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Off-Topic GTN patches for tendinopathy

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Here is a short explanation of what my tendon issue is. Tendinopathy of the distal hamstring tendon at the medial knee. First occurrence 8 years ago lasted 2 years. Issue came back strong November 2020. After 3 months of failed rehab due to load aggravating the issue twice and working with 2 different PTs I needed something more to help get ready for work as a seasonal worker for the town where I live. By mid April I was in as bad a state if not worse than in mid-January when I started rehab with the first PT. So I asked my family doctor for a treatment with GTN patches after doing a lot of reading to find something to help with my rehab.

I was only expecting the patches to help with the healing by allowing more load tolerance so that I could perform the rehab exercises without aggravating my issue when the load was augmented.

One month of GTN patch (Nitro patches) treatment update:

  1. The first thing I noticed was an almost immediate reduction of pain and irritability. After 2 days of treatment, I could go though a full day of work without anything more than light discomfort. Just before, I was putting Chinese wood-lock oil on my knees twice a day just to make it through the day at work.
  2. This allowed me to restart a rehab program with again another PT without the fear of aggravating my issue a third time.
  3. I was able to do light training without irritating or aggravating my tendons
  4. When the workload was high at work and I had irritation at my tendons, it usually dissipated within a few hours and was never more than light irritation (1-2 on a 1/10 scale)
  5. When the PT changed my rehab plan after a month and I again had an exercise that proved to be too much load, by the 2nd day irritation was down to nothing and I could again work without pain and discomfort for a full day of work.
In conclusion for the time being, the patches have allowed enough healing and pain reduction for me to go through my daily activities and more without aggravating my tendon issues and also have removed the fear of aggravating the issue. I plan on continuing the treatment for at least another 2 months and for up to 6 months total.

EDIT: I did get headaches from the patches as side effects, only at night, so I now remove them before going to bed most of the time. I do keep them when I have harder days at work and have experienced less headaches from keeping them lately.

I will update again at the end of month 2-3 depending on how things progress.

This is all anecdotal based on personal experience and not medical advice. Please contact a medical professional if you consider GTN patches as treatment for any issue you might have.

I will gladly answer any questions anyone might have though, since this treatment has really been a game changer for me, better than anything I could have hoped for.
 
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This is about all the reading I did on the subject. Not being a medical professional, some of it does escape my understanding but I think I got the general idea. It's also part of this that I sent to both my family doctor and pharmacist so they would understand the treatment plan I was asking for.

pubmed.ncbi.nlm.nih.gov

Topical glyceryl trinitrate for chronic Achilles tendinopathy - PubMed

A topical glyceryl trinitrate patch was more effective than placebo for reducing pain from chronic noninsertional Achilles tendonitis in the first 12 and 24 weeks of use.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
www.ncbi.nlm.nih.gov

Using nitric oxide to treat tendinopathy

Nitric oxide (NO) is a small free radical generated by a family of enzymes, the nitric oxide synthases (NOSs). Following injury to a tendon, NO is induced by all three isoforms of NOS and NOS activity is also upregulated in tendinopathy. In animal models ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
www.ncbi.nlm.nih.gov

Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov

Modulation of tendon healing by nitric oxide - PubMed

Nitric oxide (NO) is a small, diffusible free radical that is generated from L-arginine by a family of enzymes, collectively termed the nitric oxide synthases. We investigated the role of NO in tendon healing. NO synthase activity and immunoreactivity was absent in un-injured rat Achilles...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov

The role of nitric oxide in tendon healing - PubMed

Nitric oxide (NO) is a small free radical that is generated by a family of enzymes called the nitric oxide synthases (NOS). There are 3 isoforms of NOS: endothelial NOS (eNOS), brain or neuronal NOS (bNOS), and inducible NOS (iNOS). In experiments performed during the last 20 years, we have...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov

Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial - PubMed

Application of topical nitric oxide improved early pain with activity, late functional measures, and outcomes of patients with extensor tendinosis.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
journals.lww.com

Topical Glyceryl Trinitrate Treatment of Chronic... : JBJS

echanisms that may include stimulation of collagen synthesis in fibroblasts. The goal of the present study was to determine if topical glyceryl trinitrate improves clinical outcome measures in patients with Achilles tendinopathy....
journals.lww.com journals.lww.com

Some articles:

runningmagazine.ca

Achilles sufferers: the nitro patch as last resort - Canadian Running Magazine

Discouraged by ongoing Achilles pain? The nitro patch was a game changer for one Canadian masters record-holder
runningmagazine.ca runningmagazine.ca
athletictimemachine.com

Why Nitroglycerin Patches are a Permanent Part of My First Aid Kit

No I’m not having a heart attack. Not even a stroke. But I am religiously using nitroglycerin patches for some of my sports injuries. If you find yourself with connective tissue pain from …
athletictimemachine.com athletictimemachine.com
sportdoctorlondon.com

GTN patch for tendonitis: should you use it?

GTN patches lower pain and improves function in tendonitis. Find out whether you can use a nitroglycerin patch for your tendonitis.
sportdoctorlondon.com sportdoctorlondon.com
www.sciencedirect.com

Glyceryl trinitrate patches—An alternative treatment for shoulder impingement syndrome

Transdermal glyceryl trinitrate patches have been investigated as an alternative therapeutic intervention for a range of tendinopathies, due to the ea…
www.sciencedirect.com www.sciencedirect.com
https://www.professionsante.ca/files/2012/01/LACM02_025-027.pdf - in French

Instructions for use:
 
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@Benjamin Renaud, I have read about supplements that say they boost nitric oxide in the body but, other than that, know nothing on this subject. Is the underlying mechanism, that nitric oxide boosters may be "good" for us, the same when taken as a pill as when applied topically.

BTW, a bit of reading this morning yielded what I also see in some of the links you supplied, namely that this substance is also called nitroglycerin. I recall this being used as an emergency treatment of sorts for heart issues - I think my father-in-law, may he rest in peace, carried around this medicine.

-S-
 
@Steve Freides , the treatment I am using is actually used for angina which is a heart condition. The patches are usually applied to the chest/back area and act by dilating arteries to increase blood flow to the heart.

It seems that the body, when faced with tendonitis, locally produces some NO. It is still unclear how this acts to help the healing process of tendinopathy, but it is thought that it acts as a vasodilatator. Thus helping get more blood flow to the tendons that have a limited supply of blood compared to muscles. In cases of chronic or degenerative tendinopathies, the tendons usually have an increased vascularity (The vasculature and its role in the damaged and healing tendon) . The GTN from the patches gets converted to NO in the body.

I can't say if eating nitric oxyde boosters would be good for tendinopathy, I remember reading that the effects would be too limited to have an impact in the way that the topical treatment has.
 
Benjamin Renaud said:
I can't say if eating nitric oxyde boosters would be good for tendinopathy, I remember reading that the effects would be too limited to have an impact in the way that the topical treatment has.
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I recall something similar when I had my back injury. The Emergency Room prescribed an oral steroid but my low back specialist said it wouldn't do anything, citing the reason you mention. I later received a cortisone injection right at the site of my injury, and that was really the beginning of the healing process for me.

Thank you, @Benjamin Renaud.

-S-
 
Steve Freides said:
I later received a cortisone injection right at the site of my injury, and that was really the beginning of the healing process for me.
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I've seen the GTN patch treatment compared to cortisone injections in at least one study. what surprised me the most was the pain reduction seemed similar in both treatments. But in the case of tendinopathies, cortisone injections seem to negatively affect the healing process in the log term, whereas the GTN patches seem to do the opposite. Cortisone acting mostly on pain from what I understand but the nitro patches seem to improve tendon strength allowing for a better long term recovery.

Having episodes of low back pain myself, probably nothing like your injury though, I wonder if GTN patches would help in any way. It's something I haven't looked into yet, being more focused on recovering from my tendinopathy.
 
Steve Freides said:
My understanding is that its purpose, at least in my case, was to break the cycle of inflammation.

-S-
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Ah yes of course, I am happy it worked for you. I was also considering getting cortisone injections for my tendonitis with the very limited success I was having with the rehab. But one of the problems here in Canada are the wait times for such treatments, I would have had to wait 6+months to see a specialist to get the injections, same as the wait time for MRIs. The GTN patches seemed more accessible, once my doctor was informed and accepted the treatment option and affordable, the patches costing around 0,40$ per day with the public healthcare subsidies.
 
As Benjamin knows, as do those who follow my training log, I have been dealing with an Achilles tendonopathy as of late. A cortisone injection to that particular area is no longer recommended by most doctors (due to a high risk of tendon damage). A course of an oral steroid is however, which is what I did. Followed by physiotherapy. And although tendons don’t really get inflamed in the classical sense, the purpose of the steroid is indeed to help physiotherapy to proceed with a minimal amount of pain and distress. Benjamin and I have had some good discussions on GTN. Here in the U.S. this use for tendinopathies seems mostly unfamiliar to doctors and physiotherapists (at least to mine)
Another area of promise for certain tendinopathies is BFR. (Blood Flow Restriction) Maybe more well known than GTN here in the States, but still considered somewhat on the edge.
 
offwidth said:
Here in the U.S. this use for tendinopathies seems mostly unfamiliar to doctors and physiotherapists (at least to mine)
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It seemed mostly unknown to my doc, my PT and my pharmacist. Hence the need to do so much research and to have had to present it to all of these professionals to get approval and understanding.

Especially since there is absolutely no research on my particular tendinopathy.

I'm curious about BFR, I'll have a look into it for fun... well for educational purposes I should say.

offwidth said:
A cortisone injection to that particular area is no longer recommended by most doctors (due to a high risk of tendon damage)
Click to expand...
It's one of the things that I was afraid of with cortisone injections. I was keeping it in mind as a last resort only, if all else failed.
 
From my actual understanding, my tendinopathy also turned into chronic pain. Where I'm at now, I still have pain and peripheral sensitivity (at the nerve endings, nociceptors) but my tendons are likely mostly healed.

Understanding pain is playing a big role in my recent progress which had stalled for months, even regressed at times when I tried various exercises.
 
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