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View Full Version : Nitroglycerin to treat tendinosis/tendinopathies


Howell Hsieh
02-14-2010, 05:19 PM
Hello,

Has anyone had any experiences with using transdermal nitroglycerin patches to treat tendon related injuries?

I had chronic knee pain (patellar tendonitis/tendinosis) for over a year, found out about these patches, and 2 weeks later my symptoms were gone (actually I feel like they started noticeably reducing the pain 24-48 hours after the start of patching, but 2 weeks is probably how long it took for their effect to taper off). I did utilize a full rehab routine as well, lots of stretching and foam rolling, but I would attribute 85% of my recovery to these patches.

A few months later, I developed medial epicondylitis about my right elbow. I did a full rehab for a while without much success, but once I patched the area, voila...!

General overview link:
http://bjsm.bmj.com/content/41/4/227.full wfs

Now I am having shoulder issues (chronic), but the patches aren't working as well...probably because there are many layers of muscles in this region, and it's hard to patch directly over a tendon without muscles getting in the way.

Steven Low
02-14-2010, 05:49 PM
That's pretty interesting.. I'll have to look into this further.

Your shoulder issues may not just be because of tendonitis though. The shoulder is complex enough that often it's posture, biomechanics, limited mobility or imbalances that often screw things up there rather than strict tendinopathy in most cases.

Medial epicondylitis, and patellar tendinitis tend can be just overuse but are less likely in most cases to have lots of other things go wrong with them compared to the shoulders and for another example the low back.

Howell Hsieh
02-14-2010, 06:24 PM
Yeah, it's definitely possible that other issues are responsible here. I think scapular mobility and flexibility is fairly decent though. I will post some pictures later of posture.

The problem is that when I try to patch over the affected shoulder area, I get a different reaction than when I patch over the knee or elbow. In the case of the patellar region, it is pretty much impossible to miss hitting the patellar tendon, in fact, I hit different portions of the tendon so as not to "overwork" one spot too much. In the elbow, if I patched too close to the triceps, it would feel slightly painful and ineffective. If I patched directly onto a tendon, I might get a slight itching sensation, but no pain - basically I could very easily tell if I was patching over a tendon or not.

In the case of my shoulder, the pain is not very localized (anterior region, I am guessing bicipital tendon?)... so I am doing my best to get a fix on the area of pain, but I am pretty sure I am patching over muscle overlying the tendon, because it starts hurting pretty soon (1-2 hours) after I patch. It's hard to say how much exactly, but I am guessing just a minimal amount of NO is getting to the area.

Garrett Smith
02-15-2010, 05:51 AM
If the pain isn't completely gone after using the patches and eventually comes back, then all you are doing is treating a symptom. Not much better than NSAIDS, IMO.

Howell Hsieh
02-15-2010, 05:03 PM
From what I understand, the premise of using NO to treat tendons is very different than NSAIs. One, it dilates the blood vessels so that whatever minimal blood vessels are present in the tendons receive more blood flow, and two, it attracts fibroblast cells to the area which are responsible for the creation of new collagen fibers. It's a transdermal patch that works locally and not globally.

Anyway, it's interesting to me that more people don't know about it, given just how cheap it is... (~$40 for a 3+ month's supply). The problem was that the only doc I knew who prescribed it was halfway around the country, so prescription + plane tickets was a bit more than $40! :) Don't get me wrong though, it was worth its weight in gold!

Jason Lopez-Ota
02-16-2010, 11:20 AM
This is interesting. So it works?

Garrett Smith
02-16-2010, 11:52 AM
As I look more at it, for the more "superficial" tendonopathies, this does look pretty promising.

Bicipital tendonitis may be too deep under muscle tissue though, as you are guessing.

Next thing I would suggest you look into is why do you keep developing these tendonopathies all over the place?

Howell Hsieh
02-16-2010, 05:02 PM
From my experience, yes it works.

It needs to be used in conjunction with the usual basics, stretching, correcting posture, increasing flexibility, etc, which address the underlying cause of injury. The NO patch provides the actual healing of the tendon.

Dr. Smith, the remark about superficial tendons is spot on. I am already convinced that it works on my elbow and knee. Other potential hotspots would include: achilles tendon, wrists, and possibly the suprispinatus and hip. The first I heard of this was actually from someone treating their hip with the patches.

The reason for developing tendinopathies all over the place stems from being an overly ambitious engineering student. I was doing too much and sleeping too little. I was also on the crew team and doing two-a-days, not warming up properly, not eating/supplementing properly, etc, etc., you get the idea. Anyways you live and learn that warm tendons stretch and cold ones are irritable, and that recovery is King. :D

One more thing about the NO patches that gives you an idea of just how underdeveloped the treatment is: The patches are actually intended for angina patients, basically people who have clogged hearts and need the help of NO to open up blood vessels. So these are readily available at your local pharmacist, and you basically cut them up into quarters to lower the dosage. IMO neither the dosage nor the application (topical cream may work better?) has been optimized. The thing is that you do need a prescription.

Brandon Oto
02-16-2010, 06:07 PM
One more thing about the NO patches that gives you an idea of just how underdeveloped the treatment is: The patches are actually intended for angina patients, basically people who have clogged hearts and need the help of NO to open up blood vessels. So these are readily available at your local pharmacist, and you basically cut them up into quarters to lower the dosage. IMO neither the dosage nor the application (topical cream may work better?) has been optimized. The thing is that you do need a prescription.

A little more accurately, the main role of nitro in angina (and actually in MI, aka a heart attack) is to reduce preload -- less blood entering the heart, therefore less work that the heart needs to do, therefore less oxygen it has to burn.

Per the issue of deeper problems, I suppose it's theoretically possible to use intramuscular injection at the site; nitro can be given IM as far as I know. Doesn't seem like it'd really have the same long-duration effect though.

Garrett Smith
02-16-2010, 06:42 PM
The NO patch provides the actual healing of the tendon.
[...]
Anyways you live and learn that warm tendons stretch and cold ones are irritable, and that recovery is King.

Lindlahr, considered a main "founder" of the modern version of naturopathic medicine, said in his 1922 seminal book (http://chestofbooks.com/health/natural-cure/Henry-Lindlahr/Nature-Cure/index.html):
The cells and organs receive their nourishment from the blood and lymph currents.
The NO is not what is doing the healing. The increased blood flow that it is causing in the localized areas is, because it is the blood that "does the healing".

Your second statement above also echoes the fact that low blood flow ("cold tendons") causes irritation.

The body is what does the healing, the NO patches are simply pushing it in the right direction, giving it some help.

Jason Lopez-Ota
02-17-2010, 11:51 AM
So it does the same thing the heat Ive been using for my tendons has been doing.

Steriods also works for my tendonitis. I had some electronically injected into my wrists a couple times.

Garrett Smith
02-17-2010, 02:08 PM
Corticosteroids do not work by the "increasing blood flow" mechanism.

Corticosteroid injections do locally weaken tendons and ligaments over time (and yes, sometimes they even resolve inflammation problems).

Blair Lowe
02-18-2010, 02:32 AM
very, very interesting.

Garrett Smith
02-18-2010, 04:15 PM
Howell, what size and brand name are the nitroglycerin patches that were prescribed to you?

Howell Hsieh
02-18-2010, 04:41 PM
Dr. G, the brand is Mylan. The product is called Nitroglycerin Transdermal System, dosage rate 0.2 mg/hr. I'll try to upload a picture tomorrow when I get access to a better camera.

Edit: Actual size is 8 cm^2, recommended application is cutting into quarters for a lower dosage. I also experimented with using an eighth's portion depending on how the tendon is feeling and how long I've been patching it.

Garrett Smith
02-18-2010, 07:26 PM
And what were your dosing instructions over time (it sounds like they change)?

Howell Hsieh
02-19-2010, 09:12 AM
The instructions were to "Cut into quarters and apply to tendon every day." Each patch was good for 24 hours. I patched continuously and replaced daily, moving each successive patch to an adjacent spot as I found that if the patch was kept on the same spot for too long, I would develop an acne like reaction.

Garrett Smith
02-19-2010, 04:21 PM
Gracias. I'm now checking with my local pharmacy for a patient with lateral epicondylitis.

Tammy McClafferty
04-23-2013, 12:39 PM
Is anyone still using this? I've had it prescribed for my hamstring tendon at the insertion point... yes, I have a pain in the A$$!! lol
I have a couple questions: did any one have any side effects from this patch? I feel really funny after workouts, especially cardio.
Is it really going to work on such an area? It's larger than ankle, or knee, or even shoulder - deeper...
I'm only 4 days into the treatment... so i'm hoping to see something soon. Just thought I'd ask as this is the only place I've found any good discussion on this off-lable use.

Thanks!

James Davison
04-26-2013, 04:33 AM
Your neck problems may not just be because of tendonitis though it can be due to over exercise (https://www.rebelmouse.com/premierfitnessolutions/Cary-Weight-Loss/) or the neck is complicated enough that often it's position, bio-mechanics, restricted flexibility or instability that often attach factors up there rather than tight tendinopathy in most situations.