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Suffering from pain caused by stress fractures in her back, Becky Tutka dutifully followed her doctor's orders and began popping ibuprofen with regularity, up to six a day as he advised.
"I was like an old lady, walking around with this box of pills," she said. "It seemed like I was always taking something, but I got used to it."
She was 10 years old.
Now a sophomore on the University of Utah's gymnastics team, Tutka is accustomed to life with physical pain as a constant companion. Her history of injuries includes sprains, bulging discs and cracked vertebrae. She's had Achilles tendon and elbow surgeries.
Along the way, her pillbox has gotten bigger and more potent.
"You have to get on the right prescriptions because nothing works after a while," she said. "You get immune to things like Advil, so you have to try other things."
Young gymnasts battling physical discomfort to perform a sport they love is a common, almost clichéd storyline. However, more doctors and researchers now are not only paying attention to the high number of injuries gymnasts suffer but also to the increasing amounts of anti-inflammatory medication they take as a result.
The focus is specifically on over-the-counter painkillers, such as ibuprofen, which is in a group of drugs along with aspirin, naproxen and others commonly called nonsteroidal anti-inflammatory drugs, or NSAIDs. Ibuprofen is so popular among athletes and weekend warriors alike it has earned nicknames such as "vitamin I" or "grunt candy" because many take it to ease muscular pain that comes with long hours of training.
Like Tutka, athletes often assume because a drug is readily available, it is relatively harmless. Yet studies show it is anything but a benign mask for pain, particularly when used in conjunction with physical exertion. In some instances NSAIDs such as ibuprofen can cause long-term harm such as stomach bleeding or ulcers and damage to the liver and intestines.
Dangers revealed • A recent study in the Netherlands found athletes who took 400 milligrams of ibuprofen, the recommended dosage for adults, the night before and the morning of a one-hour cycling workout showed higher signs of intestinal leakage than those who exercised without ibuprofen or those who took the same dosage but didn't work out.
The study aligns with many others that find evidence NSAIDs, while easily available, aren't harmless.
"There isn't such a thing as a benign medication," cautioned David Nieman, a professor at Appalachian State University, who has studied the effects of ibuprofen use in athletes.
"Every drug has some kind of side effect," he said. "I would never recommend them to any teenager. I just think it is wrong to be doing something that may cause harm to the kidneys or cause gut wall permeability for training purposes."
Despite the growing concern, the NCAA has yet to implement any guidelines for NSAID use.
"The NCAA does not specify how a physician should provide medications, but does provide guidelines to the membership to support appropriate medical practice at the local level," spokesman Christopher Radford said in a statement. "Additionally, student-athletes are encouraged to report the use of all medication to their respective sports medicine staff, as there is a risk associated in taking any medication."
Dave Petron, the U.'s team physician, said the school has no guidelines although he expressed concern about the drugs' safety.
"The No. 1 thing is kidney failure," he said. "Liver damage can happen, [gastrointestinal] bleeding is a risk along with heart attacks and strokes. If you read the label, it is pretty frightening what can happen."
While none of the studies has been specifically conducted on gymnasts, researchers and doctors acknowledge risks of physical harm for gymnasts are high because the sport subjects them to massive torques and impacts at a young age. Couple all the stresses of the moves with a high number of repetitions, and it's no wonder Tutka's story is common.
She has a congenital spine condition called spondylolisthesis that makes her susceptible to back injuries, but her other injuries also are typical for gymnasts, including the elbow surgeries she underwent as a 13-year-old, which revealed she had less than 30 percent cartilage in the joints. Her doctor informed her she had the elbows "of an 80-year-old."
Tutka wasn't 80, but a young developing girl who was filling her digestive system with NSAIDs.
Doctors worry how such high doses can affect young, developing bodies, a concern Tutka shares. But she worries more about how she would feel without painkillers.
"I don't think I could do this without medicine," she said.
Hearing this story, teammate Nansy Damianova just shrugs her shoulders. It is typical, she said.
She considers herself extremely healthy for a gymnast and rarely visits Utah's training room for the ice baths, electric stimulation, massage therapy and other treatments her teammates undergo before practice. But as pain-free as she might be, she still has her habits. She takes four to six ibuprofen on competition days.
"I don't want to have to think about the pain during competition," she said. "I don't want to have to worry about it."
No real benefits • This attitude concerns researchers such as Nieman. An ardent runner who has participated in more than 55 marathons, Nieman said his research has found athletes not only have suffered damage to their intestinal tracts and more when they compete with ibuprofen in their system, but he also found the medicine ultimately didn't ease the athletes' discomfort.
"It caused all this distress to the body, but it didn't do anything to affect the pain," he said. "It wasn't as effective as they thought. There just isn't a good benefit for any athlete to take it."
His conclusion is similar to that of James Macintyre, an orthopedic specialist at the Center of Orthopedic and Rehabilitation Excellence in West Jordan.
A trim, active outdoorsman himself, Macintyre pops in and out of exam rooms with an enthusiasm that suggests his body has fewer aches and pains than many of the young girls he sees weekly. Such irony disturbs Macintyre, who says he sees several gymnasts a week with complaints of long-term injuries, many of whom are habitual NSAID users.
"Gymnasts are expected to have pain and live with pain, especially the elite ones," he said. "They've got sore backs and sore knees, and they are taking ibuprofen, Advil and prescription anti-inflammatories, sometimes all at once."
He remembers a gymnast who developed gastro-bleeding after mixing several painkillers, not realizing the risk she was taking.
Now part of his treatment protocol is schooling patients on the effects of the substances, including the risks to the digestive system, as well as sharing studies that show NSAIDs can hinder healing of tendon tissue.
"I am using them less and less," he said. "Inflammation is an important part of the healing process, and [NSAIDs] can inhibit it.
"There is some limited, but not conclusive, evidence that they might inhibit bone healing."
"Cross your fingers" • One of Macintyre's patients is 14-year-old Brittany Jeppesen, a gymnast whose career has been marked with injuries including a stress fracture that kept her out of competition for a year. She is training again under the guidance of Macintyre and a mother who feels lucky she has been educated on the risks of NSAIDs. Five years ago a trainer warned her that NSAIDs such as ibuprofen taken before practices could potentially mask pain enough that it would allow a gymnast to do further damage.
"That was like a light bulb going off for me," she said. "A lot of kids are taking a lot of things, even steroids, to train. I still worry about it, but gymnastics is such a love for these girls, at this level you almost have to just cross your fingers and hope everything goes well."
"No regrets" • Utah coach Greg Marsden doesn't try to downplay the demands of gymnastics. Whether it is eating disorders, chronic injuries or abusive coaches, he knows his sport has a reputation for pushing girls and young women to their physical limits.
Frequently, gymnasts arrive on campus with a litany of chronic injuries that can affect how much they can train. Marsden said he works with the gymnasts in determining how much is enough to get them through the long season.
"It's all about making good decisions day in and day out," he said. "They know they can come to me or their event coach if they have a concern about their physical state or need to rest. I keep reminding them we are observing, but they are the ones living it and if something isn't right, we have the opportunity to manage it first if we can get on top of it early and adjust some things. There is a big difference between a stress reaction and a stress fracture, and some things you don't want to just try and push through."
Marsden's philosophy certainly seems sound, but he acknowledges it isn't perfect.
There is no protocol in place to track what over-the-counter drugs the athletes might be taking. Athletes including gymnasts also can be notorious for hiding how much pain they might be in out of fear they may lose their spots in the lineup.
Sometimes, they've lived with such a low amount of pain for a long time they also lose perspective on what it is to be pain-free. By the time they arrive in college, gymnasts often bear visible scars from the sport.
Following the thick line of the pink scar on Corrie Lothrop's left ankle is a tattoo that says "No regrets," a reminder of the Achilles tendon tear she suffered years ago and the efforts she made to become healthy again. On her right ankle is a boot, encasing and protecting her latest Achilles tendon tear, which she suffered in the fourth meet of the season.
As with her first injury, Lothrop, a junior, has come to understand that injuries, surgeries, pain and medications are as much a part of the sport as twists and flips.
She takes pain meds but tries to limit the amounts after seeing what ibuprofen and other NSAIDs did to some of her teammates at the elite level.
"A lot would get upset stomachs and things like that," she said. "I've been lucky. I've never been a person who needed to take that much, but there were people who took a lot. Then, you just take what you think is going to help."
The lowdown on NSAIDs
Ibuprofen, naproxen and aspirin are all part of a group of drugs called nonsteroidal anti-inflammatory (NSAID) drugs often purchased over the counter for pain associated with arthritis, joint pain, headaches, menstrual cramps, etc.
A common misconception is these drugs often are believed to be completely safe, but they do come with possible side effects such as liver damage, intestinal damage including bleeding and increased risks of a heart attack or stroke.
How they work • NSAIDs work by blocking the actions of an enzyme called cyclooxygenase, which in normal function protects the stomach lining from digestive juices, maintains kidney function and is responsible for the release of prostaglandins, which cause tissue to swell when there is an injury and amplify the pain.
NSAIDs inhibit the release of the enzyme, so there is less swelling and pain, but also leave the digestive tract susceptible to damage.
Safe use • It's safest to use the drugs sparingly, not habitually as some athletes do. Do not exceed the recommended dose. Normally, ibuprofen should not be taken for more than seven days.
Compiled by reporter Lya Wodraska from multiple sources.
NCAA gymnastics championships
The University of Utah will compete as the 10th seed in the NCAA gymnastics championships at UCLA April 19-21.