What is the best approach to manage musculoskeletal pain in a healthy adult?

Management of Musculoskeletal Pain in Healthy Adults

Begin with education, physical activity/exercise, and avoid routine imaging—these form the foundation of evidence-based musculoskeletal pain management, with pharmacotherapy reserved as adjunctive therapy when needed. 1

Initial Assessment and Red Flags

• Screen for "red flag" conditions (fracture, infection, malignancy, cauda equina syndrome) that require urgent intervention before proceeding with conservative management 1
• Assess psychosocial factors including anxiety, depression, catastrophizing, fear-avoidance beliefs, and work-related stress, as these predict chronicity and treatment response 1
• Perform a focused physical examination to identify specific pain generators, movement patterns, and functional limitations rather than relying on imaging 1

First-Line Non-Pharmacological Management

Education and self-management are mandatory first-line interventions:

• Provide clear education that imaging findings (disc bulges, degenerative changes) often do not correlate with symptoms and that pain does not equal tissue damage 1
• Emphasize staying active and avoiding prolonged rest, as activity promotes recovery and prevents chronicity 1
• Prescribe structured exercise programs including strengthening, flexibility, and aerobic conditioning—this has the strongest evidence for sustained benefit 1
• Offer self-management programs that teach patients pain coping strategies and promote autonomy 1

Manual therapy can be used only as an adjunct to exercise and education, never as standalone treatment 1

Imaging: When NOT to Order

Do not routinely order radiological imaging unless: 1

• Red flag conditions are suspected (fracture, infection, malignancy)
• Findings would change management decisions
• There has been failure to respond to 6-12 weeks of conservative care

The evidence shows that routine imaging increases costs, patient anxiety, and unnecessary interventions without improving outcomes 1

Pharmacological Management: A Stepwise Approach

For Acute Musculoskeletal Pain:

First-line pharmacotherapy:

• Oral NSAIDs (ibuprofen, naproxen) reduce pain by approximately 0.93 cm on a 10-cm scale within 2 hours and improve function 2
• Acetaminophen reduces pain by approximately 1.03 cm on a 10-cm scale within 2 hours as an alternative to NSAIDs 2, 3

Critical pitfall: Do not offer paracetamol (acetaminophen) as a single medication for low back pain—it is ineffective for this indication 1

For Chronic Musculoskeletal Pain:

Avoid these medications entirely:

• Do not prescribe opioids for chronic musculoskeletal pain, including tramadol—evidence shows no benefit over NSAIDs and significant harm potential 1, 2
• Do not use "muscle relaxants" (methocarbamol, carisoprodol, chlorzoxazone, metaxalone, cyclobenzaprine) for chronic pain—they lack efficacy evidence and carry high risk of sedation, falls, and cognitive impairment in adults 1, 4
• Do not prescribe SSRIs, SNRIs (except duloxetine for specific conditions), tricyclic antidepressants, or anticonvulsants for non-specific low back pain 1

When adjuvant analgesics are appropriate:

For chronic widespread pain or fibromyalgia:

• Duloxetine (SNRI) is the preferred antidepressant with evidence for musculoskeletal pain 1
• Pregabalin (150-600 mg/day in two divided doses) or gabapentin (900-3600 mg/day in 2-3 divided doses) for neuropathic components 1
• Start at low doses and titrate slowly to monitor for side effects, particularly in older adults 1

Topical analgesics should be considered whenever pain is focal or regional to minimize systemic side effects 1

Specific Condition Considerations

Osteoarthritis:

• Offer weight loss interventions for overweight/obese patients 1
• Do not use glucosamine or chondroitin for disease modification—they are ineffective 1
• Do not perform knee arthroscopic lavage/debridement unless mechanical locking is present 1

Low Back Pain:

• Do not offer spinal injections (facet joint, medial branch blocks, intradiscal, prolotherapy, trigger point) 1
• Do not offer disc replacement outside of research trials 1
• Do not prescribe rocker shoes or foot orthotics 1

Work and Activity Management

Keep patients at work or facilitate early return to work with modified duties if needed—prolonged work absence predicts chronicity and disability 1

When to Consider Surgery

Offer evidence-based non-surgical care for at least 3 months before surgical consultation unless red flag conditions are present 1

Surgery outcomes are generally equivalent to conservative care for most musculoskeletal conditions in the long term, with higher complication risks 1

Monitoring and Follow-Up

Monitor patient progress systematically using validated outcome measures (pain scales, functional questionnaires) to determine treatment effectiveness 1

Discontinue ineffective treatments promptly rather than continuing medications or therapies that provide no benefit 1

Common Pitfalls to Avoid

• Never prescribe cyclobenzaprine labeled as a "muscle relaxant"—it is FDA-approved only for short-term use (2-3 weeks) in acute painful musculoskeletal conditions and has no role in chronic pain 5
• Avoid the trap of polypharmacy—adding multiple medications without clear benefit increases adverse effects without improving outcomes 1
• Do not use manual therapy alone—it must be combined with exercise and education to have any potential benefit 1
• Resist patient pressure for imaging—explain that normal age-related changes on imaging do not require treatment and may lead to unnecessary interventions 1