Michele Barazzuol MD1, Efthymia Lampropoulou MD1, Andrea Meneghini MD2 and Stefano Masiero MD1*
1School of Physical and Rehabilitation Medicine, Department of Neurosciences, University of Padova, Italy
2Advanced Technology in Rehabilitation Lab, Orthopedic Rehabilitation Unit, Padova Hospital, Italy
Received: 01 November, 2014; Accepted: 08 January, 2015; Published: 10 January, 2015
Stefano Masiero MD, School of Physical and Rehabilitation Medicine, Department of Neurosciences, University of Padova, Italy, Email:
Barazzuol M, Lampropoulou E, Meneghini A, Masiero S (2015) Extracorporeal Shock Waves in the Treatment of Equinovarus Foot in a Duchenne Patient: A Case Report. J Nov Physiother Phys Rehabil 2(1): 001-004. DOI: 10.17352/2455-5487.000015
© 2015 Barazzuol M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Extracorporeal shockwave lithotripsy; Duchenne muscular dystrophy; Foot deformities
Background: Duchenne muscular dystrophy (DMD) is characterized by a progressive muscular weakness, with loss of independent ambulation. When the disease results in the complete loss of ambulation, one of the purposes of treatment during the latest phase is to prevent or reduce complications such as foot deformities.
A 20-year-old DMD patient had a complete loss of muscular strength in the inferior and superior limbs and a severe bilateral clubfoot deformity. Active movements were not possible, while passive motion was very limited in dorsiflexion and pronation, inversion and eversion, with stronger limitation on the right foot.
First, the patient was treated with gentle manipulation and casting for two weeks, but no improvement in passive range of motion was detected.
The treatment was then modified by adding a session of focused extracorporeal shock wave therapy for five consecutive weeks.
Results: After five shock wave sessions, both limbs showed a bilateral correction of the talo-metatarsal angle, respectively 26° on the right and 19° on the left foot. The most relevant improvements were estimated in the passive dorsiflexion of both ankles: with a gentle manipulation, both feet could return to the anatomical position, in such a way to allow the patient to wear his own shoes.
Conclusions: There is increasing evidence that nitric oxide (NO) and vascular endothelial growth factor (VEGF) dysregulation is involved in DMD progression; on the other hand, extracorporeal shock wave therapy (ESWT) induces NO and VEGF production, thus promoting angiogenesis, and has proven effective in reducing muscular hypertone. ESWT shows a potential role in the treatment of Duchenne complications such as foot deformities, as part of a multidisciplinary rehabilitation program.
Duchenne muscular dystrophy (DMD) is the most frequent form of hereditary muscular dystrophy, affecting 1 in 3600-6000 live male births .
The disorder is characterized by a progressive muscular weakness especially of proximal muscle groups, with loss of independent ambulation. Children become wheelchair dependent when they are about 10 years, even earlier when patients are not treated with steroids [2,3].
If untreated, the progression of the DMD can lead to grotesque deformities . Equinus deformity of the ankle is one of the serious orthopedic problems associated with DMD . The major cause of foot drop is the weakness of the muscles of ankle dorsiflexion, with a primary role supported by the deficiency of tibialis anterior, but also of the long extensors of the toes (extensor hallucis longus and extensor digitorum longus) . A very important effect of this weakness is the shortening and contracture of the Achilles tendon. Most conditions that cause weakness of the dorsiflexors, may also affect the peroneus tertius, peroneus longus and tibialis posterior, respectively the muscles of eversion and inversion. The foot drop syndrome often incorporates weakness of these muscles, and associated contracture of their antagonist muscle tendons6. When ambulation is no longer possible, the rehabilitation program focuses on the prevention or reduction of complications and deformities, in order to alleviate pain and pressure, to allow the patient to wear shoes, and to correctly place the feet on wheelchair footrests .
Despite the absence of a specific treatment, the natural history of the DMD can be in part modified .
Since the surgical therapy showed controversial results on long term effectiveness, there has been a growing consideration on the conservative approach, including drugs and rehabilitation. Nevertheless, in most studies the rehabilitation programme includes stretching, eccentric and aerobic exercise, sub maximum strengthening activity when residual strength is higher, while few authors emphasize the role of physical energies, like whole-body vibration [8,9] and laser therapy .
Extracorporeal shock wave therapy (ESWT) is a relatively recent method used in the treatment of many musculoskeletal disorders, such as tendinopathies and non-union fractures.
Over the past few years, ESWT has received a widespread consensus in many other fields, including in the treatment of spastic hypertone in patients affected by stroke: even a single session of shock waves has proved to be effective in the reduction of muscle tone. Such effects are probably due both to a direct action on muscle and the production of several molecules and growth factors .
Therefore, we hypothesized that ESWT could have similar effects on dystrophic muscle.
A 20-year-old patient with bilateral equinovarus deformities (Figure 1) came to our ambulatory. At five years, he had the first difficulties during walking, getting a diagnosis of DMD at the age of seven.
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