Sesamoid osteonecrosis treated with radial extracorporeal shock wave therapy

Abstract

Sesamoid osteonecrosis is a disabling condition resulting in severe forefoot pain, for which there are limited treatment options. We present a 52-year-old man with 1-year history of pain, aggravated by walking and playing tennis. On examination, pain was localised to plantar aspect of the first metatarsophalangeal joint. Imaging revealed evolving end-stage avascular necrosis of lateral sesamoid with early secondary degenerative changes. Previous exhaustive conservative treatment had been unsuccessful in alleviating his pain. As an alternative to surgery, radial extracorporeal shock wave therapy (rESWT) was proposed. Treatment protocol was 2000 pulses at frequency of 5 Hz, and pressure was varied from 1.2 to 1.8 bar according to patient tolerance. A total of eight sessions were delivered. At completion of treatment, the patient reported minimal discomfort to no pain and was able to return to playing tennis with no recurrence. We propose rESWT to be an effective novel conservative treatment for sesamoid osteonecrosis.

Radial extracorporeal shockwave therapy (rESWT) for coccydynia: a prospective study of 14 patients

“…Each session included the delivery of at least 2000 pulses. These parameters were set based on the experience of our authors with previous cases of coccydynia and mirror those utilised in similar rESWT research 16 , 19 , 21 , 22 . Pressure, frequency, and the number of pulses were adjusted between sessions in line with patients’ pain tolerance.…”

“…In practice, rESWT devices are smaller, cheaper, and easier to use 8 . Moreover, rESWT has proven to be successful in the management of musculoskeletal disorders such as plantar fasciitis 16 – 18 , calcific shoulder tendinopathy 19 , 20 , trigger digit 21 , sesamoid osteonecrosis 22 , patellar tendinopathy 23 , medial tibial stress syndrome 24 – 26 , and lateral epicondylitis 27 , 28 .…”

Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review

“…78 In 10 male elite and subelite soccer players with delayed union/non-union of tibial or fifth metatarsal stress fractures, 3-4 sessions of F-SWT were effective in pain relief and bony union and allowed them to return to full competition at ten weeks to 24 weeks after treatment with one patient requiring repeat treatment to achieve bony union. 79 Based on the seven case reports, ESWT was found to be effective in relieving pain and facilitating in return to play in osteochondritis dissecans of bilateral medial femoral condyle, 80 scaphoid delayed union, 81 resistant stress fractures (base of the fifth metatarsal bone, medial malleolus of the ankle, middle third tibia and inferior pubic ramus), 82 avulsion fracture of the sublime tubercle of ulna, 83 sesamoid osteonecrosis, 84 delayed union of midshaft clavicle fracture 85 and symptomatic bilateral bipartite patella. 35…”

Operative Treatment of Medial and Lateral Sesamoid AVN Through an Isolated Medial Approach

“…Augments to offloading can include physiotherapy, antiinflammatory medications, injections, and bone stimulation. 3,4 Failed conservative management or recalcitrant pain is usually treated with operative excision of the affected sesamoid. In rare circumstances, patients will present with AVN of both the lateral and medial sesamoid.…”

“…Initial treatment algorithm usually begins with conservative measures primarily to offload the affected sesamoid through accommodative padding and orthoses or cast immobilization. Augments to offloading can include physiotherapy, anti-inflammatory medications, injections, and bone stimulation 3,4. Failed conservative management or recalcitrant pain is usually treated with operative excision of the affected sesamoid.…”