What are common topical ointments used in orthopedics for musculoskeletal pain or inflammation?

Common Topical Ointments in Orthopedics

Topical NSAIDs, particularly diclofenac gel and ketoprofen gel, are the first-line topical pharmacological treatments for musculoskeletal pain in orthopedics, with topical capsaicin serving as an adjunct for chronic conditions like osteoarthritis. 1, 2

First-Line Topical Agents

Topical NSAIDs (Primary Choice)

Topical NSAIDs are preferred over systemic treatments for mild to moderate musculoskeletal pain, especially when only a few joints are affected, due to their favorable safety profile and efficacy. 1

Diclofenac Formulations

• Diclofenac gel (Emulgel®) is the most effective topical NSAID for acute musculoskeletal injuries (strains, sprains), with 78% of patients achieving at least 50% pain relief versus 20% with placebo at 7 days (NNT 1.8) 3, 4
• For chronic knee osteoarthritis, apply 40 mg (2 pump actuations) to each painful knee twice daily to clean, dry skin 5
• Diclofenac topical solution reduces WOMAC pain scores by 4.5 points versus 3.6 points with placebo after 4 weeks 5
• Apply 3-4 times daily for hand and knee osteoarthritis, with clinical effects evident within 2-4 weeks 1, 6
• Approximately 60% of patients experience significant pain reduction over 6-12 weeks (NNT 9.8) 6

Ketoprofen Gel

• Ketoprofen gel is the strongest alternative to diclofenac, with 63% of patients achieving significant pain relief versus 48% with placebo (NNT 6.9) over 6-12 weeks in chronic musculoskeletal pain 7, 6
• For acute injuries, ketoprofen gel achieves 72% response versus 33% placebo at 7 days (NNT 2.5) 3, 4
• Apply to affected areas 3-4 times daily 7

Critical Anatomical Limitation

Do NOT use topical NSAIDs for hip osteoarthritis due to inadequate drug penetration to the deep hip joint; oral NSAIDs are required instead 7

Second-Line Topical Agent

Capsaicin (Adjunct for Chronic Pain Only)

Capsaicin 0.025-0.075% cream is effective specifically for chronic osteoarthritis and neuropathic pain, NOT for acute injuries. 2, 8

Evidence-Based Indications

• Hand osteoarthritis: EULAR guidelines recommend capsaicin with NNT of 3 for clinical improvement at 4 weeks 1, 2
• Knee osteoarthritis: American College of Rheumatology conditionally recommends capsaicin for moderate knee pain 2
• Contraindicated for hand OA per American College of Rheumatology due to risk of eye contamination, though EULAR guidelines support its use 2

Application Protocol

• Apply 0.025-0.075% cream 3-4 times daily to affected areas 2, 7
• Requires 2-4 weeks of continuous use before therapeutic effects occur, as capsaicin works by depleting substance P gradually 2, 8
• Initial application causes burning sensation (affects 35-100% of patients), which peaks in week 1 and declines over time 9

Critical Pitfall to Avoid

Never use capsaicin for acute sprains or strains - its mechanism and evidence base are exclusively for chronic pain conditions lasting months to years, not acute injuries 8

Safety Profile Comparison

Topical NSAIDs

• Local adverse events: Mild skin reactions occur in approximately 5% of patients versus 4% with placebo (NNH 51) 4
• Systemic adverse events: No increase in gastrointestinal events compared to placebo (RR 0.81,95% CI 0.43 to 1.56) 1
• Significantly safer than oral NSAIDs for GI bleeding risk (adjusted OR 1.45 vs 2.59 for oral NSAIDs) 1
• In acute pain conditions, systemic or local adverse event rates (4.3%) are no greater than placebo (4.6%) 4

Capsaicin

• Local burning sensation is the primary adverse event (NNH 2.6 for local reactions) 4
• No systemic toxicity reported 9
• Well-tolerated with continued use as burning sensation diminishes 9

Practical Treatment Algorithm

For Acute Musculoskeletal Injuries (Sprains, Strains)

1. Start with topical diclofenac gel (Emulgel®) applied 3-4 times daily 3, 4
2. Alternative: Ketoprofen gel 3-4 times daily if diclofenac unavailable 3, 4
3. Do NOT use capsaicin for acute injuries 8

For Chronic Hand/Knee Osteoarthritis

1. First-line: Topical diclofenac or ketoprofen gel 3-4 times daily 1, 7
2. Add capsaicin 0.025-0.075% cream if topical NSAIDs insufficient after 2-4 weeks 2, 7
3. Transition to oral NSAIDs at lowest effective dose if topical therapy inadequate after 6-8 weeks 1, 7

For Hip Osteoarthritis

Skip topical agents entirely and start with oral NSAIDs or acetaminophen as first-line pharmacotherapy due to inadequate penetration 7

Application Precautions

For Topical NSAIDs (Diclofenac)

• Avoid showering/bathing for at least 30 minutes after application 5
• Wait until treated area is completely dry before applying sunscreen, insect repellent, or other topical products 5
• Avoid skin-to-skin contact with others until treated area is dry 5
• Do not apply external heat or occlusive dressings to treated areas 5
• Wash and dry hands after use 5

When Multiple Joints Are Affected

Systemic pharmacological treatment (oral NSAIDs) may be preferred over topical agents when a large number of joints are affected 1