No Prescription Required: Treating Musculoskeletal Pain, Part I
By Andrew W. Gottschalk, M.D., Director of Sports Medicine
Champion Orthopedics & Sports Medicine at Cole Memorial Hospital
The day before the 2014 Winter Olympics proved more gut-wrenchingly dramatic than anything else in the first week of Olympic competition. Heidi Kloser of Colorado, one of the best mogul skiers in the world, crashed during warm-ups. The casualties of that accident were both major ligaments and bones in her right knee and her ability to compete in the 2014 Olympics.
Perhaps surprisingly, given the severity of her accident and resultant injuries, the pictures and videos of her after the crash did not show her in tremendous pain. In the subsequent interviews with Kloser and her family, they spoke of disappointment and sadness, yet not of physical pain.
In the clinic, one of the most common problems I see is bone and joint, or musculoskeletal, pain. From the dramatic (a crash while skiing) to the mundane (spraining an ankle stepping off a curb), musculoskeletal pain is one of the most frequent types of pain experienced in one’s lifetime.
In this column and the next, we will discuss the three main classes of oral medication used to treat musculoskeletal pain.
Class 1: Acetaminophen
Acetaminophen (better known by its brand name Tylenol) is in a class by itself. Acetaminophen is effective with few side effects, making it the perfect first-line treatment for musculoskeletal pain. In adults, 1000 mg (two extra-strength 500 mg tablets) three times a day — at breakfast, lunch and once before bedtime — is enough to treat many bumps, bruises, sprains and strains.
Acetaminophen is one of the safest medications in use today. It should be used with caution, however, in people with decreased liver or kidney function. People who drink a lot of alcohol should also be careful when using acetaminophen, because both Tylenol and alcohol are processed by the liver. Asking the liver to handle large amounts of both of these compounds simultaneously can be harmful.
Class 2: Ibuprofen and Related Medications
The second class of medication for musculoskeletal pain includes ibuprofen (brand names Advil and Motrin). Ibuprofen, like acetaminophen, is effective with few side effects and is a powerful second-line treatment for musculoskeletal pain. In adults 600 mg (three 200 mg tablets) three times a day is a good backup for pain that acetaminophen alone isn’t effectively treating. Ibuprofen should be used with caution in people with decreased kidney function. I recommend acetaminophen be used first-line — and ibuprofen as the backup — for a couple different reasons. Taking ibuprofen and other medications in this class is associated with a very small risk to the heart. This risk increases in patients who use these medications for extended periods of time and in patients of advanced age. Gastrointestinal (e.g. stomach) irritation and bleeding is another small risk associated with ibuprofen use. As with heart risk, gastrointestinal risk is very small when ibuprofen is used in appropriate doses, for short periods of time, by patients who are not elderly.
Acetaminophen and ibuprofen shut down the pain pathway at two different steps, so while they work just fine relieving pain independently, they work even more effectively when used in combination.
As with all oral medications, acetaminophen and ibuprofen have side effects. I have listed the major ones above, but to read more about the risks of use of these medications go to online.epocrates.com (or any number of other similar websites). Check with your physician to make sure these medications are appropriate for you.
An important point to remember is this: Used appropriately, acetaminophen and ibuprofen are very safe — so safe that the Food and Drug Administration allows their sale over the counter in the United States. So while you should always keep the side effects of a medication in mind and check with your physician, do not be afraid to use these medications appropriately.
In the next column, we will discuss other pain medications and other key points in the treatment of musculoskeletal pain.