Nitroglycerin Patch for Epicondylitis
Nitroglycerin patches can be considered as an adjunct treatment for chronic lateral epicondylitis that has not responded to first-line conservative therapies, though the evidence shows only short-to-mid-term benefits with no clear long-term advantage. 1, 2
First-Line Treatment Approach
The standard initial management of epicondylitis should include: 3
- Relative rest from aggravating activities 3
- Eccentric strengthening exercises as the cornerstone of rehabilitation 3
- NSAIDs for acute pain management 3
- Corticosteroid injections which demonstrate superior short-term efficacy (92% improvement at 4 weeks versus 50% with placebo) 4
Nitroglycerin is not recommended as first-line monotherapy but rather as an adjunct to eccentric strengthening programs when initial conservative measures have failed. 1
Evidence for Nitroglycerin in Epicondylitis
Short-to-Mid-Term Benefits
The research demonstrates modest effectiveness in specific timeframes:
- At 3 weeks: Significant pain reduction with mean VAS scores of 3.15 in the GTN group versus 6.45 in controls (p=0.001), with 90% of patients reporting successful treatment 5
- At 6 months: Continued benefit with mean VAS scores of 0.70 versus 4.85 in controls (p=0.001) 5
- Up to 6 months: Systematic review evidence supports improvement in elbow pain and function 2
Long-Term Limitations
At 5 years post-treatment, nitroglycerin showed no sustained benefit, indicating that any positive effects are temporary. 2
A comprehensive meta-analysis found no evidence that NTG is more effective than placebo when examining all available data across tendinopathies, with effects being "insignificant or borderline significant" for lateral epicondylitis specifically. 6
Practical Application Guidelines
Dosing Protocol
When nitroglycerin is used, the evidence supports: 2
- 1.25 mg/24 hours (most commonly studied dose) 2
- Alternative dosing of 1.44 mg/24 hours has also been evaluated 2
- Applied once daily to the area of maximal tenderness 5
Essential Combination Therapy
Topical NTG is more effective when combined with a tendon rehabilitation program rather than used as monotherapy. 2 This means continuing eccentric strengthening exercises while using the patch.
Common Side Effects to Counsel Patients About
Critical Contraindications
Before prescribing nitroglycerin patches, screen for: 1
- Hypotension (systolic BP <90 mmHg) 1
- Severe bradycardia (<50 bpm) 1
- Concurrent phosphodiesterase inhibitor use (sildenafil, tadalafil, vardenafil) 1
Clinical Decision Algorithm
Initial presentation: Start with eccentric strengthening, NSAIDs, and activity modification 3
Persistent symptoms at 2-4 weeks: Consider corticosteroid injection, which has the strongest evidence for short-term relief (92% improvement rate) 4
Chronic symptoms (>6-12 weeks) unresponsive to above: Consider adding nitroglycerin patch as adjunct to ongoing eccentric exercises 1, 2
Failure after 3-6 months of comprehensive conservative therapy: Surgical consultation becomes the definitive option 1
Important Caveats
The mechanism of benefit remains unclear, though theories include improved collagen synthesis and increased blood flow to hypovascular tendon regions. 1 This theoretical basis is not well-established.
Alternative modalities with moderate evidence include ultrasound therapy and laser therapy, which may be considered alongside or instead of nitroglycerin. 7
The evidence quality for nitroglycerin is mixed, with individual studies showing benefit but meta-analyses failing to demonstrate clinically significant superiority over placebo. 6 This suggests that any benefit may be modest and patient-specific, making it reasonable to trial but not expect universal success.