Page 138 - JSOM Spring 2020

TABLE 2 Summary of Effects of Glyceryl Trinitrate Patches on Pain and Tenderness in Patients With Achilles Tendinopathy
Initial Sample Size Estimated Follow-Up Period (mo)
(N), Experimental Glyceryl Group
Conditions, and Patient Trinitrate Dose; (Defined in 0
Study Inclusion Criteria Treatment Time Measure Column 2) (Baseline) a 3 a 6 a 36 a 42 a
Paoloni et al., 1. N = 41 GTP + CT 2.5mg/day; 1 2.3 0.9 0.4 0.2
2004 89,90 2. N = 43 PP + CT 6 mo Activity pain 2 2.4 1.6 1.0 0.5
Patients with history P value NR .02 .03 .06
of midportion AT,
clinically and ultrasound 1 0.9 0.2 0.2 0.1
confirmed Night pain 2 1.0 0.7 0.3 0.3
P value NR .04 NS .07
1 2.5 0.9 0.9 0.4
Achilles
tenderness 2 2.5 1.6 1.1 0.8
P value NR .02 NS .03
1 3.0 1.2 0.5 0.2
Hopping pain 2 3.4 2.4 1.6 1.0
P value NR NR <.01 .07
1 100
VISA-A score 2 91
P value .04
Kane et al., 1. N = 20 GTP + Ecc 1.25mg/day; 1 5.6 3.1
2008 91 2. N = 20 PP + Ecc 6 mo AOS pain 2 5.4 3.0
Patients with clinically, P value .33 .42
ultrasound, and MRI
diagnosed AT 1 3.5 2.3
AOS disability 2 4.0 2.2
P value .90 .38
Bokhari and N = 65 total, but group 1.25mg/day; Group 1 vs 2 b NR 1 < 2 1 < 2
Murrell, n values not specified NR Activity pain P value NR .02 .04
2012 88 1. GTP b
2. PP Night pain Group 1 vs 2 NR 1 < 2
Patients with symptoms P value NR .04
of chronic AT >3 mo Achilles Group 1 vs 2 b NR 1 < 2 1 < 2
tenderness P value NR .02 .03
Group 1 vs 2 b NR 1 < 2
Hop test pain
P value NR <.01
Group 1 vs 2 c NR 1 > 2
VISA-A score
P value .04
GTP, glyceryl trinitrate patch; PP, placebo patch; AT, Achilles tendinopathy; MRI, magnetic resonance imaging; CT, conventional treatment; Ecc,
eccentric exercise treatment; NR, not reported; NS, not significant (no exact P value provided); AOS, Ankle Osteoarthritis Scale (0 to 10 scale,
with higher score indicating more pain or disability); VISA-A, Victorian Institute of Sports Assessment-Achilles.
Blank cells indicate study did not report data for those cells.
b
c
a Some values estimated from graphs. Less pain in group 1 with patients wearing patches. Exact values for pain scales not reported. On the
VISA-A, a higher score indicates less pain and greater functionality. The group wearing the patch had significantly higher scores at the 3-year
follow-up.

tissue presumably causing pain) and the corticosteroids will Hyaluronic Acid. Hyaluronic acid is a substance contained
assist in reducing whatever inflammation is present in the tis- in the extracellular matrix of tendons that has been shown
sues. Randomized, placebo controlled trials that have involved to increase tenocyte proliferation and collagen disposition.
103
high-volume injections (50 to 90mL) with a corticosteroid, lo- Table 3 shows the three studies that have examined the effects
cal anesthetic, and saline have shown short-term reductions in of hyaluronic acid on pain and function in patients with AT.
pain and improvements in function. 94,97 In one case, these high Injected dosages of hyaluronic acid were either 2.0mL 104,105 or
volume injections were combined with postinjection eccentric 2.5mL. Two studies used ultrasound-guided injections 104,105
106
exercise. Another study showed that these improvements and one was unguided. These studies indicated that hyal-
98
106
97
were largely due to the corticosteroid since a mixture without uronic acid reduced pain within the first week of injection 104,106
the corticosteroid had much less effect when measured at 1.5 and pain continued to decrease over longer periods, 104,105 up
and 3 months. However, by 6 months pain and function scores to 24 weeks. Tendon thickness also decreased over time
105
had decreased slightly in the corticosteroid group while they and function improved. 104,105 The only randomized trial
105
continued to improve in the group without the corticosteroid. compared two ultrasound guided HA injections 1 week apart
Early anecdotal and case reports 99,100 of tendon ruptures due to three shock wave treatments provide at weekly intervals.
to corticosteroid injections have not been supported by more Both treatments resulted in decreased pain and improved
controlled research, 93,96,98,101,102 and there appears to be little function, but the improvements for the hyaluronic acid group
risk in this regard. were much greater than for the shock wave treatment group
132 | JSOM Volume 20, Edition 1 / Spring 2020