New guidelines for aches, pains, and strains

We’ve all been there before. A minor injury leads to a sore ankle, achy shoulder, or sore neck. You could do nothing, try to ignore it, and see if it gets better. Or you may be tempted to take something, especially if significant discomfort prevents you from doing your usual activities or keeps you up at night.

So, what’s the best initial treatment? For minor injuries, your options are many, including:

• Home remedies. Common approaches are the “RICE” treatments — Rest, Ice, Compression, and Elevation: applying cold to the sore area, wearing an elastic wrap to compress the sore area, rest, and elevation (such as propping up your sore ankle on pillows).
• Nondrug approaches. For instance, massage or acupuncture.
• Pain medicines. Examples are acetaminophen, anti-inflammatory drugs like ibuprofen, or other pain relievers.

New guidelines have been developed

Recently, the American College of Physicians and American Academy of Family Physicians gathered experts to develop new recommendations for just this sort of situation. Officially, these guidelines are for “acute pain from non-low back, musculoskeletal injuries in adults” — that is, for people whose pain started less than four weeks ago and does not include low back pain (for which separate guidelines have been developed).

To come up with these recommendations, experts reviewed more than 200 randomized controlled trials, which are considered the highest quality and most powerful type of evidence. These trials enrolled nearly 33,000 subjects (average age 34) with a variety of conditions: the most common were sprains (especially involving the ankle), strains, and neck injuries. The researchers considered not only pain relief but also physical function, quality of life, patient satisfaction, return to work, and side effects.

What the new guidelines recommend

These new guidelines did not specifically comment on the standard home remedies of rest, ice, compression, and elevation, probably because randomized controlled trials of these treatments don’t exist. But these measures still seem like reasonable first steps.

Beyond them, the new guidelines recommend the following, in this order:

• Topical nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are similar to ibuprofen (as in Motrin) but instead of pills, the medication is applied to the skin over the sore area. There are a few over-the-counter (OTC) options (such as diclofenac 1% gel or aspirin-type medicines), but most are by prescription (see below).
• Oral NSAIDs or acetaminophen. Many generic and brand-name oral NSAIDs are available, including ibuprofen and naproxen, and several are sold both OTC and at a higher dose by prescription. Acetaminophen is the active ingredient in Tylenol and many other OTC products.
• Acupressure or transcutaneous electrical nerve stimulation (TENS). These were found to be somewhat effective, but less so than NSAIDs or acetaminophen. Also, the quality of the studies was low.

Opiates were not recommended, as their benefits are modest, and risks are higher than the other options.

Some caveats about these new guidelines

It’s worth noting that

• These newly published guidelines did not consider comparisons of different topical or oral NSAIDs with each other, presumably because such studies don’t exist.
• Similarly, they didn’t look at all possible combinations of treatments (for example, acetaminophen with naproxen), acupuncture (vs. acupressure), or capsaicin, a common topical pain treatment.
• Even the medications that fared best in the balance of benefit and risk were only modestly effective, and only slightly better than placebo.

In addition, keep in mind these guidelines apply to aches and pains caused by minor injuries. For more significant injuries or symptoms, the best first step may be to see a healthcare provider right away, because x-rays or other evaluation may be important. For example, if you’ve had a significant ankle injury and now cannot walk or bear weight, it’s worth getting checked out. When in doubt, contact your doctor and explain the situation.

More on topical NSAIDs

One advantage to topical NSAIDs is their safety. Compared with pills, less medication is absorbed into the bloodstream, so they tend to cause fewer side effects. That can be a big deal for people with a sensitive stomach who cannot take oral NSAIDs. People with significant cardiovascular disease may be advised to avoid oral NSAIDs, but their doctors may deem topical NSAIDs acceptably safe.

However, topical NSAIDs may also be less effective than other treatments. For example, hip pain may not improve with topical NSAIDs because the hip joint is far from the surface of the skin.

Here are some examples of topical NSAIDs.

• Salicylates (the active ingredient in aspirin). Examples include many OTC products such as Aspercreme, Icy-Hot, and Bengay.
• OTC diclofenac 1% gel. The brand name is Voltaren Arthritis Pain.
• Prescription agents. Higher-concentration diclofenac (brand names Flector, Pennsaid, Solaraze). Or compounding pharmacies can provide other NSAIDs in a topical formulation, including ibuprofen, indomethacin, or piroxicam.

The bottom line

If you’ve had a recent injury, sorry to hear it! Take heart — most minor injuries are better within a few days regardless of the treatment.

But there are things you can do that may be helpful while awaiting recovery. These new guidelines can help you and your doctor choose the most effective and safest options first. Or, you may choose no treatment at all. Fortunately, you’ll probably improve without a needing a prescription medication or seeing a doctor.

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