Do early potent Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) improve function in non-surgical musculoskeletal pains, e.g. sprained ankle or wrist?

Early Potent NSAIDs for Non-Surgical Musculoskeletal Injuries

Oral and topical NSAIDs effectively reduce pain and improve function in the short term for non-surgical musculoskeletal injuries such as sprained ankles or wrists, but may potentially delay long-term healing by suppressing the inflammatory process necessary for tissue recovery. 1

Effectiveness of NSAIDs for Acute Musculoskeletal Injuries

Pain Relief and Function

• Pooled results from 26 RCTs (n=4,225) show that oral or topical NSAIDs provide superior pain relief in the short term (<14 days) compared to placebo for acute musculoskeletal injuries 1
• Topical NSAIDs provide good levels of pain relief for acute conditions like sprains, strains, and overuse injuries, with effectiveness likely similar to oral NSAIDs 2
• NSAIDs help reduce swelling in the short and intermediate term, which may contribute to improved function 3
• The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) recommend topical NSAIDs with or without menthol gel as first-line therapy for acute musculoskeletal injuries 1

Specific NSAID Formulations and Comparisons

• Diclofenac shows superior results at days 1 and 2 compared to piroxicam and ibuprofen for reducing pain during motion in mild-to-severe acute ankle sprains 1
• Among topical preparations, gel formulations of diclofenac (Emulgel), ibuprofen, and ketoprofen show the best efficacy for pain relief 2
• Celecoxib (200mg twice daily) is non-inferior to non-selective NSAIDs (ibuprofen, naproxen, diclofenac) for pain relief following acute ankle sprains 1

Potential Concerns with NSAID Use

Impact on Healing Process

• NSAIDs may delay the natural healing process as the inflammation suppressed by NSAIDs is a necessary component of tissue recovery 1, 4
• Animal models have demonstrated short-term benefits with NSAIDs after acute injury but potential long-term adverse effects on tissue structure and function 5
• The benefits of short-term pain relief must be weighed against potential impacts on long-term healing 5

Safety Considerations

• NSAIDs do not significantly increase the risk of adverse events compared to placebo in the treatment of acute musculoskeletal injuries 1
• Local skin reactions with topical NSAIDs are generally mild and transient 2
• Caution is warranted in elderly patients (≥75 years) and those with increased risk of renal adverse events, where topical NSAIDs are preferred over oral NSAIDs 1

Comprehensive Management Approach

Optimal Treatment Algorithm

1. First-line therapy: Topical NSAIDs with or without menthol gel for pain relief 1
2. Alternative options: Oral NSAIDs or acetaminophen if topical treatments are insufficient 1
3. Functional support: Use of ankle brace or other functional support for 4-6 weeks (for ankle sprains) 1
4. Exercise therapy: Early initiation of exercise therapy to restore motion, strength, and function 1

Additional Considerations

• Paracetamol (acetaminophen) appears equally effective as NSAIDs for pain, swelling, and range of motion in acute ankle sprains 1
• Opioids provide similar pain relief as NSAIDs but lead to significantly more side effects and should be avoided 1
• NSAIDs remain the most common medication prescribed for ankle sprains in emergency departments (56.1%), followed by opioid combinations (28.4%) 6

Key Takeaways

• Early use of NSAIDs (particularly topical formulations) provides effective short-term pain relief and improved function for acute musculoskeletal injuries 1, 2
• Functional treatment with external support and early exercise therapy should accompany pharmacological management 1
• While NSAIDs effectively manage symptoms, clinicians should be aware of their potential to delay long-term healing by suppressing the inflammatory response necessary for tissue recovery 4, 5