Treatment Protocols

Patellar 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

Place patient on treatment table in supine position with a pillow under the head.
Knees should be flexed 30-45 degrees with a pillow or wedge under the knees.
Identify trigger point (sore area near superior or inferior to the patella) by palpation and mark with pen if necessary.
Apply transmission gel over trigger point.
Swing Sonocur shock head into place and position over identified trigger point.
Apply shock waves initially at lowest energy level (level 1) at 4Hz.
Move shock head in small increments until patient reports maximal reproduction of discomfort.
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.
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.
Depending upon patient tolerance, gradually increase energy levels to the highest level that can be maximally tolerated. In patellar tendonitis, this is generally level two (2) to level four (4). 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.
Readjust the shock head position after every 200-400 shocks to precisely treat the maximal area of tenderness. This is necessary because of the slight positional movements which may occur during treatment.
Deliver a total of 2000 shocks to the affected site after it has been identified.
Remove shock head from the treated area and observe the site of application.
Wipe away the gel.
Supply patient with post treatment instructions and return appointment for additional treatment or physician visit.

HELPFUL HINTS

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.
In infrapatellar tendonitis, patients may have either central, lateral, or medial patellar tendonitis, with a single trigger point near the midline just inferior to the patella or on either border of the inferior patellar tendon. This occurs in about 70% of patients. About 30 % of patients will have medial and lateral patellar tendonitis with separate trigger points on each side of the inferior patellar tendon. In these cases, each side of the patellar tendon (medial and lateral) should be treated with 2000 shocks to each of these two trigger areas. Occasionally, one may best identify which type of involvement the patient has by applying shock waves transversely across the inferior patellar border to find the areas which reproduce discomfort, since this may be difficult to delineate with palpation alone. Quadriceps (suprapatellar) tendonitis most commonly occurs along one lateral border of the quadriceps tendon insertion.
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.

The Sonocur® Orthopedic Extracorporeal Shockwave system is available in Canada and other countries where regulatory approval has been obtained. The Sonocur® Basic is FDA approved in the United States for the treatment of chronic lateral epicondylitis (tennis elbow).

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