What is the best treatment for a pulled muscle in the back?

Best Treatment for a Pulled Back Muscle

For an acute pulled muscle in the back, apply superficial heat therapy (heat wrap or heated blanket) for 3-4 days, which is more effective than acetaminophen or ibuprofen for pain relief and functional improvement. 1

Initial Treatment Approach

First-Line Therapy: Heat Application

• Heat wrap therapy or heated blankets provide moderate superiority over placebo for short-term pain relief and back-specific functional status in acute back muscle strains. 1
• Heat therapy demonstrates better pain relief than oral acetaminophen or ibuprofen for the first 3-4 days (differences of 0.66 and 0.93 on a 6-point pain scale, respectively). 1
• Apply heat for repeated 10-minute sessions rather than continuous application to maintain therapeutic temperature while avoiding skin complications. 2
• Minor skin irritation is the primary adverse event, occurring infrequently. 1

Self-Care Measures

• Continue normal activities as tolerated rather than prolonged bed rest. 1
• Self-care education emphasizing return to normal activity, fitness programs, and lifestyle modifications is recommended. 3

Pharmacologic Adjuncts

Muscle Relaxants (If Needed)

• Cyclobenzaprine hydrochloride is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. 4
• Use only for short periods (up to 2-3 weeks) as adequate evidence for prolonged use is not available. 4
• Start with 5 mg dose and titrate slowly, particularly in patients with hepatic impairment. 4
• Common side effects include drowsiness and dry mouth. 4

NSAIDs

• While heat therapy outperforms NSAIDs in the first 3-4 days, NSAIDs can be used as adjunctive therapy if needed. 1

Additional Interventions for Non-Responders

If Symptoms Persist Beyond Self-Care (>4 weeks)

• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute low back pain. 1
• Massage therapy is moderately effective for chronic or persistent symptoms. 1
• Exercise therapy is NOT effective for acute low back pain (<4 weeks) and should be delayed until after the acute phase. 1

What NOT to Do

Ineffective Interventions to Avoid

• Ice therapy is NOT supported by the guideline evidence for acute back muscle strains - heat is superior. 1
• Traction shows no effectiveness over placebo or sham treatment. 1
• TENS (transcutaneous electrical nerve stimulation) lacks evidence for acute low back pain. 1
• Lumbar supports/braces have no proven benefit and may increase risk of back pain. 3
• Prolonged bed rest delays recovery. 1

Clinical Pitfalls

• Do not prescribe supervised exercise programs during the acute phase (<4 weeks) as they are ineffective and the optimal timing to start exercise after symptom onset remains unclear. 1
• Avoid extended courses of muscle relaxants beyond 2-3 weeks without clear continued benefit. 1, 4
• Do not rely on ice as primary therapy despite its traditional use in the RICE protocol - heat has superior evidence for back muscle strains. 1