Rotator Cuff Tendonitis
Impingement Syndrome of the Shoulder

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 the patient on treatment table in the supine position with a pillow under the head.
   
   
2. Position elbow over abdomen and support with wedge or pillow.
   
   
3. Identify trigger point or points (sore area near or over the shoulder) 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 rotator cuff tendonitis, this is generally level two (2) or three (3) and occasionally level four (4). Some patients will tolerate up to level five (5). 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.
    
    
11. Readjust the shock head position after every 200-400 shocks to precisely treat the maximal area of tenderness. This is necessary because of the small positional movements that may occur during treatment.
    
    
12. Deliver a total of 2000 shocks to the affected site after it has been identified.
    
    
13. Remove shock head from elbow 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 some cases of rotator cuff tendonitis, it is necessary to deliver 2000 shocks to each of the three approach areas (anterior, lateral, and posterior). In general, approximately 45% of patients will have a single anterior trigger area, 50% will have both an anterior and lateral area, and about 5% will have all three trigger points. To accomplish treatment of a lateral or posterior trigger point, the patient should slightly be rolled to the contralateral side and a pillow or wedge placed in front of the body (hug the pillow), as well as pillow behind the back for support.
   
   
3. 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, 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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