What is the recommended treatment for a patient with muscle pain, considering their age, weight, and medical history?

Treatment of Muscle Pain

For acute muscle pain from non-low back musculoskeletal injuries, start with topical NSAIDs (with or without menthol gel) as first-line therapy, followed by oral NSAIDs or acetaminophen if needed, while avoiding opioids. 1

First-Line Pharmacologic Treatment

Topical NSAIDs with or without menthol gel should be your initial pharmacologic choice for acute muscle pain, as they provide localized pain relief with minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications compared to oral medications. 1, 2

Second-Line Pharmacologic Options

If topical treatments are insufficient:

• Oral NSAIDs (such as ibuprofen) can reduce pain and improve physical function within 24 hours to 7 days. 1

  • Always prescribe a proton pump inhibitor concurrently for gastroprotection, particularly in patients over 60 years, those with peptic ulcer disease history, males, or those on concurrent corticosteroids. 2, 3
  • Use the lowest effective dose for the shortest duration. 2
  • Monitor for cardiovascular, gastrointestinal, and renal complications, especially in older adults. 2, 3

• Oral acetaminophen (up to 3000-4000 mg daily) can reduce pain, though it is less effective than NSAIDs for improving physical function. 1, 2

  • Consider a 3000 mg daily limit in older adults to prevent hepatotoxicity. 2
  • Regular dosing provides better sustained pain control than "as needed" dosing for chronic conditions. 2

Medications to Avoid

Avoid prescribing opioids (including tramadol) for acute musculoskeletal pain, as evidence shows low-certainty benefit and significant risks of prolonged use and dependence. 1

Do not prescribe traditional muscle relaxants (cyclobenzaprine, carisoprodol, methocarbamol) under the mistaken belief they relieve muscle spasm—their effects are nonspecific and carry fall risk in older adults. 1

Non-Pharmacologic Interventions

Heat and Cold Therapy

Apply heat immediately after exercise-induced muscle soreness for optimal pain reduction:

• Moist heat applied for 2 hours immediately after exercise provides the greatest pain reduction and is superior to cold therapy for delayed onset muscle soreness (DOMS). 4, 5
• Low-level continuous heat wraps applied for 8 hours immediately after heavy exercise significantly reduce soreness, preserve muscle strength, and improve flexibility. 6
• Heat applied 24 hours after exercise still provides benefit, but to a lesser extent. 6

Cold therapy has a more limited role:

• Cold water immersion within 1 hour after exercise reduces pain within the first 24 hours only (not beyond). 5
• Cold followed by static stretching may reduce delayed muscle pain more effectively than heat and stretching. 7
• Cold is better reserved for acute joint injuries with swelling rather than muscle soreness. 6

Exercise and Physical Activity

For chronic muscle pain (arthritis, inflammatory conditions):

• Begin with isometric strengthening exercises at 30% of maximal voluntary contraction, gradually increasing to 75% as tolerated. 1, 2
• Hold contractions for no longer than 6 seconds. 2
• Start with 1 contraction per muscle group, gradually increasing to 8-10 repetitions. 2
• Transition to isotonic (dynamic) strengthening once acute pain subsides. 2
• Exercise 30-60 minutes, 3-7 days per week for conditions like hypertension; daily exercise may be most effective. 1

Exercise structure should include:

• 5-10 minute warm-up of low-intensity range-of-motion exercises. 2
• Training phase for overload stimulus. 2
• 5-minute cool-down with static stretching. 2

Safety monitoring during exercise:

• Joint pain lasting more than 1 hour after exercise indicates excessive activity requiring modification. 2
• Joint swelling after exercise signals overexertion. 2
• Adjust intensity, volume, or type of exercise if these signs occur. 2

Additional Non-Pharmacologic Options

For acute non-low back musculoskeletal injuries:

• Specific acupressure reduces pain and improves physical function (though evidence is low-certainty). 1
• Transcutaneous electrical nerve stimulation (TENS) reduces pain (low-certainty evidence). 1

For chronic conditions:

• Manual therapy (manipulation and stretching) combined with supervised exercise may provide additional benefit. 2
• Assistive devices should be assessed for activities of daily living. 2

Special Populations and Conditions

Older Adults (≥65 years)

• Exercise caution with all NSAIDs due to increased risk of adverse events. 3
• Consider lower acetaminophen doses (3000 mg daily maximum). 2
• Be aware that many muscle relaxants and benzodiazepines increase fall risk. 1
• Vigorous training programs require medical evaluation for men ≥45 years and women ≥55 years. 1

Neuropathic Muscle Pain

• Neuropathic pain is less responsive to opioids than other pain types. 1
• Consider coanalgesics: anticonvulsants (gabapentin, pregabalin), tricyclic antidepressants, or topical lidocaine 5% patch. 1
• Baclofen may be used for severe spasticity from central nervous system injury or neuromuscular disorders. 1

Pregnancy Considerations

• Avoid NSAIDs at approximately 20 weeks gestation or later due to risk of oligohydramnios and premature closure of fetal ductus arteriosus. 3
• If NSAIDs are necessary after 20 weeks, use the lowest effective dose for the shortest duration (ideally <48 hours). 3

Common Pitfalls to Avoid

• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor). 2
• Do not use glucosamine or chondroitin—evidence does not support efficacy. 2
• Avoid exercising inflamed joints with resistance; use only isometric contractions with few repetitions. 2
• Do not exceed 4000 mg daily of acetaminophen to prevent hepatotoxicity. 2
• Avoid morning exercise in patients with rheumatoid arthritis-related stiffness. 1
• Discontinue exercise if unusual or persistent fatigue, increased weakness, decreased range of motion, or joint swelling/pain lasting >1 hour after exercise occurs. 1

When to Consider Advanced Interventions

• Intra-articular corticosteroid injections may provide temporary relief for moderate to severe pain in specific joints. 2
• Refer for surgical intervention only after offering core treatment options (exercise, pain management) and when symptoms substantially impact quality of life despite conservative management over 3-6 months. 2
• Psychological or social interventions should be considered if these factors interfere with effective pain management. 1
• Sleep interventions are indicated if sleep disturbance persists despite addressing pain and implementing good sleep hygiene. 1