As an athlete or active person, you’ve probably had your fair share of aches and pains. Chances are when you are faced with a headache, muscle soreness, or even a minor injury, you’ve probably popped a couple of ibuprofen tablets (or some other anti-inflammatory medication) and gone on your merry way.
You may have also thought that if ibuprofen helps you feel better when something already hurts, that it might also help to prevent you from getting sore or feeling the effects of a particularly hard training session. But research has shown that ibuprofen can actually have a negative effect on your training, as well as causing serious harm to your kidneys, especially in endurance athletes.
is ibuprofen bad for you?
how does ibuprofen work?
Ibuprofen is in a class of medication called a non-steroidal anti-inflammtory (NSAID). NSAIDs block a group of proteins called cyclooxygenases (COX), which are involved in the production of prostaglandins and thromboxanes. Prostaglandins and thromboxanes are involved in the inflammatory process.
What the research says
It is relatively common knowledge that ibuprofen and other NSAIDs are hard on your gut and have the potential to cause ulcers and other gut problems. But what about your other organs? There have been many studies investigating the effects and safety of NSAIDs before exercise.
In 2012 researches looked at the effects of taking a standard dose of ibuprofen before and after a cycling workout. This study determined that both working out and consumption of ibuprofen resulted in small intestinal injury, the injury was worse after exercising and consuming a standard dose of ibuprofen.  This shows us that consuming ibuprofen as an athlete (or at the very least, around exercise) is not harmless and should be avoided as much as possible.
Another study found that while taking 400mg of ibuprofen four hours before exercise did decrease the amount of muscle soreness experienced, it did not actually prevent injury to the muscle cells.  This is a concern because that means that ibuprofen has the potential to mask pain and increase the potential for injury because pain is often a limiting factor in how hard you push yourself. So if you feel less pain, you are able to push yourself harder, but you may also not be aware of the fact that you are causing damage or injury to your body.
What about using NSAIDs during events?
A 2005 study determined that use of NSAIDs during long events like a marathon or triathlon decreases kidney function enough to lead to serious issues. One of the most serious and concern issues was the impaired ability to regulate your electrolyte status (specifically your sodium levels) and hydration. This problem is exacerbated during events in the heat were your kidneys are already under increased stress and can lead to long-term kidney damage or even kidney failure. 
The Western States 100 mile trail race provides a great opportunity to study endurance athletes. One study done during this race in 2006 looked at the effects of various doses of ibuprofen before the race. One group took 600mg one day before and the day of the race and another group took 1200mg one day before and on race day. This study determined found that both groups had significantly higher markers of severe muscle damage (C-reactive protein, plasma cytokines, and macrophage inflammatory protein) and that this effect increased with higher doses of ibuprofen. The other interesting part of this study is that ibuprofen intake had no effect on race time, post-workout soreness, or perceived exertion. 
The Western States study is particularly eye opening because it shows that not only did the ibuprofen not really help, but that it actually cause significantly more muscle damage and inflammation compared to those who did not take any ibuprofen.
Several more recent studies have come to similar conclusions.
One study had participants in multi-day ultramarathons consume ibuprofen or a placebo every four hours during a 50 mile stage of their race. After, they drew blood to look at markers of kidney stress (specifically, creatinine) and found that a significant portion of all the participants (about 44%) had levels that indicated kidney injury. Participants who had taken ibuprofen, were 18% more likely to have an acute kidney injury than those who received the placebo and their injuries were more severe. 
Note: One major problem that I have with this study is that taking ibuprofen every four hours is not recommended. A normal dose frequency of ibuprofen is every six to eight hours. I would like to have seen what the effect on the kidneys would be if someone who was not exercising took ibuprofen every four hours. However, I do still believe that this illustrates the potential harm that can come from consuming ibuprofen during exercise.
Another recent study (this one from 2017) reinforced the idea that NSAIDs change how a body responds to muscular exertion. This study was done in mice and looked at muscle cells and tissue that had experienced muscular injury compared to the type of injuries typical to strenuous exercise. They also tested the mice after the injuries had healed which showed that the healed tissue was stronger than it had been before.
This mimics what happens in humans during and after strenuous exercise as well. However, when NSAIDs were introduced into the process, they found that the muscle tissue (even after healing) was not as strong as it was without NSAIDs which suggests that NSAIDs might impair the ability fo your muscles to regenerate and strengthen after hard workouts. 
misconceptions about nsaids
A study in the January 2011 issue of Sports Health looked at the use of over the counter pain medications in college football players. The findings of the survey conducted among Division 1 NCAA football players at eight colleges found that these athletes were using over the counter pain medications frequently, without supervision, and at much higher doses than recommended. They also found that this population used these medications at a much higher rate than the general population. 37% of the football players surveyed used more than the recommended dose. 64% made the decision to use the medication themselves rather than at the suggestion of their certified athletic trainer or physician.
There also seemed to be several misconceptions about these medications amongst the athletes. 36% of the athletes who took more than the recommended dose believed that it would make the pain go away faster. 89% too more because they thought they needed a higher dose due to their large size, however, adult doses are not based on body weight. 41% took the medication because they expected to be in pain after practice or a game and 31% took them to avoid missing practice or a game.
You might be wondering what this has to do with you if you aren’t a college football player. I think that this study, even though it looked at a very specific population, can be generalized to the average person (though maybe not quite to the same extent). I definitely agree that NSAIDs are ok to use without the recommendation of a healthcare provider, but only very short term. I also think that it’s important to understand, as illustrated by many of the studies I cited, the impact that these medications have on your physiology. They are relatively safe, but they are not consequence free mediations. I also think that proper patient education either by a healthcare provider or package information would help to decrease the chances of taking too much or taking these medications for too long. I also think it’s important to realize that if you feel you need to take medication for pain for more than 7-10 days that it is important to seek the help of a healthcare provider as there is likely something else going on and it’s important to treat the underlying cause of the pain rather than just masking the pain.
alternatives to ibuprofen
It’s easy to pop some ibuprofen when something hurts because it works on a lot of different types of pain. However, I think we’ve covered a lot of reasons why that may not be the best or safest option, especially if you are an athlete. Finding an alternative to ibuprofen and NSAIDs might prove a little difficult and require some trial and error because the root cause of your pain might determine what works best to alleviate it.
All things collagen
Studies have suggested that collagen doses of 1-2g per day  can improve joint comfort and that those who have the greatest joint deterioration with the least intake of meat had the greatest benefit.  Collagen also decreases pain and protects cartilage in those with osteoporosis and osteoarthritis. 
Glycine, a major component of collagen, is linked to collagen synthesis. Humans are only able to synthesize 3g of glycine per day, but our bodies require up to 12g of glycine in order to meet the demands of collagen synthesis.  This is where consuming bone broth can be very helpful as the best source of collagen and glycine comes from the cartilage and other tissues of animal. Also, making sure to add some lemon or consume something with vitamin C in conjunction with your collagen rich foods (such as bone broth) is helpful, as it can increase exercise-induced collagen synthesis and is a critical part of skin health. [11, 12]
If you choose to go the route of adding collagen powder to your smoothies or coffee (this one is my favorite), aim for 20g twice a day (though I’d argue that you shouldn’t skip the bone broth even if you do go this route). I have long been adding scoops of collagen to my coffee in the morning and I feel that my skin looks and feels better and my joints tend to feel less sore after workouts.
First of all, magnesium may be beneficial to your sports performance because ATP (the main source of energy in your cells) needs to be bound to a magnesium ion in order to be biologically active. And second, most people are deficient in magnesium, which is especially detrimental to athletes. Magnesium is involved in numerous processes that affect muscle function including oxygen uptake, energy production and electrolyte balance. 
It is thought that topical magnesium is better absorbed than oral magnesium, though more research is needed in this area.  There are several options for getting your magnesium through your skin, there is magnesium spray (which tends to feel a little sticky after it dries) or there’s magnesium lotion which is great for sensitive skin. You can also get magnesium flakes which you can put into your bath.
Applying magnesium topically either with the spray or using the lotion seems to not only help people who get nighttime leg cramps, but also anyone who has done a tough race or had a hard training session. If you’ve ever been kept awake at night with aching, twitching, or cramping legs or arms after a tough workout, topical magnesium appears to help prevent that.
Omega-3 Fatty Acids
Multiple studies have shown that omega-3 fatty acids act as an anti-inflammatory, especially when they are consumed in doses over 1 gram.  Omega-3s also appear to be able to decrease joint pain due to inflammation and health issues such as inflammatory bowel disease, dysmenorrhea, and rheumatoid arthritis.  Omega-3s are also great for improving mood and cognition and supporting a healthy circulatory and nervous system.
Fish oil is the best source of omega-3 fatty acids. But, it’s important to remember that taking bad fish oil (i.e. oxidized or low quality) is worse than not taking fish oil. Sustainability is also a concern when it comes to finding a good fish oil supplement.
The two brands I recommend based on my own experience and research are Green Pastures Fermented Cod Liver Oil and Jarrow Max DHA. You can find more information about how to pick a good omega-3 supplement in this blog post from Chris Kresser.
Sudden and intense exposure to cold causes the release of cold-shock proteins. This special class of proteins helps to speed up recovery and decreases inflammation.  You can use an ice pack or take an ice bath to get the benefits of cryotherapy at home.
Cold therapy triggers the release of norepinephrine which has anti-inflammatory properties and can help to reduce pain. One study done with cold water, winter swimming for 2 minutes, showed that norepinephrine remained elevated for 12 weeks after cold water exposure.  There is also evidence that low doses of physical stress from exposure to extreme cold can trigger and adaptive response that strengthens your immune system by increasing white blood cells.  Short bursts of cold therapy have also been shown to increase the powerful antioxidants glutathione and superoxide dismutase, which helps to support liver function, immune function, cellular function, and protects again oxidative stress. 
While there’s still a lot of debate over whether there’s enough evidence to support the use of CBD oil in the management of conditions such as chronic pain or anxiety, there is some evidence that CBD oil is effective for pain management. It acts on various pathways and is a relatively safe way to manage pain with a low incidence of side effects. 
There are an increasing number of studies on CBD and it shows great promise as a way to decrease the impact of inflammation on oxidative stress  as well as decrease inflammation. 
I have found in using this myself as well as with patients that it works very well for some and not so well for others. The effectiveness also seems to vary depending on what it’s being used for. Some have great luck in using CBD cream topically for pain, others have great luck in taking CBD oil for anxiety, sleep, or pain. However, it does not always seem to work for everything on everyone, so I would encourage you to experiment a bit. The source also matters as there is little regulation on purity and potency. I like NuLeaf Naturals the best as it has a third party certificate verifying its purity and it is truly full-spectrum.
alternating heat & cold
While there are many benefits to heat and cold on their own, combining the two has even greater benefits. Everything from anti-aging, skin healing, detoxification, and speeding up muscle and joint recovery. Alternating with hot and cold therapy, which can be done in the shower (alternating hot and cold water) takes advantage of many of the benefits of activating both heat-shock and cold-shock proteins. If you have access to a sauna or steam room, you could also alternate 10-15 minutes of hot with a 2-5 minute cold shower or cold water swim.
eat sulfur rich foods
Sulfur is commonly found in methionine which is an essential amino acid found in meat, cheese, and eggs. It’s also found in cysteine, which is an amino acid found in poultry, pork, eggs, and milk. You can also find sulfur in many vegetables in the form of “organosulfur compounds.”
If you’ve ever smelled an egg or broccoli and thought that it smelled bad, that’s the sulfur. All fibrous non-leafy green vegetables contain decent amounts of sulfur. Vegetables like broccoli, cauliflower, Brussels sprouts, onions, garlic, and leeks.
The sulfurous compounds in garlic have been shown to protect your body from oxidative damage.  Sulforaphane, a sulfurous compound found in broccoli, cabbage, Brussels sprouts, and cauliflower reduces oxidative stress by increasing glutathione activity  and inhibits mitochondrial permeability. 
curcumin & other herbal medicine
The active compound in turmeric is curcumin, which is what gives the spice its healing properties. One systematic review determined that there was sufficient evidence to support the efficacy of about 1000 mg/day of curcumin in the treatment of pain associated with arthritis. 
Unfortunately, turmeric root itself is about 2-5% curcumin, so it’s important to make sure that you are buying curcumin not powdered turmeric root. Cucumin is also not easily absorbed in the digestive tract, so make sure that you find a high-potency option and ingest it with an oil since it is fat soluble. Black epper has also been shown to increase the bioavailability of curcumin by about 2000%. 
Other herbs that have anti-inflammatory effects include ginger,  Boswellia,  and rosemary. 
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS is a powerful tool for pain and inflammation. While it might look and sound like electrical shock therapy, it’s much less scary and more gentle than that. TENS sends a mild electrical current through muscle and soft tissue which stimulates repair compounds and pain-relieving endorphins.
One study showed that pain caused by joint inflammation was decreased in response to both high and low frequency TENS. It also showed that while typical application of the electrodes is at the site of injury, there was also a benefit to applying the electrodes elsewhere.  There is also evidence demonstrating its effectiveness in managing postoperative pain. 
The evidence also suggests that a tolerance to the action of TENS can be developed. There are no defined parameters for TENS application that appear to best relieve pain, but the intensity of the stimulation appears to be a critical factor in its effectiveness. 
Massage or manual therapy is effective in treating many different types of pain.  It appears to be least effective for pain related to fibromyalgia , but can help decrease the pain associated with a tough workout.  Massage can also help to correct musculoskeletal issues or dysfunctional movement patterns that may be contributing to pain (this is part of treating the root cause of your pain).
Massage can also help to lower high blood pressure,  help to manage depression, anxiety, and fatigue,  and improve immunity. 
While there are certainly many medications that are less safe than ibuprofen and NSAIDs, this group of medications is not without consequences, and based on the scientific evidence, is less safe if you are an athlete as it can contribute to several serious health concerns such as GI issues and kidney damage.
There are may alternatives to NSAIDs when it comes to relieving or reducing the pain associated with intense physical activity (if you have an acute injury, please see a healthcare provider to get treatment). If you implement any or all of the methods outlined here, you’ll likely bounce back faster and feel better after your workouts. Many of these NSAID alternatives can also help you recover from an injury faster, but I do encourage you to seek professional medical help to get an official diagnosis and treatment in the case of injury.
Do you have any non-NSAID or pain medication-free approaches to managing your pain? Leave a comment and tell me about what works for you!
1. Van Wijck, K., Lenaerts, K., Van Bijnen, A., Boonen, B., Van Loon, L., DeJong, C., & Buurman, W. (2012). Aggravation of Exercise-Induced Intestinal Injury by Ibuprofen in Athletes. Medicine & Science In Sports & Exercise, 44(12), 2257-2262. doi: 10.1249/mss.0b013e318265dd3d
2. Donnelly, A., Maughan, R., & Whiting, P. (1990). Effects of ibuprofen on exercise-induced muscle soreness and indices of muscle damage. British Journal Of Sports Medicine, 24(3), 191-195. doi: 10.1136/bjsm.24.3.191
3. Rahnama, N., Rahmani-Nia, F., & Ebrahim, K. (2005). The isolated and combined effects of selected physical activity and ibuprofen on delayed-onset muscle soreness. Journal Of Sports Sciences, 23(8), 843-850. doi: 10.1080/02640410400021989
4. Nieman, D. (2007). Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition. Yearbook Of Sports Medicine, 2007, 236-237. doi: 10.1016/s0162-0908(08)70190-9
5. Lipman, G., Shea, K., Christensen, M., Phillips, C., Burns, P., Higbee, R., . . . & Krabak, B.J. (2017). Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial. Emergency Medicine Journal, 34(10), 637-642. doi: 10.1136/emermed-2016-206353
6. Ho, A., Palla, A., Blake, M., Yucel, N., Wang, Y., & Magnusson, K., . . . & Blau, H.M. (2017). Prostaglandin E2 is essential for efficacious skeletal muscle stem-cell function, augmenting regeneration and strength. Proceedings Of The National Academy Of Sciences, 201705420. doi: 10.1073/pnas.1705420114
7. Bruyère, O., Zegels, B., Leonori, L., Rabenda, V., Janssen, A., Bourges, C., & Reginster, J. (2012). Effect of collagen hydrolysate in articular pain: A 6-month randomized, double-blind, placebo controlled study. Complementary Therapies In Medicine, 20(3), 124-130. doi: 10.1016/j.ctim.2011.12.007
8. Benito-Ruiz, P., Camacho-Zambrano, M., Carrillo-Arcentales, J., Mestanza-Peralta, M., Vallejo-Flores, C., & Vargas-López, S. et al. (2009). A randomized controlled trial on the efficacy and safety of a food ingredient, collagen hydrolysate, for improving joint comfort. International Journal Of Food Sciences And Nutrition, 60(sup2), 99-113. doi: 10.1080/09637480802498820
9. Porfírio, E., & Fanaro, G. (2016). Collagen supplementation as a complementary therapy for the prevention and treatment of osteoporosis and osteoarthritis: a systematic review. Revista Brasileira De Geriatria E Gerontologia, 19(1), 153-164. doi: 10.1590/1809-9823.2016.14145
10. Li, P., & Wu, G. (2017). Roles of dietary glycine, proline, and hydroxyproline in collagen synthesis and animal growth. Amino Acids, 50(1), 29-38. doi: 10.1007/s00726-017-2490-6
11. Shaw, G., Lee-Barthel, A., Ross, M., Wang, B., & Baar, K. (2016). Vitamin C–enriched gelatin supplementation before intermittent activity augments collagen synthesis. The American Journal Of Clinical Nutrition, 105(1), 136-143. doi: 10.3945/ajcn.116.138594
12. Bjørnsen, T., Salvesen, S., Berntsen, S., Hetlelid, K., Stea, T., & Lohne-Seiler, H. . . . & Paulsen, G. (2015). Vitamin C and E supplementation blunts increases in total lean body mass in elderly men after strength training. Scandinavian Journal Of Medicine & Science In Sports, 26(7), 755-763. doi: 10.1111/sms.12506
13. Nielsen, F.H. & Lukaski, H.C. (2006). Update on the relationship between magnesium and exercise. Magnesium Research, 19(3), 180-189.
14. Suppveristy. (2018). Transdermal magnesium - finally a human study suggests that low-dose Mg2+ cream works, at least in non-athletes. Retrieved from http://suppversity.blogspot.com/2017/10/transdermal-magnesium-finally-human.html
15. Maroon, J. & Bost, J. (2006). ω-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4), 326-331. doi: 10.1016/j.surneu.2005.10.023
16. Goldberg, R., & Katz, J. (2007). A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain, 129(1), 210-223. doi: 10.1016/j.pain.2007.01.020
17. Lindquist, J., Brandt, S., Bernhardt, A., Zhu, C., & Mertens, P. (2014). The role of cold shock domain proteins in inflammatory diseases. Journal Of Molecular Medicine, 92(3), 207-216. doi: 10.1007/s00109-014-1136-3
18. Leppäluoto, J., Westerlund, T., Huttunen, P., Oksa, J., Smolander, J., Dugué, B., & Mikkelsson, M. (2008). Effects of long‐term whole‐body cold exposures on plasma concentrations of ACTH, beta‐endorphin, cortisol, catecholamines and cytokines in healthy females. Scandinavian Journal Of Clinical And Laboratory Investigation, 68(2), 145-153. doi: 10.1080/00365510701516350
19. Shevchuk, N. & Radoja, S. (2007). Possible stimulation of anti-tumor immunity using repeated cold stress: a hypothesis. Infectious Agents And Cancer, 2(1), 20. doi: 10.1186/1750-9378-2-20
20. Lubkowska, A., Dołęgowska, B., & Szyguła, Z. (2012). Whole-body cryostimulation - potential beneficial treatment for improving antioxidant capacity in healthy men - significance of the number of sessions. Plos ONE, 7(10), e46352. doi: 10.1371/journal.pone.004635221. https://www.ncbi.nlm.nih.gov/pubmed/11238809
22. Guerrero-Beltrán, C., Calderón-Oliver, M., Pedraza-Chaverri, J., & Chirino, Y. (2012). Protective effect of sulforaphane against oxidative stress: Recent advances. Experimental And Toxicologic Pathology, 64(5), 503-508. doi: 10.1016/j.etp.2010.11.005
23.Greco, T., Shafer, J., & Fiskum, G. (2011). Sulforaphane inhibits mitochondrial permeability transition and oxidative stress. Free Radical Biology And Medicine, 51(12), 2164-2171. doi: 10.1016/j.freeradbiomed.2011.09.01724. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5003001/
25. Shoba, G., Joy, D., Joseph, T., Majeed, M., Rajendran, R., & Srinivas, P. (1998). Influence of piperine on the pharmacokinetics of curcumin in animals and human volunteers. Planta Medica, 64(04), 353-356. doi: 10.1055/s-2006-957450
26. Mashhadi, N. S., Ghiasvand, R., Askari, G., Hariri, M., Darvishi, L., & Mofid, M. R. (2013). Anti-oxidative and anti-inflammatory effects of ginger in health and physical activity: review of current evidence. International journal of preventive medicine, 4(Suppl 1), S36-42.
27. Ammon, H. (2006). Boswellic acids in chronic inflammatory diseases. Planta Medica, 72(12), 1100-1116. doi: 10.1055/s-2006-94722728. https://www.clinicaladvisor.com/alternative-meds-update/rosemary-boasts-cognitive-and-anti-inflammatory-benefits/article/270616/
29. Ainsworth L, Budelier K, Clinesmith M, Fiedler A, Landstrom R, Leeper B.J., . . . & Sluka K.A. (2006. Transcutaneous electrical nerve stimulation (TENS) reduces chronic hyperalgesia induced by muscle inflammation. Pain. 20(1-2), 182-187.
30. DeSantana J.M., Santana-Filho V.J., Guerra D.R., Sluka K.A., Gurgel R.Q., & da Silva W.M. (2008). Hypoalgesic effect of the transcutaneous electrical nerve stimulation following inguinal herniorrhaphy: a randomized, controlled trial. Journal of Pain. 9(7), 623-629.
31. DeSantana, J. M., Walsh, D. M., Vance, C., Rakel, B. A., & Sluka, K. A. (2008). Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Current rheumatology reports, 10(6), 492-499
32. Sherman, K., Cook, A., Wellman, R., Hawkes, R., Kahn, J., Deyo, R., & Cherkin, D. (2014). Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. The Annals Of Family Medicine, 12(2), 112-120. doi: 10.1370/afm.1602
33. Tsao J. C. (2007). Effectiveness of massage therapy for chronic, non-malignant pain: A review. Evidence-based complementary and alternative medicine : eCAM, 4(2), 165-179.
34. Zainuddin, Z., Newton, M., Sacco, P., & Nosaka, K. (2005). Effects of massage on delayed-onset muscle soreness, swelling, and recovery of muscle function. Journal of athletic training, 40(3), 174-180.
35. Givi, M. (2013). Durability of effect of massage therapy on blood pressure. International Journal of Preventive Medicine 4(5), 511-516.
36. Currin, J., & Meister, E. (2008). A hospital-based intervention using massage to reduce distress among oncology patients. Cancer Nursing, 31(3), 214-221. doi: 10.1097/01.ncc.0000305725.65345.f3
37. Rapaport, M., Schettler, P., & Bresee, C. (2010). A preliminary study of the effects of a single session of swedish massage on hypothalamic–pituitary–adrenal and immune function in normal individuals. The Journal Of Alternative And Complementary Medicine, 16(10), 1079-1088. doi: 10.1089/acm.2009.0634
38. Russo, E. (2008). Cannabinoids in the management of difficult to treat pain. Therapeutics And Clinical Risk Management, 4(1), 245-259. doi: 10.2147/tcrm.s1928
39. Booz, G. (2011). Cannabidiol as an emergent therapeutic strategy for lessening the impact of inflammation on oxidative stress. Free Radical Biology And Medicine, 51(5), 1054-1061. doi: 10.1016/j.freeradbiomed.2011.01.007
40.Burstein, S. & Zurier, R. (2009). Cannabinoids, endocannabinoids, and related analogs in inflammation. The AAPS Journal, 11(1), 109-119. doi: 10.1208/s12248-009-9084-5