Clinical Question

Are oral nonsteroidal anti-inflammatory drugs (NSAIDs) superior to other oral analgesics for the treatment of pain associated with acute soft tissue injuries?

Evidence-Based Answer

There is no difference in effectiveness between NSAIDs and other pain relievers, including acetaminophen and opioids, for pain reduction in patients younger than 65 years who have acute strains and sprains.¹ (Strength of Recommendation: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

More than 65 million health care visits for musculoskeletal injuries occur annually in the United States.² NSAIDs are commonly recommended to reduce pain and inflammation related to these injuries, but they are associated with gastrointestinal, renal, and cardiovascular adverse effects.^3,4 The authors of this Cochrane review sought to determine whether NSAIDs are superior to other agents for treating pain related to acute soft tissue injuries.

The review included 20 randomized or quasi-randomized controlled trials involving 3,305 participants with acute soft tissue injury, defined as a sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within the past 48 hours.¹ Eleven studies (n = 1,853) compared NSAIDs with acetaminophen, six studies (n = 1,212) compared NSAIDs with opioids, and four studies (n = 240) compared NSAIDs with the combination of acetaminophen and an opioid. Seven of the studies included patients with ankle sprains only. Three studies included children only (n = 360; six to 17 years of age), and the remaining studies included predominantly young adults. Although studies may have included participants older than 65 years, only one study reported data in that age group that could be aggregated. The average age of participants across all comparisons was 20 to 35 years. Studies were completed in a variety of locations, including primary care clinics, emergency departments, student health centers, sports medicine clinics, research facilities, orthopedic clinics, urgent care centers, and rheumatology clinics. The primary outcome investigated was pain. Secondary outcomes included swelling, function, and adverse effects.

No significant differences were noted between NSAIDs and acetaminophen in pain measured with a visual analog scale at one to two hours, one to three days, or seven days or more following treatment.

There was no difference in pain response for patients treated with NSAIDs vs. those treated with opioids. NSAIDs did not appear to improve swelling compared with opioids, but this conclusion is based on very limited participant numbers. Participants treated with NSAIDs were more likely than those treated with opioids to return to function in seven to 10 days (relative risk [RR] = 1.13 [95% CI, 1.03 to 1.25]; number needed to treat = 11 [95% CI, 6.2 to 43]; n = 749). The NSAID group was less likely than the opioid group to develop gastrointestinal adverse effects (RR = 0.48 [95% CI, 0.36 to 0.62]; number needed to harm [NNH] = 12 [95% CI, 7.7 to 23]; n = 1,151) or neurologic adverse effects (RR = 0.40 [95% CI, 0.30 to 0.53]; NNH = 10 [95% CI, 7.0 to 17]; n = 1,151). Studies comparing NSAIDs with the combination of acetaminophen and an opioid showed no difference in pain response at day 1, days 1 to 3, or day 7 or later.

These findings are consistent with recent guidelines by the American College of Physicians and the American Academy of Family Physicians, which suggest that patients should use topical or oral NSAIDs or acetaminophen rather than opioids for acute musculoskeletal pain not involving the back.⁵

Editor's Note: The NNHs, number needed to treat, and related CIs reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.

The practice recommendations in this activity are available at https://www.cochrane.org/CD007789.