Musculoskeletal pain in the elderly is common and disabling. As the conditions causing rheumatic pain, including osteoarthritis, inflammatory arthritis and soft-tissue conditions such as tendonitis and bursitis, are, for the most part, not curable, pain control is paramount in order to maintain quality of life. Pain management should be multimodal and tailored to the individual patient, and will likely include a combination of both nonpharmacological and pharmacological interventions. Nonpharmacological treatments begin with education of the patient, encouragement to practise self-management strategies and attention to healthy life habits such as weight control and regular physical activity and exercise. Advice in this regard may be effectively given by healthcare professionals other than physicians. Although herbal products and nutritional supplements are commonly used by patients, studies of their efficacy and safety, especially in the elderly, are limited. In contrast, topical applications, and in particular those containing NSAIDs, are being used more frequently, are associated with fewer adverse effects than oral preparations and offer a new and safer treatment alternative. Similarly, intra-articular and soft-tissue injections of corticosteroids provide an easy and cost-effective option for symptom relief with minimal risk. The use of any pharmacological agent in the elderly should be tempered with caution regarding increased sensitivity to medications, drug-drug interactions and associated co-morbidities. Therefore, the elderly will often require down-adjustment of dosage and careful attention to the risk/benefit ratio of the treatment. There is, however, no single ideal pain medication for management of rheumatic pain. The four broad categories of treatments, namely simple analgesics (i.e. paracetamol [acetaminophen]), NSAIDs, stronger analgesics (i.e. opioids) and adjuvant drugs, each have unique and particular concerns regarding their adverse effect profiles. The continued use of any medication should also be repeatedly assessed to ensure that efficacy is maintained. Throughout the treatment period, physicians must remain vigilant for emergent adverse effects. Patients and physicians should have realistic outcome goals for effective rheumatic pain management. Although complete pain relief is seldom achieved, modulation of pain and the associated components of sleep disturbance, fatigue and mood disorder will improve overall quality of life in the elderly. However, barriers to effective pain management from both the patient and the healthcare professional perspectives still exist, and will be overcome only by educational efforts. Successful rheumatic pain management in the elderly should begin with an accurate diagnosis by the physician, and patients must be realistic in their expectations. Treatments should be multimodal, with attention given to the co-morbidities of pain as well as the global health status of the patient. Whether or not an outcome is favourable should be determined not only by the treatment's impact on pain but also by its capacity to improve function and enhance quality of life. The wider range of treatment options now available is both useful and encouraging for the physician managing musculoskeletal aches and pain in the elderly.