Musculoskeletal Strains and Sprains - Guidelines for Prescribing NSAIDs

Description
  • Musculoskeletal pain arises from the muscles, bones, joints, and connective tissue. 
  • The musculoskeletal system includes the muscles, tendons, ligaments, cartilage, and bones. Muscles are attached to bones by tendons, and ligaments connect bone to bone. Under normal conditions, tendons and ligaments have limited ability to stretch and twist. Because of their tensile strength, tendons and ligaments rarely rupture unless subjected to intense forces, but may become damaged when hyperextended or over-used. Synovial bursae are fluid-filled sacs located between joint spaces to provide lubrication and cushioning.
  • Similar to other types of pain phenomena, musculoskeletal pain can be idiopathic, iatrogenic, or related to injury.
    • Pain receptors are located in skeletal muscle and the overlying fascia, and can be stimulated as a result of overuse or injury to the muscle or surrounding structures. 
    • Sprains are injuries to ligament without dislocation or fracture caused by abnormal or excessive forces applied to a joint.
      • Grade 1 sprain:  Minimal pain, swelling or loss of function.  Minimal bruising.
      • Grade 2 sprain:  Some instability or looseness of joint.  Moderate pain and swelling.  Bruising common with some pain on weight bearing, but still functional.
      • Grade 3 sprain:  Significant instability and looseness of joint.  Severe pain, swelling and bruising.  Significant difficulty bearing weight that compromises function.
    • Strains ("pulls") are injuries to muscles caused by stretching or tearing of muscle fibres as a result of stretching muscles beyond their limits or forcing muscles to contract too strongly.
      • Grade 1 strain:  Mild strain with few muscle fibers torn; mild pain and little or no loss of strength.
      • Grade 2 strain:  Moderate strain with definite loss in strength.
      • Grade 3 strain:  Complete tear of the muscle with significant swelling and bruising; complete loss of muscle function and strength.
  • Musculoskeletal complaints result in a significant amount of lost work days, work limitations.
    • Pain related conditions that most frequently result in primary care visits include back pain (17.63 cases/1000 visits ), headaches ( 16.10/1000 ), knee pain (8.51/1000 ),lower back pain (8.42/1000 ), shoulder pain ( 6.97 /1000 ), and neck pain ( 6.50/1000 ).
  • Because pain and inflammation increase prostaglandin production, drugs that inhibit peripheral prostaglandin production reduce pain by decreasing the transmission of pain impulses from the periphery to the CNS.
  • For more information, go to:
    • Clinical Knowledge Summaries – Sprains and strains. (Free access, registration required)
    • e-therapeutics+ - Musculoskeletal Disorders: Sports Injuries. Available at SHIRP website
Signs and Symptoms
  • Patients with musculoskeletal injuries generally present with similar symptoms - pain and swelling of the affected area.
  • These conditions have similar treatment approaches.
  • Acute pain is the body's alarm system; it signals injury by trauma, disease, muscle spasms or inflammation. 
  • Chronic pain may or may not be indicative of injury and requires a primary care provider's assessment before treatment is initiated.

  • Initial assessment should include:

    • Characteristics of the pain
      • Scale of 1 to 10
      • Pain on movement or rest
      • Description (eg. stiff, sore, dull ache vs. tingling, shooting or stabbing pain)
      • Onset
      • Location
      • What makes it better or worse
      • Systemic symptoms
    • Functional impairment
      • Any significant functional impairment moves their pain beyond a "minor" ailment and should be considered severe.
    • History of pain
      • Previous injuries
      • What has been tried before
    • Must differentiate between acute and chronic
      • Chronic pain is any pain lasting greater than 2 weeks
    • Comorbidities / complicating factors -- these will influence your treatment choice and help with the differential assessment.
      • Diabetes - expect longer healing times
      • Stroke - could cause one-sided weakness
      • Cancer - pain with no apparent cause could be a sign of worsening cancer control in a patient with a history of cancer
      • Bleeding disorders - avoid NSAIDs in these patients
      • History of DVT - significant leg or calf pain may be a sign of a DVT, especially in a patient who has had a prior DVT
      • GI disorders - may choose to avoid NSAIDs in these patients
      • Cardiovascular disorders - may choose to avoid NSAIDs, or prefer naproxen if an NSAID is used
    • Other medications -- some medications can cause pain as a side effect (see below)
Differential Assessment

Musculoskeletal strains and sprains are assessed based on history and the presence of pain and swelling. Rule out the following conditions that may present with similar signs and symptoms:

  • Fracture - indicated by marked bruising, swelling, deformity, bone tenderness, or inability to bear weight.
  • Tendon rupture - indicated by inability to move muscle.
  • Cartilage injury - indicated by tearing sensation, severe pain.
  • Arthritis flare-up - history of arthritis.
  • Adverse drug reaction
    • Some drugs, including statins and colchicine are direct myotoxins.
    • Statins, fibrates, colchicine, corticosteroids, hydroxychloroquine and amiodarone can cause pain.  Fluoroquinolones can cause severe tendon or joint pain.
    • Statins can increase the risk of rhabdomyolysis in patients with other predisposing conditions, such as hypothyroidism or an inflammatory myopathy. Drug-drug interactions may be responsible for rhabdomyolysis in some individuals. The nature of the interactions vary. As an example, some drugs interfere with the clearance of statins and lead to elevated plasma levels; offending agents include macrolide antibiotics (eg, erythromycin), cyclosporine, gemfibrozil, and some protease inhibitors used in the treatment of HIV infection.
    • Dietary supplements containing multiple ingredients may lead to rhabdomyolysis, possibly as a result of metabolic "stress”. In one report, nutritional supplements used in strength training were associated with rhabdomyolysis in an otherwise healthy individual.
When to Refer

Patients with typical signs / symptoms of musculoskeletal sprains and strains often do not require further investigation. However an assessment by the patient's primary care provider should be recommended in the following situations:

  • Moderate to severe pain (pain score greater than 6 on a 10 point scale).
  • Pain that has persisted for longer than 2 weeks.
  • Pain that persists for more than 7 days without improvement after treatment initiation.
  • Increased intensity or change in character of pain.
  • Pelvic or abdominal pain (other than dysmenorrhea) - Refer to Guidelines for Dysmenorrhea.
  • Accompanying nausea, vomiting, fever, or other signs of systemic infection or disorder.
  • Visible joint changes, abnormal movement, weakness or inability to bear weight in any limb, or suspected fracture.
  • Age less than 2 years.
  • Comorbidities such as GI disorders, cardiovascular disease, renal dysfunction, liver dysfunction if NSAID therapy is being considered.
  • Pain due to trauma, such as a fall
Treatment

1) Nonpharmacologic Treatment

  • RICE therapy, which stands for rest, ice, compression and elevation.  Useful within first 72 hours of injury.
    • Resting the affeced area should be done, but that does not mean complete immobilization.  Avoid over-use or exertion of the area for 24 hours, and then gradually re-introduce activity.  Resting for too long can delay recovery.
    • Ice should not be applied for more than 15 minutes because excessive icing causes considerable vasoconstriction and reduces vascular clearance of inflammatory mediators from the damaged area. Ice should be applied 3 to 4 times per day for the first 48 to 72 hours after the injury.
    • Compression with a simple elastic bandage or elasticated tubular bandage, applied below the site of injury to 10cm above and should be snug but not tight, can assist in reducing the swelling and pain.
    • Elevation of the injured area above the level of the heart may also help to limit swelling.
  • For the first 48 hours avoid heat, alcohol, exercise and massage. 
  • Heat therapy is an alternative for patients with non-inflammatory pain persisting for more than 48 hours after the injury. It has been studied in the treatment of acute low back pain with increasing blood flow. Although its mechanism of action is not fully understood, heat may help to reduce pain by increasing blood flow. Do not use with other topical agents or on broken skin.
  • Physical and rehabilitative therapies have been used to treat acute pain from sports injuries and to treat chronic pain. Physical therapy can assist in building up supporting muscle structures such as the abdominal muscles that support the lower back.                                                       
    • For sprains, do not immobilize the joint. Begin flexibility exercises as soon as they can be tolerated without excessive pain. It is thought that functional stress stimulates collagen replacement.                                                                                    
    • For strains immobilize the muscles for the first few days after the injury. This allows granulation tissue to gain enough strength to withstand the forces caused by the contracting muscle. Longer term immobilization can cause healthy microfibers to atrophy and reduces the muscle's tensile strength.  The muscle can become tight, weak, and overly contracted resulting in chronic muscle pain syndromes.

2) Pharmacological Treatment

  • The lowest effective dose of an analgesic should be used. Analgesic doses should be decreased and stopped as soon as possible as the injury improves.

i) Over-the-Counter Drug Options

  • Topical analgesics
    • Local analgesic, anesthetic, antipruritic, and/or counterirritant effects can be used as adjuncts to pharmacologic and nonpharmacologic therapy.
      • Rubefacients (ex: methylsalicylate ) produce heat sensation
      • Camphor, menthol produce cooling sensation
      • Methyl nicotinate causes vasodilation
      • Capsaicin causes irritation without heat.  Takes 2-4 weeks for significant analgesia, so not appropriate for acute pain.
      • Patients should be advised not to use heating devices with topical counterirritants or to cover with a tight bandage.
    • Topical NSAIDs - diclofenac
      • Weak evidence suggests that topical NSAIDs are effective in reducing pain caused by strains and sprains.  Main role is use in osteoarthritis.
  • Acetaminophen
    • Indicated for selfcare treatment of mild to moderate pain.
    • Instruct patient not to exceed recommended doses on package instructions.
    • Should not be used for longer than 10 days in adults or 5 days in children without physician supervision.
    • Little, if any, anti-inflammatory activity.
  • OTC Nonsteroidal Anti-inflammatories (NSAIDs) - ASA, ibuprofen, naproxen sodium
    • Indicated for self-care treatment of mild to moderate pain.
    • Ibuprofen and naproxen do not have significant anti-inflammatory effects at OTC dosages.
    • Should not be used for longer than 10 days in adults or 5 days in children without physician supervision.
    • Advise patient not to exceed recommended doses on package instructions.
  • OTC Muscle Relaxants - methocarbamol / ASA, acetaminophen or ibuprofen
    • Indicated for short-term treatment of spasm associated with acute musculoskeletal conditions.
    • Poor evidence that muscle relaxants reduce symptoms; main benefit may be due to sedative effect
    • Caution in regards to drowsiness, cognitive and functional impairment.

ii) Prescription Drug Options

  • Prescription strength NSAIDs (Table 1)
    • Indicated for short-term treatment of mild to moderate pain and inflammation caused by musculoskeletal injury
    • Inhibit the activity of cyclooxygenase and decrease the production of pain-modulating prostaglandins.
    • No evidence that NSAID use results in more rapid resolution of symptoms.
    • No evidence that any of the NSAIDs are superior to each other, but patients may respond better to one than the other.
    • Older adults are more likely to experience adverse effects. Acetaminophen is the drug of choice in this age group.
    • Base choice of NSAID on:
      • patient preference / comorbidities
      • side effect profile of the NSAID
      • cost
      • convenience of dosing schedule
    • Use of multiple NSAIDs concurrently should be avoided.
      • Low-dose acetylsalicylic acid counts as a NSAID. 
      • COX-2 inhibitors and low-dose ASA (< 325 mg) co-therapy is associated with fewer GI ulcers and serious upper GI disorders.
      • Regular use of NSAIDs, in particular ibuprofen, might interfere with the antiplatelet effect of ASA. ASA should be taken an hour before the NSAID
    • Pregnancy: NSAIDs are not recommended during the first and third trimesters of pregnancy due to risk of miscarriage in the first trimester and interference with closure of the ductus arteriosis in the third trimester.
    • Lactation: Ibuprofen is a preferred drug for analgesia in breastfeeding women. Celecoxib is not secreted in significant amounts in breast milk; no special precautions are recommended. Data on the use of other NSAIDS during lactation are limited.

    • Cardiovascular and/or Cerebrovascular disease: 
      • Treatment with NSAIDs must be undertaken with caution in patients with pre-existing cardiovascular disease (CVD) or cerebrovascular disease, or presenting risk factors for CVD. For these patients, treatment options other than non-steroidal anti-inflammatory drugs (NSAIDs) should be considered first.
        • CVD includes:
          • Myocardial infarction, angina, heart failure
          • Peripheral artery disease (eg. intermittent claudication)
          • Atherosclerosis
        • Cerebrovascular disease includes:
          • Stroke or transient ischemic attack
        • Risk factors include:
          • Age >65
          • Family history of premature cardiovascular disease
          • Uncontrolled hypertension
            • NSAIDs may raise blood pressure to a small degree and should be monitored during therapy, even if patient has controlled hypertension
          • Uncontrolled dyslipidemia
          • Diabetes
          • Kidney disease
        • Diclofenac is the highest risk NSAIDs and should never be recommendation in this population.
        • Naproxen has been found to be the lowest risk NSAID in patients with cardiovascular or cerebrovascular concerns.
        • Short-term use of NSAIDs still carries risk in this population.

    • Gastrointestinal disease
      • Highest risk NSAIDs for causing or aggravating a GI disorder such as ulcers: Naproxen or diclofenac
      • Medium risk: Ketoprofen
      • Lowest risk: Ibuprofen, celecoxib

    • Other safety concerns
      • Renal impairment: If CrCl <30 ml/min, avoid use of NSAIDs.  Those with less compromised renal function may use NSAIDs short-term, but caution is still required, especially if they are on other medications such as diuretics or ACE-inhibitors.
      • Pulmonary effects:  NSAIDs can induce an asthma attack in some patients.  ASA is the most common cause, and COX-2 inhibitors have NOT been found to precipitate asthma attacks.  If a patient has previously tolerated an NSAID, it is safe to take them again.
      • Anti-platelet effects:  NSAIDs have anti-platelet effects, which can increase the risk of a bleed occuring.  This is especially a concern for patients on warfarin or other anticoagulants.  NSAIDs increase bleeding risk independently of the INR or other lab tests, so it is not possible to monitor for this interaction.
Advice / Monitoring
  • Treatment should always include non-pharmacological measures.
  • NSAIDs should be taken with a full glass of water to facilitate dissolution.
  • Encourage patients on NSAIDs to drink fluids to maintain adequate hydration (to prevent kidney dysfunction).
  • Taking NSAIDs with food is often recommended to prevent GI symptoms, although there is no evidence this reduces the incidence of dyspepsia or ulceration.
  • Expect onset of pain relief with analgesics in 30 - 60 minutes.
  • Patients with a sprain or strain should be advised to seek further medical advice if there is no response to treatment or if pain and swelling worsen.

Assess Benefit

  • Follow-up with patients using prescription NSAIDs in 7 days and assess response.
    • Refer patient to their primary care provider if:
      • Pain or swelling worsens
      • Weight bearing is still difficult
      • Unable to perform daily activities with minimal discomfort
      • Little or no improvement
    • If symptoms are improving, may continue prescription for two weeks; if needed for  longer than two weeks, contact or refer to patient's primary care provider
    • If symptoms are resolved, discontinue or step down to OTC strength NSAIDs as needed.

Assess for adverse effects

  • NSAIDs are generally well-tolerated for short-term therapy in adults <65 years old without comorbidities (GI disease, heart failure, renal dysfunction, etc).
  • Dyspepsia is the most common reason patients discontinue NSAIDs. Cyclooxygenase -2 inhibitors (COX-2s) are associated with significantly fewer GI complications
  • For mild GI upset - suggest small frequent meals, chewing gum or sucking lozenges.
  • Discontinue if persistent nausea / vomiting, ringing in ears, shortness of breath; unusual bruising or bleeding (mouth, urine, stool), skin rash, swelling of limbs, chest pain, or palpitations. Refer to patient's primary care provider.
Products

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the CPS (e-CPS), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca).
This information should be routinely consulted before prescribing.

 

Drug

OTC Dose

Prescription dose

Comments

ASA

Adults: 325 - 975 mg QID
Avoid in children < 16 years of age

 

Increased risk of GI adverse effects with higher doses

Ibuprofen

Adults & children > 12 years: 200-400 mg q 6 h PRN
Maximum 1200 mg /24 hrs
Children up to 12 years: 5-10 mg/kg/dose every 6-8 hours

Adult: 600-800mg TID-QID
Maximum 3200 mg /24 hrs

No increase in analgesic effect in doses exceeding 400 mg

Naproxen

Adults & children > 12 years: 220 mg every 12 hrs PRN
Maximum: 440 mg naproxen sod/24 hours
Children 2 - 12 years: 5mg/kg BID. Maximum 15mg/kg/day

250 - 500 mg BID

Maximum 1000 - 1500 mg/24hr

12 hour duration of activity.  May be least likely to cause cardiovascular side effects

Ketoprofen

25-50 mg every 6-8 hours up to a maximum of 300 mg/day

50 mg - 100 mg T-QID
Maximum of 300 mg/day

OTC product available in US

Celecoxib

 

400mg STAT on day 1; 200mg once daily on subsequent days

Short-term use (7 days or less) for musculoskeletal  trauma
Lower risk of GI adverse effects

Diclofenac potassium  
   - Diclofenac K
   - Apo-Diclo Rapide 50
   - Voltaren Rapide
   - Teva-Diclofenac-K

50mg q6-8h, max of two doses

Max of 100mg per day

Flurbiprofen

50mg QID, max of 200mg / day

Mefenamic acid

500 mg initially , then 250 mg every 6 hours for 2 to 3 days

Not indicated for children < 14 years of age.

Limit to maximum of 1 week therapy

Diflunisal

Initial: 1 g, followed by 500 mg every 12 hours; maintenance doses of 500 mg every 8 hours may be necessary in some patients; maximum daily dose: 1.5 g

Floctafenine

Oral: 200-400 mg every 6-8 hours as needed, up to a maximum of 1200 mg/day

See RxFiles chart NSAIDS, COXIBs & Other Analgesics for doses / comparisons of other NSAIDs

 


 

Prescribing and Billing Details
  • pseudoDIN: 00951099
    • Max of 4 claims per 365 days per patient

  • May prescribe sufficient quantity to treat for 7 days with one refill.
    • If significant improvement, but not complete resolution, after 7 days, provide the refill.

  • If an OTC strength of ibuprofen is chosen (200mg or 400mg), it will NOT be eligible for the assessment fee.  This means only ibuprofen 600mg products are eligible.

  • Only products with an official indication from Health Canada for musculoskeletal sprains or strains are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing. 
Treatment Flowchart
Pharmacist Assessment Documents
References / Suggested Reading
  1. Lum, L. Musculoskeletal Conditions: Sports Injuries.  In: Minor Ailments. e-Therapeutics Complete [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca. (In Saskatchewan available through www.shirp.ca.)
  2. Taylor, T. Musculoskeletal Disorders: Sports Injuries. In: Therapeutic Choices. e-Therapeutics Complete [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca. (In Saskatchewan available through www.shirp.ca.)
  3. Sprains and Strains. In: NICE Clinical Knowledge Summaries. Available at http://cks.nice.org.uk/dysmenorrhoea. (Free Access)
  4. Sprains and Strains. In: DynaMed. Available at https://dynamed.ebscohost.com/ by subscription. (In Saskatchewan available through www.shirp.ca.
  5. Brooks, G.  Musculoskeletal injury in the young athlete: Overview of treatment principles for nonoperative injuries. In: UpToDate. Available at www.uptodate.com by subscription.
  6. Sprains and Strains. In: Mayo Clinic. www.mayoclinic.org. (Free access)
  7. Rx Files 9th edition – NSAID comparison chart. Available at www.rxfiles.ca

Prepared by medSask.
Reviewed by Dr. D. G. Bishop and Loren Regier, Pharmacist, RxFiles Academic Detailing Program.
Funded by the Saskatchewan College of Pharmacy Professionals.
Posted May, 2010. Updated May 2017.