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from the American Academy of Orthopaedic Surgeons

Diseases & Conditions



Staying Healthy

Managing Orthopaedic Surgery-Related Pain With Medications

After orthopaedic surgery, your doctors will make every effort to control pain during your recovery. While you should expect to feel some discomfort, moderate and severe pain can actually limit your recovery. Fortunately, there are safe and effective options available to you when you need pain relief:

To manage your pain after orthopaedic surgery, your surgeon will consider several factors that are unique to you and your situation. That is why it is important to openly discuss your fears and expectations, as well as your past experiences with pain control, with your surgeon.

This article focuses on the medications used to control pain both during and after orthopaedic surgery. To learn about alternative approaches your doctor may recommend to supplement your pain medication program: Alternative Methods To Help Manage Pain After Orthopaedic Surgery


Medication can help you feel more comfortable, allowing you to:

  • Start moving sooner
  • Get your strength back more quickly
  • Recover from surgery faster

Many types of medicines are available to help manage pain:

NOTE: Opioid use after orthopaedic surgery has appropriate safety concerns and is considered only after alternative non-medication and non-opioid medication approaches are tried and not sufficient.  Surgeons and their patients increasingly choose non-medication methods such as ice/heat, hypnosis, and acupuncture as a supplement to conventional medicine. A combined, tailored approach to pain management often gives the best result.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce swelling and soreness and are often used alone for mild to moderate pain. Some examples of NSAIDs include ibuprofen, naproxen, and celecoxib.

To manage the moderate to severe pain after surgery, NSAIDs are often used in combination with acetaminophen (e.g., Tylenol) and opioids as well as non-medication strategies for an optimal result.

How NSAIDs Work

NSAIDs work by preventing an enzyme (a protein that triggers changes in the body) from doing its job. The enzyme is called cyclooxygenase, or COX, and it has two forms:

  • COX-1 protects the stomach lining from harsh acids and digestive chemicals. It also helps maintain kidney function.
  • COX-2 is produced when your body is injured or inflamed.

Traditional NSAIDs block both COX-1 and COX-2; however, COX-2 specific NSAIDs are also available.

COX-1 and COX-2 enzymes play a key role in making prostaglandins, which cause pain and swelling by irritating your nerve endings. By blocking the COX enzymes — and, therefore, the production of prostaglandin —  NSAIDs essentially stop your body from making too much inflammation. This directly reduces your pain and swelling.

Advantages and Disadvantages of NSAIDs

  • Like all medications, NSAIDs do have side effects, but they are typically minimal with less risk when compared to opioids.
  • NSAIDs alone may not relieve the moderate to severe pain you may have after surgery. However, using NSAIDs may limit your need for opioid medications and, therefore, reduce common opioid side effects like constipation and drowsiness.
  • NSAIDs typically do not lead to addiction or dependence. 
  • As mentioned above, traditional NSAIDs like naproxen and ibuprofen block the actions of both COX-1 and COX-2 enzymes, which is why they can cause stomach upset and bleeding and are associated with ulcers.
  • COX-2 specific inhibitors, like celecoxib, are a special category of NSAIDs. These medications target only the COX-2 enzyme that stimulates the inflammatory response. Because they do not block the actions of the COX-1 enzyme, these medications generally do not cause the kind of stomach problems associated with traditional NSAIDs. However, COX-2 inhibitors have possible cardiac side effects.

Centrally-Acting Non-Opioids


Acetaminophen does not interfere with the COX-1 or COX-2 enzyme to reduce pain, so it does not have anti-inflammatory properties. Scientists believe that acetaminophen relieves mild to moderate pain by elevating (raising) your body's overall pain threshold. It also lowers fevers by helping the body eliminate excess heat.

Used alone, acetaminophen works well for headaches, fever, and minor aches and pains, but it does not reduce the inflammation and swelling that might accompany a muscle sprain.

Like NSAIDs, acetaminophen may be used after surgery to reduce the amount of stronger opioid medications you need to control pain. Acetaminophen is also often combined with opioid tablets. When taken alone by mouth — in tablet form — opioids are not easily absorbed by the body. But when combined with acetaminophen, the opioid medication absorbs more easily and effectively.

Opioid Analgesics

Opioids are effective medicines used for moderate to severe pain. When taken as prescribed, they can be especially effective for managing short-term pain after surgery.

Individual doctors and medical facilities may have different policies, procedures, and pain control options available. In most cases after surgery, oral (PO), intramuscular (IM), or intravenous (IV) opioids will be prescribed. Doctors usually prefer to prescribe oral opioid medications for use when you return home.

Opioid Dependency

Be aware that although opioids help relieve pain after surgery or injury, they are narcotics and can be addictive. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few days of your treatment.

Since your surgeon can only estimate how much medication you will need, you may have opioids leftover after your full recovery. Unused opioids after surgery are a safety risk to you and those in your home.

The American Academy of Orthopaedic Surgeons (AAOS) strongly recommends that you return all UNUSED OPIOIDS to certified drop-off locations directed by your pharmacy.

Types of Opioids

  • Natural opioids — among the world's oldest known drugs — are made from the dried "milk" of the opium poppy plant.
  • There are other types of opioids that are made artificially in a laboratory. These are called synthetic or semi-synthetic opioids.

How Opioids Work

Both natural and synthetic opioids work by binding (attaching) to opioid receptors in the brain, spinal cord and gastrointestinal tract. When these drugs attach to certain opioid receptors, the transmission of pain messages to the brain is decreased or blocked.

Opioids can attach to the opioid receptors because they look just like your body's natural painkillers, called endorphins. This similarity in structure "tricks" the receptors into turning on electrical signals to the specific brain nere cells that release dopamine. Dopamine is a natural substance that activates the pleasure center(s) of your brain and causes feelings of euphoria. Large amounts of dopamine are released as the opioid activates the nerve cell, which produces the "opioid effect."

Advantages and Disadvantages of Opioids for Pain Management

  • Movement and range of motion may be a key part of your orthopaedic surgery recovery. Opioids work rapidly to block the experience of pain and also change the way your brain perceives (senses) pain. The pain relief provided by opioids can allow you to be more active during your recovery.
  • Opioids can be effective when given in a variety of ways, including by mouth, through the skin, under the tongue, and directly into the bloodstream.
  • Opioids do not cause bleeding in the stomach or other parts of the body.
  • A serious disadvantage of opioids is the potential for dependency. Many studies have exposed the addictive consequences of opioid misuse. It cannot be stressed enough that you should stop using opioids as soon as possible to prevent dependency.
  • Opioids can cause a range of side effects*, such as:
    • Drowsiness
    • Confusion
    • Difficulty breathing
    • Nausea
    • Difficulty passing urine (urinary retention)
    • Constipation
    • Itching

*All of these side effects are treatable by your doctor and should be reported urgently.

Methods of Opioid Treatment

During some surgeries, an anesthesiologist or nurse anesthetist will use opioids in combination with other anesthetic medications to sedate you and help keep you asleep. Opioids may also be given in the surgical recovery room to control pain as you wake from anesthesia.

There are several options for further pain relief after you leave the recovery room:

Oral opioid medication. Because of the increasing concern about opioid overuse, the current trend is to use oral opioid medication mainly for pain control for a short period of time (3 to 5 days) after surgery. When taking the medication by mouth, smaller amounts are absorbed through the stomach and intestinal tract over a period of time, which can provide extended pain relief without giving more medication than is needed.

The same oral opioid medication that is given in the hospital or surgical center can be gradually tapered (reduced) and discontinued (stopped) soon after you return home.

Patient-controlled analgesia (PCA) pump. In some cases, doctors provide opioid medicines after surgery with a PCA pump. This allows you to press a button to release a small amount of medicine through an intravenous (IV) tube when you begin to feel pain. As other non-opioid forms of pain management have emerged, PCA’s are being used less and less.

Opioids and Over-the-Counter Drugs

Some forms of pain medication combine the opioid drug with other pain medicines like acetaminophen and aspirin. If you take acetaminophen or aspirin in addition to pain medicine your doctor has prescribed, you may accidentally receive dangerously high doses. This can cause serious problems, especially for people with liver or renal disease.

Be sure to talk to your doctor about all your medications — even over-the-counter drugs, supplements, and vitamins. Depending on which pain medicine you have been prescribed, any of these may have potential to cause a harmful reaction. Your doctor will tell you which over-the-counter medicines are safe to take while using the pain medication they have prescribed for you.


Tramadol is a synthetic opioid, which means it is made in a laboratory. It is modeled after a popular opioid called codeine. Although it is technically an opioid because of its structure, the way it works in your body sets it apart from all the other opioids previously discussed.

Tramadol relieves pain through two totally different methods.

  • Like a traditional opioid, tramadol works in the brain and spinal cord to change the way the body senses pain.
  • However, tramadol also works in a similar way to some antidepressant medications — by interfering with the regulation of certain neurochemicals (serotonin and norepinephrine). Neurochemicals affect the nervous system. When the amount of these chemicals is changed, it becomes difficult for pain messages to be relayed from one nerve cell to the next. Therefore, tramadol reduces the amount of pain you feel.

Although tramadol alone is helpful for treating moderate pain, it is most effective when used in combination with acetaminophen or NSAIDs.

Just like any other drug, tramadol is associated with side effects, including dizziness and seizures, especially when used in combination with some anti-depressant medications.

Local Anesthetics

Local anesthetics block pain in a targeted area of the body. In orthopaedic surgery, they may be used as anesthesia during a procedure, or as part of a pain management program after surgery.

The most commonly used local anesthetics include lidocaine, bupivacaine, and ropivacaine. These medicines work by blocking the pain signals that travel along the nerves to your brain.

For pain management, local anesthetics are given in a shot (or multiple shots) near your surgical incision, or as an epidural through a small tube in your back.

Local anesthetics do not cause the side effects of drowsiness, constipation, or breathing problems that you get with opioids.

Using local anesthetics carries the risk of a possible allergic reaction and may cause nerve damage, muscle spasms, and convulsions. For the most part, side effects can be avoided when you share your complete medical history with your doctor.

Regional Anesthetics

Regional anesthetics offer the advantage of providing anesthesia during surgery and pain relief for several hours afterward.

Medication is injected around the nerves in the part of your body where surgery is being performed. The medication can block feeling and movement:

  • In the lower part of your body (spinal, epidural)
  • In one of your arms (interscalene, supraclavicular)
  • In one of your legs (femoral, sciatic)

Often, you can remain conscious (awake) during the procedure and require only light sedation. Other times, regional blocks may be used in addition to general anesthesia. Either way, you will have little or no pain when you wake up.  There is a risk of "rebound pain" when the block wears off and pain can increase dramatically.

Spinal and Epidural

Spinal and epidural anesthesia are neuraxial blocks. They block feeling and movement below the level at which they are given, typically the lower portion of the spine. They can numb the area from the lower abdomen and pelvis down to the toes.

  • A spinal is given as a single injection of a local anesthetic or morphine directly into the spinal canal. Since it is only a single injection, its effect will last for the duration of the procedure but only a few hours afterward.
  • Epidural anesthesia is given in the space around the spinal canal. The canal itself is protected by a lining membrane called the dura. The medication will pass through the dura and reach the spinal nerves. A small tube or catheter may be placed in the space around the dura and left in place for 1 or 2 days after surgery. Medication may then be given at various times through the catheter.

Epidural anesthesia often has less effect on the motor nerves than spinal and will allow for some function and mobility even when the catheter is in place.

In addition to orthopaedic procedures, epidural anesthesia is often given during childbirth.

  • The most common side effects of giving opioids via the spine are nausea and severe itching.
  • The most serious side effect is respiratory depression, which means that your breathing slows down and becomes shallow. Although this rarely happens, your surgical team will closely monitor you for several hours to prevent or address all side effects.

Learn more: Spinal Injections


Regional anesthetics can be used to numb up a smaller area, such as your arm or leg.

In the upper extremity (shoulder to hand) the most common blocks are:

  • Given at the base of the neck to numb up your shoulder and arm.
  • Given above your collarbone to numb up your shoulder and arm.

In the lower extremity (hips to toes) the most common blocks are:

  • Given in the groin area to numb the front of your thigh and knee.
  • Given at the back of your knee to numb your lower leg, foot, and ankle.

As with an epidural, a catheter may be left in place following an interscalene, supraclavicular, or femoral nerve block. The epidural is used to provide pain relief for 24 to 48 hours after knee or shoulder surgery. It is then removed by the anesthesiologist.

Many anesthesiologists now use ultrasound technology to help guide placement of the needle or catheter before medication is injected around the nerves. An image on a monitor shows the nerves, muscles, arteries, and veins in the affected area. This allows the anesthesiologist to make sure the medication is injected into the right place.

Ultrasound is most commonly used for blocks involving the upper and lower extremities. Because it is not an X-ray, there is no radiation exposure from the procedure.

Combined Approach To Pain Management

There are many different pain medications (opioids, NSAIDs, anesthetics) and different methods for giving them (injections, tablets, epidurals).

In orthopaedic surgery, there has been a recent trend toward combining different medicines with individualized delivery methods to produce the most effective pain relief in each patient. In addition to improved pain management, a combined approach can reduce opioid use and the side effects associated with it.

Doctors and researchers continue to investigate new combined pain management strategies to improve surgical recovery times and help patients return to their normal activities as quickly and safely as possible.

The American Academy of Orthopaedic Surgeons (AAOS) has conducted research to provide some useful guidelines that help manage each patient's pain after orthopaedic surgery. These are recommendations only and may not apply to every case. For more information: Pain Alleviation | American Academy of Orthopaedic Surgeons (aaos.org)

Last Reviewed

December 2023

Contributed and/or Updated by

Nina R. Lightdale-Miric, MD, FAAOSAaron Chamberlain, MD, FAAOS

Peer-Reviewed by

Thomas Ward Throckmorton, MD, FAAOS

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.