What treatments are available for muscle pain?

Treatment Options for Muscle Pain

For acute muscle pain from strains, sprains, or soft tissue injuries, topical NSAIDs with or without menthol gel should be your first-line treatment, offering superior pain relief, improved function, and high patient satisfaction compared to other options. 1

First-Line Therapy for Acute Musculoskeletal Pain

Topical NSAIDs are strongly recommended as first-line therapy based on moderate-certainty evidence from the American College of Physicians and American Academy of Family Physicians 2020 guidelines. 1

Specific Topical NSAID Formulations with Proven Efficacy:

• Diclofenac Emulgel: Most effective option with 78% achieving pain relief vs 20% with placebo (NNT 1.8) at 7 days 2
• Ketoprofen gel: 72% pain relief vs 33% placebo (NNT 2.5) 2
• Diclofenac plasters: 88% relief vs 57% placebo (NNT 3.2) 2
• Topical NSAIDs with menthol gel: Reduced pain by 1.68 cm on 10-cm scale at <2 hours 1

Key advantage: Topical NSAIDs provide high treatment satisfaction (OR 5.20) and have systemic adverse event rates (4.3%) no greater than placebo (4.6%) in acute pain. 1, 2

Second-Line Pharmacologic Options

Oral Medications (Conditional Recommendation):

• Oral NSAIDs: Reduce pain by 0.99 cm on 10-cm VAS at 1-7 days, improve physical function (moderate-certainty evidence) 1
• Acetaminophen: Reduces pain by 1.07 cm at 1-7 days (moderate-certainty evidence) 1
• Tramadol: May be considered for up to 3 months specifically for osteoarthritis-related muscle pain 1

Important caveat: Oral NSAIDs carry gastrointestinal and cardiovascular risks; limit use to patients without coronary artery disease risk factors. 1

Heat-Based Topical Treatments

Capsaicin Cream (Heat-Producing Agent):

Capsaicin cream has limited and inconsistent evidence for muscle pain, with better data for neuropathic conditions rather than musculoskeletal pain. 3, 4

• FDA-approved indication: Temporarily relieves minor aches and pains of muscles and joints from simple backache, arthritis, strains, and sprains 3
• Low-dose capsaicin (0.075%): NNT of 6.6 for any pain relief over 6-8 weeks, but this data is primarily from neuropathic pain studies 5
• High-dose capsaicin (8%): More effective for neuropathic pain (postherpetic neuralgia) than musculoskeletal conditions 4, 6
• Adverse effects: Local burning and hyperemia occur in 85% of patients, though typically mild and transient (NNH 2.6 for local reactions) 6, 5

Clinical reality: While capsaicin is marketed for muscle pain, the evidence supporting topical NSAIDs is substantially stronger for acute musculoskeletal injuries. 1, 2

Non-Pharmacologic Options (Conditional Recommendation):

• Specific acupressure: Reduces pain by 2.09 cm at 1-7 days and improves physical function (moderate-certainty evidence) 1
• TENS (Transcutaneous Electrical Nerve Stimulation): Reduces pain by 1.18 cm at 1-7 days (low-certainty evidence) 1
• Massage therapy: Reduces pain by 0.70 cm at <2 hours (moderate-certainty evidence) 1

What to Avoid:

Opioids (including tramadol for acute injuries) are NOT recommended for acute non-low back musculoskeletal injuries due to low-certainty evidence of benefit and significant risks of misuse, addiction, respiratory depression, and cognitive impairment. 1

Chronic Musculoskeletal Pain Considerations:

For chronic conditions (>4 weeks) like osteoarthritis:

• Topical diclofenac: 60% achieve relief vs 50% placebo over 6-12 weeks (NNT 9.8) 2
• Topical ketoprofen: 63% relief vs 48% placebo (NNT 6.9) 2
• Acetaminophen and NSAIDs: Remain first-line for chronic musculoskeletal pain 1

Critical formulation note: The exact formulation matters significantly—Diclofenac Emulgel specifically outperforms other diclofenac formulations in acute pain. 2