Extracorporeal Shock Waves in the Treatment of Equinovarus Foot in a Duchenne Patient: A Case Report

Abstract

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 talometatarsal 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.of their antagonist muscle tendons 6 . 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 [7].Despite the absence of a specific treatment, the natural history of the DMD can be in part modified [1].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 [10].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