What medications are recommended for ankle muscle pain?

Medications for Ankle Muscle Pain

For acute ankle muscle pain, start with topical NSAIDs (such as diclofenac gel with or without menthol) as first-line therapy, which provides effective pain relief with minimal systemic side effects. 1, 2

First-Line Treatment: Topical NSAIDs

• Topical NSAIDs with or without menthol gel are the strongest recommendation for acute musculoskeletal injuries including ankle pain, based on moderate-certainty evidence from the American College of Physicians and American Academy of Family Physicians. 1

• Topical diclofenac provides superior symptom relief compared to placebo (OR 6.39) and excellent treatment satisfaction (OR 5.20). 2

• When combined with menthol gel, topical NSAIDs show even greater symptom relief (OR 13.34). 2

• The key advantage is significantly fewer gastrointestinal adverse events compared to oral NSAIDs, while maintaining equivalent pain relief. 2

• Local skin reactions are the most common side effects but occur at similar rates to placebo. 2

Second-Line Treatment: Oral NSAIDs

If topical NSAIDs are insufficient or impractical:

• Oral NSAIDs (ibuprofen, naproxen, celecoxib, diclofenac) reduce pain and swelling and accelerate return to activity compared to placebo. 1

• Pooled data from 26 RCTs (n=4,225) demonstrate that oral NSAIDs provide superior short-term pain relief (<14 days) without significantly increasing adverse events in young, healthy patients. 1

• Diclofenac shows superior results at days 1-2 compared to piroxicam and ibuprofen for reducing pain during motion. 1, 2

• Celecoxib 200 mg twice daily is non-inferior to non-selective NSAIDs (ibuprofen, naproxen, diclofenac) for pain relief with similar adverse event rates. 1

• Naproxen as-needed dosing (500 mg PRN) is as effective as fixed twice-daily dosing but has a better safety profile (6.7% vs 13.3% adverse events). 3

Alternative Oral Analgesic: Acetaminophen

• Acetaminophen (paracetamol) is equally effective as NSAIDs for pain, swelling, and range of motion in acute ankle sprains based on high-certainty evidence. 1, 2, 4

• There is no difference in pain relief between acetaminophen and NSAIDs at 1-2 hours, 2-3 days, or day 7 or beyond. 4

• Acetaminophen may result in slightly fewer gastrointestinal adverse events compared to NSAIDs. 4

• Consider acetaminophen for patients with contraindications to NSAIDs or those at high risk for gastrointestinal complications. 1

Medications to Avoid

Opioids (including tramadol) should NOT be used for ankle muscle pain:

• The ACP and AAFP recommend against opioids for acute musculoskeletal injuries based on conditional recommendation with low-certainty evidence. 1

• While opioids provide similar pain relief to NSAIDs, they cause significantly more side effects (neurological and gastrointestinal adverse events). 1, 4

• NSAIDs are probably superior to opioids in allowing earlier return to function. 4

• Despite this evidence, opioids are still prescribed at relatively high rates (28.4% of ankle sprain ED visits), representing an opportunity for improvement. 5

Important Caveats and Practical Considerations

Potential concern with NSAIDs: NSAIDs may theoretically delay natural healing by suppressing inflammation, which is necessary for tissue recovery. 1 However, the clinical significance of this remains unclear, and the benefits of pain control and improved function generally outweigh this theoretical risk for short-term use.

Special populations:

• Use caution with NSAIDs in elderly patients (≥75 years) and those with increased risk of renal adverse events; prefer topical over oral formulations in these groups. 2
• NSAIDs should be used at the lowest effective dose for the shortest duration necessary. 6

Comprehensive management approach:

• Medications should be combined with functional treatment including ankle support (lace-up or semirigid braces), early mobilization exercises (starting 48-72 hours post-injury), and activity modification. 1, 2
• The PRICE protocol (Protection, Rest, Ice, Compression, Elevation) alone has limited evidence for efficacy. 1

Drug interactions: Be aware of potential interactions with colchicine, anticoagulants, and corticosteroids when prescribing NSAIDs. 1, 6