Treatment of a Pulled Back Muscle
For a pulled back muscle, start with NSAIDs, stay active, and apply heat—this combination provides the most effective initial management and should be continued for 2-3 weeks maximum. 1, 2
Immediate First-Line Treatment (Days 1-3)
Begin NSAIDs immediately at the lowest effective dose for the shortest duration, as they provide small to moderate pain relief superior to acetaminophen. 1
- Apply ice initially (first 24-48 hours) to reduce bleeding and swelling into the muscle tissue, following the RICE principle (Rest, Ice, Compression, Elevation). 3, 4
- Brief immobilization for the first 3-5 days helps reduce re-injury rate and accelerates granulation tissue formation, but avoid prolonged bed rest as it prolongs recovery. 1, 3, 4
- Acetaminophen is acceptable only if NSAIDs are contraindicated (maximum 4g/day), though it shows no significant difference from placebo in acute back pain. 1
Transition Phase (Days 3-7)
Switch from ice to heat after the acute inflammatory phase (typically day 3-5), as heating pads provide short-term relief of acute low back pain. 1, 5
- Begin gradual mobilization within pain limits, as early return to activity optimizes muscle regeneration and recovery of flexibility and strength. 4
- Avoid complete rest beyond 5 days, as activity restriction prolongs recovery and staying active is critical for optimal outcomes. 1, 6
Second-Line Options (If No Improvement After 1-2 Weeks)
Add a skeletal muscle relaxant like cyclobenzaprine for short-term relief (2-3 weeks maximum) when muscle spasm contributes to pain, but be aware of sedation risk. 1, 2
- Consider spinal manipulation by appropriately trained providers (chiropractor, physical therapist, osteopath), which shows small to moderate short-term benefits with pain reduction of approximately 10 points on a 100-point scale. 1, 7
- Refer for goal-directed manual physical therapy if no improvement occurs, focusing on progressive agility and trunk stabilization exercises rather than passive modalities like ultrasound or TENS. 4, 6
Rehabilitation Program (Weeks 2-6)
Start progressive exercises including trunk stabilization, stretching, and strengthening once the acute phase resolves, as these yield better outcomes than stretching alone. 4
- Gradually increase activity within pain limits, as 90% of episodes resolve within 6 weeks regardless of treatment. 6
- Return to work early when possible, as this is associated with less disability. 6
Red Flags Requiring Urgent Evaluation
Immediately assess for cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia, progressive neurological deficits) requiring emergency intervention. 1
- Screen for infection or malignancy if fever, unexplained weight loss, or night pain is present. 1
- Check for fracture risk in patients with trauma history, osteoporosis, or prolonged corticosteroid use. 1
Common Pitfalls to Avoid
Do not prescribe opioids for simple muscle strains, as they carry substantial abuse risk and are not more effective than NSAIDs. 1, 6
- Do not order imaging unless symptoms persist beyond 4-6 weeks or red flags are present, as most muscle strains resolve without advanced diagnostics. 1, 6
- Do not recommend prolonged bed rest, which is less effective than remaining active and delays recovery. 1, 5, 6
- Limit muscle relaxants to 2-3 weeks, as adequate evidence for longer use is not available and muscle spasm associated with acute conditions is generally short-duration. 2