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Injured Athletes: A Meta-Analysis Comparing Topical And Oral Analgesic Efficacy

Injured Athletes: A Meta-Analysis Comparing Topical And Oral Analgesic Efficacy


Injured athletes often resort to analgesic medication for pain relief, employing both non-prescription topical and oral medications without comprehensive guidance. However, the efficacy of such pain medications in injured athletes, as compared to a placebo, has not been extensively studied. To address this gap, a systematic review and meta-analysis were conducted to evaluate the effectiveness of topical and oral medications in reducing pain among injured athletes.

The researchers conducted an exhaustive electronic search across various databases, including Medline/Pubmed, Web of Science, Ovid, and SportDiscus, to identify relevant literature pertaining to pain management in athletes post-injury using topical or oral medications. Two reviewers meticulously screened the studies and assessed their quality. The efficacy of the treatments was measured using the Hedges’ g value, and the findings were visually presented through forest plots with 95% confidence intervals to summarize the meta-analyses.

The meta-analysis revealed a significant pooled effect size, indicating that topical treatments were more effective in reducing pain outcomes when compared to a placebo. However, the same level of pain reduction was not observed for oral treatments compared to the placebo.

These results imply that topical medications should be preferred over oral medications by injured athletes seeking pain relief, as they have demonstrated greater efficacy with fewer reported adverse effects. It’s essential to note that the outcomes of this study differ from other investigations that focused on experimentally induced pain rather than musculoskeletal injuries.

In conclusion, this systematic review and meta-analysis provide valuable evidence supporting the use of topical medications for pain management in injured athletes. The findings underscore the importance of evidence-based approaches to guide athletes in their choice of pain medications, promoting optimal recovery and performance while minimizing potential risks.


Elite athletes, defined as those competing at a high level for their age category, experience a notable prevalence of sports injuries, which can be acute or chronic and often associated with pain. Despite the risks of masking pain before a full recovery, athletes need to manage their pain effectively to facilitate a quick return to play. Consequently, many athletes turn to analgesic medications, especially non-prescription drugs available over-the-counter (OTC), to alleviate pain. Surveys have shown a significant percentage of collegiate athletes using non-steroidal anti-inflammatory drugs (NSAIDs) without proper consultation, potentially unaware of associated adverse effects or the most suitable medication for their injury management.

Remarkably, athletes display a higher pain tolerance than non-athletes, raising questions about the efficacy of analgesic medications in athletes compared to non-athletes. Previous studies on pain medication efficacy often employed experimentally induced pain models, such as delayed onset muscle soreness (DOMS), which may not fully replicate the inflammation cascade or psychological impact of actual musculoskeletal injuries. Additionally, the placebo effect further complicates pain treatment evaluation, as athletes might respond differently to placebo analgesia compared to non-athletes.

The objective of this review is to assess the pain reduction achieved by athletes using topical or oral OTC medications compared to placebos for treating musculoskeletal injuries. While previous reviews have explored medication efficacy in non-athletes, it remains uncertain whether the results would differ in athletes. Understanding this information can assist healthcare practitioners in advising athletes on pain management effectively.

Furthermore, topical medications are reported to have fewer adverse effects compared to oral counterparts, making it essential to determine if they are equally effective in athletes. If proven to be equally effective, topical medications would be a safer choice for pain management.

In conclusion, addressing the pain management needs of elite athletes is crucial given the high prevalence of sports injuries. This review aims to provide valuable insights into the effectiveness of topical and oral OTC medications compared to placebos in athletes, allowing healthcare practitioners to make informed recommendations for safer and more efficient pain management.


The study adhered to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent approach. A comprehensive search was conducted across four electronic databases – Web of Science, Ovid/Medline, PubMed/NCBI, and SPORTDiscus – spanning from the inception of the databases up to February 2022. The search strategy employed a combination of key terms, synonyms, Boolean conjunction, and truncation to maximize the retrieval of relevant articles.

During the initial search, two independent reviewers meticulously screened titles and abstracts of potential articles. In cases where there was disagreement, a third reviewer, who possesses expertise in pain research, was consulted to make a final decision on whether a study should be included in the analysis. Subsequently, the two reviewers thoroughly examined the full texts of eligible articles to determine their suitability for inclusion in the study.

Additionally, to ensure a comprehensive review, the researchers engaged in hand-searching of references and times-cited lists of the included articles, as well as scrutinized the bibliographies of the authors. This step aimed to identify any relevant articles that might not have been captured through the initial search strategy.

By following the PRISMA guidelines and employing a rigorous search and screening process, the study was conducted in a methodical and transparent manner, enhancing the reliability and validity of the findings. In our research, we investigated the impact of topical and oral analgesic medications in comparison to a placebo among athletes. Our study focused on the type of medication as the independent variable and measured pain improvement through various scales, such as the Visual Analogue Scale (VAS), the Numerical Rating Scale (NRS), and 4 or 5-point (Likert) function scales, as the dependent variable.

To gauge the effectiveness of each intervention, we calculated the effect size (Hedges’ g) for every study, enabling us to compare pain reduction between the oral or topical medication and the placebo. We meticulously conducted this analysis for each individual study.

By conducting this thorough investigation, we aimed to gain valuable insights into the efficacy of topical and oral analgesic medications for pain relief in athletes. Our research will contribute to the existing body of knowledge and potentially provide valuable guidance for the management of pain in sports-related scenarios.

In this study, we used the Downs and Black checklist (DBC) to assess research quality, considering reporting, external validity, internal validity (bias and confounding), and statistical power. The maximal quality index (QI) is 28, and we categorized scores as good (>20), moderate (11–20), or poor (<11). We employed ICC analysis to ensure reviewer agreement. No articles were excluded based on DBC scores. This approach enhances the credibility and significance of our findings, benefiting future research and clinical decision-making.

Inclusion Criteria

Studies that were included into this analysis were: studies which consisted of athletes who had musculoskeletal injuries, involved an intervention such as oral or topical analgesia, involved a placebo group, studies which measured the pain management and physical improvement as an outcome and randomized controlled studies.

Exclusion Criteria

Studies that were excluded from the analysis were: studies carried out on animals, studies which used alternative or natural means of analgesia, studies carried out on non-athletes, studies where analgesics were used to manage delayed onset muscle soreness and studies done on soreness or injuries that were induced. 


In this study, we initially identified 835 articles through our search strategy. After screening and removing duplicates, we narrowed down the selection to 13 relevant articles. The agreement between reviewers during the data extraction process was strong, with an ICC value of 0.805.

We reported the results of the Downs and Black checklist (DBC) for each study, with DBC scores ranging from 13 to 25. Seven articles obtained QI scores above 20, indicating good quality, while six articles scored between 11 and 20, indicating moderate quality. No study scored below 11 on the DBC. The agreement between reviewers when using the DBC was high, with an ICC value of 0.840.

Overall, there were 13 studies with 16 interventions included in this article. Among the 1304 participants, 1273 received an intervention, with 410 of them being females. The weighted average age of participants was 31.07 years, with the youngest being 17.5 years-old and the oldest 58 years-old. Most studies reported data from both males and females, except for May et al., which analyzed data only from males. All articles compared an intervention group to a placebo group. Eight interventions utilized topical medications, while five used oral medications, and intervention durations ranged from 24 hours to 1 year. The post-intervention pain level, used for calculating effect size, was typically measured on the day of the peak difference from the beginning of treatment, usually occurring within 2 weeks from the onset of pain.

In the meta-analysis, we observed a significant pooled effect size for the topical treatment, indicating a reduction in pain outcomes. However, the meta-analysis for the oral treatment did not show a significant reduction in pain outcomes. The analysis for both topical and oral treatments displayed a significant pooled effect size with moderate heterogeneity.

To ensure the integrity of our findings, we checked for publication bias using funnel plots and Egger’s regression tests, but no indications of bias were found for either the topical or oral treatment.

To standardize comparisons between outcomes, we transformed the mean and standard deviations of pain outcomes to a 100 mm Visual Analogue Scale (VAS).

In conclusion, our study indicates the effectiveness of topical treatments in reducing pain outcomes, while oral treatments did not show significant benefits. The comprehensive meta-analysis, along with rigorous quality assessment, enhances the reliability and relevance of our research, providing valuable insights for future studies and clinical applications.


Topical analgesic medications prove more effective than oral medications in reducing pain for athletes, with fewer reported adverse effects. Athletes should consider opting for topical medications over oral ones to alleviate pain after injury. As many athletes may use medications without professional guidance, it is crucial for them to be aware of the most effective and least harmful option.

Sports medicine staff, including athletic therapists/trainers, should also be well-informed about the optimal medication to recommend for injured athletes. Although traditionally outside their scope of practice, this knowledge can benefit athletes, encouraging better-informed medication usage. Athletes without access to a team doctor may turn to their team therapist for injury management, making it vital for therapists to be aware of the study results to offer proper guidance in medication use.

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