SGEM#521: Hit Me with Your Best Shot – IM Ketorolac for Back Pain?

Date: September 22, 2026 Dr. Sergey Motov Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department. Reference: Sharabun et al. Oral Ibuprofen Versus Intramuscular Ketorolac for Acute Musculoskeletal Back Pain in the Emergency Department: A Prospective Analysis. Journal of Pharmacy Practice. 2026 Case: A 42-year-old man presents to the emergency department (ED) with three days of severe lower back pain that started after moving boxes at work. There was no fall or direct trauma. He describes constant, non-radiating pain rated 8/10 that is worse with movement and is preventing him from sleeping and returning to work. He denies fever, intravenous drug use, cancer, recent infection, weight loss, leg weakness, saddle anesthesia, or bowel or bladder dysfunction. His vital signs are normal. He has bilateral lumbar paraspinal tenderness, no midline tenderness, and an intact lower-extremity neurologic examination. He has not taken an analgesic or muscle relaxant in the preceding four hours and has no history of kidney disease, peptic ulcer disease, gastrointestinal bleeding, hepatic failure, or NSAID allergy. You diagnose acute atraumatic musculoskeletal back pain and offer oral ibuprofen. He replies that pills never work for him and asks for the Toradol shot because it is stronger. Background: Back pain is one of those emergency department (ED) complaints that can fill the waiting room, empty the medication cupboard, and still leave both the patient and clinician frustrated. Patients commonly present after lifting, twisting, shovelling, moving furniture, or sometimes with no memorable trigger at all. The pain can be severe enough to interfere with walking, sleeping, working, and activities of daily living. Most have no concerning neurologic findings or other red flags, but our first job remains identifying the uncommon patient with fracture, infection, malignancy, cauda equina syndrome, or another serious cause. Once you have considered serious pathology, the next challenge is treatment. Unfortunately, there is no magic analgesic for uncomplicated acute low back pain. Acetaminophen, NSAIDs, corticosteroids, benzodiazepines, skeletal muscle relaxants, opioids, and various medication combinations have all been studied, generally producing small, inconsistent, or clinically unimpressive benefits. Non-pharmacologic approaches, including cognitive behavioural therapy, mindfulness, chiropractic manipulation, physiotherapy, acupuncture, massage, and most recently TENS, have also been tried. Some patients report benefit, but no single treatment has emerged as the reliable winner. The SGEM has returned to this topic repeatedly because low back pain is common, disabling, and stubbornly difficult to treat. NSAIDs remain a common starting point for eligible ED patients with acute musculoskeletal back pain. Oral ibuprofen is inexpensive, familiar, and easy to administer. Ketorolac is frequently given intravenously or intramuscularly and carries a certain aura of being faster, stronger, or somehow more serious medicine. Patients will sometimes specifically request the injection because they believe it must work better. Route of administration can matter when a patient cannot swallow, is vomiting, must remain nil by mouth, or already has vascular access. However, a parenteral route does not automatically provide superior analgesia. It also comes with additional expense, administration time, injection pain, hematoma risk, and occupational needlestick risk. In 2000, Schwartz and colleagues examined whether the perception of receiving an injection created additional analgesia. Every participant unknowingly received 800 mg of ibuprofen in an orange-flavoured drink and was then randomized to a placebo pill or placebo saline injection. Pain relief was virtually identical between groups, with no evidence that the injection produced a selective placebo effect. Back pain patients were excluded from that study, so it addressed the psychology of route rather than this specific clinical population. Earlier ED trials comparing oral ibuprofen with IM ketorolac also generally failed to show better analgesia with the injectable option. However, many used 800 mg of ibuprofen and 60 mg of ketorolac, above the ceiling dose for both analgesics. Clinical Question: In adults aged 21–65 years presenting to the ED with acute, atraumatic musculoskeletal back pain of at least moderate severity, does oral ibuprofen 400 mg provide similar pain reduction at 60 minutes to IM ketorolac 10 mg? Reference: Sharabun et al. Oral Ibuprofen Versus Intramuscular Ketorolac for Acute Musculoskeletal Back Pain in the Emergency Department: A Prospective Analysis. Journal of Pharmacy Practice. 2026 Population: Adults (21-65) presenting to a single urban Bronx ED with acute, atraumatic musculoskeletal back pain lasting four weeks or less and a baseline VAS pain score of at least 50/100 mm. Exclusions: Age under 21 or over 65; subacute pain lasting 4–12 weeks; chronic pain lasting over 12 weeks; pregnancy or breastfeeding; active peptic ulcer disease; acute GI hemorrhage; CKD stage IV or V; Child-Pugh B or C hepatic insufficiency; ESI category below 3; NSAID allergy; or receipt of another analgesic or skeletal muscle relaxant within four hours. Intervention: Ibuprofen 400 mg oral suspension plus an IM placebo injection. Comparison: Ketorolac 10 mg IM plus an oral placebo suspension. Outcome: Primary Outcome: Absolute change in 100-mm VAS pain score from baseline to 60 minutes. Secondary Outcomes: Rescue analgesia at 60 minutes and adverse drug reactions. The investigators also reported administration of skeletal muscle relaxants and optional pain measurements at 90 and 120 minutes for patients who remained in the ED. Type of Study: Prospective, single-centre, parallel-group, randomized, double-blind, double-dummy, active-comparator superiority Authors’ Conclusions: “Ketorolac 10 mg IM and ibuprofen 400 mg PO seem to provide similar reductions in pain scores for the treatment of acute, atraumatic, musculoskeletal back pain. Further research is warranted to assess if there is similar reduction in pain scores for the treatment of acute, atraumatic, musculoskeletal back pain and other acute pain etiologies between ibuprofen and ketorolac.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Unsure The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. No Funding of the study? The authors stated that they received no financial support for the research, authorship or publication. Financial conflicts of interest. No COIs declared by the authors Results: A total of 153 patients were considered. Sixty were excluded: 32 declined consent, 27 did not satisfy the inclusion criteria, and one left before completing the study period. Ninety-three participants were randomized (47 to ibuprofen and 46 to ketorolac). The median age was 42 years in both groups. Men made up 66% of the ibuprofen group and 59% of the ketorolac group. The population was racially and ethnically diverse. Baseline mean pain scores were high: 78/100 mm with ibuprofen and 84/100 mm with ketorolac. Key Result: There was a significant decrease in pain with oral ibuprofen and IM ketorolac but no statistically significant difference between the two groups. Primary Outcome: Absolute VAS pain reduction at 60 minutes 35mm oral Ibuprofen vs 32mm IM ketorolac Between-group mean difference of 3mm (95% CI; -8.03 to 15.03mm) p-0.27 Secondary Outcomes: There were no statistically significant differences in rescue acetaminophen or use of the reported skeletal muscle relaxants. Two ketorolac patients reported injection-site pain. No nausea, vomiting, diarrhea, headache or flushing was reported in either group during the brief observation period. The study was much too small and too short to assess uncommon renal, gastrointestinal or cardiovascular NSAID harms. 1. Randomization & Analysis: These were incompletely reported. The authors refer to a predetermined randomization table but do not say how it was generated or whether restrictions such as blocks or stratification were used. Allocation concealment appears reasonable, but proper sequence generation cannot be independently assessed. Intention-to-treat analysis was not explicitly stated, and protocol deviations or crossovers were not described. Using a STROBE cohort checklist rather than CONSORT may have contributed to these reporting gaps. Randomized trials can remain vulnerable to selection bias when sequence generation or concealment is inadequately described or implemented. 2. Non-consecutive Recruitment: Enrollment was limited to weekdays between 8 am and 10 pm when a pharmacist was available. Thirty-two otherwise potentially eligible patients declined participation. Patients younger than 21, older than 65, more acutely ill patients, and those with several common comorbidities were excluded....