Nitro Patches for Achilles Tendinopathy
As part of my advanced practice in treating runners, I often come across cases that don’t evolve well with conservative treatments. After a few experiences with various approaches and different practitioners, some patients come to me and, in most cases, the key lies in going back to basics. Let’s take the example of Achilles tendinopathy.
First things first, the best thing to start with is properly explaining the concept of mechanical stress quantification. In my own experience, taking that extra 15 minutes has been key in treating the pathology, and you should know that I have encountered hundreds of these cases! A series of interventions will then be determined depending on our assessment and the progress achieved; e.g., eccentric reinforcement, stretching, remove the possible local friction (cut the heel notch). In most cases, no time will be wasted with foot orthotics, biomechanical correction, manual therapy and electrotherapy (ultrasounds, TENS). Anti-inflammatory drugs and cortisone injections are to be avoided as well. It is to be noted that this approach works with over 95 percent of runners who come to us for a consultation. What to do when this doesn’t work? Shock wave? PRP? Are nitro patches a legitimate option for Achilles tendinopathy?
In North America, the new trend for a number of sports physicians consists in using nitro patches as soon as the above-mentioned pathology is detected, as well as for other conditions involving overuse injuries. You will find below a summary of the evidence put forward to date in that area.
- Only a single group of scientists have looked into this option (Murrell group).
- One study (two publications) has been carried out relative to the Achilles tendon (follow-ups after one and three years, respectively).
- This study involved 65 participants. Good methodology but high risk of bias (Cochrane analysis). Average success rate/overall results for both groups (Patient with chronic symptoms > 3 months of Achilles tendonitis... Of patients on GTN patches 78% were asymptomatic with activities of daily living at 6 months compared with 49% of patients who received tendon rehabilitation alone... We found 88% of patients with GTN treatment were asymptomatic at 3 years compared with 67% of patients treated with tendon rehabilitation alone).
- Promising results for the Achilles tendon, less positive though for other tendons (Long-term efficacy of GTN patches was demonstrated in non-insertional Achilles tendinopathy but not in chronic lateral epicondylitis. In chronic lateral epicondylitis, OrthoDerm patches given in the absence of an exercise program failed to demonstrate evidence for efficacy, suggesting exercise rehabilitation may be important to GTN patch efficacy.).
- The known effect is analgesic, after only three months (pain reduction in activities of daily living, night, hop testing, palpation)
- Tendon quality is expected to improve but on the basis of biochemical/physiological theories that have not been validated in-vivo.
- Although side effects (headache, skin irritation) are moderate and reversible, they have been noted in half of the patients.
- The use of the patch under the study was for a six-month period (big job for the patient)... effects unknown when using the patch for a few weeks only.
In summary, I find that we must remain cautious when it comes to giving therapeutic importance to nitro patches. We are only beginning to learn about the effects of this method. However, it is an interesting option for persistent cases of Achilles tendinopathy where treatment through mechanical stress quantification is not sufficient, or when eccentric exercises are limited due to pain.