What is the role of ketorolac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in treating Achilles tendonitis and peroneal tendinitis?

Ketorolac in the Treatment of Achilles Tendonitis and Peroneal Tendinitis

NSAIDs, including ketorolac, are recommended as a first-line treatment option for Achilles tendonitis and peroneal tendinitis, but should be used short-term (less than 2 weeks) to avoid potential complications. 1

Mechanism and Efficacy

Ketorolac is a potent NSAID that works by inhibiting both COX-1 and COX-2 enzymes, reducing prostaglandin production and thereby decreasing pain and inflammation 1, 2. Its analgesic efficacy is comparable to opioids in many pain conditions, making it a valuable non-opioid option for managing tendon pain 2.

For tendinopathies like Achilles and peroneal tendinitis:

• Ketorolac helps reduce the inflammatory component and provides significant pain relief
• It can be administered orally, intramuscularly, or intravenously, though oral administration is most common for outpatient management of tendinitis 2
• It has a relatively rapid onset of action compared to other oral NSAIDs

Dosing and Administration

For adults with Achilles or peroneal tendinitis:

• Oral ketorolac: Typically 10mg every 4-6 hours as needed for pain
• Maximum duration: Limited to 5 days of continuous use
• Maximum daily dose: 40mg for most adults, reduced to 20mg in elderly patients or those with renal impairment 3

Treatment Algorithm for Tendinitis

1. First-line approach:

   • Rest and activity modification
   • NSAIDs (including ketorolac) for pain control
   • Physical therapy with eccentric strengthening exercises 1
   • Open-backed shoes or orthoses to reduce pressure on the affected area 1

2. If no improvement after 6-8 weeks:

   • Consider immobilization with cast or fixed-ankle walker-type device 1
   • Referral to specialist (podiatric foot and ankle surgeon) 1

3. For refractory cases:

   • Consider local interventions
   • Surgical options may be necessary in persistent cases

Advantages of Ketorolac

• Strong analgesic properties comparable to opioids without respiratory depression or addiction potential 2, 4
• Effective for moderate to severe musculoskeletal pain 5
• Can be used as part of a multimodal pain management approach

Important Precautions and Limitations

1. Duration of use: Limit ketorolac to short-term use (≤5 days) to minimize adverse effects 3

2. Contraindications:

   • History of gastrointestinal bleeding or ulcers
   • Renal impairment
   • Compromised hemostasis or coagulopathy
   • Hypersensitivity to aspirin or other NSAIDs 3

3. Potential adverse effects:

   • Gastrointestinal irritation or bleeding
   • Renal impairment (usually reversible upon discontinuation)
   • Platelet dysfunction with potential for increased bleeding 3
   • Cardiovascular risks with prolonged use 1

4. Special populations:

   • Use lower doses in elderly patients
   • Use with caution in patients with cardiovascular disease
   • Not recommended during pregnancy or breastfeeding 3

Evidence for Tendon Healing Concerns

There has been controversy regarding NSAID use in tendinopathies due to potential interference with tendon healing. However, current evidence suggests that short-term use (less than 2 weeks) of NSAIDs like ketorolac is unlikely to significantly impair tendon healing 1. The benefits of pain relief and reduced inflammation typically outweigh potential concerns when used appropriately.

Alternative and Adjunctive Treatments

If ketorolac is contraindicated or ineffective, consider:

• Acetaminophen for pain relief
• Physical therapy with eccentric strengthening exercises (particularly beneficial for Achilles tendinopathy) 1
• Local treatments such as ice application for 10-minute periods 1
• Orthotic devices to correct biomechanical issues 1
• For persistent cases, consultation with a podiatric foot and ankle surgeon 1

Remember that ketorolac should be prescribed at the lowest effective dose for the shortest duration necessary to control pain while monitoring for potential adverse effects.