Any patients worse after shockwave therapy?

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Hi Pod-Arena. I hope you can advise me on treatment for recalcitrant tendoachilles enthesopathy.
Patient is a 50 yoa female. Fairly sedentary. There is a ~1 year Hx of pain in the tendon of the Achilles complex. Over time she has had orthotics, shoe heel height advice and a stretching program. Her improvement was moderate.

Patient went to a sports med doctor and had 1 x prp injection, a strengthening program, ECSwT and 2 x cortisone injections. It is now 12 months on from this . Her pain in the tendon is gone but she has developed a large bump at the Haglund's location. She is of the opinion that this developed fairly rapidly after the shockwave treatment. This bony area is now more painful than the original site. We were going reasonably well with a protocol of taping / heel raise / orthotics and no strengthening work to get the area settled down but unfortunately she has had a (really nasty) tape reaction stopping that part of the treatment. Pain is starting to escalate.

Might the bony proliferation be due to the shockwave therapy?
Have other patients' symptoms worsened after treatment?
Is the use of anti-inflammatory substances contraindicated with shockwave therapy?
If surgery was ultimately required, would you choose a z plasty over a chilectomy?
What should I try for her next?

Thanks for any input! Stephanie

 

I have not had anyone worse after ESWT and there is no logical reason this should have caused bony proliferation. It is certainly not a reported complication. Have you confirmed bony prominence via X-ray?

If she has an insertional spur then surgery requires reflection of the Achilles, removal of the spur and the superior posterior calcaneal prominence and then reattachment of the Achilles, generally with a bone anchor. These cases can have a protracted recovery and symptoms can persist.

 

Stephanie:

The more significant the bony proliferation or spurring at the Achilles tendon insertion and the more chronic the posterior heel pain becomes, the more likely this patient will require surgical excision of the posterior spur. I have never heard that shockwave therapy creates spurs but no one here in our medical community uses shockwave therapy for these conditions either since, in my opinion, it doesn't make any sense.

The good news is that I have had excellent results using the surgical techniques that Rich Bouche, DPM described in his chapter in Tom Chang, DPM's book on foot and ankle surgery. Dr. Bouche is one of the most intelligent podiatric surgeons here in the USA and is also a very accomplished sports podiatrist.

http://www.amazon.com/Master-Techniques-Podiatric-Surgery-Ankle/dp/0781732352

Basically, the patient is laid prone on the surgical table, a "Z" skin incision is made, the Achilles tendon is split in half, reflected off the posterior calcaneal spur and then the tendon is debulked. The superior aspect of the posterior calcaneus is remodelled with an osteotome and mallet, bone wax is applied and the Achilles tendon is reattached to the posterior calcaneus with three bone anchors. The patient is usually back to walking painfree within about 6 months but needs about 12 months to be completely healed. The surgery does work very well and have yet to have a patient that has not returned to full, all-day walking activities without any pain within a year following the surgery.