Many of us are familiar with the TV ad that shows two women engaged in a sword fight, one of whom is seized with elbow pain. Her adversary then throws her a tube of Volteran, stating that its local (topical) application will relieve the pain. But is there any evidence that this, or any other local applicant, will accomplish this purpose? In general, topical analgesic drugs are used for a variety of painful conditions, some of which are acute strains, sprains, or muscle aches. Others are afflicted with chronic pain, typically from degenerative arthritis (osteoarthritis) of hand or knee, or neuropathic pain such as shingles.
One large review provided an overview of the analgesic efficacy and associated adverse events of topical analgesics that included nonsteroidal anti‐inflammatory drugs (NSAIDs), salicylates, capsaicin, and lidocaine, all applied to intact skin for the treatment of acute and chronic pain in adults. Results of relief of pain were published in 2017. The primary outcome was at least 50% pain relief, as reported by the participants, at appropriate durations. Outcomes were evaluated for each topical analgesic or formulation, and they included harmful or adverse events. The review involved studies totaling 30,700 participants that applied topical analgesics to intact skin in a number of acute and chronic painful conditions. Reviews concentrated on evidence comparing topical analgesics with topical placebo, an important component of all modern research studies. For at least 50% pain relief, they considered evidence was moderate or high quality for several therapies.
For acute musculoskeletal pain (strains and sprains) averaging seven days, therapies included differing strengths of diclofenac (Voltaren) and other non-steroidal anti-inflammatory drugs (ketoprofen gel and piroxicam gel). In chronic musculoskeletal pain (mainly hand and knee osteoarthritis) therapies were topical diclofenac and other related preparations. Evidence of efficacy for therapies besides those were judged as low or very low quality, extending to topical preparations of ibuprofen (Advil, Motrin) gels and creams, and for salicylates, (aspirin formulations: Aspercreme, Icy Hot, Bengay). Evidence for other interventions and herbal remedies was even lower quality. With regard to adverse systemic or local event rates, they were low disclosing topical NSAIDs (4.3%) being no greater than with topical placebo (4.6%). In chronic pain, local adverse events with topical diclofenac and capsaicin (the chemical compound found in chili peppers that is responsible for their “hot” sensation) were slightly higher than topical placebo. In all studies, serious adverse events were rare.
Although not included in the studies above, topical gels with menthol or camphor probably distract the brain so it focuses less on pain signals, suggesting relief. Also, menthol or camphor are substances that make one’s skin feel hot or cold, also distracting the brain from focusing on the pain signals.
From these studies, the researchers concluded that there is good evidence that formulations of topical NSAIDs, including diclofenac and ketoprofen, are useful in acute pain conditions such as sprains or strains. In chronic musculoskeletal conditions persisting over 6 to 12 weeks, topical diclofenac and ketoprofen had limited efficacy in hand and knee osteoarthritis, as did topical high‐concentration capsaicin in postherpetic (shingles) neuralgia. All these topical treatments have fewer risks than various oral medications. Thus, using topical painkillers is a modest way to get relief with strained muscles (like a hamstring) or sprains of ankles. Topical painkillers—such as ointments, creams, sprays, and patches that contain topical diclofenac—are a good choice. In general, a topical formulation is reasonable, because the effects are more localized, targeting just the relevant part of the body, and as a result, other parts of the body are exposed to lower blood levels of the medicine. Lower medicine levels in the blood is an important consideration, since some painkillers pose severe potential risks. For example, long-term use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) in pill form, such as ibuprofen (Advil, Motrin), lead to blood levels that can increase blood pressure, irritate the stomach lining and cause ulcers or stomach bleeding, and damage the kidneys. Even short-term use of NSAID pills raises heart attack and stroke risk. If one uses a topical NSAID, however, the drug reaches primarily the part of the body that’s in pain: blood levels are much lower those resulting from NSAID pills. For example, a 2013 trial that analyzed the amount of NSAIDs in the body following oral versus topical treatment applied to one area—the knee—found that oral use led to 17 times the level resulting from topical use. Topical NSAIDs should also reduce the risk of gastrointestinal side effects.
If one needs to use topical medications for more than a few days (for new pain) or for long stretches of time, or if topicals don’t work well, one should notify his/her physician, for what was thought to be a minor sprain or strain could be something more serious. Other ways to recover from a strain or sprain, along with topical painkillers, certain strategies can help healing from a strain or sprain, depending on its location, are the following: 1) Avoid activities that put too much demand on the strained or sprained area. 2) Rest and elevate the injury. 3) Use hot or cold therapy for 15 to 20 minutes at a time. 4) Consider walking aids, such as crutches. 5) Wear a brace to protect the injury. 6) Try an ice massage with a chunk of ice for three to five minutes, which can deliver a powerful punch in a very brief amount of time, compared with using an ice pack.
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