What medications are used to treat ligament injuries?

Medications for Ligament Injuries

For acute ligament injuries, topical NSAIDs (particularly diclofenac gel) should be your first-line pharmacological treatment, providing effective pain relief with minimal systemic side effects, while oral NSAIDs or acetaminophen serve as alternatives when topical therapy is insufficient. 1

First-Line Pharmacological Treatment

• Topical NSAIDs (diclofenac gel with or without menthol) are recommended as first-line therapy for acute musculoskeletal injuries including ligament injuries, providing superior pain relief compared to placebo with fewer systemic adverse effects than oral NSAIDs 1
• Topical diclofenac provides equivalent pain relief to oral NSAIDs but with markedly fewer gastrointestinal adverse events and significantly lower systemic absorption 1
• Local skin reactions are the most common side effects but occur at similar rates to placebo 1

Oral NSAID Options When Topical Therapy Is Insufficient

• Oral NSAIDs should be considered when topical formulations are inadequate, with diclofenac showing superior results at days 1 and 2 compared to piroxicam and ibuprofen for reducing pain during motion in acute ankle sprains 1
• Celecoxib (200mg twice daily) is non-inferior to non-selective NSAIDs (ibuprofen, naproxen, diclofenac) for pain relief following acute ankle sprains 1
• NSAIDs should be used at the lowest effective dose and for the shortest duration possible to minimize gastrointestinal, cardiovascular, and renal risks 2
• NSAIDs should never be used right before or after coronary artery bypass graft (CABG) surgery 2

Acetaminophen as an Alternative

• Acetaminophen (paracetamol) appears equally effective as NSAIDs for pain, swelling, and range of motion in acute ankle sprains and may be used as an alternative when NSAIDs are contraindicated 1
• Acetaminophen has a lower side-effect profile compared to NSAIDs and is cheaper 3

Critical Considerations Regarding NSAIDs and Healing

• NSAIDs may delay the natural healing process as the inflammation suppressed by NSAIDs is a necessary component of tissue recovery 1
• Despite theoretical concerns, NSAIDs do not significantly increase the risk of adverse events compared to placebo in the treatment of acute musculoskeletal injuries 1
• One animal study showed piroxicam administration on days 1-6 post-injury resulted in a 42% increase in ligament strength at day 14 post-injury, suggesting short-term NSAID use may not impair early healing 4
• A large cohort study of 7,822 patients undergoing anterior cruciate ligament reconstruction found that NSAID administration did not negatively affect graft survival, risk of revision, or quality of life scores at 2-year follow-up 5

Medications to Avoid

• Opioids should be avoided as they provide similar pain relief as NSAIDs but lead to significantly more side effects 1

Special Populations Requiring Caution

• In elderly patients (≥75 years) and those with increased risk of renal adverse events, topical NSAIDs are strongly preferred over oral NSAIDs 1
• Patients with cardiovascular disease, history of gastrointestinal ulcers, or those taking corticosteroids or anticoagulants require careful risk-benefit assessment before NSAID use 2

Comprehensive Treatment Algorithm

1. Start with topical diclofenac gel (with or without menthol) applied to the affected area 1
2. Combine with immediate cold therapy: apply ice and water mixture surrounded by damp cloth for 20-30 minutes, 3-4 times daily for the first 48-72 hours 1
3. If topical therapy is insufficient, consider oral NSAIDs (diclofenac, celecoxib, ibuprofen, or naproxen) at the lowest effective dose for the shortest duration 1, 2
4. If NSAIDs are contraindicated, use acetaminophen as an alternative analgesic 1
5. Initiate functional support (ankle brace for 4-6 weeks for ankle ligament injuries) and early exercise therapy immediately to restore motion, strength, and function 1, 6

Common Pitfalls to Avoid

• Using NSAIDs for prolonged periods without reassessing necessity, as this increases risk of gastrointestinal, cardiovascular, and renal complications 2
• Prescribing oral NSAIDs when topical formulations would be equally effective with fewer systemic risks 1
• Relying solely on pharmacological treatment without implementing functional rehabilitation, which is essential for optimal recovery 6
• Using opioids for routine ligament injury pain management 1