Mitchell S Howard, Wade Lee-Smith, Justin P Reinert
Acute musculoskeletal injuries are common among sports participants and are frequently treated with topical analgesics; however, the comparative efficacy and safety of topical formulations remain under investigation. The objective of this study was to evaluate the efficacy and safety of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and alternative topical therapies in the management of acute sports-associated soft tissue injuries, including sprains, strains, contusions, and soreness. A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, including randomized controlled trials that evaluated topical NSAIDs or other topical analgesics in patients with acute sports-related musculoskeletal injuries. Bias was assessed with the RoB-2 tool. The primary efficacy outcome was reduction in pain, measured by the visual analog scale (VAS) or similar validated tools, while the primary safety outcome was the incidence of treatment-emergent adverse effects. Eight randomized controlled trials comprising 1027 patient encounters met inclusion criteria. Across studies, topical diclofenac, ibuprofen, ketoprofen, and etofenamate demonstrated statistically significant reductions in VAS pain scores compared with placebo. Meta-analysis of all included trials revealed no significant reduction in pain intensity in active topical interventions versus placebo (95% CI -0.3768-5.2806; p = 0.09). A direct comparative analysis of diclofenac versus other NSAIDs did not demonstrate a statistically significant difference (effect size -2.07; 95% CI -5.60-1.46; p = 0.25), though heterogeneity of studies may limit these findings. Adverse effects were primarily mild and localized and were no different between groups (RR = 0.79; 95% CI 0.45-1.39; p = 0.41). Topical NSAIDs and alternative topical formulations may provide improved pain outcomes but did not show superiority between NSAID agents.