Think of Voltaren® Gel as “ibuprofen in a gel.” (It’s actually diclofenac, but ibuprofen is a much more familiar drug name in North America, where the product is still relatively new.) It’s a topical anti-inflammatory medication,NSAID“Non-steroidal anti-inflammatory drug,” usually pronounced “en-sed.” and FDA-approved to treat osteoarthritis in “joints amenable to topical treatment, such as the knees and those of the hands.”1 The evidence shows that it “provides clinically meaningful analgesia.”2 This is an appealing treatment idea that actually works reasonably well: what a pleasure to be able to say that!3
Other topical treatments have shown little potential in the past, like the ubiquitous rubefacients — “spicy” ointments like tiger balm, or Arnica creams (Traumeel, for example) are extremely popular. It’s unlikely that even full-strength arnica is medically potent, let alone when diluted down to traces.4
So, a rub-on pain killer that is actually promising is a pretty new idea!
Commercial availability — still not over-the-counter in the US
Although it’s been readily available in Europe for many years, Voltaren was only approved for use in the United States in 2007.
The first generic (cheaper) equivalent of Voltaren® Gel entered the marketplace in 2016, produced by Amneal Pharmaceutical. It should be for sale most places now. There’s a rack of tubes of Voltaren by the till at my neighbhourhood drugstore, and I suspect pretty much every drugstore everywhere by now.
So, what is a joint that’s “amenable” to treatment with Voltaren® Gel?
What makes a joint “amenable”? Is it mellow and easy-going? No, just accessible: a pain-killing gel is useful only for joints that aren’t covered by a thick layer of muscle (like the shoulder). The medication gets diluted as it penetrates deeper into tissue, and a meaningful amount can only get into joints if the joint is just under the surface of the skin.
For those amenable joints, though, Voltaren® Gel delivers a good dose of medication directly to the joint, while sparing the gastrointestinal tract from the harshness of NSAIDs — which are actually known as “gut burners,” and many people just can’t stomach ibuprofen. A gel almost completely eliminates the risks associated with digesting the stuff.5
There are probably some good uses for Voltaren® Gel above and beyond what it’s already been specifically approved for (“off-label” uses). Here are some of the common conditions I think it might be most useful for:
- iliotibial band syndrome
- plantar fasciitis
- shin splints (particularly medial tibial stress syndrome)
- most common tendinitises,6 especially where the tendon is just under the skin, such as …
- acute muscle strains
Voltaren for back pain too? Maybe
Surprisingly, Voltaren may even help some kinds of deep back pain.
I’ve just emphasized that Voltaren is mainly appropriate for shallow inflammation, but there is some evidence that Voltaren might be able to “reach deeper.” This is hardly the stuff of medical certainty yet, but researchers Huang et al found that Voltaren treated pain coming from deep inside the spine, right in the centre.7 They concluded that it could be a “convenient and safe clinical intervention” for a few types of back pain. An anti-inflammatory gel will likely fail with many kinds of back pain, but there’s also virtually no down-side to trying. See my low back pain tutorial for extremely detailed information about medications for back pain.
However, it probably does not work well for deeper tissues in most cases. For instance, there’s evidence that it doesn’t work at all for the muscle soreness that follows unfamiliar exercise intensity,8 probably because it can’t be absorbed far enough into thick muscle tissue — but oral NSAIDs do have a modest effect on that kind of pain910 (one of the only things that does).
Voltaren® Gel is probably better than ice!
Obviously icing has some advantages. Other than the cost of running your freezer, it’s free. And extremely safe. And “natural.”13 But Vitamin I (for “ibuprofen”) in a gel? C’mon! That’s just awesome! Medication delivered straight to the inflamed tissues, and only the inflamed tissues … it’s kind of futuristic.
There’s no reason not to use both, of course. But Voltaren® Gel has the potential to make ice nearly obsolete as a treatment choice, except for situations where you don’t have any Voltaren® Gel handy.
On the other hand, no medication is completely risk-free.
What do the skeptics say?
Many readers assume that “skeptics” will always favour mainstream and pharmaceutical treatments like Voltaren, but nothing could be further from the truth. Indeed, some skeptics are leading the charge against bad pharmaceutical industry science and practices (and a great example is Ben Goldacre’s new book, Bad Pharma: How drug companies mislead doctors and harm patients). Pharmacist Scott Gavura of Science-Based Pharmacy was certainly skeptical about topical NSAIDs like Voltaren when he first tackled the topic early in 2011.14 “When I recently noticed a topical NSAID appear for sale as an over-the-counter treatment for muscle aches and pains … I was confident it would make a good case study in bad science.”
He was surprised, however, and he changed his mind when he read the evidence. Having worked with Scott as an editor, I know he can’t be persuaded by anything less than robust evidence. On a few occasions, Scott has proven himself to be even harder to impress than I am (which is really saying something). He concludes:
Over the past two decades, evidence has emerged to demonstrate that topical versions of NSAIDs are well absorbed through the skin and reach therapeutic levels in synovial fluid, muscle, and fascia. … For chronic conditions like osteoarthritis, the data are of fair quality and are persuasive. On balance, there’s good evidence to show that topical NSAIDs are clinically- and cost-effective for short term (< 4 weeks) use, especially when pain is localized.
Nothing’s perfect, however, and some concerns about Voltaren are covered below.
Where’s the fire? Treating “inflammation”
Are you sure that you’re actually inflamed? Don’t answer too quickly.
One concern about the use of products like Voltaren is that several conditions are less inflammatory in nature than they feel like. Patients usually assume that the “burning” pain of repetitive strain injuries like tendinitis is caused by inflammation, but in fact classic inflammation is largely absent, especially after initial flare-ups have died down (but pain is still carrying on). While it is possible, even likely, that tendinitis is still inflamed in some sense, it’s doubtful that they are inflamed in a way that NSAIDs are actually good for. The biochemistry of cranky tendons is rather complex and largely unknown. There’s probably some overlap between the biology of acute, classic inflammation and the subtler biology of chronic tendinitis, but no one really knows. So the value of Voltaren for tendinitis is unclear.
You can read about this in much greater detail in my RSI article: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome
Remember, exercise is also an anti-inflammatory medication
Note that moderate exercise is almost certainly anti-inflammatory as well.15 Never just use Voltaren. Ideally, even the safest pain-killer should only be used sparingly, and to make it easier to exercise — whatever exercise you can do without excessive discomfort. Even if you’re really hurting, you may still be able to do easy pain-free range of motion exercises. Just beware of overdoing it while medicated!
More about safety
Long term and/or large oral doses of NSAIDs can be extremely dangerous, even lethal. They “nuke” your entire system with much more active ingredient than you really need, all of it absorbed through the digestive tract and distributed through your entire circulatory system. These drugs can and do cause complications at any dose, and are linked to heart attacks and strokes and ulcerations of the GI tract. For example, Diclofenac …
Diclofenac is an extremely popular drug — again, we’re talking oral here — and it is associated with serious cardiovascular risks: “There is increasing regulatory concern about diclofenac. … Diclofenac has no advantage in terms of gastrointestinal safety and it has a clear cardiovascular disadvantage.”16 This has been in the news quite a bit, and NPR had a hit in 2013 with this headline: “World's Most Popular Painkiller Raises Heart Attack Risk.”
And it’s not wrong, that headline. It’s not hype and alarmism — there is a real problem.
But the difference between oral and topical is extremely important.
Topical diclofenac is a completely different animal
Spreading a medication on your skin is not the same thing as swallowing it. Because Voltaren Gel is applied to the skin, dramatically less medication reaches the bloodstream — only a tiny fraction of what you would get from oral usage.1718 It is safe to assume that cardiovascular risks of moderate topical use are negligible compared to oral diclofenac, because so much less medication is actually getting into general circulation, and that is what the evidence now shows.19 Multiple studies have concluded that topical NSAIDs are both effective and safe.202122
At correct dosages for limited time periods, I think Voltaren Gel is probably very safe: the worst side effect is probably the chance of irritated skin. ScienceBasedMedicine.org agrees:23
The main advantage of topical NSAIDs is the reduced exposure of the rest of the body to the product, which reduces the side effect profile. Given the toxicity of NSAIDs is related in part to the dose, it follows that topical treatments should have a better toxicity profile. Consequently, the cardiovascular risks of topical diclofenac, even in those with a high baseline risk of disease, should be negligible with the topical forms.
Some mild adverse effects on skin for some people
I am definitely not saying Voltaren is completely safe or risk free. No drug is! The drug is still being absorbed, but instead of being a “gut burner” it can be a “skin burner.” From the Voltaren® Gel website …
The most common adverse reactions reported in Voltaren Gel clinical trials were application site reactions in 7% of treated patients. With all NSAIDs there may be an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.
Sounds bad, doesn’t it? But those warnings are primarily there in an abundance of legal and medical caution provoked by the problems with oral NSAIDs. For short-term, moderate topical use, I believe the benefits clearly outweigh the minor risks.
What about long-term use?
This drug was basically invented as an arthritis treatment. Those patients may be interested in using topical diclofenac regularly and indefinitely. Is that kind of long term usage safe? Is regular use of any medication a good idea?
There is no good data on long term safety that I’m aware of. It probably doesn’t exist yet.
In principle, long-term use of any medication should be minimized as much as possible. The benefits of topical diclofenac aren’t so great that they justify the risks of frequent use indefinitely.
If I wished I could use it that way, I’d probably plan to take usage breaks: just stop using it for a while, a few times a year.
On the other hand, it’s probably about as safe for regular use as any medication gets. But that’s just an educated guess, extrapolating from the short term safety data.
What about other common pain problems? Could it help low back pain, neck pain, and muscle pain?
A lot of people who read this are going to want to try it on their low back pain, neck pain, and/or other kinds of muscle pain. Will it work? The only honest answer is, “Who knows?” I have no clinical experience with this yet, and certainly it’s unstudied. It might be worth trying, in moderation, with the full awareness that there’s every possibility that it could be a waste of time and money.
Here’s why it probably won’t work …
Low back pain and neck pain often involve a substantial amount of muscle pain,24 and muscle pain is not particularly inflammatory by nature. Muscle knots (trigger points) are more like poisoned muscle than injured muscle. Although there’s some anecdotal evidence that taking an anti-inflammatory medication reduces muscle pain, mostly it doesn’t seem to work very well. One of the classic signs of low back pain powered by muscle, for instance, is that ibuprofen doesn’t have much effect!
A topical NSAID gel isn’t likely to either.
Also, many painful factors in neck, back and muscle pain are deep inside the body — probably much deeper than Voltaren® Gel can “reach.” For instance, if your low back pain is coming from the facet joints — small joints deep in the spine, under a thick layer of muscle — chances are that a topical treatment simply doesn’t stand a chance of having an effect.
That said, why not try it? It’s almost certainly safer than popping ibuprofen! Although not tested and approved for reckless experimentation on any pain problem, obviously the entire point of Voltaren® Gel is to limit exposure to the active ingredient. So you might choose to experiment — taking full responsibility for your actions, of course, and not suing me if something goes horribly wrong, because of course I’m not actually recommending it. 😉 Seriously: just run it by your doctor.
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About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
What’s new in this article?
Six updates have been logged for this article since publication (2009). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
2019 — Added small new section: “Remember, exercise is also an anti-inflammatory medication.”
2018 — Added a brief anecdote about a personal success.
2018 — Added a small section about the safety of long-term regular use.
2018 — Science update. Added several citations substantiating what was previously presented only as a rational opinion: topical NSAIDs are a lot safer than oral NSAIDs.
2016 — Added link to new opioids article, and a footnote clarifying the mechanism of action of “gut burning.” Added information about availability and the new generic equivalent of Voltaren.
2015 — Significant safety update (and a reassuring one).
2009 — Publication.
FDA approval does remotely not mean that something is “proven,” and in fact FDA approval only requires evidence of efficacy for drugs (not proof). For everything else they regulate, they are focused on safety. For instance, FDA approval of food additives and medical devices mainly just means “probably safe” (for medical devices, they officially require “valid scientific evidence that there is a reasonable assurance that the devices are safe and effective for their intended uses”).
And of course they screw up; there’s a long history of embarrassing examples of things the FDA should never have approved. So FDA approval is hardly a guarantee of anything, but it is also better than nothing.
- Altman R, Barkin RL. Topical therapy for osteoarthritis: clinical and pharmacologic perspectives. Postgrad Med J. 2009 Mar;121(2):139–47. PubMed #19332972 ❐
Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown efficacy in patients with osteoarthritis (OA) pain but are also associated with a dose-dependent risk of gastrointestinal, cardiovascular, hematologic, hepatic, and renal adverse events (AEs). Topical NSAIDs were developed to provide analgesia similar to their oral counterparts with less systemic exposure and fewer serious AEs. Topical NSAIDs have long been available in Europe for the management of OA, and guidelines of the European League Against Rheumatism and the Osteoarthritis Research Society International specify that topical NSAIDs are preferred over oral NSAIDs for patients with knee or hand OA of mild-to-moderate severity, few affected joints, and/or a history of sensitivity to oral NSAIDs.
In contrast, the guidelines of the American Pain Society and American College of Rheumatology have in the past recommended topical methyl salicylate and topical capsaicin, but not topical NSAIDs. This reflects the fact that the American guidelines were written several years before the first topical NSAID was approved for use in the United States. Neither salicylates nor capsaicin have shown significant efficacy in the treatment of OA.
In October 2007, diclofenac sodium 1% gel (Voltaren Gel) became the first topical NSAID for OA therapy approved in the United States following a long history of use internationally. Topical diclofenac sodium 1% gel delivers effective diclofenac concentrations in the affected joint with limited systemic exposure. Clinical trial data suggest that diclofenac sodium 1% gel provides clinically meaningful analgesia in OA patients with a low incidence of systemic AEs.
This review discusses the pharmacology, clinical efficacy, and safety profiles of diclofenac sodium 1% gel, salicylates, and capsaicin for the management of hand and knee OA.
- The great majority of therapies and interventions that sound good actually don’t work all that well. In medicine, “common sense” rarely correlates with reality. I get tired of being the bearer of disappointing news about popular therapies and treatments, and it’s a genuine pleasure to have good news for once.
- Homeopathic (diluted) herbal ointments featuring Arnica are claimed to be good medicine for muscle pain, joint pain, sports injuries and bruises, but their effectiveness is questionable. Known to most customers as an “herbal” arnica cream, most actually contain only trace amounts — too little to be a chemically active ingredient. Homeopathy involves extreme dilution of ingredients, to the point of completely removing them. Some other herbal ingredients may be less diluted and more useful. However, neither homeopathic or pure herbal creams of this type have produced results better than placebo in good quality modern tests. See Does Arnica Gel Work for Pain? A detailed review of popular homeopathic (diluted) herbal creams and gels like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation.
- The effect of NSAIDs on the GI tract is actually indirect: it’s not because the medicine comes into direct contact with the walls of the GI tract, but because the medication, once it is in the bloodstream, affects the behaviour of cells in the lining of the gut. So it’s actually just a matter of dosage. If you were to smear a diclofenac gel all over your body, you would absorb enough of it that it would be a “gut burner” too!
“Tendinitis” versus “tendonitis”: Both spellings are acceptable these days, but the first is the more legitimate, while the second is just an old misspelling that has become acceptable only through popular use, which is a thing that happens in English. The word is based on the Latin “tendo” which has a genitive singular form of tendinis, and a combining form that is therefore tendin. (Source: Stedmans Electronic Medical Dictionary.)
“Tendinitis” vs “tendinopathy”: Both are acceptable labels for ticked off tendons. Tendinopathy (and tendinosis) are often used to avoid the implication of inflammation that is baked into the term tendinitis, because the condition involves no signs of gross, acute inflammation. However, recent research has shown that inflammation is actually there, it’s just not obvious. So tendinitis remains a fair label, and much more familiar to patients to boot.
- Huang ZJ, Hsu E, Li HC, et al. Topical application of compound Ibuprofen suppresses pain by inhibiting sensory neuron hyperexcitability and neuroinflammation in a rat model of intervertebral foramen inflammation. J Pain. 2011 Jan;12(1):141–52. PubMed #20797917 ❐
- Hyldahl RD, Keadle J, Rouzier PA, Pearl D, Clarkson PM. Effects of ibuprofen topical gel on muscle soreness. Med Sci Sports Exerc. 2010 Mar;42(3):614–21. PubMed #19952809 ❐
- Hasson SM, Daniels JC, Divine JG. Effect of iboprufen use on muscle soreness, damage and performance: a preliminary investigation. Med Sci Sports Exerc. 1993;1:9–17. PubMed #8423760 ❐
An old and small but well-designed test of ibuprofen for muscle soreness, showing a modest but definite benefit for pain, but probably not function. In other words, ibuprofen reduced the soreness only, but had no significant effect on other outcomes, like muscle function and inflammatory markers.
- Tokmakidis SP, Kokkinidis EA, Smilios I, Douda H. The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise. J Strength Cond Res. 2003 Feb;17(1):53–9. PubMed #12580656 ❐
Another very small test of ibuprofen, very similar to Hasson 1993 in design and results: “ibuprofen can decrease muscle soreness induced after eccentric exercise but cannot assist in restoring muscle function.”
- For more detail, see another article on PainScience.com, Icing for Injuries, Tendinitis, and Inflammation: Become a cryotherapy master.
- There are a lot of reasonable reasons to try icing, but it’s not proven medicine. In fact, strangely, it’s almost completely untested. See Collins.
- Especially if you use organic, free range ice. From icebergs.
- ScienceBasedMedicine.org [Internet]. Gavura S. Topical NSAIDs; 2011 Mar 3 [cited 13 Mar 27].
- Fu S, Thompson CL, Ali A, et al. Mechanical loading inhibits cartilage inflammatory signalling via an HDAC6 and IFT-dependent mechanism regulating primary cilia elongation. Osteoarthritis Cartilage. 2019 Jul;27(7):1064–1074. PubMed #30922983 ❐ PainSci #52660 ❐
This is a highly technical petri-dish study of the effect of “exercise” (mechanical loading) on the inflammation signalling of cartilage cells. Basically, they mechanically stressed samples of excised cartilage and cartilage cells. The surprising, good-news result was that the researchers reported that moderate loading actually reduced inflammation. That is, fewer inflammatory signals were produced by the cells.
While it is a near certainly that too much loading would increase inflammatory signalling, it is nifty that mechanical loading in the “just right” Goldilocks zone might actually be anti-inflammatory. It implies a very specific and substantive way in which “exercise is medicine.”
- McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Med. 2013 Feb;10(2):e1001388. PubMed #23424288 ❐ PainSci #54748 ❐
- Holt RJ, Taiwo T, Kent JD. Bioequivalence of diclofenac sodium 2% and 1.5% topical solutions relative to oral diclofenac sodium in healthy volunteers. Postgrad Med. 2015 Aug;127(6):581–90. PubMed #26077436 ❐ “Systemic exposure to diclofenac is substantially lower after topical application as compared to oral administration.”
- PharmacyTimes.com [Internet]. Fudin J. Should Topical NSAIDs Have Strict Heart Risk Warnings?; 2018 March 10 [cited 18 Jun 12]. Although this article’s title implies concerns about topical NSAID safety, it ends up answering that concern with very reassuring data, and it turns into a piece suggesting that the FDA needs to make it clearer that only oral NSAIDs are of concern, while topical is an extremely safe alternative! “ … all topical vehicles of diclofenac delivery result in only a small fraction of the diclofenac that actually reaches the systemic circulation compared with the oral route.”
- Pontes C, Marsal JR, Elorza JM, et al. Analgesic Use and Risk for Acute Coronary Events in Patients With Osteoarthritis: A Population-based, Nested Case-control Study. Clin Ther. 2018 Feb;40(2):270–283. PubMed #29398161 ❐ “No significant associations were observed” between topical NSAIDs and acute coronary events.”
Interesting side note: this study not only confirmed that oral NSAIDs increase the risk of heart attack, but that opioids do too! Despite the opioid crisis, this is not a widely recognized concern about that type of drug.
- Rannou F, Pelletier JP, Martel-Pelletier J. Efficacy and safety of topical NSAIDs in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Semin Arthritis Rheum. 2016 Feb;45(4 Suppl):S18–21. PubMed #26806189 ❐ “Topical NSAIDs have a moderate effect on pain relief, with efficacy similar to that of oral NSAIDs, with the advantage of a better risk:benefit ratio. In real-life studies, topical and oral NSAIDs demonstrate an equivalent effect on knee pain over 1 year of treatment, with fewer adverse events due to lower systemic absorption of topical NSAIDs compared with oral NSAIDs.”
- Deng ZH, Zeng C, Yang Y, et al. Topical diclofenac therapy for osteoarthritis: a meta-analysis of randomized controlled trials. Clin Rheumatol. 2016 May;35(5):1253–61. PubMed #26242469 ❐ “Topical diclofenac is effective in pain relief as a treatment of OA. It may also have a potential effect in function improvement, which needs further studies to be explored. Although, some adverse effects were observed in the application of topical diclofenac, none of them was serious.”
- Zeng C, Wei J, Persson MS, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: a systematic review and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med. 2018 Feb. PubMed #29436380 ❐ “Topical NSAIDs were effective and safe for OA. Diclofenac patches may be the most effective topical NSAID for pain relief. No serious gastrointestinal and renal AEs were observed in trials or the general population.”
- Science Based Pharmacy [Internet]. Gavura S. How risky are NSAIDS?; 2015 Jul 25 [cited 16 Aug 18].
- This is one of the most important and useful major ideas presented and explained on this website. For full details and all the evidence, see the neck pain or low back pain tutorials.