What is the initial treatment for acute musculoskeletal pain?

Initial Treatment for Acute Musculoskeletal Pain

Topical NSAIDs with or without menthol gel should be used as first-line therapy for acute musculoskeletal pain due to their efficacy in pain reduction, improvement in physical function, and favorable safety profile. 1, 2

First-Line Treatment Options

Topical NSAIDs

• Provide significant pain reduction within 2 hours (WMD, −1.02 cm on 10-cm VAS) 1
• Continue to provide pain relief at 1-7 days (WMD, −1.08 cm) 1
• Improve physical function (WMD, 1.66 cm) 1
• Result in higher treatment satisfaction compared to placebo (OR, 5.20) 1
• Have fewer systemic adverse effects than oral NSAIDs 2
• Can be combined with menthol gel for enhanced effect (WMD, −1.68 cm within 2 hours) 1

Second-Line Treatment Options

If topical NSAIDs provide insufficient relief:

Oral NSAIDs

• Provide moderate pain reduction within 2 hours (WMD, −0.93 cm) 1
• Continue to provide pain relief at 1-7 days (WMD, −0.99 cm) 1
• Improve physical function (WMD, 0.73 cm) 1
• Should be used at the lowest effective dose for the shortest duration 3
• For ibuprofen: 400mg every 4-6 hours as needed for pain relief 3
• Caution: Consider cardiovascular, renal, and gastrointestinal risk factors 2

Oral Acetaminophen

• Provides moderate pain reduction within 2 hours (WMD, −1.03 cm) 1
• Continues to provide pain relief at 1-7 days (WMD, −1.07 cm) 1
• Has a favorable safety profile, particularly in patients with contraindications to NSAIDs 2
• Research shows acetaminophen is not inferior to diclofenac or the combination of both for acute minor musculoskeletal trauma 4

Non-Pharmacologic Options

Specific Acupressure

• Reduces pain at 1-7 days (WMD, −2.09 cm) 1
• Improves physical function (WMD, 1.51 cm) 1

Transcutaneous Electrical Nerve Stimulation (TENS)

• Reduces pain within 2 hours (WMD, −1.94 cm) 1
• Continues to provide pain relief at 1-7 days (WMD, −1.18 cm) 1

Other Physical Strategies

• Ice and elevation are recommended 5
• Massage therapy can reduce pain within 2 hours (WMD, −0.70 cm) 1

Important Considerations

Combination Therapy

• Research shows that combining acetaminophen with ibuprofen does not provide superior pain relief compared to either agent alone 6
• However, multimodal analgesia (using different mechanisms of action) is generally recommended for optimal pain control 5

Avoid Opioids

• ACP and AAFP recommend against using opioids, including tramadol, for acute musculoskeletal pain 1, 2
• Opioids should only be considered when pain is severe and not controlled with acetaminophen and NSAIDs 2
• When opioids are used for severe refractory pain, they should be prescribed at the lowest effective dose for the shortest period 7
• Oxycodone/acetaminophen provides only slightly better pain relief than acetaminophen alone for ibuprofen-refractory pain, but with significantly more adverse events 8

Treatment Algorithm

1. Start with topical NSAIDs (with or without menthol gel)
2. If insufficient relief after 1-2 hours:
   • Add oral NSAIDs (if no contraindications) OR
   • Add oral acetaminophen (especially if NSAIDs are contraindicated)
3. Consider adding non-pharmacologic approaches (TENS, specific acupressure)
4. For persistent moderate-severe pain despite above measures:
   • Consider brief course of muscle relaxants for appropriate conditions
   • Reserve opioids only for severe pain not responding to above measures, using lowest effective dose for shortest duration

Common Pitfalls to Avoid

• Skipping topical NSAIDs and going straight to oral medications
• Using opioids as first-line or routine treatment
• Failing to consider non-pharmacologic approaches
• Not adjusting treatment based on specific contraindications (e.g., using oral NSAIDs in patients with renal disease or high cardiovascular risk)
• Continuing medications longer than necessary for acute pain management