Ask the Doc: Managing aches and pain


Q: After a weekend of off-road riding, what's the best way to deal with the aches and pains?

A: We have all done it.  It seemed like such a good idea before it started and by the end we wondered — often aloud — “What was I thinking?”

Welcome to “weekend warrior syndrome,” brought on by overexertion, muscular and ligament stress and marked by the inevitable aftermath of pain. Even if you have an Olympic level of fitness, you are not immune from the effects of stress and strain on your pain receptors (nocioceptors, from the Latin noxius, or noxa, which means harm; docs love Latin, as we were tortured with it in medical school), but you are probably armored against weekend warrior syndrome. Since few of us are Olympic athletes, however, weekend warrior syndrome is common. It is followed by a plethora of choices in pain relievers.

Which one is best for us mere mortals? Turns out, the answer is deceptively complex. Let's start with what pain indicates about the body parts you abused.

Pain generally reflects injury and injury is marked by inflammation. Injury leads to local swelling that increases tissue stretch and activates pain receptors. Therefore, when treating pain you should treat the injury, but you must also treat the inflammation.

These observations underpin the approach used by athletic coaches known as RICE (Rest, Ice, Compression, Elevation). Rest reduces motion and stretch. Ice reduces inflammation, local blood flow and swelling, as do light compression and elevation. Elevation also partly immobilizes the injured part so that you don't reinjure it.

Over-the-counter medications

It is no coincidence that over-the-counter (OTC) pain relievers are also anti-inflammatory agents, since inflammation underlies pain in a big way.

over-the-counter pain relieversPerhaps the two best known are acetaminophen and ibuprofen. They are both pain relievers but only ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) which also reduces inflammation. Acetylsalicyclic acid (ASA), better known as aspirin, is also an NSAID.

What is the difference? First, aspirin permanently inactivates your platelets. These tiny packets are essential for blood clotting. With aspirin, none of yours will work until you generate new ones. Therefore, aspirin can make bleeding after injury more likely, especially if you are already on it before injury.

Fortunately, healthy people make about 10 percent of their normal platelets each day. You can always be transfused platelets, but it is always better to avoid getting something that isn't yours — unless you are at a swap meet and are getting the better end of the bargain (take Lemmy along to be sure).

Therefore, aspirin is great if you have narrowed coronary arteries (at risk of clotting off), but not always great after injury (but don't stop taking ASA just because you are going to ride). Therefore, ibuprofen (or similar drugs, like naproxen, trade name Naprosyn) has an advantage after injury compared to aspirin, by having a nearly negligible effect on platelets and clotting. Many take alternating doses of acetaminophen and then a NSAID to get the most pain relief while limiting side effects on your stomach, liver and kidneys.

Ice is an anti-inflammatory agent and is great right after injury. Limiting to 20 minutes per hour helps avoid additional injury from excessive cold. Ice in a bag overtop of some material, like a towel, works well in place of the more expensive chemical ice packs. Of course, if you are injured in Indonesia (looking at you, Chris Force), where ice may be scarce, the chemical pack wins hands down. If you have no ice and no chemical pack, immersing your limb in a cool stream will work in a pinch. Avoid immersion if you also have any cuts or scrapes if you are not sure of water cleanliness.

Topical creams and patches

What about topical cream pain relievers? A 2014 Consumer Report provides a rundown of common products. Results with these may vary, depending on what has caused the pain (bad for broken bones), and your personal pain threshold and tolerance. If you have chronic pain, the impact of a topical gel or ointment may be hard to notice. But if you have acute pain, it certainly won’t hurt. Advantages are that it won't impact the rest of your body and unlike pills you don't have to worry about an empty stomach or swallowing. The best active ingredient is capsaicin (the main ingredient in hot chili peppers). You know it is working by a warm and tingly feeling followed by pain relief. After capsaicin, methyl salicylate (an aspirin derivative) appears to be next best, typified by Bengay cream (aspirin, menthol, and camphor). The aspirin treats pain, the menthol creates a cooling sensation, while the camphor carries the aspirin across your skin (the substance that does the carrying is called a vehicle).

Relatedly, Lidocaine patches are used for acute pain management too. Lidocaine is the same drug as the Novocaine the dentist used to numb you before drilling your cavity. Topical lidocaine requires a vehicle, just like the other creams. Using a lidocaine gel designed for sunburn will not be very effective for a sprain, since it is not in an appropriate vehicle — but it is great for sunburn, especially when paired with aloe! Of note, one NSAID also comes as a gel but is significantly restricted and quite expensive (dicolfenac, trade name Voltaren).

Opoids, alcohol, marijuana

Opioids, the current target for prescriber monitoring, do absolutely nothing to address inflammation, or the nerves that help you sense pain. Remember, pain is useful because it keeps you from worsening your injury by limiting activity. Once the deed is done, opioids only blunt your brain’s perception of pain. Unlike NSAIDs and topicals, opioids carry serious addiction potential, impair judgment, depress your central nervous system (brain), have overdose risks, and can result in death when misused; you are all likely aware of the opioid epidemic and rescue efforts using naloxone (trade name Narcan). If you need opioids because you have a serious injury, or your pain from a lesser injury is not reasonably controlled using non-opioids, you cannot safely drive while on them, and they are unsafe to mix with alcohol.

Despite alcohol being commonly used to blunt pain, it is not recommended. Similar warnings exist for alcohol, just like opioids. Before you ask, marijuana will be explored in another article, but is also not appropriate for acute injury pain management. On the other hand, novel prescription medications such as anticonvulsants are increasingly used as an add-on medication for acute pain management, but commonly make you “slow” and do not mix with riding, even if your pain is well managed.

Remember, pain management does not mean that the injured arm or leg is fully functional — just that it feels like it is. Reassess whether the speed and the strength in your injured limb is back to something close to normal before you get back in the saddle for your next epic ride.

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