What are the treatment options for muscle aches and joint pain?

Treatment of Muscle Aches and Joint Pain

Start with acetaminophen 500-1000 mg every 6-8 hours as first-line therapy for mild to moderate muscle aches and joint pain, reserving NSAIDs for cases where acetaminophen provides insufficient relief. 1, 2, 3

Initial Pharmacologic Management

First-Line: Acetaminophen

• Acetaminophen is the preferred initial pharmacologic treatment for mild to moderate musculoskeletal pain, including osteoarthritis-related joint pain and muscle aches 1, 2
• Dosing: 500-1000 mg every 6-8 hours (maximum 4 grams per day) 1, 3
• Acetaminophen provides pain relief comparable to NSAIDs but without gastrointestinal, renal, or cardiovascular toxicity 1
• In acute musculoskeletal trauma, acetaminophen was non-inferior to diclofenac for pain reduction both at rest and with movement 4

Second-Line: NSAIDs

• If acetaminophen is insufficient after 3-5 days, add or switch to an NSAID such as ibuprofen 800 mg three times daily or naproxen 1
• NSAIDs show modest superiority over acetaminophen for knee and hip pain in osteoarthritis, but not for functional improvement 5
• Avoid high doses for prolonged periods, particularly in elderly patients who are at high risk for GI bleeding, platelet dysfunction, and nephrotoxicity 1
• Consider gastroprotection with proton pump inhibitors in patients with GI risk factors (age >65, history of ulcers, concurrent corticosteroids) 1, 2
• Avoid COX-2 selective NSAIDs in patients with cardiovascular disease due to increased thrombotic risk 2

Combination Therapy

• The combination of acetaminophen plus NSAIDs does not provide additional pain relief beyond either agent alone in acute musculoskeletal injuries 6
• Therefore, use monotherapy rather than combination therapy for most patients 6

Non-Pharmacologic Interventions (Essential First-Line)

Exercise Therapy

• Non-pharmacologic therapy should be considered the initial treatment, with medications used as adjunctive therapy 1
• For osteoarthritis: Aerobic, aquatic, and resistance exercises reduce pain and improve function with effects sustained for 2-6 months 1
• Aquatic exercise in warm water (86°F) is particularly beneficial, providing analgesia through buoyancy that reduces joint loading while strengthening periarticular muscles 1
• Avoid high-impact aerobic training as rapid joint loading may worsen pain and damage 1

Specific Exercise Prescription for Joint Pain

• Perform strengthening exercises 5-7 times, 3-5 times daily (before getting out of bed, before stairs, before sleep) 1
• Quadriceps sets: Squeeze thigh muscles, hold 6-7 seconds, rest 2-3 seconds between repetitions 1
• Progress from lying to sitting to standing positions as tolerated 1
• Never hold breath during exercises 1

Special Populations and Conditions

Polymyalgia Rheumatica

• Glucocorticoids are strongly recommended instead of NSAIDs for polymyalgia rheumatica 1
• Initial prednisone dose: 12.5-25 mg daily, tapered to 10 mg within 4-8 weeks 1
• NSAIDs may be used short-term only for pain related to other concurrent conditions 1

Inflammatory Arthritis

• For peripheral inflammatory arthritis in ankylosing spondylitis, consider sulfasalazine after NSAIDs 1
• Intra-articular or periarticular corticosteroid injections are effective for localized joint inflammation (sacroiliitis, peripheral arthritis) 1

Severe or Refractory Cases

• If CK is elevated with weakness, hold potentially causative medications (statins, immune checkpoint inhibitors) and refer to rheumatology/neurology 2
• For moderate symptoms: Consider oral prednisone 10-20 mg/day for 4-6 weeks 1, 2
• For severe weakness or markedly elevated CK: Urgent specialist referral with prednisone 0.5-1 mg/kg/day or IV methylprednisolone 2

Monitoring and Red Flags

Signs Requiring Escalation

• Inability to complete normal activities or persistent pain despite acetaminophen after 10 days warrants reassessment 1, 3
• Muscle weakness (not just pain) suggests myositis and requires urgent workup with CK, ESR, CRP, and autoimmune panel 2
• Joint swelling, erythema, or systemic symptoms (fever, rash) require rheumatology evaluation 1

Common Pitfalls to Avoid

• Do not exceed 4 grams acetaminophen daily due to hepatotoxicity risk 1, 3
• Do not use NSAIDs chronically without gastroprotection in high-risk patients 1
• Do not use systemic corticosteroids for axial osteoarthritis as evidence does not support efficacy 1
• Avoid muscle relaxants (methocarbamol, carisoprodol, cyclobenzaprine) for chronic pain as they lack efficacy evidence and cause significant adverse effects in older adults 1