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10 Articles in Volume 16, Issue #4
Achilles Tendon Injuries
Brain Trauma in Sports
Genetic Testing: Adjunct in the Medical Management of Chronic Pain
Letters to the Editor: Sleep Apnea, SPG Blocks for Migraines, Pancreatic Pain, CDC Guidelines
Pain and Weather—A Cloudy Issue
Phulchand Prithvi Raj, MD, Pioneer in Pain Management, Dies at 84
Physical Medicine & Rehabilitation
Preventing Chronic Overuse Sports Injuries
Sports-Related Pain: Topical Treatments
The “Missing Link” in the Physiology of Pain: Glial Cells

Sports-Related Pain: Topical Treatments

A guide to topical treatments for acute injuries, tendinopathies, bursitis, strains, and sprains.

The Obama administration, the American Medical Association, and the Centers for Disease Control and Prevention (CDC) have been encouraging Americans to get off the couch and go outside or into the gym. But the downside of couch potatoes taking up an exercise program is an increase in sports-related injuries.

Topical therapies are often highly effective for managing sports-related muscle sprains and strains.“When it comes to recreational activities, a group ‘at risk’ for injuries includes adults who have been ‘out of practice’ for a particular sport or are not accustomed to physical activity. Adults sometimes overestimate their abilities to [take up] a new exercise program and push themselves to the point of injury,” noted the CDC.1

Another at-risk group for sports-related injuries is children and young adults. Because playing sports involves a certain amount of risk, those who play are at a higher risk for sports-related injuries. Recreational activities account for an estimated 3.2 million visits to emergency rooms each year for children ages 5 to 14 years, while sports-related injuries are the leading cause of emergency room visits in 12- to 17-year-olds, according to the CDC.1

Collision or contact sports have higher injury rates—football, basketball, baseball, and soccer account for about 80% of all sports-related emergency room visits for children between 5 and 14 years of age. Sports-related concussions continue to be a serious public health concern, as approximately 1.6 million to 3 million concussions occur annually in the United States. Recent studies have shown increases in the prevalence and incidence of concussion in both high school and college athletes. Approximately 8.9% of all high school athletic injuries are concussions, while incidence rates for college athletes range from 5% to 7.9%.2

Because pain is a common complaint of patients with sports-related injuries, many patients seek medical care for their injuries.3 Many prescription and over-the-counter medications are available for the treatment of pain, including acute pain, which is defined as pain lasting less than 4 weeks.4 Sports- and exercise-related injuries, described in Table 1, often cause acute musculoskeletal pain.4,5

This article will review topical options for sports-related injuries. Topical agents are a convenient alternative or adjunct to oral medications, since they provide pain relief with minimal systemic adverse events.4,6 Understanding the current efficacy and safety data related to topical analgesics is crucial to ensure appropriate prescribing and use of these medications.

Ice or Heat Therapy

Oftentimes, the first-line treatment of pain in patients with acute musculoskeletal injuries includes rest, ice, compression, and elevation, also termed RICE.4,7 The use of ice in 15- to 20- minute intervals improves pain by reducing edema, inflammation, and pain nerve impulses.4 Overall, data supporting the use of ice are conflicting.8 For example, patients using menthol experienced greater improvement in pain compared with patients using ice for the treatment of delayed onset muscle soreness (DOMS).9 However, other experts have cited the efficacy of ice for analgesia in sports-related injuries, particularly in patients with DOMS.7

Heat therapy is a common non-pharmacological treatment of muscle pain without inflammation.4 The use of a heating pad or warm compress can improve circulation and stiffness in the affected area; however, heat may aggravate vasodilation and vascular leakage and should be avoided with inflammatory pain. Although data are limited, heat therapy has been used for short-term symptomatic relief of low back pain.4,10

Nonsteroidal Anti-Inflammatory Drugs

The data on topical nonsteroidal anti-inflammatory drugs (NSAIDs) comprise the majority of evidence supporting the use of topical analgesics for musculoskeletal injuries.7,11 While systemic NSAIDs have long been used for the relief of acute pain associated with musculoskeletal injuries, topical NSAIDs have been approved by the US Food and Drug Administration (FDA) more recently.7

A new nationwide survey, “Understanding America’s Pain,” revealed that many patients lack a basic understanding about NSAIDs, including the risks (cardiovascular and gastrointestinal) associated with their systemic use. In 2014, 123 million prescriptions were filled for NSAIDs in the US,12 and it is reported that one-third of the general population have used over-the-counter (OTC) NSAIDs.13 In fact, over half of medication users (58%) acknowledge that there are risks associated with NSAIDs, but only 27% were aware of the FDA recommendations to use the lowest effective dose for the shortest duration—reiterating the need to educate patients about prescription and OTC NSAIDs.

Both systemic and topical NSAIDs block prostaglandin formation through inhibition of cyclooxygenase.11 The inhibition of prostaglandin synthesis results in analgesia due to the large role of prostaglandins in nociception and inflammation. Topical formulations of NSAIDs, in addition to select other topical agents discussed in this review, are listed in Table 2. These include diclofenac sodium topical gel, diclofenac epolamine topical patch, and diclofenac sodium topical solution.14 Compounding kits for ibuprofen and ketoprofen are also available.15

The efficacy and safety of topical NSAIDs for acute musculoskeletal pain due to sports injuries were evaluated in a recent meta-analysis that included 61 randomized, double-blind studies with over 8000 patients.11 Use of topical diclofenac, ibuprofen, ketoprofen, piroxicam, or indomethacin resulted in higher rates of clinical success, defined as more than 50% pain reduction, compared to placebo.

The most common concentrations of these topical agents included in the assessed studies were diclofenac 1%, ibuprofen 5%, piroxicam 0.5%, and indomethacin 1%.11 The concentration of ketoprofen varied from 1% to 5% in most studies. Formulations also differed among the studies and consisted of cream, gel, patch, spray, and others.

The meta-analysis found that the most effective products were diclofenac gel, ketoprofen gel, and ibuprofen gel.11 The meta-analysis noted trends for fewer systemic adverse events with topical NSAID formulations compared to oral NSAIDs but the available data to compare the topical versus oral agents are limited.

The use of topical NSAIDs for the treatment of lateral elbow pain was evaluated in a systematic review.16 The authors concluded that, based on the results of 5 clinical studies, the use of topical NSAIDs (mainly topical diclofenac) may result in a reduction of short-term pain. However, these conclusions were limited due to the low quality of the included studies. Rates of mild adverse events, including rash, were 2.5% with the use of topical NSAIDs compared to 1.3% with placebo.

Transdermal Nitroglycerin

Much of the data regarding the use of transdermal nitroglycerin, also known as glyceryl trinitrate, for the treatment of sports-related injuries are in the off-label setting of tendinopathies. A recent meta-analysis of 7 studies evaluated the use of transdermal nitroglycerin patches for tendinopathy injuries.17 The dose of nitroglycerin patch varied from 0.72 mg per day to 5 mg per day. Use of a nitroglycerin patch improved pain with daily activities in patients with both acute and chronic tendinopathies. The most common adverse events were headache and contact dermatitis.

A recent randomized, double-blind study explored the use of a nitroglycerin patch for tendinopathy.18 Forty patients with chronic patellar tendinopathy received either transdermal nitroglycerin 5 mg per day or placebo for 12 weeks in addition to participating in an exercise program. Both the nitroglycerin patch and placebo groups saw improvement in pain over the course of treatment, but changes in pain scores were not significantly different between transdermal nitroglycerin and placebo.


Capsaicin, an ingredient in chili peppers and derived from the Capsicum plant family, produces analgesia through counterirritation and depletion of the pain transmitter substance P.4 A counterirritant produces irritation at superficial skin layers to help relieve more severe pain in the deeper tissues.

Data supporting the use of capsaicin in sports-related injuries are limited, although the agent is used for symptomatic pain relief in other conditions such as osteoarthritis.4,7 A recent review found that products derived from Capsicum frutescens result in improved pain relief compared to placebo in patients with chronic low back pain, but these products have low quality evidence in acute low back pain.19

Patients typically experience pain relief within 2 weeks but some patients may need to use capsaicin for 4 to 6 weeks to notice any changes in their pain.4 Patients should be counseled on the importance of using capsaicin regularly to obtain the most benefit and to apply with gloves in order to prevent accidental contamination and irritation to more sensitive tissues, such as the eyes.

Methyl Salicylate and Trolamine Salicylate

Methyl salicylate is a counterirritant that blocks prostaglandin formation, similar to NSAIDs.2 While anecdotal evidence and older studies support the use of salicylates for acute injuries, a meta-analysis did not find a beneficial effect in more recent studies.4,20,21

The use of salicylates is not recommended in children, and caution should be used when applying heat to areas treated with methyl salicylate due to an increased risk of systemic absorption and toxicity.4

Trolamine salicylate is thought to exert its therapeutic effects by increasing salicylate concentrations in the synovial fluid.4 Trolamine salicylate is available over-the-counter, but data supporting its use in sports-related injuries are lacking.


When used alone for pain relief, menthol produces anesthesia at low concentrations (<1%) and counterirritation at higher concentrations (>1.25%).4 While data are limited, menthol alone at a concentration of 3.5% produced greater pain relief compared to ice for DOMS, and the use of a methyl salicylate 10%/menthol 3% patch produced significant analgesia compared to placebo in patients with muscle strain.9,20

Herbal Products

Several over-the-counter herbal products are advertised for the relief of pain, but they have limited evidence. Traumeel contains ingredients derived from plants and minerals that contribute to pain relief.22 This agent is mostly used to treat sprains or traumatic injuries. Traumeel ointment has shown efficacy compared to placebo in a variety of musculoskeletal injuries, such as ankle sprains.

One study in 449 adults found that Traumeel gel or ointment was as effective as topical diclofenac gel (1%) when used for 14 days for pain relief of an ankle sprain.23

The herbal product Arnica montana is thought to reduce bruising and myalgia.24 When evaluated for the symptomatic relief of DOMS, topical arnica provided possible analgesia lasting 72 hours following exercise.25 However, a previous study found that arnica resulted in greater calf pain compared to placebo at 24 hours following exercise, and a recent review in patients with low back pain found that only low quality data supports the use of arnica.19,24

The extract of comfrey root, derived from the plant Symphytum officinale L., is an herbal topical analgesic reported to provide symptomatic relief of musculoskeletal injury pain through analgesic and anti-inflammatory properties.26

Clinical trials in the treatment of back pain, osteoarthritis, and blunt injuries have favored the use of comfrey-based products. However, one review found that while comfrey root extract provided short-term analgesia compared to placebo in patients with acute low back pain, the evidence was of low quality.19

Practitioners should keep in mind that products not approved by the FDA, such as certain herbal products, often lack the same level of efficacy and safety data, as well as regulation, of FDA-approved products.27 Herbal products are excluded from Table 2 due to limited information on safety and quality of available products.

Other Agents

Lidocaine and tetracaine are hypothesized to provide symptomatic pain relief by acting as anesthetics.28 Data are lacking to support the use of lidocaine for the treatment of exercise induced injuries.6 Lidocaine formulated with tetracaine may produce analgesia in patients with patellar tendinopathy, although the only study evaluating its use was limited by a small sample size and lack of placebo control.28

Similar to menthol, camphor exerts analgesic and anesthetic effects at low concentrations (0.1% to 3%) and works as a counterirritant at higher concentrations (>3%).4 No studies have evaluated its use for musculoskeletal injuries. The American Academy of Pediatrics recommends considering other therapeutic alternatives to camphor due to the risk of severe central nervous system toxicity, which may occur with accidental ingestion.4,29,30


Many agents are available for the topical treatment of sports-related injuries; however, most lack reliable data to support their use. NSAIDs such as diclofenac, ibuprofen, and ketoprofen gels have robust evidence supporting their use with minimal reported adverse events; diclofenac is available in the United States in various topical formulations.4,11,14,16 The transdermal nitroglycerin patch has efficacy data for its use in tendinopathies.17 More studies in sports-related injuries are needed to make definite conclusions regarding the efficacy of menthol, methyl salicylate, lidocaine, tetracaine, and capsaicin, as well as the herbal products arnica, Traumeel, and comfrey root extract.

Last updated on: May 17, 2016
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Genetic Testing: Adjunct in the Medical Management of Chronic Pain

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