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It is a simple motion, one NFL players know very well, sending a message without uttering a word.

You take your index and middle fingers on either hand, spread them apart and push your thumb back and forth into the area between them, closing the fingers each time.

It's the universal hand signal for taking the needle: using painkillers to numb the pain and play the game.

Jerome Bettis had his injection backfire last Sunday. (AP)

It has been a part of the NFL for years, documented in movies about the sport, talked about secretly and quietly staying in the background as one of the hidden little tricks of the sport.

There's nothing illegal about it. The NFL has no policies concerning it; the NFLPA has no voice on the matter.

"It's a medical matter between the player and the doctor," said Greg Aiello, the NFL's vice president of public relations. "They are prescription drugs. It is regulated by our policies on prescription drugs."

Aiello said part of that policy is that all teams must notify the league of all prescription drugs that are dispensed to the players.

But in the end, it's simply the player's choice.

If the quad muscle hurts, take the needle.

If the knee is sore, take the needle.

If the groin is sore, take the needle.

It has gone on for years. But it came back into focus last week when Pittsburgh running back Jerome Bettis took a shot for his injured groin last week before the Steelers met the Baltimore Ravens in an AFC divisional playoff game. Bettis had a bad reaction and was unable to play, the announcement on his status coming just before kickoff. If he had not reacted badly, few would have known about the shot.

Since he did, it again opens up the debate about the ethics of taking painkilling injections to play a game.

Should a player do whatever it takes to play? Is there a risk of more damage? Should they be allowed?

Mark Brunell dealt with the needle this season for a quad injury. (Allsport)

"We leave it up to the player," one NFL head coach said. "We don't force it on them. It's up to them to decide with input from our medical staff. There is no pressure to do it."

Maybe not directly. But there is indirect pressure and, of course, peer pressure. Players privately question others who won't do whatever it takes to play.

Some players refer to the shots as "liquid Advil," which downplays the significance of taking them.

Bettis took a shot of an unknown substance to help ease the pain from a groin pull that forced him out of five games. The discomfort wasn't enough to keep him on the sidelines, but Bettis wanted to dull it for the three-hour game.

Instead, the shot numbed his leg, and he was unable to stand, let alone run.

"The injury, for all intents and purposes, is healed," Bettis said. "But there's a pain threshold that I have to deal with. I didn't want to go into the game with that."

It's the same for others on regular-season Sundays, and even more so in the postseason.

Players want to play. Taking the needle helps.

Jaguars quarterback Mark Brunell struggled through the season having to deal with a serious quadriceps injury. He took a shot of Toridol before several games, just to get him through.

"If I need them, I'll take them," Brunell said. "I've been taking shots since 1995 for a bunch of different things. I get the shot in the butt, not directly where the injury occurred."

Brunell said the numbness lasts for four hours -- enough to finish a game -- and then slowly wears off. Players usually follow that with an oral painkiller, sometimes Advil or perhaps Vicodin.

Brunell doesn't think the shots are anything to be too worried about, aside from the fact there is some chance that a player could hurt himself worse while playing and not really know it until the shot wears off.

The real concern, Brunell said, comes with the Vicodin pills players take after the game. That's what Green Bay quarterback Brett Favre admitted to abusing a few years back, leading to a stay in a rehab facility. Many teams hand them out to their players.

"That's where you can see some problems," Brunell said.

Some players take cortisone shots during the week to help the painful area instead of taking pre-game injections. That slowly helps ease the pain and repair the injury. Whatever it takes to be a contributor on Sunday.

"Guys want to play," said the coach. "That's the way football players are. They will do almost anything to get out on the field. We don't have to force them out there to play. It's not like we tell players that if they don't take a shot, then they will be looked at in a different light."

But it's almost a given that if a player doesn't do what it takes -- and coaches are informed by their training and medical staffs of who does what -- he can be given a bad label. Those are hard to shed and can follow a player throughout his career.

Teams are nonetheless quick to note they don't make players take shots. Bettis made that quite clear last week and other Steelers players said pretty much the same thing this week leading up to Sunday's AFC Championship Game against New England.

It's their choice.

Bettis said he would not take a shot this week, saying it's up to the aspirin to numb the pain. But you can bet that in both games Sunday, there will be a good number of players who are taking the shots.

It's January, players are one game away from the Super Bowl, and anything goes.

"In the regular season, guys take them, but there's not as many," said a player who played in a Super Bowl. "As you get closer to the big game, more and more guys take the needle. It becomes a part of what you're expected to do."

"Expected to do." Those three little words there might sum up the painkilling situation in the NFL.

No one is pushing the issue, but it's almost expected.

There are risks, of course, but winning football games, staying on the field to help, seems far more important than anything bad that might happen from taking the needle.