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Musculoskeletal pain is common, frequently under-reported, and inadequately treated in the older adult. The objective of this article is to review the management of musculoskeletal pain syndromes in older adults emphasising the potential role of opioid agents in carefully selected patients. Systematic analysis of the relevant literature was done. Even in cognitively impaired patients, assessment of musculoskeletal pain is mandatory. An algorithm for musculoskeletal pain is presented emphasising a stepwise pharmacological approach in combination with an array of non-pharmacological therapies. Comorbid conditions may limit therapeutic choices, particularly in the elderly. Repeated assessment of pain levels as well as functional status is critical for optimal pain management.