When Daniel Agger, the former Liverpool defender, retired last year at the age of 31, he spoke in Jyllands-Posten, a Danish newspaper, of years of reliance on anti-inflammatories to play with the pain of a prolapsed disc in his back. The nadir came when he was withdrawn after 29 minutes of a league game for Brondby against Copenhagen, in March 2015, before collapsing in the physio’s room. “I took too many anti-inflammatories in my career,” he said, before urging players to consider taking “a pill or two less”.

So how widespread is their use? “[Lovren] Taking five to get through a game is extreme,” says Michael Dawson, the Hull City defender, “and I remember reading about Daniel Agger — that was crazy. But I know players who are reliant on them, and have been for years.”

The most common painkillers among footballers are non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, naproxen and ibuprofen, all of which can be prescribed or bought directly over the counter. “A lot of players take them, and I’m no different,” Dawson says. “If you’ve got a problem, you can miss a game, but your body never feels 100 per cent. Flippin’ hell, I’d have never played if my body had to have been 100 per cent.

 

 

“Anti-inflams are part of football, and always will be, because you need to be able to play as many games as possible. The more senior lads, who have been playing for 15 years or so, your joints are pounded every day, your body is worked to the extreme. Without them you might miss more games than you would play.”

Dawson, as with every player spoken to for this article, believes as much as half of a starting line-up on any given matchday could be taking painkillers before a game. Professor Jiri Dvorak, Fifa’s former chief medical officer, drew a similar conclusion from data collected from every player at Fifa tournaments, from under-17 to senior club and national team tournaments, between 1998 and 2014. At the World Cup in Brazil, in 2014, a study by the medical magazine BMJ found that 54.2 per cent of players were using NSAIDs. “It has become a cultural issue, part of the game,” Dvorak told the BBC in March, adding that it as an “alarming trend” and “clearly abuse of the drugs”.

Many believed that to be somewhat alarmist, but the risks are clear. Dr Nick Tindall was chief medical officer of the Lilleshall national sports centre injury clinic for 27 years, until 2013, and of the FA’s School of Excellence there for 14. The most common problems associated with overuse, he says, are damage to stomach lining, stomach ulcers, kidney damage and potentially issues with rehydration and blood circulation.

Regularly masking symptoms of injury can turn a minor injury into something more serious, or become degenerative. About 350 footballers a year passed through his doors at Lilleshall, largely funded by the Professional Footballers’ Association (PFA), which stated in March that painkiller use “was not a major issue” among its members. “There has always been this triangle of player, manager and medical team,” Dr Tindall says. “The manager wants the player to play, by and large the player wants to play, and the medical team must give their opinion despite those surrounding conflicts. That’s always the dilemma, while keeping in mind the player’s best interest.”

Dawson believes that the primary pressure to play comes from players themselves, and anti-inflammatories can often be the difference between doing so and not. “On many occasions I’ve played when I’ve been struggling from minute one, but you get through it, and then maybe you don’t train for three or four days,” the former Nottingham Forest, Tottenham Hotspur and England defender, says. “And then there are days when, once the game starts, you feel better. And afterwards you think, ‘I’m glad I played today. I took a risk and I got through it.’

“But I played when I knew I was struggling with my hamstring and I missed a cup final [the League Cup final in 2008], and that will live with me for ever. I probably knew I wasn’t right, but I put my body on the line and it backfired.”

One Premier League player, suffering with a back injury a few years ago, describes his body’s condition before a crucial European fixture. “My leg was numb,” he says, “like when you sleep on your arm, and you get those tingles, and your arm feels dead; that’s how my leg was. I couldn’t sit properly; it would take me five seconds to stand up straight. Then I’d start walking and it would gradually ease a little.” A large course of anti-inflammatories the week before the game dulled the pain but “when I was running I had no power in my left leg,” he says. “I remember, at one point, racing for a ball, but I couldn’t get up to speed because my back was locking up.”

He is still reliant on anti-inflammatories to play, but he is not alone. A former international player describes many months of battling a persistent hip problem. His routine was “two anti-inflammatories and two co-codamol tablets the night before a game,” he says, “and then in the morning two more anti-inflams and two paracetamol”. Co-codamol, while ensuring a “good night’s sleep”, contains codeine, which is an opioid. Dr Tindall believes that “with analgesics you start to get into a different league where there is a risk of addiction”.

So how much is too much to take? A former Manchester United academy player, now playing in the EFL, says he took three diclofenac pills a day for three years so that he could play after an operation. He has since learnt to ration his consumption, he says, which is now about “five or six a week” — taken largely in the build-up to a game. There is no doubt, Dr Tindall says, that he and others with similarly prolonged use are straying into dangerous territory.

A physiotherapist of 20 years’ experience, now working at a Championship club, recalls a player who was ruled out for three months with a stomach ulcer — but in truth such examples in football do appear to be rare. He insists that no medical department he has worked in would issue a player with “a month’s supply of anti-inflammatories”. When there are medical grounds, for a set period of time, they are a “valuable tool”, he says. But when a box of 96 max-strength ibuprofen can be bought for under £8, he does accept that “they are misused”.

Many players, however, suggest there is no need to spend their own money. “Before we go out [for a game], the physio’s got a strip of them, saying, ‘Anyone? Pill? Pill? Pill?’ ” one player says. “He’s flipping them out like they’re Skittles.” There is nothing illegal in providing players with drugs routinely given to sufferers of rheumatoid arthritis and osteoarthritis. But as Phil Newton, who was lead physiotherapist at Lilleshall’s sports injury clinic, says: “Pain is there for a reason. It’s usually a danger sign — something untoward is happening.

“But nowadays clubs have hugely experienced medical teams who will highlight when and when not that pain needs to be thought about more seriously. One of the things we’re realising now, which perhaps we should have done some years ago, is that stress and anxiety and pain are all linked. It’s not a particularly relaxing thing to be injured and be a professional sportsman. Pain is a complex thing.”

In the case of Lovren, therefore, it has hardly been a stress-free start to the season. His injury, coupled with the scrutiny he and Liverpool’s porous defence has been subjected to, will have no doubt made the opening weeks an ordeal.

Perhaps, then, it is worth a moment’s pause this weekend, before scolding a player having a day to forget. “Sometimes the public don’t realise what you’re playing with,” Dawson says.

…..

 

It’s an easy decision to make when financial or professional pressures take hold

During the latter years of my career I never played a game without anti-inflammatories, despite the havoc wreaked on my stomach, which often rendered Saturday nights a write-off.

 

 

Without wishing to be too graphic, the toilets on the team bus were meant for use only when standing up, if you catch my drift. On several journeys home, though, the fine for breaking that rule was one I had no choice but to pay.

During a flurry of games towards the end of the 2013-14 season, I was playing for Northampton Town with torn knee cartilage (which would be operated on during the summer), in the midst of a relegation battle, with my contract due to expire. After repeated anti-inflammatory use so that I could play, I had to pull out of one game an hour before kick-off due to stomach pains and I was bed-bound for almost a week. I was given another drug, omeprazole, to counter the anti-inflammatories, and I have no doubt my stomach lining was damaged.

After convincing myself that I would never take them again, with my knee just holding up, and a relegation decider on the last day of the season, I was knocking them back again.

The pressures on players are relative: for me my livelihood was at stake, as was Football League survival. For a Premier League player, with four years remaining on his contract, the driver may be to keep his place in the team, or perhaps to be part of winning a title. When a few pills can make that happen, despite the risks, it’s an easy decision to make.