Clinical Inquiries

Are topical nitrates safe and effective for upper extremity tendinopathies?

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References

NTG plus rehabilitation improves 
chronic shoulder pain, range of motion

A double-blind RCT evaluating NTG patches for 53 patients (57 shoulders) with chronic supraspinatus tendinopathy (shoulder pain lasting longer than 3 months) found that they improved pain, strength, and range of motion at 3 to 6 months.2 Investigators randomized patients to receive one-quarter of a 5-mg 24-hour NTG patch or placebo patch daily and enrolled all patients in a rehabilitation program. They assessed subjective pain (at night and with activity), strength, and external rotation at baseline and at 2, 6, 12, and 24 weeks.

NTG patches improved nighttime pain about 30% (at 12 and 24 weeks), pain with activity about 60% (at 24 weeks), strength about 10% (at 12 and 24 weeks), and range of motion about 20% (at 24 weeks; P<.05 for all comparisons). The placebo group initially had more pain, less strength, and less mobility than the NTG group. Investigators reported no adverse effects.

NTG and rehab improve elbow pain, 
but with side effects


Another RCT comparing topical NTG patches in patients with chronic extensor tendinosis of the elbow found that they improved most parameters.3 Investigators randomized 86 patients with elbow tendonitis (longer than 3 months) to NTG patches (one-quarter of a 5-mg 24-hour patch) or placebo patches and enrolled all patients in a tendon rehabilitation program. They assessed subjective pain, extensor tendon tenderness, and muscle strength at baseline and at 2, 6, 12, and 24 weeks.

Topical nitroglycerin patches improve subjective pain scores by about 30% and range of motion over 3 days in patients with acute shoulder tendinopathy. NTG patches improved subjective pain, tendon tenderness, and strength significantly more than placebo at all follow-up points, by 15% to 50% (P<.05 for all comparisons). The study was flawed because the control group started with more pain, tenderness, and weakness than the NTG group. Five patients discontinued NTG because of adverse effects (headache, dermatitis, and facial flushing).

A follow-up study done 5 years after discontinuation of therapy found equal outcomes with NTG and placebo.4 Investigators evaluated, by phone or in person, 58 of the 86 patients in the original study. NTG and placebo therapy produced equivalent reductions in subjective 0 to 4 elbow pain scores over baseline (average pain 2.5 initially, 1.5 at 12 weeks, and 1.0 at 5 years; P<.01 for all comparisons with baseline, no significant difference between nitrates and placebo).

Evidence-based answers from the Family Physicians Inquiries Network

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