Tendinopathies of the Foot and Ankle

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 supine or lateral position, dependent upon the site to be treated, with a pillow under the head.
   
   
2. Knees should be flexed 30-45 degrees with a pillow or wedge under the knees if the patient is supine. If in the lateral position, flex the hips and knees and place a pillow between the thighs.
   
   
3. Identify trigger point (sore area on the ankle or foot) by palpation and mark with a 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 foot and ankle tendinopathies, this is generally level two (2) to level three (3). Rarely patients will tolerate 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.
    
    
11. Readjust the shock head position after every 200-400 shocks to precisely treat the maximal area of tenderness. This is necessary because of small positional movements that may occur during treatment.
    
    
12. Deliver a total of 2000 shocks to the affected site.
    
    
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. Peroneus longus, tibialis anterior, and tibialis posterior tendinopathies are easily positioned and treated. Occasionally, more than one trigger point is identified along these tendons. If this is found, then each site, up to a maximum of three trigger points, should each be treated with 2000 shocks each (total maximum of 6000 shocks).
   
   

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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