Achilles Tendonitis

Prior to any Sonocur treatment, care must be taken to be certain that the patient meets the treatment criteria, has no treatment contraindications, has had the necessary pre-treatment imaging studies, and has read and signed the proper informed consent.

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PROCEDURE TECHNIQUE

1. Place patient on treatment table in prone position with a pillow under the head. If the patient has neck or back discomfort in the prone position, then a pillow may be placed under the abdomen or thorax
   
   
2. Position the foot over the end of the table with the toes pointing to the floor. A pillow should be placed under the lower leg to slightly flex the knees.
   
   
3. Identify trigger point (sore and/or indurated area along the Achilles tendon) by palpation and mark with pen if necessary.
   
   
4. Apply transmission gel over trigger point.
   
   
5. Swing Sonocur shock head into place and position over identified trigger point.
   
   
6. Apply shock waves initially at lowest energy level (level 1) at 4Hz.
   
   
7. Move shock head in small increments until patient reports maximal reproduction of discomfort.
   
   
8. Accomplish fine adjustment of shock wave penetration depth by adjusting amount of fluid in bellows, again with patient feedback to identify maximal trigger point stimulation.
   
   
9. Great care must be taken to precisely identify the exact area of pain. It may require the use of several shocks (eg.100) to identify this site.
   
   
10. Depending upon patient tolerance, gradually increase energy levels to the highest level that can be maximally tolerated. In Achilles tendonitis this may be quite variable. For patients with insertional Achilles tendonitis, only lower energy levels are usually tolerated (levels 1-3). In patients with nodular tendonitis, with well defined areas of induration or nodules, medium energy levels (levels 3-5) are usually well tolerated. Be certain that the patient does not become too uncomfortable. It is more important to deliver all the shock waves to the correct area at a lower energy level than miss the mark with higher levels because the patient is too uncomfortable. AT NO TIME SHOULD AN ENERGY LEVEL GREATER THAN 5 BE USED IN ANY TYPE OF ACHILLES TENDONITIS.
    
    
11. Readjust the shock head position after every 200-400 shocks to precisely treat the maximal area of tenderness.
    
    
12. Deliver a total of 2000 shocks to the affected site after it has been identified.
    
    
13. Remove shock head from the treated area and observe the site of application.
    
    
14. Wipe away the gel.
    
    
15. Supply patient with post treatment instructions and return appointment for additional treatment or physician visit.
    

HELPFUL HINTS

1. If the patient is exquisitely tender or has significant discomfort, it may be helpful to initiate treatment slightly away from the point of maximal tenderness. After 100-200 shocks, slowly readjust the shock head so that the shock waves are focused more progressively toward area of maximal tenderness. Slowly advance to the maximal trigger point and complete the treatment.
   
   
2. In patients with nodular Achilles tendonitis, about 30 % will have two (2) nodular tender trigger areas and approximately 15% will have three (3) areas. In these cases, each area should be treated with 2000 shock waves but no more than 6000 shocks delivered in any case.
   
   
3. Some patients may experience shock wave exit sensations opposite the application site at medium or higher energy settings. This is normal and causes no harm.
   
   
4. Inform the patient that it is usual to have soreness after treatment and that often the pain will be worse for a few days until healing begins. Explain that if multiple treatments are necessary, that subsequent treatments can sometimes be more uncomfortable than the initial treatment. In addition, emphasize that healing may take several weeks to occur and that one should not expect maximal improvement until 12 weeks after the last treatment.
   
   

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