[Thermal radiofrequency of the medial genicular nerves in chronic pain related to degenerative meniscopathy. A clinical case]

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 gap», 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.

[Ultrasound-guided radiofrequency ablation of the sural nerve for chronic ankle pain: A case report]

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.

[Thermal radiofrequency as an alternative in the treatment of persistent localized neuropathic pain due to entrapment of a collateral nerve of the hand]

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.

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.

[Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]

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.

[Platelet-rich plasma as a therapeutic option in heel fat pad syndrome]

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.

[Ultrasound-Guided Peritendinous Hydrodissection, an Alternative to Tenolysis Adhesions?]

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.

[Radial nerve entrapment in the spiral groove. Nerve block as a diagnostic and therapeutic tool]

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.

[Selective ultrasound-guided hydrodissection of gastrocnemius nerve branch after post-surgical entrapment: Apropos of a case]

Chronic or recalcitrant plantar fasciitis is a cause of persistent plantar pain. These cases are usually resistant to conventional treatments consisting of exercises, orthoses, shock waves and infiltrations and require a surgical approach. Proximal medial gastrocnemius release is a surgical option that provides satisfactory results, but is not free of complications, which include injuries and nerve entrapment. We report the first published case of symptomatic medial gastrocnemius branch entrapment in the post-surgical scar of a tenotomy for the treatment of recalcitrant plantar fasciitis. We propose ultrasound-guided hydrodissection with local anesthetic as a treatment with promising results.

Regulated deficit irrigation and the recovery of water relations in pistachio trees

Recovery of water status in water-stressed pistachio trees (Pistacia vera L. cv. Kerman) was investigated by subjecting trees to regulated deficit irrigation (RDI) (60% of crop evapotranspiration rate, ET(c)) during stages I and II of fruit development (FD) followed by full irrigation during FD stage III (kernel-filling). Trees irrigated at 100% ET(c) throughout FD stages I, II and III served as controls. Water-stress severity was characterized by changes in soil water content and midday stem water potential (Psi(md)). Midday leaf conductance (g(1)) and trunk diameter variation (TDV) were also measured. In RDI trees, the lowest Psi(md) value, -1.8 MPa, occurred at the end of the RDI period. The corresponding value for the control trees was around -1.1 MPa. Although the RDI treatment affected gas exchange later than Psi(md), the greatest reductions in gas exchange (60% of control values) also appeared at the end of the RDI period. There were significant differences in TDV between control and RDI trees at the end of the RDI period. Although plant water status recovered within 20 days of resuming irrigation, the TDV values indicated a longer period might be necessary for complete recovery. Recovery of g(1) was faster than that of Psi(md), although differences in TDV between control and RDI trees indicated that gas exchange recovered later than Psi(md). The slow recovery of pistachio trees during FD stage III from water stress imposed during FD stages I and II suggests that irrigation should exceed 100% ET(c) during FD stage III or that more extensive irrigation should commence before the end of FD stage II.