To the sore itself a compress, anointed with white cerate, will be sufficient, for if a piece of flesh or nerve [tendon?] become black, it will fall off . . .
On Fractures, Part 27: The Treatment of Sores; 400 BC.
The potential for injury is embedded in athletic competition. Today’s amateur and professional athletes, however, are pampered in comparison to competitors in many ancient sports. Underhanded tactics in the early Olympics were often considered part of the game. In boxing matches, gouging with all fingers was permitted. Boxers wrapped their hands with leather thongs that caused painful wheals to develop on opponents struck during competition. In competitive pankration, a violent combination of boxing and wrestling, kicking and strangling were allowed, and breaking an opponent’s fingers was a common first move.1
Treating sports-related injuries has challenged physicians since antiquity, but today’s compounding pharmacists offer new therapies that can minimize tissue damage and ensure a rapid return to fitness. Some formulations can be used before exercise or competition to ready the body for increased physical stress. Other preparations can be applied shortly after injury to enhance healing.
Sports trainers, physicians and compounding pharmacists have unique perspectives on sports injuries but a common goal: healing the injured athlete. Danny Poole, MEd, ATC, is the director of sports medicine and head athletic trainer at Clemson University in Clemson, South Carolina. Austin Gore, PharmD, and William Wills, RPh, are compounding pharmacists whose specialties include sports medicine preparations. Patrick Knost, MD, is a physician skilled in the treatment of sports injuries, including those sustained in extreme-sports competition. In this article, these experts explain their use of compounds in treating amateur and professional athletes- and weekend warriors as well.
The Trainer’s Perspective
A staff member of the Clemson athletic department for more than 20 years, Danny Poole now oversees 18 intercollegiate sports programs for men and women, including football, volleyball, basketball, swimming, soccer, baseball, golf, tennis and track. Approximately 550 students who range in age from 18 to 22 years participate in Clemson sports.
As a certified athletic trainer, Poole has a three-fold responsibility: first, to prevent injuries from occurring; then, if they do occur, to intervene with immediate first aid to prevent injury-related complications; and, finally, to rehabilitate the athlete to pre-injury fitness level and a quick return to competition. Poole works closely with coaches and an onsite team physician who prescribes either compounded or commercially prepared medications and oversees therapy as healing progresses. “Many factors are involved in preventing and treating sports injuries,” Poole said. “We handle almost all the medical needs of our student athletes. We ensure that protective sports equipment fits correctly and that the athlete has the proper equipment before competition begins. For example, the correct type of brace can prevent injury to the knees or ankles during practice. We try to cover all the bases, literally; the practice area must be carefully surveyed before use. Holes in a football field must be filled and devices like sprinkler heads must be removed before practice or a game. Accidents do occur, though, and treating sports injuries is a big part of the professional life of every athletic trainer.”
Sports medicine staff are often the first responders to medical emergencies that occur during competition, and prompt treatment is essential. “We see two types of sports injuries,” said Poole. “Chronic overuse injuries are caused by repetitive stress and/or improper style. Acute injuries are caused by traumatic contact during competition. The type of injury varies with the sport. Swimmers and baseball players most often sustain overuse injuries such as tendinitis or muscle inflammation, or they experience pain caused by mechanically improper style. Acute injuries like sprains, strains or fractures are common in those who participate in a contact-collision sport like football; they can injure anything from their head to their toes. Muscle strain and tendinitis often occur in athletes who participate in track. Soft-tissue injuries are very common in all sports, and skin problems like cuts, rashes or abrasions can afflict any athlete.”
Over the years, Poole has found that certain compounded topicals applied immediately after injury are especially effective in minimizing soft-tissue damage. “Nothing available over the counter comes close to the effectiveness of compounds,” he said. “They are prescription-based medications prepared specifically for the injured patient.” About half the medications he uses to treat sports injuries are compounded, and he keeps a supply of various preparations on hand. Because a compound must be used within a specified period of time, he always verifies that each medication has not expired before it is applied. “We often use a topical compound as a second-line treatment for chronic injury when therapy with ice, muscle stimulation, ultrasound or moist-heat packs has failed. If an injury is severe, we might follow up with iontophoresis or phonophoresis to convey a compounded anti- inflammatory drug, acetic acid (which reduces scar tissue) or lidocaine in a special cream or gel base to injured tissue.”
The Medicine Chest
Poole keeps the following compounds handy to treat injured Clemson athletes. The schedule for application and the duration of treatment vary from patient to patient.
* Ketoprofen 10%, 15% or 20% in Pluronic lecithin organogel (PLO) to treat sprains, strains and inflammation. A pea-sized amount of the PLO gel is rubbed with a moist fingertip into the skin three to four times daily. An aqueous solution of that drug can also be administered by iontophoresis, or the medication can be prepared as an ultrasound gel for use in phonophoresis.
* Dexamethasone 0.4% in an aqueous solution for iontophoresis to treat sprains, strains and inflammation. That concentration of dexamethasone can also be prepared in PLO for application immediately after a sports-related injury to minimize inflammation. In those cases, a pea-sized amount of the gel is rubbed with a moist fingertip into the skin.
* Acetic acid 2% or 4% in an aqueous solution administered by iontophoresis to reduce scar tissue.
* A combination of baclofen 5%, lidocaine 10% and guaifenesin 10% or 20% in PLO to prevent muscle cramps.
* Lidocaine 4%, epinephrine (adrenalin) 0.05% and tetracaine 0.5% (LAT) in a spray or hydroxyethylcellulose gel to treat cuts and abrasions. This preparation is applied immediately after injury.
* Muscle relaxants such as guaifenesin (usually 10% or 20%) in PLO or cyclobenzaprine 0.5%, 1% or 2% in PLO. The mechanism of action of those drugs determines which is selected to treat muscle strain. Cyclobenzaprine in PLO is administered topically or by ultrasound, and guaifenesin in PLO is applied topically three to four times daily until relief is noted.
“Compounds definitely have a place in the treatment of the injured college athlete,” said Poole. “The customized topicals that we use for sports injuries are not commercially available. Athletic trainers should work with a compounding pharmacist and a physician to devise treatments for the injuries their athletes usually sustain. They should also keep an adequate supply of those medications on hand for immediate use or long-term therapy. It is our goal to put athletes back into their field of play as safely and quickly as possible, and compounding pharmacists can often help. They can provide us with therapeutic tools to restore the injured athlete to pre-injury fitness.”
The Compounded Viewpoint
Austin Gore, PharmD, CGP, is a certified geriatrics pharmacist, a clinical pharmacist and the owner of Clinical Specialties Compounding Pharmacy in Augusta, Georgia. He is also the compounder who provides most of the customized topicals for injured Clemson athletes. “Clinical Specialties is a compounding-only pharmacy with a wide range of services,” said Gore. “Our patients range in age from 8 weeks to 98 years, and among them are Danny Poole’s students. But many of the injuries that occur during sports competition (sprains, muscle inflammation, contusions) also afflict nonathletes.
“Sports medicine today has a broad definition. It’s not just about athletes any more; it’s also about the average individual, the patient in rehabilitation and the weekend warrior. For example, the gels and creams used to treat sports injuries can be used by podiatric or orthopedic patients, people undergoing physical therapy, individuals who have everyday aches and pains and arthritis sufferers.” Gore always works with a physician who provides a prescription for the compounds prepared. “My goal is to enhance the practice of sports medicine by the trainer, the physician or the physical therapist to improve outcome. Compounding often provides more and better treatment options for doing so.”
Gore’s most often requested sports medications are topical gels that are not available commercially. “Topical medications convey the drug directly to the site of injury and produce minimal adverse effects,” he said. “Some of the most effective topicals we prepare contain combinations of various a\nti-inflammatories or corticosteroids such as ketoprofen, dexamethasone, diclofenac, indomethacin, naproxen sodium, lidocaine or magnesium sulfate plus methylsulfonylmethane (MSM) in PLO or Lipoderm. Many of these preparations are very effective as a pregame rub and are popular remedies for the weekend warrior’s anticipated overuse injuries.
“LAT gel, which can be used to minimize bleeding from scrapes and cuts, is frequently requested. When the cuts begin to heal, we prepare our ‘special blend’ (a cream that accelerates the healing process) for our patients.” Gore has applied for a patent on that preparation, which is very promising as a wound-care treatment.
Also popular is an electrolyte-balancing preparation that contains a combination of potassium chloride, sodium chloride, magnesium and calcium carbonate. It is available in capsules or as a powder that must be mixed with a liquid, and the formulation can be adjusted to meet athletes’ specific rehydration needs. Unlike some commercially available electrolyte products and supplements that may be unregulated in content, the concentration of ingredients in the compound is carefully monitored by the compounding pharmacist. “We also prepare capsules of magnesium glycinate, which reduces postgame stiffness and soreness and promotes restful sleep,” said Gore. “The compounds requested most frequently for sports-related trauma, though, are those used to treat soft-tissue injuries: dexamethasone 0.4% or ketoprofen 10% in cither PLO or in an aqueous solution for use in iontophoresis, ketoprofen 10% or 20% solid anhydrous, diclofenac 10% solid anhydrous or indomethacin 10% or 20% solid anhydrous. To treat calcifications, we prepare an aqueous solution of acetic acid 4% for administration by iontophoresis.”
Gore is now researching the half-life of various nonsteroidal anti-inflammatory drugs (NSAIDs) to determine whether better, safer topical formulations could reduce the number of doses administered daily. “I like to think outside the box,” he said. “For example, topical ketoprofen is often applied three or four times daily by student athletes or patients, but oral NSAlDs like oxaprozin can be compounded in a PLO gel for once-daily topical use. That preparation is not commercially available but could be very effective and safe in treating soft-tissue injuries.
“We’re also investigating the stability and efficacy of naproxen sodium for use in iontophoresis,” Gore said. “The space left in the vial containing naproxen sodium must be blanketed with sterile nitrogen gas. Because I don’t have access to sterile nitrogen gas, we have dispensed that medication in unit-dose packages that contain no dead space.”
Gore has been very successful in building the sports-medicine component of his compounding practice. He has done so by creating relationships with his clients and with local physicians, athletic trainers and physical therapists. “If you want to market the sports medicine component of your practice,” he said, “identify and contact the doctors who treat high school or college athletes. Local colleges or universities usually have a variety of athletic programs, and the athletic trainers there can often use your help. Contact local orthopedic and family practice physicians, and get to know your patients.
“Remember that sports medicine preparations can also be helpful to the nonathlete. Patients who are recovering from knee replacement or are undergoing rehabilitation can, in my opinion, recover faster when a compounded topical medication is applied to the surgical site. Almost every patient that pharmacists see has some aches and pains that would respond to a customized sports preparation. Your intervention can prepare the way for your visit to those patients’ healthcare professionals to share information about other useful compounds.”
Patrick M. Knost, MD, is a family medicine physician with expertise in diverse specialties: sports medicine, wilderness medicine, travel medicine and the treatment of andropause. In solo private practice in Placerville, California, he is also a nationally renowned lecturer on men’s health and bioidentical hormone replacement. Dr. Knost has long been a participant in extreme sports and martial arts competitions and provides medical care for athletes in a variety of national and international sports events. He has also served as a medical committee member of the USA National Karate- do Federation (USA-NKF) and as an attending physician at the international 2000 TreK competition. Sports medicine remains his special interest. “I enjoy working with people who want to recover,” he said, “and most injured athletes are highly motivated to return to their pre-injury functional level.” Suturing, taping and gluing are often required onsite for more severe competition-related injuries such as open nasal fractures and transient paralysis. Common lesser trauma includes sprains, muscle inflammation and abrasions.
Dr. Knost has found that topical compounds can be very effective in the treatment of sports-related soft-tissue injuries. “I often use a compound of aloe vera, lidocaine and bupivacaine to treat abrasions,” he said. “The lidocaine and bupivacaine are regional infiltrative anesthetics. The aloe, which has antibiotic properties, also acts as an antiprostaglandin to reduce inflammation, soothe injured tissue, and promote healing.”
Knost’s prescription of choice for treating the scrapes and soft- tissue injuries sustained during competition is ketoprofen 20% in penetration-enhancing vehicles. “In sports medicine, compounded ketoprofen cream is incredibly effective,” he said. “It provides immediate relief, and it’s very safe-I don’t know what I’d do without it. It’s an excellent treatment for contusions, sprains (especially twisted knees), strains, insect bites and crush injuries. I often give my injured patients a 10-mL syringe filled with the cream for later application. I’ve also prescribed it for patients who have trochanteric bursitis, which often afflicts weekend warriors or those who have just started an exercise program. It provides relief from tennis elbow in 10 minutes, and it’s a great treatment for osteoarthritis of the fingers. Compounds like this cream provide my patients with effective treatments that aren’t available commercially.”
For additional information on the treatment of sprains, strains and abrasions, contact Patrick M. Knost, MD, 1106 Corker Street, Placerville, CA 95667. E-mail: [email protected]
William R. Wills is the owner of Grandpa’s Compounding Pharmacy in Placerville, California. He prepares ketoprofen 20% cream and other formulations for Dr. Patrick Knost and a host of other physicians who treat sports- and work-related injuries. “Compounds provide practitioners with a greater variety of treatment options,” said Wills. “Every sports medicine chest should be equipped with a compounded topical anti-inflammatory like ketoprofen 20% cream for use as a pregame rub or a treatment for sprains and strains. Guaifenesin 20%, a muscle relaxant, can be added to the ketoprofen cream or used as the sole ingredient in a cream base to relieve muscle tightness in seconds. Bruises, scrapes, cuts, abrasions and other injuries (including open wounds) can be treated with a topical preparation containing vitamins B5 and B6 in PLO. That preparation has anti-infective properties, inhibits bleeding, provides analgesia without anesthesia and promotes rapid healing. It causes the worst bruises to resolve within 4 days and heals blisters very rapidly.
“Athletes do have health problems other than injuries,” Wills notes. “For refractory athlete’s foot, we can compound an anti- fungal, antibacterial ‘foot bomb’ containing a customized combination of ketoconazole, miconazole, clotrimazole, terbinafine, ibuprofen, nystatin and/or tea tree oil in Dermabase.
“Because they convey prescribed drugs immediately to targeted tissues, topical compounds are very effective in treating injuries and chronic pain. Most of those medications are not available commercially. There are no contraindications to their use, and they produce no adverse effects. We can use them to treat and resolve many sports-related injuries without causing more problems for our patients.”
For additional information on the treatment of sprains, strains and abrasions, contact William R. Wills, HPh, Grandpa’s Compounding Pharmacy, 7563 Green Valley Road, Placerville, CA 95667-3917. E- mail: [email protected]
1. Kuntz T. The guy who ate a cow and other Olympic stars. New York Times. [New York Times Website.] July 14, 1996. Available at: http://www.nytimes.com/specials/olympics/cntdown/ 0714oly- review.html. Accessed April 26, 2004.
St. Louis, Missouri
Address correspondence to: Danny Poole, MEd, ATC, PO Box 31, Clemson, SC 29633. E-mail: [email protected]; or Austin Gore, PharmD, Clinical Specialties Compounding Pharmacy, 3708-A Executive Center Drive, Augusta, GA 30907. E-mail: [email protected]; Website: www.clinicalrx.net
Copyright International Journal of Pharmaceutical Compounding Nov/ Dec 2004