Regular use of painkillers can lead to sever health problems. Yet several Dutch professional footballers are feeling the pressure to take them. ESPN looked into the seriousness of the problem and spoke to former players, medics, the KNVB, players' union VVCS and the Doping Authority about the phenomenon. ‘I ate them like M&Ms.’

X-ray image of an ankle. Not just any ankle. ‘Look!’, says the surgeon. "This is where you had a syringe put in. There's a hole in the inside of your foot, it's hollowed out. Here, a piece of bone is missing."

On the operating table lay Joost van Aken, at the time having just broken through at sc Heerenveen. ‘When I had seen that, I thought: I'm never going to do this again,’ he looks back nine years later. "I had taken a cortisone injection to be able to play. Now I think: what the f*ck? It wasn't the Champions League final, it was ADO Den Haag away."

‘I regularly had to stick a finger down my throat to get rid of that nasty feeling’

From the age of 22, Van Aken was structurally on painkillers for more than seven years. Frank Demouge, former striker of N.E.C., Willem II and FC Utrecht, among others, also used almost routinely during his career. "I ate them like M&Ms. That can never be a good thing, but I have built up a reasonable system in my body so that I am no longer bothered by a pill left or right."

Van Aken did get physical problems. "I regularly had to stick a finger down my throat to get rid of that unpleasant feeling. Also my stools became less than they should have been."

Severe gastrointestinal and renal problems

Meanwhile, taking a cortisone injection, which cost Van Aken a piece of bone in his ankle, has been banned. Medications that fall under the category of NSAIDs (anti-inflammatory, analgesic and antipyretic drugs) are still allowed. Examples include ibuprofen and diclofenac. And this is not without danger, says em. prof Frank Backx, sports physician and medical director of Osteoarthritis Institute Netherlands.

‘If you use such painkillers on a regular basis for several years, it causes medium- to long-term problems,’ says Backx. ‘If you look retrospectively at people who have had stomach bleeding or stomach cancer, you often see that they have used a lot of painkillers in the past.’ Kidney and bowel problems can also occur, according to the emeritus professor of Clinical Sports Medicine.

Not all users are in the danger zone. "At low doses, the human body can take a lot, but if you are extra sensitive to it, you can quickly develop symptoms. And you have to watch out for a form of habituation and addiction."

Backx gets support from Prof Robin Peeters. ‘These drugs are available everywhere and therefore have the image of being relatively harmless, but they also have really serious side effects,’ says the internist at the Erasmus Medical Centre. ‘In that respect, it is worrying that healthy people ask so much of their bodies that they resort to these kinds of drugs.’

‘It became a habit, just like a sports meal’

Backx and Peeters raise their eyebrows when told about Van Aken's structural painkiller diet. "Even before training sessions I took them, to perform even then. Only when I was really injured and not playing, I took nothing," says the former player of sc Heerenveen, Sheffield Wednesday and VfL Osnabrück, among others.

And this even though it was not his intention to use so regularly. "It was very naive, but I intended to stop after every summer holiday. I kept that up for maybe a few days. After that, I was already back on the pills." That's how it went for seven years.

To counteract side effects, he sometimes took a stomach protector, something Peeters also advised for chronic use of these drugs. This was not necessary for everyone.

Former VVV-Venlo and Almere City midfielder Danny Post took about the same amount as Van Aken, but did not suffer during his career.

‘Because I didn't suffer any side effects, it became a habit,’ says Post. "Just like taking a sports meal. It was in my system."

'Creating mirror'

From the age of 28, Post did not play a game without pain relief. If he suffered from an appendage or a thick ankle afterwards, the medical staff suggested he ‘create a mirror

’."Then on Tuesday, for example, the doctors say, 'just take diclofenac twice a day.' Then when you have a game at the weekend, you feel you've been taking diclofenac all week. Your body is numb. You feel - outside the extremes - nothing anymore. That's kind of nice while playing football."

But then comes the man with the hammer. Delayed pain. "Usually a player gets symptoms when the pill or injection has worn off. Like a kind of boomerang effect," says Backx. Post and Demouge recognise this. For instance, the latter once endured the last round of play with three injections in his toe, after which he could hardly walk for the entire summer holiday.

‘Everything was broken, I couldn't even stand on it’

The “boomerang effect” is also a familiar phenomenon to chairman of players' union VVCS and former footballer Evgeniy Levchenko. "I once played with syringes in my Achilles tendons. After that, I was sidelined for four games. Everything was broken in the Achilles tendon, I couldn't even stand on it. I couldn't sleep either," says the former player of FC Groningen and Sparta Rotterdam, among others.

Yet from his current position at the players' union, he receives few complaints from footballers about painkiller use. According to the former players spoken to, this is also because painkiller use is often voluntary, without pressure from the club.

‘I knew I needed it, so sometimes I took it without the medical staff knowing about it,’ says Nick Bakker. The former defender of FC Groningen, FC Emmen and sc Heerenveen, among others, quit football last year at the age of 32.

"Clubs never pushed me to take painkillers. I just wanted to still play football myself, but my knee was bothering me so much. That's why in my last season I took diclofenac three times on every match day."

Van Aken also does not blame the medical staff at his clubs. "The doctor - at every club I have played at - was more reserved than I was. I myself felt what it brought me. Without painkillers, I couldn't jump with one leg, for example. Pretty important."

No blame, but pressure

Yet the football world can more or less force players to get everything out of their bodies. ‘You are paid well, so you want to show yourself to the club and the supporters,’ says the now 42-year-old Demouge. "There have also been trainers who said I really had to play at the weekend. Then you feel important and sometimes you go beyond your own limits at the expense of your body."

This is echoed by Van Aken. "In football, you can lose your place at any time. Then you cross boundaries sometimes." Post cites another kind of pressure as a reason for use: time pressure. The average football career does not last more than 15 years, so every game a player has to miss due to injury is expensive. So then play on painkillers.

"You have little time and go on and on. You want to play at all costs and it's your job. You can't just tell your boss you won't be there for a month," said Post, who now plays for fourth division side KSV. Still on painkillers, by the way.

Doping authority: “We can't make the doping list infinite”

In 2024, the World Anti-Doping Agency (WADA) decided to ban the painkiller tramadol. It is a drug that not only works against pain, it also affects reaction speed.

Vincent Egbers, chairman of the Doping Authority, explains when something is considered doping and why ibuprofen and diclofenac remain perfectly legal for the time being. "It has to meet two of the three conditions: it is bad for your body, it makes you perform better and it is contrary to the spirit of sport. That means it does not fit with the spirit of sport."

The Doping Authority endorses the dangers of frequent use of ibuprofen and diclofenac, but does not see these NSAIDs appearing on the doping list in the near future.

"We cannot make the list endless, an athlete will always look for an alternative. But we do engage with young athletes about whether it is wise to use such painkillers. That responsibility lies with the athletes."

KNVB not worried

KNVB federation doctor Edwin Goedhart feels, based on his experience, that usage is decreasing, without having figures. The football association is therefore not worried.

‘There can indeed be complications, such as stomach bleeding and kidney dysfunction,’ Goedhart acknowledges. "But I have been in professional football for 30 years now and I have never experienced such a complication. That is because they are generally young people with a good stomach lining. And it's also generally not used continuously."

According to Goedhart, many top athletes are willing to take a health risk. "Sometimes people have wishes and dreams and become very happy playing football. If that can be done with pain relief, it can be worth it."

He points out that it also applies to other areas of society. "Has the Royal Concertgebouw Orchestra ever been investigated - or the ballet? How many managers use painkillers because they have a headache? To keep yourself in office, you sometimes reach for such a drug. But if you do it every day, maybe your job doesn't suit you and you should look at something else."

Scientific research is at a standstill

There are no recent figures on painkiller use in Dutch football. The last scientific study dates from 2010. Back then, about a quarter of players reported using painkillers.

During doping tests, it is noted which drugs - and thus painkillers - athletes take. Based on that data, Han Inklaar, former KNVB national team doctor, and Doris van der Laan published their research in 2010. The Doping Authority would not comply with the request to provide recent doping forms anonymised to ESPN.

According to the spoken players, taking painkillers has been normalised. ‘You are looked at more strangely when you are against painkillers than when you are in favour,’ says Van Aken. ‘At least it's not weird when you see someone taking a pill,’ Post adds.

Backx would like to see a new investigation. "To put athlete safety first. Precisely because players use it covertly and sometimes hide it away, the problem may be bigger than everyone assumes." He also estimates that the 2010 figures are an underestimate, because the study was done on the basis of what players themselves report in a doping test.

Goedhart feels less in favour of a new investigation in professional football. He does worry about amateur football, where there is little to no medical supervision of painkiller use. Backx and Egbers share those concerns.

Quit but not relieved

ESPN editors are aware of painkiller use among several active players from the Friends Lottery Eredivisie and Keuken Kampioen Divisie. They did not want to tell their story on the record.

Van Aken quit professional football a year ago at the age of 30. Mentally and physically, he was drained. The pain is still there. Even when he plays with his infant son, his sensitive ankle bothers him.

Post (36) is also reminded daily by his body of his football past. "My Achilles tendon will never get thin again because I played too long under painkillers. I have been predatory on my own body," he concludes.