1 0
63 74 74 90 91 96 96 — 97 99 99
0.2 0.2 0.2 0.5 0.3 0.2 0.2 — 0.3 0.2 0.2
MDP, Medrol Dosepak; GI, gastrointestinal.
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FIGURE 3. Reasons for restricting MDP use in respondents who prescribe it.
injury, and treatment consisted of a corticosteroid preparation. A total of 43 studies met the inclusion criteria, all of which used injectable forms of corticosteroids. No studies were identified that specifically addressed oral corticosteroid use or complications in the treatment of sports injuries. Two recent survey studies regarding the use of oral corticosteroids for athletic injury focused on the prescribing patterns of team physicians for professional football players and a group of primary care physicians who attended a national sports medicine conference.7,8 In the NFL survey,7 the oral corticosteroid most commonly used was methylprednisolone, given
TABLE 5. Complications Observed in Decreasing Frequency for Respondents Who Do Not Prescribe MDP for Sports Injuries (n ⫽ 672)
Osteonecrosis Glucose intolerance GI disturbance/ulcers Behavior disturbances Impaired wound healing Hypertension Tendon/ligament rupture Infection Other Myopathy Growth inhibition
Yes %
No. of Cases
No %
Blank %
25 17 11 10 7.0 5.5 5.4 5.1 0.9 0.4 0.4
500 299 173 137 140 152 73 70 — 9 0
34 41 47 47 51 52 52 53 — 57 57
41 42 42 42 42 42 42 42 — 42 43
MDP, Medrol Dosepak; GI, gastrointestinal.
at a starting dose of 12 to 24 mg prescribed over a 1-week period; the primary care sports medicine physician survey favored a 60-mg dose of prednisone given over the same time.8 The MDP contains 21 MDP 4-mg tablets, prepackaged as a tapered dosing regimen, along with instructions to take 6 tablets the first day, 5 tablets the second day, 4 tablets the third day, 3 tablets the fourth day, 2 tablets the fifth day, and 1 tablet on the last day. The total dose was 84 mg of MDP given over a 6-day period. This total dose is equivalent to 105 mg of prednisone and 15.75 mg of dexamethasone.7 Results of our study provide further insight into the use of, indications for, perceived efficacy of, and complications specific to MDP use in the treatment of patients with athletic musculoskeletal injuries; Tucker and Yorio found that 0.3% of NFL team physicians who use variable oral corticosteroid regimens believed that the short-term use of oral corticosteroids in elite athletes is safe and effective.7 On the other hand, 58.6% of primary care sports medicine physicians reported that they had prescribed assorted oral corticosteroids in their patient population, with a trend toward increased usage with additional clinical experience.8 The most common indications for corticosteroid prescription in the NFL survey were intervertebral disc herniation and acute peripheral nerve injury (e.g., brachial plexopathy). The primary care physician’s survey did not ask about specific indications but did note that approximately one third prescribe for acute injuries only, one third for chronic injuries only, and one third for both acute and chronic injuries. In our
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study, postinjury disease was the most common indication for prescribing a MDP, particularly postinjury swelling (55%; 332 of 603), postinjury stiffness (48%; 289 of 603), and postinjury pain (59%; 353 of 603). We found a statistically significant relationship between average patient age ⱕ40 years and prescribing of MDP for sports injuries (P ⫽ .001 by square test). This relationship may be due to the increased frequency of sports playing or the playing of different sports by younger patients. No statistically significant association was found between MDP prescribing and number of patients seen per year or years in practice. This observation may indicate that the decision of orthopaedic surgeons to prescribe MDP for sports injuries is not affected by patient contact time, and that the choice does not change with increased time in practice, although a survey asking about prescribing patterns over time would be needed to clarify this. The NFL physician survey revealed that 9.7% of physicians who treated elite athletes with corticosteroids reported serious complications. The complication rate was 25% when the physician reported combined clinical experience with general patients, elite athletes, and patients seen by a practice partner. Complications listed included osteonecrosis (5 cases total, 2 in elite athletes), tendon rupture, dyspepsia, psychosis, and cataracts. The complication most commonly reported in our study was glucose intolerance, which was seen by 37% of prescribing members (222 of 603) (Table 4). More than 40% of respondents who do not prescribe MDP for sports injuries also did not respond to any of the questions about observed complications (Table 5). Therefore, frequencies are presented in Tables 4 and 5, but any statistical inferences regarding an association between observed complications and prescribing of MDP would be highly speculative. In our study, of those physicians who indicated that they prescribe MDP, 8.5% (51 of 603) stated that they had seen 101 cases of osteonecrosis, predominantly in the hip. Of those who reported that they do not routinely prescribe this drug, 25% (171 of 672) stated that they had seen 500 cases of osteonecrosis resulting from use of MDP, most often in the hip. These numbers of observed cases are likely underestimates because many respondents who reported seeing osteonecrosis did not provide a number. Similar frequencies were reported in the NFL study, with 5 cases in the general patient population (16%) and 2 among elite athletes (5%).7 Fear of the risk of osteonecrosis as a complication is a concern as reported by 63% (20 of 31) of NFL physicians and 21% (273 of 1290) of AOSSM and AANA members surveyed. No notations of ten-
don rupture were made. In our study, members who do not prescribe MDP stated that the potential for general complications (27%) and osteonecrosis (30%) were important factors (Fig 3). Of note, only 4.5% (30 of 672) of those who reportedly do not routinely use MDP as a treatment adjunct listed fear of malpractice as the most important reason; 61% (409 of 672) stated that it was least important as a factor. No consensus has been reached about the mechanism of osteonecrosis, and it is generally believed that this is a multifactorial process.11 Numerous case studies strongly link corticosteroid use to osteonecrosis.12-19 In each of these reports, the total methylprednisolone equivalent dose ranged from 232 to 1,400 mg, which is substantially greater than 84 mg, the total dose of methylprednisolone given in an MDP. No case reports or basic science models have linked osteonecrosis to lower dosage levels of methylprednisolone, similar to those of an MDP. It is interesting to note that, in our study, of those physicians who prescribe MDP and who indicated that they had seen osteonecrosis resulting from the use of corticosteroids, 67% (34 of 51) reportedly have never used it multiple times in a single patient in a given year. Our survey has several limitations. This study is retrospective and voluntary in nature and therefore is subject to selection bias and recall bias among respondents. Surveys remain an important epidemiologic technique for capturing cross-sectional or longitudinal data and providing fundamental insights about health and disease.20 Observational studies can be a useful supplement for systematic assessment of treatment harms, such as adverse drug reactions, which tend to be under-reported in clinical trials.21 Low response rates and nonresponse bias are certainly ongoing concerns in mail surveys because they threaten one’s ability to extrapolate valid inferences from a research sample to the larger population.22,23 Yet, mailed surveys offer a practical means of investigating and understanding the practicing patterns, concerns, and beliefs of the health care community. Response rates after the first mailing of questionnaires in health care research have averaged 62% (SD ⫽ 21).24 Physicians tend to produce lower mean response rates— 54% (SD ⫽ 17)—than other health care workers.24 Return rates have been especially low in surveys of surgeons, who have responded at rates ranging from 15% to 77%.25-27 The good response reflects wide-reaching interest and concern regarding corticosteroid use as a treatment modality. Strategies designed to improve response rates, such as prenotification letters, faxing, postage paid return envelopes, personalized cover letters, limited questionnaire length, monetary incentives, and the use of university envelopes, have achieved varying success.22
USE OF MEDROL DOSEPAK FOR SPORTS INJURIES Additional studies, including randomized trials undertaken to determine the efficacy of corticosteroids for athletic injuries and longitudinal observational studies of low-dose regimens conducted to assess risk for potential harm such as osteonecrosis, are needed.
8. 9.
CONCLUSIONS
10.
Descriptive data generated by our survey provide the first analysis of a commonly prescribed, short-term oral corticosteroid used for athletic injuries. No consensus has been reached regarding oral corticosteroid use for sports injuries; members are approximately evenly split regarding their use. Average patient age ⱕ40 years was associated with a statistically significant increase in the prescribing of MDP for sports injuries (P ⫽ .001). Postinjury disease is the most common indication for prescribing MDP. Lack of proven efficacy and osteonecrosis are deterrents to its prescription.
11.
Acknowledgments: Statistical analyses were provided by Jason T. Machan, Ph.D., and Mark Brady, B.S. The authors also express deepest thanks to Suzanne Swanson.
12. 13. 14. 15.
16. 17. 18.
REFERENCES 19. 1. Behrens T, Goodwin J. Oral corticosteroids. In: Ledbetter WB, Buckwalter JB, Gordon SL, eds. Sports-induced inflammation: Clinical and basic concepts. Park Ridge, Ill: American Academy of Orthopaedic Surgeons, 1990. 2. Buckwalter J, Woo S. Basic science and injury of muscle, tendon, and ligaments: Effects of medications in sports injuries at the tissue level. In: DeLee J, Drez D, Miller M, eds. DeLee & Drez’s orthopaedic sports medicine principles and practice. Vol 1, 2nd ed. Philadelphia: WB Saunders, 2003;50-55. 3. Ledbetter W. Overview of modifiers of inflammation. In: Ledbetter WB, Buckwalter JB, Gordon SL, eds. Sports-induced inflammation: Clinical and basic concepts. Park Ridge, Ill: American Academy of Orthopaedic Surgeons, 1990. 4. Mishra DK, Friden J, Schmitz MC, Lieber RL. Anti-inflammatory medication after muscle injury: A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am 1995;77:1510-1519. 5. Da Silva JA, Jacobs JW, Kirwan JR, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: Published evidence and prospective trial data. Ann Rheum Dis 2006;65: 285-293. 6. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med 2005;15:E370. 7. Tucker AM, Yorio MA. Oral corticosteroids and treatment of
20. 21. 22. 23. 24. 25.
26. 27.
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National Football League players: A survey of team physicians. Curr Opin Orthop 2004;15:108-112. Harmon KG, Hawley C. Physician prescribing patterns of oral corticosteroids for musculoskeletal injuries. J Am Board Fam Pract 2003;16:209-212. Steiner ME, Quigley DB, Wang F, Balint CR, Boland AL Jr. Team physicians in college athletics. Am J Sports Med 2005; 33:1545-1551. Fauci AS. Harrison’s principles of internal medicine. 14th ed. New York: McGraw-Hill Health Professions Division, 1997. Jones LC, Hungerford DS. Osteonecrosis: Etiology, diagnosis, and treatment. Curr Opin Rheumatol 2004;16:443-449. Anderton JM, Helm R. Multiple joint osteonecrosis following short-term steroid therapy: Case report. J Bone Joint Surg Am 1982;64:139-141. Hernigou P, Beaujean F, Lambotte JC. Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroidinduced osteonecrosis. J Bone Joint Surg Br 1999;81:349-355. Humphreys S, Spencer JD, Tighe JR, Cumming RR. The femoral head in osteonecrosis: A quantitative study of osteocyte population. J Bone Joint Surg Br 1989;71:205-208. McKee MD, Waddell JP, Kudo PA, Schemitsch EH, Richards RR. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: A report of 15 cases. CMAJ 2001;164:205-206. Nishimura T, Matsumoto T, Nishino M, Tomita K. Histopathologic study of veins in steroid treated rabbits. Clin Orthop Relat Res 1997;37-42. O’Brien TJ, Mack GR. Multifocal osteonecrosis after shortterm high-dose corticosteroid therapy: A case report. Clin Orthop Relat Res 1992;176-179. Wang GJ, Rawles JG, Hubbard SL, Stamp WG. Steroidinduced femoral head pressure changes and their response to lipid-clearing agents. Clin Orthop Relat Res 1983;298-302. Wang GJ, Sweet DE, Reger SI, Thompson RC. Fat-cell changes as a mechanism of avascular necrosis of the femoral head in cortisone-treated rabbits. J Bone Joint Surg Am 1977; 59:729-735. Sackett DL, Wennberg JE. Choosing the best research design for each question. BMJ 1997;315:1636. Chou R, Helfand M. Challenges in systematic reviews that assess treatment harms. Ann Intern Med 2005;142:1090-1099. Kellerman SE, Herold J. Physician response to surveys: A review of the literature. Am J Prev Med 2001;20:61-67. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res 2001;35:1347-1355. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129-1136. Khalily C, Behnke S, Seligson D. Treatment of closed tibia shaft fractures: A survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International–Gerhard Kuntscher Kreis meeting. J Orthop Trauma 2000;14:577-581. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Surgeons’ preferences for the operative treatment of fractures of the tibial shaft: An international survey. J Bone Joint Surg Am 2001;83:1746-1752. Matarasso A, Elkwood A, Rankin M, Elkowitz M. National plastic surgery survey: Face lift techniques and complications. Plast Reconstr Surg 2000;106:1185-1195; discussion 1196.
USE OF MEDROL DOSEPAK FOR SPORTS INJURIES Questionnaire: Medrol Dosepacks & Routine Sports Injuries Instructions: Please circle the correct answer and elaborate as indicated 1. 2. 3. 4. 5.
6.
7.
8.
9. 10.
How many years have you been in practice? < 10 10-20 > 20 What is the average age of your patient population? < 20 20-40 40-55 > 55 How many total patients do you see in a year? < 500 500-2000 2000-4000 > 4000 Do you use Medrol Dosepacks in the treatment of any sports injuries? Yes No If not, OR if you restrict their use, why? (1 = Least ? 2= Somewhat? 3= Very? 4 = Most Important) a) Fear of complications in general? 1 2 3 4 b) Specific fear of osteonecrosis? 1 2 3 4 c) Lack of proven efficacy? 1 2 3 4 d) Fear of lawsuit/malpractice? 1 2 3 4 If you prescribe Medrol Dosepacks a) How long have you used them? < 1 yr 1-5 yrs 5-10 yrs >10 yrs b) How often do you use them in any given year? < 10/yr 10-50/yr 50-100/yr 100-250/yr >250/yr c) Have you ever used them multiple times in a single patient in a given year? Yes No d) What is the estimated total # of times you have prescribed them? < 10 10-50 50-100 100-250 >250 Why do you prescribe them? a) Delayed Onset Muscle Soreness (DOMS) Yes No b) Accelerate recovery (return to play) Yes No c) Post-Injury i. Swelling Yes No ii. Stiffness Yes No iii. Pain Yes No d) Post-Surgical i. Swelling Yes No ii. Stiffness Yes No iii. Pain Yes No Have you ever seen any of the following complications result from using Medrol Dosepacks? a) Osteonecrosis Yes (# = ; Location(s) = ) No b) Glucose intolerance Yes (# = ) No c) Hypertension Yes (# = ) No d) Infection Yes (# = ) No e) Impaired wound healing Yes (# = ) No f) Tendon/Ligament rupture Yes (# = ) No g) GI disturbance/ulcers Yes (# = ) No h) Myopathy Yes (# = ) No i) Behavior disturbances Yes (# = ) No j) Growth inhibition Yes (# = ) No k) Other? Do you have an age limit below which you will not prescribe? Yes (Age limit = ) No What is the efficacy of Medrol Dosepacks in your experience? Do they – a) Improved function Yes No b) Decreased pain Yes No c) Improved joint motion Yes No d) Accelerated a return to activity? Yes (How many days? # = ) No e) Other?
FIGURE 1.
Medrol Dosepak survey mailed to AANA and AOSSM members.
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TABLE 1. Demographic Profile of Respondents Who Do and Do Not Prescribe MDP for Sports Injuries
Years in practice ⬍10 10–20 ⬎20 Average age of patient, yr ⬍20 20–40 20–55 40–55 40–⬎55 ⬎55 Total patients/yr ⬍500 500–2,000 2,000–4,000 ⬎4,000 MDP, Medrol Dosepak.
Percent of Those Who Use MDP (n ⫽ 603)
Percent of Those Who Do Not Use MDP (n ⫽ 672)
33 35 32
38 31 30
1 53 5 39 1 1
1 43 7 45 0 3
2 26 44 28
3 27 47 22
Purpose: To study the use of a methylprednisolone taper (Medrol Dosepak; Pfizer, New York, NY) short-term oral corticosteroid treatment modality by sports medicine physicians; included is discussion on indications, perceived efficacy, and complications. Methods: A survey specific to Medrol Dosepak (MDP) use was mailed to all members of the Arthroscopy Association of North America (AANA) and the American Orthopedic Society for Sports Medicine (AOSSM). Surveys were collected and data were collated and analyzed. Results: Total response rate was 41% (1,290/3,167), US response rate 43% (1,247/2,906), and international response rate 16% (43/261). Prescribing of MDP for sports injuries was significantly associated with average patient age ⱕ40 years ( square; P ⫽ .001), but it was not associated with years in practice or patients seen per year. It was found that 47% of members (603/1,290) prescribe MDP. Postinjury disease was the most common indication. The most frequent complication was glucose intolerance (37%; 222/603). Of members who prescribe MDP, 8.5% (51/603) reported that they had seen 101 total cases of osteonecrosis, predominantly in the hip. Results revealed that 52% of members (672/1,290) do not prescribe MDP. The most frequent reasons for not prescribing included fear of osteonecrosis (30%; 201/672), fear of complications in general (27%; 183/672), lack of proven efficacy (27%; 180/672), and fear of malpractice (4.5%; 30/672). Of nonprescribing members (171/672), 25% had seen 500 cases of osteonecrosis, most often in the hip. Conclusions: The responding membership of AANA and AOSSM is evenly split regarding MDP use. Average patient age ⱕ40 years was associated with a greater likelihood that MDP would be prescribed for sports injuries. Postinjury disease is the most common indication; lack of proven efficacy and osteonecrosis are deterrents to prescription. Level of Evidence: Level V, expert opinion. Key Words: Sports injuries—Methylprednisolone—Oral corticosteroids.
T
he routine use of anti-inflammatory medications, including corticosteroids, for the treatment of patients with athletic injuries is controversial. Anti-inflammatory medications have gained
From the Department of Orthopedic Surgery, Brown University Medical School, Providence, Rhode Island, U.S.A. Supported by outside funding or grants from University Orthopedics, Inc., and Rhode Island Orthopaedic Foundation. The authors report no conflict of interest. Address correspondence and reprint requests to Phillip Langer, M.D., Department of Orthopedic Surgery, Brown Medical School/ Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2212-0684$32.00/0 doi:10.1016/j.arthro.2006.08.020 Note: To access the supplementary table and figure accompanying this report, visit the December issue of Arthroscopy at www.arthroscopyjournal.org.
widespread acceptance by athletes, athletic trainers, and physicians as a treatment adjunct during rehabilitation for sports-related musculoskeletal problems. Although these medications effectively reduce inflammation and pain, concern has been expressed about the scarcity of published clinical trials, unclear indications, potentially serious adverse effects, and even inhibition or delay of normal healing after injury.1-4 Corticosteroids, the most potent inhibitors of inflammation, have been particularly scrutinized because of untoward effects that have been documented with long-term high-dose systemic use. Reports on adverse effects associated with low-dose corticosteroid use have shown that few commonly held beliefs about their incidence are supported by clear evidence.5 Nichols6 searched medical literature that described the risks and complications associated with corticoste-
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roid treatment given for athletic injuries. This investigation failed to identify a single article that addressed the use of systemic oral corticosteroids or complications resulting from their use for the treatment of patients with sports-related musculoskeletal injuries. The author concluded that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids for the treatment of patients with athletic injuries. In a more recent survey of head team physicians for the National Football League (NFL),7 83.9% of 31 respondents (29 orthopaedic surgeons and 2 primary care physicians) reported that they had prescribed oral corticosteroids, most commonly for intervertebral disc herniations. The oral corticosteroid most commonly used was methylprednisolone, at a starting dose of 12 to 24 mg given over 1 week. Of these physicians, 25.8% reported serious complications, most commonly osteonecrosis (16.1%). In another recent report,8 primary care physicians were surveyed during a national sports medicine meeting. The 99 respondents were sports medicine clinicians who had undergone varied training and who had different types of practices. Of these providers, 58.6% reported that they had prescribed oral corticosteroids for musculoskeletal injuries. Prednisone was the most commonly prescribed corticosteroid (82%). Usual starting dose was 60 mg, and average prescription length was 7 days; 57.1% tapered the dose over the duration of treatment. Although these surveys have enhanced our understanding of the prescribing practices of sports medicine physicians who use oral corticosteroids as a treatment modality for patients with athletic injuries, the descriptive data that have been generated are limited by the small sample size of respondents and by the failure of investigators to gather information on specific oral corticosteroid treatment regimens. Thus, the need remains for additional descriptive data that specifically reflect the orthopaedic sports medicine community. The purpose of the present study was to survey the collective membership of the Arthroscopy Association of North America (AANA) and the American Orthopedic Society for Sports Medicine (AOSSM) to gain insight into the use of, indications for, perceived efficacy, and complications associated with the Medrol Dosepak (MDP, methylprednisolone; Pfizer, New York, NY) used in the treatment of patients with athletic musculoskeletal injuries.
METHODS A survey was designed by the authors to explore the use of MDP as a treatment modality for patients with routine musculoskeletal sports-related injuries (Fig 1, online only, available at www.arthroscopyjournal.org). The survey was mailed to members of AANA and AOSSM. Mailing lists, obtained upon request from each respective organization, included all current international and national members as of June 2005. Over a 2-week period during the end of June 2005, surveys were mailed out in university envelopes with postage paid return envelopes. A personalized cover letter written on university letterhead with the signatures of each author was included. Survey responses were collected over a 7-week period extending from June to August 2005. Data were collated and entered onto a spreadsheet, and descriptive results were generated. square tests were used to determine whether prescribing of MDP for sports injuries was statistically related to years in practice, average patient age, or number of patients seen per year. RESULTS The survey was mailed to 3,167 active members of the AANA and the AOSSM. Total response rate was 41% (1,290 of 3,167). Of US members, 43% (1,247 of 2,906) responded, as did 16% (43 of 261) of those from various other countries. square tests showed no significant association between prescribing of MDP for sports injuries and years in practice (P ⫽ .19) or total patients seen per year (P ⫽ .25). The square test showed that respondents with an average patient age ⱕ40 years exhibited a significantly higher frequency of prescribing MPD for sports injuries than did respondents whose patients were ⬎40 years old (P ⫽ .001). Members Who Prescribe MDP Of current members, 47% (603/1290) prescribe MDP. Table 1 (online only, available at www.arthros copyjournal.org) shows data for time in practice, average patient age, and number of patients seen per year for those who prescribe MDP. Responses showed that 49% (295 of 603) had prescribed MDP for longer than 10 years, 26% (157 of 603) between 5 and 10 years, 22% (133 of 603) between 1 and 5 years, and 2% (12 of 603) for less than 1 year. When questioned about the total number of times they had prescribed MDP for athletic injuries
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FIGURE 2. Reasons for not prescribing or for restricting MDP use in respondents who do not prescribe it.
over the course of their entire clinical practice, 14% (84 of 603) reported less than 10 times, 27% (163 of 603) between 10 and 50 times, 20% (121 of 603) between 50 and 100 times, 21% (127 of 603) more than 250 times, and 18% (109 of 603) between 100 and 250 times. Respondents reported that total use of MDP in their practice each year was as follows: 41% (247 of 603) ⬍10 times per year; 42% (253 of 603) 10 to 50 times per year; 11% (66 of 603) 50 to 100 times per year; 4% (24 of 603) 100 to 250 times per year; and 2% (12 of 603) ⬎250 times per year. When questioned about whether they had prescribed MDP multiple times for an individual patient over a 1-year interval, 58% (350 of 603) of members responded no, and 41% (247 of 603) answered yes. Of these members, 75% (455 of 603) have an age limit below which they will not prescribe a MDP (10 to 40 years; mean, 17 yr of age; standard deviation [SD], 3 years). A total of 23% (139 of 603) reported that they do not have an age threshold. All reasons listed by these 603 members for restricting MDP use are shown in Fig 2. Postinjury disease was the most common indication given by respondents for prescribing a MDP; specific reasons for its use included postinjury swelling (55%; 332 of 603), postinjury stiffness (48%; 289 of 603), and postinjury pain (59%; 353 of 603) (Table 2). Regarding perceived efficacy, 82% (492 of 603) reported improved patient function, 92% (556 of 603) decreased pain, 70% (421 of 603) improved motion, and 52% (313 of 603) an accelerated return to activity. Specifically, time to return to play was believed to be
decreased by a mean of 7 days (SD, 4.5 days; range, 0.5 to 30 days). Several members wrote in additional comments regarding use and postoperative and postinjury timeline recommendations (Table 3). The most commonly reported complication was glucose intolerance; this had been seen by 37% of members (222/603) (Table 4). Other complications cited were facial flushing, insomnia or sleep disturbance, shingles, weight gain, gastrointestinal disturbance, hypertension, and behavior disturbances, such as anger, brief manic-depressive episodes, anxiety, and hyperactivity. In all, 8.5% (51 of 603) reported that they had seen a total of 101 cases of osteonecrosis, predominantly in the hip, as a complication of MDP use. Notably, of these 51 physicians, 67% (34 of
TABLE 2. Common Indications Given by Those Respondents Who Prescribe MDP for Sports Injuries (n ⫽ 603)
Postinjury pain Postinjury swelling Postinjury stiffness Postsurgical stiffness Accelerated recovery (return to play) Postsurgical swelling Postsurgical pain Delayed onset of muscle soreness MDP, Medrol Dosepak.
Yes %
No %
Blank %
59 55 48 32 31 27 24 6.5
41 44 51 67 68 73 75 92
0.8 0.8 0.8 0.7 1.5 0.7 0.8 1.5
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TABLE 3. Other Uses for MDP Cited by Respondents Who Do and Do Not Use MDP for Sports Injuries Do Not Use MDP for Sports Injuries
Do Use MDP for Sports Injuries
Poison ivy Severe allergic reactions Sinusitis Seasonal allergies Arthritis flare-ups Hip bursitis Sciatica HNP Cervical/lumbar radiculopathy Neurogenic acute inflammation Chronic LBP Acute tenosynovitis Spinal stenosis
Alternative to cortisone shots Frozen shoulder (adhesive capsulitis) Postinjury/postsurgical arthrofibrosis, knee Acute inflammatory event Tendonitis Ligament sprains AC joint sprain SA bursitis RSD/CRPS MO prevention (after severe soft tissue injury) Concussions Peripheral neuropathy Acute neurologic injury Burners/stingers Brachial plexus traction injuries Low back pain/spasms Discogenic pain Herniated discs, cervical/lumbar Radiculopathy, cervical/lumbar
MDP, Medrol Dosepak; HNP, herniated nucleus pulposus (disc); LBP, low back pain; RSD, reflex sympathetic dystrophy; CRPS, complex regional pain syndrome; MO, myositis ossificans.
51) reported that they had never prescribed a MDP multiple times to a single patient in a given year; only 31% (16 of 51) reported the contrary. Members Who Do Not Prescribe Medrol Dosepak Of current members, 52% (672 of 1290) do not prescribe MDP. A demographic profile of these patients is presented in Table 1. A total of 97% (649 of 672) provided explanations for why they did not use MDP as a treatment modality. The reasons most frequently cited included fear of osteonecrosis (30%; 201 of 672), fear of complications in general (27%; 183 of 672), lack of proven efficacy (27%; 180 of 672), and fear of malpractice (4.5%; 30 of 672) (Fig 3). The least important reasons in decreasing order were as follows: fear of malpractice (61%; 409 of 672), lack of proven efficacy (25%; 167 of 672), fear of complications in general (17%; 112 of 672), and fear of osteonecrosis (14%; 95 of 672). Of 672 (25%) nonprescribing physicians, 171 reported that they had seen a combined total of 500 cases of osteonecrosis as a complication of MDP use (Table 5). Most of these cases reportedly occurred in the hip. In all,
5% (31 of 672) reported that they had observed osteonecrosis but did not provide a number of cases; 41% (275 of 672) did not respond to this question. DISCUSSION For the athlete, musculoskeletal injuries that manifest with pain, swelling, stiffness, atrophy, dysfunction, and loss of athletic fitness are the leading cause of training room visits and of missed practices and games.9 Potential benefits of anti-inflammatory medications for the treatment of patients with an injury include analgesia and prevention of an excessive inflammatory response, diminished swelling and stiffness allowing for early restoration of motion and strength, and a rapid return to functional exercise and sports. Detractors argue that rates of healing and return to sports are not influenced by anti-inflammatory medications, and that such pharmacologic modalities may cause harm by interfering with normal healing, by masking symptoms and allowing premature return to activity (which may lead to reinjury), and by producing serious adverse effects. Corticosteroids are potent inhibitors of the inflammatory response. Macrophage and leukocyte adhesion, migration, and activation are inhibited, and levels of cytokines, prostaglandins, kinins, and histamine are diminished.10 Nichols’ review of 3 databases—MEDLINE, CINAHL, and Cochrane Clinical Trial Register— was performed with use of the OVID interface for all years between 1966 and 2003 to determine the risks and complications associated with corticosteroid treatment of patients with athletic injuries.6 Studies were included if subjects were human, treatment was provided for athletic TABLE 4. Complications Observed in Decreasing Frequency for Respondents Who Do Prescribe MDP for Sports Injuries (n ⫽ 603)
Glucose intolerance Behavior disturbances GI disturbance/ulcers Hypertension Osteonecrosis Infection Impaired wound healing Other Tendon/ligament rupture Myopathy Growth inhibition
Yes %
No. of Cases
No %
Blank %
37 26 26 9.6 8.5 4.0 4.0 2.8 2.3 0.5 0.5
1,149 559 630 247 101 31 25 — 30 1 0
63 74 74 90 91 96 96 — 97 99 99
0.2 0.2 0.2 0.5 0.3 0.2 0.2 — 0.3 0.2 0.2
MDP, Medrol Dosepak; GI, gastrointestinal.
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FIGURE 3. Reasons for restricting MDP use in respondents who prescribe it.
injury, and treatment consisted of a corticosteroid preparation. A total of 43 studies met the inclusion criteria, all of which used injectable forms of corticosteroids. No studies were identified that specifically addressed oral corticosteroid use or complications in the treatment of sports injuries. Two recent survey studies regarding the use of oral corticosteroids for athletic injury focused on the prescribing patterns of team physicians for professional football players and a group of primary care physicians who attended a national sports medicine conference.7,8 In the NFL survey,7 the oral corticosteroid most commonly used was methylprednisolone, given
TABLE 5. Complications Observed in Decreasing Frequency for Respondents Who Do Not Prescribe MDP for Sports Injuries (n ⫽ 672)
Osteonecrosis Glucose intolerance GI disturbance/ulcers Behavior disturbances Impaired wound healing Hypertension Tendon/ligament rupture Infection Other Myopathy Growth inhibition
Yes %
No. of Cases
No %
Blank %
25 17 11 10 7.0 5.5 5.4 5.1 0.9 0.4 0.4
500 299 173 137 140 152 73 70 — 9 0
34 41 47 47 51 52 52 53 — 57 57
41 42 42 42 42 42 42 42 — 42 43
MDP, Medrol Dosepak; GI, gastrointestinal.
at a starting dose of 12 to 24 mg prescribed over a 1-week period; the primary care sports medicine physician survey favored a 60-mg dose of prednisone given over the same time.8 The MDP contains 21 MDP 4-mg tablets, prepackaged as a tapered dosing regimen, along with instructions to take 6 tablets the first day, 5 tablets the second day, 4 tablets the third day, 3 tablets the fourth day, 2 tablets the fifth day, and 1 tablet on the last day. The total dose was 84 mg of MDP given over a 6-day period. This total dose is equivalent to 105 mg of prednisone and 15.75 mg of dexamethasone.7 Results of our study provide further insight into the use of, indications for, perceived efficacy of, and complications specific to MDP use in the treatment of patients with athletic musculoskeletal injuries; Tucker and Yorio found that 0.3% of NFL team physicians who use variable oral corticosteroid regimens believed that the short-term use of oral corticosteroids in elite athletes is safe and effective.7 On the other hand, 58.6% of primary care sports medicine physicians reported that they had prescribed assorted oral corticosteroids in their patient population, with a trend toward increased usage with additional clinical experience.8 The most common indications for corticosteroid prescription in the NFL survey were intervertebral disc herniation and acute peripheral nerve injury (e.g., brachial plexopathy). The primary care physician’s survey did not ask about specific indications but did note that approximately one third prescribe for acute injuries only, one third for chronic injuries only, and one third for both acute and chronic injuries. In our
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study, postinjury disease was the most common indication for prescribing a MDP, particularly postinjury swelling (55%; 332 of 603), postinjury stiffness (48%; 289 of 603), and postinjury pain (59%; 353 of 603). We found a statistically significant relationship between average patient age ⱕ40 years and prescribing of MDP for sports injuries (P ⫽ .001 by square test). This relationship may be due to the increased frequency of sports playing or the playing of different sports by younger patients. No statistically significant association was found between MDP prescribing and number of patients seen per year or years in practice. This observation may indicate that the decision of orthopaedic surgeons to prescribe MDP for sports injuries is not affected by patient contact time, and that the choice does not change with increased time in practice, although a survey asking about prescribing patterns over time would be needed to clarify this. The NFL physician survey revealed that 9.7% of physicians who treated elite athletes with corticosteroids reported serious complications. The complication rate was 25% when the physician reported combined clinical experience with general patients, elite athletes, and patients seen by a practice partner. Complications listed included osteonecrosis (5 cases total, 2 in elite athletes), tendon rupture, dyspepsia, psychosis, and cataracts. The complication most commonly reported in our study was glucose intolerance, which was seen by 37% of prescribing members (222 of 603) (Table 4). More than 40% of respondents who do not prescribe MDP for sports injuries also did not respond to any of the questions about observed complications (Table 5). Therefore, frequencies are presented in Tables 4 and 5, but any statistical inferences regarding an association between observed complications and prescribing of MDP would be highly speculative. In our study, of those physicians who indicated that they prescribe MDP, 8.5% (51 of 603) stated that they had seen 101 cases of osteonecrosis, predominantly in the hip. Of those who reported that they do not routinely prescribe this drug, 25% (171 of 672) stated that they had seen 500 cases of osteonecrosis resulting from use of MDP, most often in the hip. These numbers of observed cases are likely underestimates because many respondents who reported seeing osteonecrosis did not provide a number. Similar frequencies were reported in the NFL study, with 5 cases in the general patient population (16%) and 2 among elite athletes (5%).7 Fear of the risk of osteonecrosis as a complication is a concern as reported by 63% (20 of 31) of NFL physicians and 21% (273 of 1290) of AOSSM and AANA members surveyed. No notations of ten-
don rupture were made. In our study, members who do not prescribe MDP stated that the potential for general complications (27%) and osteonecrosis (30%) were important factors (Fig 3). Of note, only 4.5% (30 of 672) of those who reportedly do not routinely use MDP as a treatment adjunct listed fear of malpractice as the most important reason; 61% (409 of 672) stated that it was least important as a factor. No consensus has been reached about the mechanism of osteonecrosis, and it is generally believed that this is a multifactorial process.11 Numerous case studies strongly link corticosteroid use to osteonecrosis.12-19 In each of these reports, the total methylprednisolone equivalent dose ranged from 232 to 1,400 mg, which is substantially greater than 84 mg, the total dose of methylprednisolone given in an MDP. No case reports or basic science models have linked osteonecrosis to lower dosage levels of methylprednisolone, similar to those of an MDP. It is interesting to note that, in our study, of those physicians who prescribe MDP and who indicated that they had seen osteonecrosis resulting from the use of corticosteroids, 67% (34 of 51) reportedly have never used it multiple times in a single patient in a given year. Our survey has several limitations. This study is retrospective and voluntary in nature and therefore is subject to selection bias and recall bias among respondents. Surveys remain an important epidemiologic technique for capturing cross-sectional or longitudinal data and providing fundamental insights about health and disease.20 Observational studies can be a useful supplement for systematic assessment of treatment harms, such as adverse drug reactions, which tend to be under-reported in clinical trials.21 Low response rates and nonresponse bias are certainly ongoing concerns in mail surveys because they threaten one’s ability to extrapolate valid inferences from a research sample to the larger population.22,23 Yet, mailed surveys offer a practical means of investigating and understanding the practicing patterns, concerns, and beliefs of the health care community. Response rates after the first mailing of questionnaires in health care research have averaged 62% (SD ⫽ 21).24 Physicians tend to produce lower mean response rates— 54% (SD ⫽ 17)—than other health care workers.24 Return rates have been especially low in surveys of surgeons, who have responded at rates ranging from 15% to 77%.25-27 The good response reflects wide-reaching interest and concern regarding corticosteroid use as a treatment modality. Strategies designed to improve response rates, such as prenotification letters, faxing, postage paid return envelopes, personalized cover letters, limited questionnaire length, monetary incentives, and the use of university envelopes, have achieved varying success.22
USE OF MEDROL DOSEPAK FOR SPORTS INJURIES Additional studies, including randomized trials undertaken to determine the efficacy of corticosteroids for athletic injuries and longitudinal observational studies of low-dose regimens conducted to assess risk for potential harm such as osteonecrosis, are needed.
8. 9.
CONCLUSIONS
10.
Descriptive data generated by our survey provide the first analysis of a commonly prescribed, short-term oral corticosteroid used for athletic injuries. No consensus has been reached regarding oral corticosteroid use for sports injuries; members are approximately evenly split regarding their use. Average patient age ⱕ40 years was associated with a statistically significant increase in the prescribing of MDP for sports injuries (P ⫽ .001). Postinjury disease is the most common indication for prescribing MDP. Lack of proven efficacy and osteonecrosis are deterrents to its prescription.
11.
Acknowledgments: Statistical analyses were provided by Jason T. Machan, Ph.D., and Mark Brady, B.S. The authors also express deepest thanks to Suzanne Swanson.
12. 13. 14. 15.
16. 17. 18.
REFERENCES 19. 1. Behrens T, Goodwin J. Oral corticosteroids. In: Ledbetter WB, Buckwalter JB, Gordon SL, eds. Sports-induced inflammation: Clinical and basic concepts. Park Ridge, Ill: American Academy of Orthopaedic Surgeons, 1990. 2. Buckwalter J, Woo S. Basic science and injury of muscle, tendon, and ligaments: Effects of medications in sports injuries at the tissue level. In: DeLee J, Drez D, Miller M, eds. DeLee & Drez’s orthopaedic sports medicine principles and practice. Vol 1, 2nd ed. Philadelphia: WB Saunders, 2003;50-55. 3. Ledbetter W. Overview of modifiers of inflammation. In: Ledbetter WB, Buckwalter JB, Gordon SL, eds. Sports-induced inflammation: Clinical and basic concepts. Park Ridge, Ill: American Academy of Orthopaedic Surgeons, 1990. 4. Mishra DK, Friden J, Schmitz MC, Lieber RL. Anti-inflammatory medication after muscle injury: A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am 1995;77:1510-1519. 5. Da Silva JA, Jacobs JW, Kirwan JR, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: Published evidence and prospective trial data. Ann Rheum Dis 2006;65: 285-293. 6. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med 2005;15:E370. 7. Tucker AM, Yorio MA. Oral corticosteroids and treatment of
20. 21. 22. 23. 24. 25.
26. 27.
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National Football League players: A survey of team physicians. Curr Opin Orthop 2004;15:108-112. Harmon KG, Hawley C. Physician prescribing patterns of oral corticosteroids for musculoskeletal injuries. J Am Board Fam Pract 2003;16:209-212. Steiner ME, Quigley DB, Wang F, Balint CR, Boland AL Jr. Team physicians in college athletics. Am J Sports Med 2005; 33:1545-1551. Fauci AS. Harrison’s principles of internal medicine. 14th ed. New York: McGraw-Hill Health Professions Division, 1997. Jones LC, Hungerford DS. Osteonecrosis: Etiology, diagnosis, and treatment. Curr Opin Rheumatol 2004;16:443-449. Anderton JM, Helm R. Multiple joint osteonecrosis following short-term steroid therapy: Case report. J Bone Joint Surg Am 1982;64:139-141. Hernigou P, Beaujean F, Lambotte JC. Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroidinduced osteonecrosis. J Bone Joint Surg Br 1999;81:349-355. Humphreys S, Spencer JD, Tighe JR, Cumming RR. The femoral head in osteonecrosis: A quantitative study of osteocyte population. J Bone Joint Surg Br 1989;71:205-208. McKee MD, Waddell JP, Kudo PA, Schemitsch EH, Richards RR. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: A report of 15 cases. CMAJ 2001;164:205-206. Nishimura T, Matsumoto T, Nishino M, Tomita K. Histopathologic study of veins in steroid treated rabbits. Clin Orthop Relat Res 1997;37-42. O’Brien TJ, Mack GR. Multifocal osteonecrosis after shortterm high-dose corticosteroid therapy: A case report. Clin Orthop Relat Res 1992;176-179. Wang GJ, Rawles JG, Hubbard SL, Stamp WG. Steroidinduced femoral head pressure changes and their response to lipid-clearing agents. Clin Orthop Relat Res 1983;298-302. Wang GJ, Sweet DE, Reger SI, Thompson RC. Fat-cell changes as a mechanism of avascular necrosis of the femoral head in cortisone-treated rabbits. J Bone Joint Surg Am 1977; 59:729-735. Sackett DL, Wennberg JE. Choosing the best research design for each question. BMJ 1997;315:1636. Chou R, Helfand M. Challenges in systematic reviews that assess treatment harms. Ann Intern Med 2005;142:1090-1099. Kellerman SE, Herold J. Physician response to surveys: A review of the literature. Am J Prev Med 2001;20:61-67. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res 2001;35:1347-1355. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129-1136. Khalily C, Behnke S, Seligson D. Treatment of closed tibia shaft fractures: A survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International–Gerhard Kuntscher Kreis meeting. J Orthop Trauma 2000;14:577-581. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Surgeons’ preferences for the operative treatment of fractures of the tibial shaft: An international survey. J Bone Joint Surg Am 2001;83:1746-1752. Matarasso A, Elkwood A, Rankin M, Elkowitz M. National plastic surgery survey: Face lift techniques and complications. Plast Reconstr Surg 2000;106:1185-1195; discussion 1196.
USE OF MEDROL DOSEPAK FOR SPORTS INJURIES Questionnaire: Medrol Dosepacks & Routine Sports Injuries Instructions: Please circle the correct answer and elaborate as indicated 1. 2. 3. 4. 5.
6.
7.
8.
9. 10.
How many years have you been in practice? < 10 10-20 > 20 What is the average age of your patient population? < 20 20-40 40-55 > 55 How many total patients do you see in a year? < 500 500-2000 2000-4000 > 4000 Do you use Medrol Dosepacks in the treatment of any sports injuries? Yes No If not, OR if you restrict their use, why? (1 = Least ? 2= Somewhat? 3= Very? 4 = Most Important) a) Fear of complications in general? 1 2 3 4 b) Specific fear of osteonecrosis? 1 2 3 4 c) Lack of proven efficacy? 1 2 3 4 d) Fear of lawsuit/malpractice? 1 2 3 4 If you prescribe Medrol Dosepacks a) How long have you used them? < 1 yr 1-5 yrs 5-10 yrs >10 yrs b) How often do you use them in any given year? < 10/yr 10-50/yr 50-100/yr 100-250/yr >250/yr c) Have you ever used them multiple times in a single patient in a given year? Yes No d) What is the estimated total # of times you have prescribed them? < 10 10-50 50-100 100-250 >250 Why do you prescribe them? a) Delayed Onset Muscle Soreness (DOMS) Yes No b) Accelerate recovery (return to play) Yes No c) Post-Injury i. Swelling Yes No ii. Stiffness Yes No iii. Pain Yes No d) Post-Surgical i. Swelling Yes No ii. Stiffness Yes No iii. Pain Yes No Have you ever seen any of the following complications result from using Medrol Dosepacks? a) Osteonecrosis Yes (# = ; Location(s) = ) No b) Glucose intolerance Yes (# = ) No c) Hypertension Yes (# = ) No d) Infection Yes (# = ) No e) Impaired wound healing Yes (# = ) No f) Tendon/Ligament rupture Yes (# = ) No g) GI disturbance/ulcers Yes (# = ) No h) Myopathy Yes (# = ) No i) Behavior disturbances Yes (# = ) No j) Growth inhibition Yes (# = ) No k) Other? Do you have an age limit below which you will not prescribe? Yes (Age limit = ) No What is the efficacy of Medrol Dosepacks in your experience? Do they – a) Improved function Yes No b) Decreased pain Yes No c) Improved joint motion Yes No d) Accelerated a return to activity? Yes (How many days? # = ) No e) Other?
FIGURE 1.
Medrol Dosepak survey mailed to AANA and AOSSM members.
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TABLE 1. Demographic Profile of Respondents Who Do and Do Not Prescribe MDP for Sports Injuries
Years in practice ⬍10 10–20 ⬎20 Average age of patient, yr ⬍20 20–40 20–55 40–55 40–⬎55 ⬎55 Total patients/yr ⬍500 500–2,000 2,000–4,000 ⬎4,000 MDP, Medrol Dosepak.
Percent of Those Who Use MDP (n ⫽ 603)
Percent of Those Who Do Not Use MDP (n ⫽ 672)
33 35 32
38 31 30
1 53 5 39 1 1
1 43 7 45 0 3
2 26 44 28
3 27 47 22