Analgesia for acute soft-tissue limb conditions
Busse, 2020Jones, 2020Qaseem, 2020Morelli 2018
Not all people with acute soft-tissue limb conditions will require analgesia. A 2020 Cochrane review1 found that in acute soft-tissue injury, nonsteroidal anti-inflammatory drugs (NSAIDs) (when compared with paracetamol) made no difference to pain at 1 to 2 hours or at 2 to 3 days, and may make no difference at day 7 and beyondJones, 2020.
Paracetamol and NSAIDs are often used for short-term pain relief by people with acute soft-tissue limb conditions. If analgesia is required for an acute soft-tissue limb condition, first-line treatment is oral paracetamol; use:
1paracetamol immediate-release 1 g orally, 4- to 6-hourly, up to a maximum of 4 g daily paracetamol paracetamol paracetamol
OR
1paracetamol modified-release 1.33 g orally, 8-hourly. paracetamol paracetamol paracetamol
If the analgesic effect from paracetamol is inadequate, an NSAID may be used instead of, or in combination with, paracetamol.
For superficial soft-tissue limb conditions (eg de Quervain tenosynovitis), topical NSAIDs are considerably safer than oral NSAIDs because of minimal systemic absorption. If a trial of a topical NSAID is considered appropriate for a superficial soft-tissue limb condition, useBusse, 2020Qaseem, 2020:
1diclofenac 1% gel applied to the painful area, up to 4 times daily if required diclofenac diclofenac diclofenac
OR
1diclofenac 2% gel applied to the painful area, once or twice daily if required diclofenac diclofenac diclofenac
OR
1ibuprofen 5% gel applied to the painful area, up to 4 times daily if required ibuprofen ibuprofen ibuprofen
OR
1piroxicam 0.5% gel applied to the painful area, up to 4 times daily if required. piroxicam piroxicam piroxicam
All of the NSAIDs listed below are equally effective, and drug choice should be based on patient factors (eg comorbidities); see Choosing an NSAID for advice on drug choice. If an oral NSAID is indicated for a soft-tissue limb condition, use:
1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib
OR
1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib
OR
1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen
OR
1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin
OR
1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen
OR
1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam
OR
1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen
OR
1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen
OR
1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam
OR
2diclofenac 25 to 50 mg orally, 2 or 3 times daily until symptoms subside. diclofenac diclofenac diclofenac
The potential benefits of an NSAID should be weighed against its potential harms, particularly in people at high risk of harms (see Principles of NSAID use for musculoskeletal pain for more information).
Other analgesic therapies that may be considered for acute soft-tissue limb conditions include local anaesthetic nerve blocks and acupuncture. Opioids are rarely indicated for acute soft-tissue limb injuries and are associated with a significant risk of harms.
Local corticosteroid injections can be used for analgesia in people with tendinopathy for short-term pain relief (6 to 8 weeks). They are not recommended for acute soft-tissue conditions, including muscle strain and ligament sprain.