성균관의대 강북삼성병원 재활의학과 이 용택

Hughes et al (2007)

101 Morton’s neuroma (2004-2005)

10 months f/u by questionnaire & telephone

AJR 2007

20% ethyl alcohol 0.5 ml 100% ethyl alcohol 0.1 ml

0.25% bupivacaine 0.4 ml 14-day interval 4회 injection Incomplete response

▪ 14-day interval additional injection AJR 2007

Results 10 months f/u by questionnaire & telephone

▪ Median VAS 8 → 0 ▪ 94 % total or partial symptom relief ▪ 84 % completely pain free

Conclusion High success rate Comparable results to OP

AJR 2007

Op

mean 24 months

36% (16/45)

Complication (12)

Immense pain at the time of injection (9)

Extensive bruising (3)

Ongoing numbness of the toes (2)

transient pain relief < 2weeks (13)

Only long term data for Morton’s neuroma Alcohol injection

Encouraging short term result (-) Permanent resolution

Accurately enveloped 3rd common digital nerve

No contrast in MTP joint

Poterior tibial nerve block RFA

0.25% bupiva 1cc+ dexa 4mg

22GN 5cm with 10 mm electrode tip

Temperature 81°C

5 cycles of 2 min

No response → 4 weeks interval RFA Failed 3 sessions of RFA -> OP

Average No. of RFA 1.6 (1-3)

86.7% satisfactory outcome (26/30) 32% Unpleasant experience (8)

All would have undergone RFA again first-line treatment Complication (1)

posterior tibial nerve irritation for 3 weeks 10%Surgical excision despite improvement (3)

RFA was preferable

Alcohol injection

spread locally

Fat necrosis

RFA

More controlled area target

Fewer local side effect

Notoriously do not respond to primary simple excision

Other techniques

Capping with silicone

Chemical agents

Placing nerve end into bone, muscle, vein etc.

Pain 85% significantly improved and functional with conduit op

▪ 43% painless (43/69) ▪ 33 % VAS 1-4 ▪ 9% VAS 5-7

15% VAS 8-10 Complication

3 stich abscesses 3 CRPS

▪ 1 dorsal column stimulator ▪ 2 sympathetic block

Conclusions Collagen conduits were safe & generally successful adjuncts to

simple excision

All experimental design for effect of ESWT on insertional or non-insertional Achilles tendinopathy

PRISMA guideline Preferred Reporting Items for Systemic Reviews &

Meta-analysis English study within the past 10 YR 2 reviewer Methodological Quality assessment

▪ PEDro scale (0-10) for RCT ▪ Modified McMaster Quantitative Critical Appraisal Tool for

non-RCT (0-15)

Grade C evidence (NHMRC)

Low-energy ESWT in chronic insertional & non-insertional Achilles tendinopathy.

Improved pain & functional outcomes for minimum of 3 months

ESWT must be considered before surgery Further study

Dosage, long-term outcome

Female 49yr with plantar fasciitis Hx

▪ Previous conservative Tx. for 3weeks ▪ → 2 sessions of ESWT within 10 days (Energy

dosage ?) ▪ Pain increased

P/E ▪ Pain & tenderness at med/lateral calcaneus

Tx ▪ 6 weeks cast immobilisation

Delius et al

Shock wave to femurs of rabbits

▪ fractured and displaced.

Martini et al

Amount of energy was the key

a dose-dependent destructive effect

especially > 21 kV (0.22 mJ/mm2),

Appearance, symptom, clinical sign were similar to stress fracture

Foot Ankle Int 2012

Case 1 F/22 dancer with 2nd metatarsal base Fx.

▪ Hx. ▪ fall

▪ 6 weeks non-wt bearing + 4 weeks protected wt-bearing

▪ Return to dance at 4 months despite ongoing pain

▪ Pain was still present at 2yr

▪ X-ray showed nonunion

Low energy ESWT ▪ 3 sessions, 3,000 impulses, 0.2 mJ/mm2 without anesthesia

▪ Avoid from dancing for 6 weeks

▪ mobilize with a flat postoperative shoe until recovery

f/u at 3 month Pain free

Radiological union Dance slowly restart at 14wk Full training at 19wk Remained pain free at 6-months f/u

Foot Ankle Int 2012

Case 2 Female 29yr ballet dancer with 2nd metatarsal

base stress Fx. ▪ Hx.

▪ Insidious pain and exacerbation with training ▪ Avoid dance and protected wt-bearing in a boot for 3

months ▪ Pain for 6 month

▪ X-ray showed nonunion

Low energy ESWT ▪ 3 sessions, 3,000 impulses, 0.2 mJ/mm2 ▪ Local anesthesia (-)

No pain at 3 month Return to training at 14wks Full training at 21wks Pain free at 1yr

side effects of urolithiasis increase in pelvic bone formation

High-energy ESWT increasingly employed in Mx. of nonunion, AVN, delayed

union

Success rate 75-91% Low-energy ESWT 6 soccer players with 5th metatarsal fx & delayed union

▪ Radiographic consolidation 6-12 weeks

▪ Full return to activity at 4 month

Low-energy ESWT should be considered as first-line Tx. for painful delayed union

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