Topical NSAIDs first line treatment for musculoskeletal pain: ACP guidelines

ACP and AAFP recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient's treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).

ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain (Grade: conditional recommendation; moderate-certainty evidence).

ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain (Grade: conditional recommendation; low-certainty evidence).

ACP and AAFP suggest against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

Musculoskeletal injuries are common and are most frequently treated in outpatient settings. In 2010, they accounted for more than 65 million health care visits in the United States and 4 of 5 injuries that were treated in a physician's office were musculoskeletal (1). The estimated annual cost of treating musculoskeletal injuries was $176.1 billion in 2010 (1).

Acute musculoskeletal pain lasts less than 4 weeks and includes strains and sprains, soft tissue injuries, whiplash, and various other conditions ranging from nonsurgical fractures to contusions (2). Numerous treatment options exist, including nonpharmacologic and pharmacologic interventions (nonopioid and opioid) (3–6). In the United States, approximately one fifth of patients presenting with pain in the outpatient setting receive an opioid prescription (7) and opioid prescriptions for acute musculoskeletal injuries, such as ankle sprains, are common (8, 9). As of 2015, 2 million persons had an opioid use disorder involving prescription opioids (10), although prescribing rates have decreased in recent years.

The Comparative Effectiveness of Nonpharmacologic and Pharmacologic Treatments showed that interventions that had statistically significant benefit compared with placebo and at least 1 other intervention were considered to be "among the most effective" interventions. For pain reduction at less than 2 hours, moderate-certainty evidence showed that the following interventions were among the most effective: acetaminophen, acetaminophen plus oral diclofenac, oral NSAIDs, and topical NSAIDs alone or plus menthol. Low-certainty evidence showed that transbuccal fentanyl may be among the most effective for pain reduction at less than 2 hours. Moderate-certainty evidence showed that for pain reduction at 1 to 7 days, acetaminophen, oral NSAIDs, and topical NSAIDs may be among the most effective interventions. Low-certainty evidence showed that acetaminophen plus chlorzoxazone, specific acupressure, and TENS may be among the most effective. Moderate-certainty evidence showed that topical NSAIDs were among the most effective interventions for improvement in function. Low-certainty evidence showed that specific acupressure may be among the most effective. High-certainty evidence showed that topical NSAIDs were among the most effective interventions for treatment satisfaction. Moderate-certainty evidence showed that acetaminophen plus oral diclofenac, oral NSAIDs, and topical NSAIDs were among the most effective interventions for symptom relief.

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