What are the preferred Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) prescriptions, dosing, and timing for musculoskeletal (MSK) injuries, such as meniscus tears and tendon tears, among sports medicine orthopedic surgeons?

From the Guidelines

Sports medicine orthopedic surgeons should prescribe topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy for musculoskeletal injuries, such as meniscus tears and tendon tears, to reduce or relieve symptoms, including pain, and improve physical function and patient treatment satisfaction. This recommendation is based on a strong recommendation with moderate-certainty evidence from the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) guideline on nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults 1.

For patients who cannot use topical NSAIDs, oral NSAIDs, such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), may be used as an alternative to manage pain and inflammation. The dosing and duration of oral NSAIDs may vary depending on the injury type and severity, with acute inflammatory conditions like bursitis requiring shorter courses (5-7 days) and chronic tendinopathies benefiting from intermittent 7-10 day courses 1.

It is essential to consider the potential risks and benefits of NSAID use, including gastrointestinal side effects and the potential impact on tissue healing. Surgeons should recommend taking NSAIDs with food to minimize GI irritation and advise consistent dosing rather than as-needed use to maintain therapeutic anti-inflammatory levels. The timing of NSAID administration is also crucial, with some surgeons limiting use to 3-7 days post-injury to control initial inflammation without potentially interfering with the natural healing process 1.

For patients with contraindications like kidney disease, GI ulcers, or certain cardiovascular conditions, acetaminophen or topical NSAIDs may be recommended as alternatives. The ACP and AAFP guideline suggests against using opioids, including tramadol, for acute pain management due to the risk of opioid use disorder and other adverse effects 1.

Key considerations for NSAID prescriptions include:

• Injury type and severity
• Patient factors, such as medical history and comorbidities
• Potential risks and benefits of NSAID use
• Alternative treatment options, such as acetaminophen or topical NSAIDs
• Timing and duration of NSAID administration to balance pain management and tissue healing.

From the Research

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Prescriptions for Musculoskeletal (MSK) Injuries

• The use of NSAIDs for MSK injuries, such as meniscus tears and tendon tears, is a common practice among sports medicine orthopedic surgeons 2.
• A systematic review and meta-analysis found that NSAID use can reduce strength loss, soreness, and blood creatine kinase level after an acute muscle injury, at least in humans and in the short term 2.
• However, the optimal dosing and timing of NSAIDs for MSK injuries are not well established, and more research is needed to determine the most effective treatment protocols.

Preferred NSAIDs and Dosing

• There is no consensus on the preferred NSAIDs for MSK injuries, and the choice of medication may depend on individual patient factors and surgeon preference.
• A study on the effect of NSAIDs on recovery from acute skeletal muscle injury found that the use of NSAIDs was associated with a small to medium, significant decrease in markers of injury, but the optimal dosing and duration of treatment were not specified 2.

Timing of NSAIDs Administration

• The timing of NSAIDs administration for MSK injuries is not well established, and more research is needed to determine the most effective treatment protocols.
• A study on the effect of NSAIDs on recovery from acute skeletal muscle injury found that NSAID use was more effective when lower-body muscles in humans were injured, and that NSAID use appeared to be detrimental at later times after injury in animals but not humans 2.

Meniscus Tears Treatment

• Meniscus tears can be managed non-operatively, and preservation of the meniscus should be considered as the first line of treatment when possible 3, 4, 5.
• The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification system is a reliable and valid classification system for meniscal tears, and can help guide treatment decisions 5.
• Surgical management of meniscus tears, including arthroscopic partial meniscectomy, meniscal repair, and meniscal reconstruction, should be individualized based on patient and lesion factors 5.