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.

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

Quote:

Originally Posted by Howell Hsieh

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

Quote:

Originally Posted by Howell Hsieh

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:

Quote:

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.