Pearls of Wisdom: Alternative Treatment Options For Tennis Elbow
A 52 year-old man has tried numerous remedies for tennis elbow (lateral epicondylitis) with scant relief. Although NSAIDs have provided the best symptom control, since pain bothers him every day he would rather not use NSAIDs on a daily basis. He has tried rest, bracing, physical therapy, stretching, and steroid injections.
Is there anything else that might help?
A. Low dose systemic methotrexate
B. 5% dimethyl sulfoxide solution
C. Iontophoresis
D. Topical nitroglycerin
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
Answer: Topical nitroglycerin is an inexpensive, non-toxic treatment for lateral epicondylitis.
Maybe this question wasn’t completely fair, since there are modest sized trials that suggest some benefit from a variety of treatments. Most recently, steroid injection for lateral epicondylitis has come under scrutiny, with some long-term data indicating worse outcomes with steroid injection than placebo, even though injected steroids enjoyed several decades of advocacy. Dimethyl sulfoxide (DMSO) 5% has been used as placebo in comparison trials with therapeutic DMSO (70% solution), so we don’t really expect any efficacy from that. Short-term effects of steroids delivered through iontophoresis were positive, but seem to disappear by 6 months. So where does that leave our patient?
While there is no universally accepted solution to tennis elbow, the results of a 2003 study published in the American Journal of Sports Medicine are quite promising.1
The Research
The authors point out that nitric oxide has been used to treat fractures in animal trials, with a putative mechanism of augmented fibroblast-stimulated collagen synthesis. They performed a prospective, double blind, randomized, placebo controlled trial in patients with chronic tennis elbow (n=99). Patients were treated with either nitroglycerin topically, which is a direct nitric oxide donor, or placebo. Nitroglycerin was administered as ¼ of a 5 mg/24 hr Nitrodur patch, or a placebo patch. Both groups received standard physical therapy.
Outcomes were measured at 2, 6, 12, and 24 weeks, and included pain at rest and with activity, nocturnal pain, local tenderness, and strength.
TD-NTG: Pain with Activity1
The Results
Looking specifically at the endpoints “pain with activity” (Bar Graph 1) and “epicondylar tenderness” (Bar Graph 2), a consistent pattern of statistically significant efficacy of nitroglycerin over placebo can be seen at each study point.
“The results of this clinical trial demonstrated that there were significant improvement in symptoms clinical signs, provocative functional tests, and patients outcomes in patients with extensor tendinsosis treated with topical nitric oxide therapy when compared with tendon rehabilitation alone,” the authors concluded.
TD-NTG: Pain with Activity1
What’s the “Take Home”?
Topical nitroglycerin is an inexpensive, non-toxic treatment for lateral epicondylitis that has shown promising results in a randomized double blind placebo controlled trial.
Reference:
- Paoloni JA, Appleyard RC, Nelson J, Murrell GAC. Topical nitric oxide application in the treatment of chronic extensor teninosis at the elbow. Am J Sports Med. 2003;31(6):915-920.