Sports-Related Pain: Topical Treatments
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.
“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.