[Thermal radiofrequency of the medial genicular nerves in chronic pain related to degenerative meniscopathy. A clinical case]. / Radiofrecuencia térmica de las ramas geniculares mediales para dolor crónico en contexto de meniscopatía degenerativa. A propósito de un caso.

Persistent knee pain in patients around the fifth decade of life is a frequent cause of attention in rehabilitation consultations. The most common cause of diagnosis is knee osteoarthritis, considering the existence of different degrees seen in simple radiographies. The advanced degrees present joint space reduction, osteophytosis and subchondral sclerosis; however, in the initial degrees, the findings are more subtle and sometimes nonexistent for conventional radiology. Clinical ultrasound has partly come to fill this «diagnostic gap¼, making it possible to detect meniscal extrusions and small osteophytes as signs of incipient osteoarthritis and to relate them as triggers of pain. In clinical practice we find a group of patients who, with little or no radiological alterations, present persistent and severe pain with medial predominance in most cases. These, until the appearance of the current evidence, were subsidiaries of meniscectomies. At this moment, when meniscectomies are not recommended, it is necessary to find a treatment for those cases in which conservative and non-ablative interventional treatment has failed. In this context, the possibility of using radiofrequency arises. Its use is widespread in the case of tricompartmental and advanced osteoarthritis. However, little data is available on its usefulness in cases of medial meniscal extrusion. It seems that thermal radiofrequency has greater effects than pulsed radiofrequency. We present a clinical case where thermal radiofrequency of the medial genicular nerves of the knee is proposed as a therapeutic alternative for chronic pain secondary to medial meniscal extrusion associated with incipient knee osteoarthritis, with the result of a decrease in pain (VAS 8 before treatment, VAS 1 after one year), subjective improvement of 80% and gait capacity.

Plasma rico en plaquetas como opción terapéutica en el síndrome de la almohadilla grasa plantar / Platelet-rich plasma as a therapeutic option in heel fat pad syndrome

El síndrome de la almohadilla grasa plantar es la segunda causa de talalgia más frecuente en las consultas de Rehabilitación. Se trata de una desestructuración de la grasa plantar que conlleva la pérdida de amortiguación en la marcha y dolor plantar. Es debido a la degeneración o el traumatismo repetido que causa la alteración de la estructura de la almohadilla plantar, perdiendo su compresibilidad y función. El diagnóstico del síndrome de la grasa plantar se realiza mediante ecografía. El tratamiento se basa fundamentalmente en medidas conservadoras. Se plantea la infiltración con plasma rico en plaquetas como opción terapéutica con el objetivo de mejorar el dolor y la inflamación de la almohadilla grasa plantar. Describimos el primer caso clínico publicado de infiltración con plasma rico en plaquetas como tratamiento del síndrome de la almohadilla grasa plantar.(AU)

Heel fat pad syndrome is the second most frequent cause of heel pain at Rehabilitation services. It is a structure damage of the plantar fat that leads to loss of cushioning in gait and plantar pain. It is due to degeneration or repeated trauma that causes alteration of the structure of the foot pad losing its compressibility and function. The diagnosis of heel fat pad syndrome is made by ultrasound study. Treatment is primarily based on conservative measures. Infiltration with platelet-rich plasma is proposed as a therapeutic option with the aim of improving pain and inflammation of the plantar fat pad. We report the first published case of ultrasound-guided infiltration with platelet-rich plasma as a treatment for heel fat pad syndrome.(AU)

Técnica de radiofrecuencia ablativa ecoguiada del nervio sural para el dolor crónico de tobillo. A propósito de un caso / Ultrasound-guided radiofrequency ablation of the sural nerve for chronic ankle pain: A case report

El dolor crónico en la cara lateral del tobillo relacionado con la neuralgia sural es una patología poco frecuente. El nervio sural inerva la sensibilidad del borde posterolateral de la pierna, así como del borde dorsolateral del pie. En ocasiones la neuralgia sural es resistente al tratamiento conservador, pudiendo afectar a la esfera psicoemocional y social del paciente. Describimos el caso de un paciente de 54años con dolor neuropático en territorio del sural y con el antecedente de varias cirugías de tobillo. Tras tratamiento conservador sin éxito, se realiza radiofrecuencia ablativa ecoguiada en nervio sural con posterior cese completo del dolor sin efectos secundarios. Nos proponemos dar importancia a la ecopalpación en consulta de un médico rehabilitador, así como describir la radiofrecuencia ablativa ecoguiada como una técnica segura y eficaz para la neuralgia sural que no responde a tratamiento conservador. Sin embargo, se necesitan más estudios de calidad para corroborar estos resultados.(AU)

Chronic lateral ankle pain related to sural neuralgia is a rare pathology. The sural nerve innervates the sensitivity of the posterolateral border of the leg, as well as the dorsolateral border of the foot. On occasions, sural neuralgia is resistant to conservative treatment and can affect the patient's psycho-emotional and social sphere. We describe the case of a 54-year-old patient with neuropathic pain in the sural territory and a history of several ankle surgeries. After unsuccessful conservative treatment, ultrasound-guided ablative radiofrequency is performed in the sural nerve with subsequent complete cessation of pain without side effects. We propose to give importance to ecopalpation in the consultation of a rehabilitation physician, as well as to describe ultrasound-guided ablative radiofrequency as a safe and effective technique for sural neuralgia that does not respond to conservative treatment. However, more quality studies are needed to corroborate these results.(AU)

[Ultrasound-guided radiofrequency ablation of the sural nerve for chronic ankle pain: A case report]. / Técnica de radiofrecuencia ablativa ecoguiada del nervio sural para el dolor crónico de tobillo. A propósito de un caso.

Chronic lateral ankle pain related to sural neuralgia is a rare pathology. The sural nerve innervates the sensitivity of the posterolateral border of the leg, as well as the dorsolateral border of the foot. On occasions, sural neuralgia is resistant to conservative treatment and can affect the patient's psycho-emotional and social sphere. We describe the case of a 54-year-old patient with neuropathic pain in the sural territory and a history of several ankle surgeries. After unsuccessful conservative treatment, ultrasound-guided ablative radiofrequency is performed in the sural nerve with subsequent complete cessation of pain without side effects. We propose to give importance to ecopalpation in the consultation of a rehabilitation physician, as well as to describe ultrasound-guided ablative radiofrequency as a safe and effective technique for sural neuralgia that does not respond to conservative treatment. However, more quality studies are needed to corroborate these results.

Radiofrecuencia térmica como alternativa en el tratamiento del dolor neuropático localizado persistente por atrapamiento de un nervio colateral de la mano / Thermal radiofrequency as an alternative in the treatment of persistent localized neuropathic pain due to entrapment of a collateral nerve of the hand

El dolor neuropático localizado (DNL) es una causa relativamente frecuente de dolor musculoesquelético cuya prevalencia puede llegar a representar el 60% de las condiciones de dolor neuropático. Su aparición puede asociarse a numerosas patologías (herpes, diabetes, etc.). Una causa menos habitual sería la compresión directa de una rama nerviosa periférica. Su diagnóstico suele ser clínico, ya que pruebas complementarias como las neurofisiológicas no aportan datos definitivos. Como medidas terapéuticas disponemos de analgésicos orales, anticonvulsivantes, parches cutáneos analgésicos y acciones intervencionistas, entre las que se incluye la radiofrecuencia (RF). La RF térmica consiste en el paso de una corriente eléctrica a través de una aguja alcanzando un aumento controlado de temperatura con el que se consigue una lesión ablativa nerviosa.Se presenta un caso donde se propone como alternativa terapéutica la RF térmica del nervio colateral de la mano, cuyo atrapamiento es el causante del dolor, obteniendo una mejoría clínica satisfactoria.(AU)

Localized neuropathic pain (LNP) is a relatively common cause of musculoskeletal pain, which can be present in up to 60% of neuropathic pain conditions. Its appearance can be associated with numerous pathologies (herpes, diabetes, etc.). A less common cause would be the direct compression of a peripheral nerve branch. Its diagnosis is usually clinical since complementary tests such as neurophysiological tests do not provide definitive data. As therapeutic measures we have oral analgesics, anticonvulsants, analgesic skin patches and interventional actions, including radiofrequency (RF). Thermal RF consists in the transmission of an electric impulse through a needle reaching a controlled increase in temperature with which a nerve ablative injury is achieved.We present a clinical case where thermal RF of the collateral nerve of the hand is proposed as a therapeutic alternative, whose entrapment is the cause of pain, obtaining a satisfactory clinical improvement.(AU)

Síndromes por atrapamiento del nervio intercostal y sus ramas / Entrapment syndromes of the intercostal nerve and its branches

El dolor torácico de origen musculoesquelético plantea un diagnóstico diferencial amplio, donde destaca la afectación de los nervios intercostales. Su atrapamiento o el de alguna de sus ramas puede asemejarse a un dolor visceral, por lo que puede pasar fácilmente desapercibido. Con una buena exploración y el uso de la ecografía dinámica, la aproximación diagnóstica puede ser más sencilla. Presentamos un varón de 40años valorado en consultas de Rehabilitación por dolor costal bajo derecho, desencadenado por ciertos movimientos y que asociaba una deformidad torácica tipo pectus excavatum. Mediante el uso de maniobras ecográficas dinámicas fue diagnosticado de neuralgia del séptimo nervio intercostal derecho secundaria a un atrapamiento dinámico en el contexto de una deformidad torácica con hipermovilidad costal. Desarrollamos la presentación clínica, las imágenes ecográficas, el tratamiento y la evolución tras el mismo. En este caso, se describen los síndromes por atrapamiento del nervio intercostal y de las ramas cutáneas, su diagnóstico clínico y ecográfico, y su abordaje terapéutico.(AU)

Musculoskeletal chest pain poses a broad differential diagnosis, among which intercostal nerve involvement stands out. Its entrapment or that of any of its branches can resemble visceral pain and therefore can easily go unnoticed. With a good examination and the use of dynamic ultrasound, the diagnostic approach can be simpler. We present a 40-year-old man evaluated in a rehabilitation department for right lower rib pain, triggered by certain movements and associated with a pectus excavatum type thoracic deformity. Using dynamic ultrasound maneuvers, he was diagnosed with neuralgia of the 7th right intercostal nerve secondary to dynamic entrapment in the context of a thoracic deformity with costal hypermobility. We describe the clinical presentation, ultrasound imaging, treatment, and evolution after treatment. In this case, we describe entrapment syndromes of the intercostal nerve and its branches, their clinical and ultrasound diagnosis, and their therapeutic approach.(AU)

[Thermal radiofrequency as an alternative in the treatment of persistent localized neuropathic pain due to entrapment of a collateral nerve of the hand]. / Radiofrecuencia térmica como alternativa en el tratamiento del dolor neuropático localizado persistente por atrapamiento de un nervio colateral de la mano.

Localized neuropathic pain (LNP) is a relatively common cause of musculoskeletal pain, which can be present in up to 60% of neuropathic pain conditions. Its appearance can be associated with numerous pathologies (herpes, diabetes, etc.). A less common cause would be the direct compression of a peripheral nerve branch. Its diagnosis is usually clinical since complementary tests such as neurophysiological tests do not provide definitive data. As therapeutic measures we have oral analgesics, anticonvulsants, analgesic skin patches and interventional actions, including radiofrequency (RF). Thermal RF consists in the transmission of an electric impulse through a needle reaching a controlled increase in temperature with which a nerve ablative injury is achieved. We present a clinical case where thermal RF of the collateral nerve of the hand is proposed as a therapeutic alternative, whose entrapment is the cause of pain, obtaining a satisfactory clinical improvement.

[Platelet-rich plasma as a therapeutic option in heel fat pad syndrome]. / Plasma rico en plaquetas como opción terapéutica en el síndrome de la almohadilla grasa plantar.

Heel fat pad syndrome is the second most frequent cause of heel pain at Rehabilitation services. It is a structure damage of the plantar fat that leads to loss of cushioning in gait and plantar pain. It is due to degeneration or repeated trauma that causes alteration of the structure of the foot pad losing its compressibility and function. The diagnosis of heel fat pad syndrome is made by ultrasound study. Treatment is primarily based on conservative measures. Infiltration with platelet-rich plasma is proposed as a therapeutic option with the aim of improving pain and inflammation of the plantar fat pad. We report the first published case of ultrasound-guided infiltration with platelet-rich plasma as a treatment for heel fat pad syndrome.

[Entrapment syndromes of the intercostal nerve and its branches]. / Síndromes por atrapamiento del nervio intercostal y sus ramas.

Musculoskeletal chest pain poses a broad differential diagnosis, among which intercostal nerve involvement stands out. Its entrapment or that of any of its branches can resemble visceral pain and therefore can easily go unnoticed. With a good examination and the use of dynamic ultrasound, the diagnostic approach can be simpler. We present a 40-year-old man evaluated in a rehabilitation department for right lower rib pain, triggered by certain movements and associated with a pectus excavatum type thoracic deformity. Using dynamic ultrasound maneuvers, he was diagnosed with neuralgia of the 7th right intercostal nerve secondary to dynamic entrapment in the context of a thoracic deformity with costal hypermobility. We describe the clinical presentation, ultrasound imaging, treatment, and evolution after treatment. In this case, we describe entrapment syndromes of the intercostal nerve and its branches, their clinical and ultrasound diagnosis, and their therapeutic approach.

Hidrodisección ecoguiada peritendinosa ¿alternativa a la tenólisis para tratar adherencias? / Ultrasound-Guided Peritendinous Hydrodissection, an Alternative to Tenolysis Adhesions?

El tratamiento de las lesiones de los tendones flexores de la mano sigue siendo un problema clínico importante y frecuente. La tasa de adherencias posterior a la tenorrafia de tendón flexor es elevada. A día de hoy, el tratamiento es la tenólisis quirúgica, no siempre con resultados satisfactorios.La hidrodisección ecoguiada por ultrasonido es una novedosa técnica intervencionista que consiste en introducir una solución para liberar un espacio comprometido o distender y separar mecánicamente estructuras comprimidas o adheridas. Se plantea la hidrodisección ecoguiada como una alternativa a la reintervención o tras fracaso de la cirugía.Describimos el primer caso publicado de hidrodisección ecoguiada peritendinosa de adherencias tras lesión de tendón flexor. Proponemos como alternativa a la cirugía o tenólisis, con resultados esperanzadores.(AU)

Flexor tendon injuries of the hand treatment remains an important and common clinical problem. The rate of adhesions after flexor tendon tenorrhaphy is high. Today the treatment is surgical tenolysis, not always with satisfactory results.Ultrasound-guided hydrodissection is a novel interventional technique that consists of introducing a solution to free a compromised space or to distend and mechanically separate compressed or adhered structures. Ultrasound-guided hydrodissection is considered as an alternative to reoperation or after surgery failure.We report the first published case of ultrasound-guided peritendinous hydrodissection of adhesions after flexor tendon injury. We propose as an alternative to surgery or tenolysis, with encouraging results.(AU)

Guía clínica para el tratamiento de la espasticidad: consenso y algoritmos / Clinical practice guideline for the treatment of spasticity: Consensus and algorithms

La espasticidad es un fenómeno complejo de expresión clínica extremadamente variable, un proceso dinámico y evolutivo que puede condicionar la funcionalidad y tratamiento del paciente. La recomendación actual de tratamiento temprano persigue evitar su progresión y complicaciones, e implica un planteamiento individualizado basado en un amplio abanico de medidas farmacológicas y no farmacológicas. Esta guía resulta de un foro de especialistas expertos que afrontaron algunas incertezas frecuentes en el proceso de valoración y planteamiento terapéutico como la idoneidad de iniciar tratamiento, consideraciones para iniciar, continuar y cesar el tratamiento con toxina botulínica, tratamientos adyuvantes, el dolor o el seguimiento del paciente espástico. El resultado es un algoritmo de decisión para el abordaje terapéutico de la espasticidad. Tanto el avance científico como el intercambio de experiencia clínica en el que se basa esta guía puede apoyar la toma de decisiones sobre algunas áreas de penumbra que encontramos en la práctica clínica diaria.(AU)

Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.(AU)

[Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]. / Guía clínica para el tratamiento de la espasticidad: consenso y algoritmos.

Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.

[Ultrasound-Guided Peritendinous Hydrodissection, an Alternative to Tenolysis Adhesions?] / Hidrodisección ecoguiada peritendinosa ¿alternativa a la tenólisis para tratar adherencias?

Flexor tendon injuries of the hand treatment remains an important and common clinical problem. The rate of adhesions after flexor tendon tenorrhaphy is high. Today the treatment is surgical tenolysis, not always with satisfactory results. Ultrasound-guided hydrodissection is a novel interventional technique that consists of introducing a solution to free a compromised space or to distend and mechanically separate compressed or adhered structures. Ultrasound-guided hydrodissection is considered as an alternative to reoperation or after surgery failure. We report the first published case of ultrasound-guided peritendinous hydrodissection of adhesions after flexor tendon injury. We propose as an alternative to surgery or tenolysis, with encouraging results.

Neuropatía peronea secundaria a ganglión extraneural: revisión de literatura y propuesta de tratamiento. Caso no positivo / Peroneal neuropathy caused by an extraneural ganglion: literary review and treatment proposal. A non-positive case

La discopatía lumbar con afectación de raíces lumbares L4 o L5 es una causa frecuente de consulta y, en casos severos, puede ser el origen de dolor neuropático en el miembro inferior y/o de un pie equino por compromiso de la musculatura dorsiflexora del pie. Sin embargo, la causa de esta clínica no siempre está en relación con la patología lumbar ni el sistema nervioso central, siendo vital su correcto diagnóstico diferencial. Este artículo presenta el caso de un paciente de 69 años con una neuropatía compresiva peronea secun­daria a un ganglión, inicialmente interpretada como una radicu­lopatía L5. Este incorrecto enfoque supuso la sobremedicación del paciente, un mal control algésico, la realización de una discectomía L4-L5 innecesaria y una pobre evolución neurológica. Un enfoque diagnóstico correcto y un abordaje tera­péutico precoz habrían supuesto una mayor mejoría clínica e incluso una recuperación neurológica completa del paciente. Por ello, este caso sirve para resaltar: a) el va­lor de la ecografía en neuropatías periféricas como herramienta diagnóstica y pronóstica y el de la ecografía en gangliones como arma diagnóstico-­terapéutica; b) el uso de las pruebas diagnósticas como apoyo a una exploración física exhaustiva, y no como diagnóstico en sí mismas, y c) la importancia de la publicación de casos no positivos para optimizar recursos, evitar repetir errores, reducir el sesgo de publicación y facilitar el inicio de proyectos de investigación.(AU)

Lumbar disc disease with L4 or L5 lumbar root involvement is a common cause of medical attendance. In severe circumstances it can lead to neuropathic pain, weakness and foot drop. However, this clinical presentation is not always related with lumbar or central nervous system pathology, being the differential diagnosis of great importance. It is reported a case of 69-year-old patient with a peroneal nerve entrapment caused by an extraneural ganglion, misdiagnosed as a L5 radiculopathy. This incorrect approach entailed patient overmedication, poor pain control, an unnecessary L4-L5 discectomy, and a poor neurological outcome. In this case, an early diagnosis and therapeutic approach would have meant not only a greater clinical improvement and even a complete neurological recovery. Moreover, this case highlights: a) the value of ecography in periphe­ral neuropathies as a diagnostic and prognostic tool and ultrasounds in ganglions cyst as a diagnostic and therapeutic weapon; b) the use of diagnostic tests to support a thorough physical examination, not as a diagnosis themselves; and c) the importance of non-positive cases publication to optimize resources, avoid repeating mistakes, reduce publication bias and facilitate the start of research projects.(AU)

Atrapamiento del nervio radial a nivel del canal de torsión humeral. Bloqueos nerviosos como arma diagnóstica y terapéutica / Radial nerve entrapment in the spiral groove. Nerve block as a diagnostic and therapeutic tool

El nervio radial tiene un recorrido largo y sinuoso por el miembro superior que abarca desde la axila hasta la mano y dedos. En este camino puede presentar varias zonas de compresión, siendo la más frecuente a nivel de arcada de Frohse con atrapamiento de su rama terminal, el nervio interóseo posterior. Presentamos un caso clínico de una paciente con atrapamiento del nervio radial a nivel del canal de torsión humeral y cómo la ecografía y los bloqueos nerviosos pueden ser útiles tanto para su diagnóstico como su tratamiento, con la particularidad de que en nuestro caso fue insuficiente con el bloqueo del tronco principal del nervio radial, siendo necesario en una segunda intervención actuar también sobre su rama el nervio cutáneo braquial lateroinferior para obtener un óptimo resultado clínico (AU)

The radial nerve has a long and sinuous course in the upper limb from the axilla to the hand and fingers. There are several possible areas of compression along this trajectory, the most frequent being on the Arcade of Frohse, with entrapment of its terminal nerve, the posterior interosseous nerve. We report the case of a patient with radial nerve entrapment in the spiral groove and describe how ultrasound and nerve blocks could be useful in diagnosis and treatment. In our patient, nerve block at the main radial nerve in the spiral groove was insufficient. A second nerve block was needed in the inferior lateral cutaneous nerve of the arm to achieve an optimal clinical result (AU)

Propuesta de abordaje para bloqueo selectivo del nervio tibial en paciente espástico. A propósito de un caso / Proposal for approach to selective tibial nerve block in spastic patient. A propos of a case

El patrón más frecuente de espasticidad en el miembro inferior es el pie equino-varo. En pacientes con daño en el sistema nervioso central y espasticidad severa es frecuente que el tratamiento conservador y la toxina botulínica tipo A presenten un efecto limitado. En estos casos, los bloqueos nerviosos pueden ser de mucha utilidad para decidir nuestra actuación terapéutica. Presentamos un caso clínico como ejemplo de abordaje ecoguiado novedoso para el bloqueo del principal nervio involucrado en este patrón de pie equino-varo como es el nervio tibial, adaptado a la idiosincrasia de los pacientes espásticos y su utilidad para el manejo clínico de la espasticidad (AU)

The most frequent pattern of spasticity in the lower limb is equinovarus foot. Patients with central nervous system injury and severe spasticity, conservative treatment and botulinum toxin type A often have a limited effect. In these cases, nerve blocks can be very useful in deciding our therapeutic action. We present a clinical case as an example of a new ultrasound-guided approach to tibial nerve block, as this is the main nerve involved in equinovarus foot pattern, specific for spastic patients and its usefulness for the clinical management of spasticity (AU)