Painkillers vs Physio: What Heals and What Hides

Two beliefs turn up in my clinic with roughly equal frequency, and they contradict each other completely.

The first is that painkillers are the treatment. Take enough ibuprofen, wait it out, and the shoulder will sort itself. The second is that painkillers are cheating, that they only mask the problem, and that a properly disciplined person should feel their pain honestly while it heals.

Both are wrong, and the question of painkillers or physio is a false choice to begin with. They do different jobs. Understanding which job is which makes the decision much easier.

What painkillers actually do

Analgesics change how much pain you experience. They do not repair a tendon, restore a joint's range of movement, or rebuild the strength you lost during three weeks of limping. Nothing in a blister pack builds capacity.

That is not a criticism. It is simply a description of the mechanism. A painkiller turns down the volume; it does not change the song.

Anti-inflammatories are slightly different in that they also act on the inflammatory process, which is genuinely useful in some acute presentations. But even there, the effect is on symptoms and swelling rather than on the underlying capacity of the tissue.

What the guidance actually says, which surprises people

This is where the conversation usually takes a turn.

NICE guidance on low back pain advises against offering paracetamol on its own, and recommends oral anti-inflammatories only at the lowest effective dose for the shortest possible time, with the risks weighed up first. It advises against opioids for persistent back pain, and against gabapentinoids for sciatica. For chronic primary pain, the guidance is more striking still: it recommends against starting most analgesics at all, and puts supervised exercise near the top of what is worth doing.

Meanwhile, exercise-based treatment holds up consistently across a wide range of musculoskeletal problems. It is not a fashionable alternative to medication. In current guidance, it is the main event, and medication is the supporting act.

For knee osteoarthritis, topical anti-inflammatory gel is generally favoured over tablets, because the local effect comes with far less systemic risk. That is a small, practical piece of information that a lot of people have never been told.

Where painkillers genuinely earn their place

I am not anti-medication. Used deliberately, it is enormously helpful, and there are three situations where I actively encourage people to speak to their pharmacist or GP about it.

To protect sleep. Poor sleep amplifies pain, slows recovery and wrecks your tolerance for rehabilitation. Getting a few decent nights early in an acute episode is worth a great deal.

To create a window for movement. If pain is stopping you walking, standing up from a chair or doing a basic exercise programme, appropriate pain relief lets you move — and the movement is the treatment. This is the most legitimate use of all.

Immediately after injury or surgery. Nobody rehabilitates well through severe acute pain.

Notice that in each case the medication is a bridge to activity, not a substitute for it. If you are taking something and then sitting still, you have used the tool and skipped the job.

Where the concern about hiding is real

The worry that painkillers mask damage is overstated, but it is not baseless.

The genuine risk is the person who takes a strong dose specifically so they can do the thing that hurt them, at full intensity, with no modification. Playing the match on tablets. Getting through a shift by chemical means, every shift, for months. In those situations, pain is giving you accurate information about load, and you are switching off the alarm rather than reducing the fire.

The more common problem, though, runs the other way. Far more people under-treat their pain, stop moving, lose strength, get frightened of the movement, and end up in a much deeper hole three months later. Avoidance does more damage in my caseload than analgesia does.

There is also a real safety dimension. Anti-inflammatories are not benign for everyone. They interact with stomach, kidney, blood pressure and cardiac conditions and with a number of common prescriptions. Which drug, which dose, and for how long is a conversation for a pharmacist or GP, not for a physiotherapist and certainly not for a blog.

What physiotherapy does that a tablet cannot

Assessment comes first. Knowing what is actually wrong changes everything, and no amount of medication substitutes for a diagnosis.

Then there is loading. Tendons, muscles, bone and cartilage respond to graded mechanical load by adapting. That adaptation is the healing you are after, and it can only be produced by doing things.

There is also the part that gets underestimated: understanding what is happening, knowing which sensations are safe, and having a plan with a shape to it. Persistent pain is influenced by sleep, stress, activity levels and expectations, not by tissue alone, and addressing those is a large part of what good rehabilitation does.

Across my caseload in Liverpool and Merseyside, the people who recover fastest are usually the ones who used sensible pain relief early, moved as soon as they reasonably could, and then tapered the medication as the exercise programme took over.

The practical takeaway

Use pain relief with a purpose and an end point. Ask yourself what the medication is for — sleep, walking, exercising — and check whether it is achieving that.

Pair it with movement every single time. The tablet buys you a window; something has to happen in the window.

Review it. If you have been on the same analgesic for more than a couple of weeks for a musculoskeletal problem, that is a prompt to speak to your GP or pharmacist and to get the underlying problem assessed properly.

And do not delay physiotherapy because you are still taking something. Turning up medicated is completely fine; I would rather assess a comfortable knee than a guarded one.

When pain relief is itself a warning sign

See your GP promptly, or attend A&E, if you need escalating doses to control pain, if pain wakes you every night and is unrelieved by rest or position, if it comes with unexplained weight loss, fever, or feeling generally unwell, if you have numbness around the groin or saddle area or any change in bladder or bowel control, or if you have sudden significant weakness in a limb. Pain that refuses to respond to ordinary measures deserves a medical opinion rather than a bigger box of tablets.

For context on the most common problem this comes up with, see back pain, or read more about physiotherapy in Liverpool and how musculoskeletal physiotherapy works in practice.

If you are managing something with tablets and hoping it settles, an assessment will tell you whether that is a reasonable plan. Book at /portal/book or call me on +44 7553 370300. Home visits across Liverpool and Merseyside are £90 a session, online consultations £60, evenings Monday to Friday, plus Saturday and Sunday daytimes, no GP referral required.