Bilateral Calcification of Achilles’ Tendons, and Acetic Acid Iontophoresis Plus Ultrasound Effectivenness

Marcos Edgar Fernandez-Cuadros,1,2,* Olga Susana Perez-Moro,1 Maria Jesus Albaladejo-Florin,1 Luz
Otilia Casique-Bocanegra
,2 and Ruben Algarra-Lopez1
1Rehabilitacion y Medicina Fisica, Hospital Universitario Santa Cristina, Madrid, Spain
2Rehabilitacion y Medicina Fisica, Fundacion Hospital de la Santisima Trinidad, Salamanca, Spain
*Corresponding author: Marcos Edgar Fernandez-Cuadros, Calle del Ansar 44, piso Segundo, CP 28047, Madrid, Spain. Tel: +34-620314558, E-mail: marcosefc@hotmail.com

Abstract
Introduction: Calcifying tendonitis is the deposition of hydroxyapatite within tendons. It could affect different tendons. In the current case report, bilateral Achilles’ tendons were affected. The etiology is multifactorial. The treatment is conservative and surgical. Iontophoresis is a conservative technique that favors the penetration of 5% acetic acid, based on the attraction and repulsion of charges with the help of continuous electric current.
Case Presentation: A 57-year-old female presented a 12-month experience of bilateral Achilles’ tendon pain. Conservative treatment (nonsteroidal anti-inflammatory drugs (NSAIDs), laser therapy, and physiotherapy) and advanced treatment (shock waves) did not alleviate her pain. Radiography and ultrasound scan showed bilateral insertional formative calcification on both Achilles’ tendons, 9.3mmon left Achilles’ tendon and 6.6mmon right one. After 15 sessions of 5% acetic acid iontophoresis (2 mL, 4.7 mA10 minutes) and continuous ultrasound (1 W/cm2,1 MHz5 minutes) over the calcification area, calcification sizes decreased from 9.3 to 4.3 mm (left
Achille’s tendon) and disappeared on right Achille’s tendon. Pain also decreased from 9/10 to 4/10 on left Achille’s tendon and from 5/10 to nothing on right tendon.
Conclusions: Based on the authors‘ best knowledge, the current study was the first case report that confirmed the effectiveness of 5% acetic acid iontophoresis plus ultrasound to treat bilateral Achilles’ calcifying tendonitis.

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Calcifying Tendonitis of the Ankle, Effectivenness of 5% Acetic Acid Iontophoresis and Ultrasound over Achiles Tendon: A Prospective Case Series

Marcos E Fernández-Cuadros1,2*, Olga S Pérez-Moro2, María Jesús Albaladejo-Florin2, Ruben Algarra-
López
2 and Luz Casique-Bocanegra1
1Rehabilitation Department, Santísima Trinidad’s General Foundation Hospital, Salamanca, Spain
2Rehabilitation Department, Santa Cristina’s University Hospital, Madrid, Spain
*Corresponding author: Marcos E Fernández-Cuadros, PhD, Rehabilitation Department, Santa Cristina’s University, Santísima Trinidad’s General Foundation Hospital, Salamanca, Spain, Calle Maestro Vives 2, CP 28009, Madrid, Spain

Abstract
Objective: To conduct a prospective Multicentre Quasiexperimental
before-and-after study (Non-Randomized Control Trial) to demonstrate the effectiveness of Acetic Acid Iontophoresis and Ultrasound in the treatment of Calcifying Tendonitis (CT) of the ankle.
Material and methods: Prospective, multicentre, quasiexperimental
before-after intervention study, to 10 patients who attended to both Rehabilitation Departments, at Santísima Trinidad’s General Foundation Hospital, Salamanca-Spain and at Santa Cristina’s University
Hospital, Madrid-Spain, from June-2014 to December-2018.
Outcome measures: 1) Pain: Measured by Visual Analogical Scale (VAS); 2) Calcification size: In millimetres (mm), both measured radiologically at the beginning/end of treatment.
Intervention: Iontophoresis with 5% acetic acid at 4.7 mA × 10 minutes and continuous Ultrasound 1 W/cm2 /1MHz × 5 minutes over calcification.
Results: Mean age 49.2 ± 7.28-years (n = 10). Female 50% (n = 5). Average number of sessions was 21.7 ± 7.22. Treatment showed a significant amelioration of pain measured by VAS from 7.9 ± 1.66 to 2.8 ± 2.09 points (p = 0.0002). Calcification size diminished significantly from 10 ± 5.3 to 5.3 ± 5.22 mm (p = 0.0186).
Conclusions: CT is more common in middle-aged people. In our study, CT affects similarly both male and female. Iontophoresis with 5% Acetic Acid and Ultrasound is a safe, simple and inexpensive technique. Twenty sessions of 5% acetic acid iontophoresis plus Ultrasound are capable of reducing significantly pain and size of calcification on Achilles’ tendon at the ankle.
This study shows a level of evidence II-1 and grade of recommendation B that allows us to postulate Acetic Acid iontophoresis and ultrasound as an effective treatment in CT.

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Acetic-Acid Iontophoresis and Ultrasound Effectiveness on Calcifying Tendonitis of the Elbow

Marcos E Fernández Cuadros1,2*, María J Albadalejo-Florín1, Rubén Algarra-López1, Luz O Casique Bocanegra2
and Olga S Pérez-Moro1
1Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Spain
2Rehabilitación y Medicina Física, Fundación Hospital de la Santísima Trinidad, Spain
Received: August 09, 2017; Published: August 22, 2017
*Corresponding author: Marcos E Fernández-Cuadros, Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Fundación Hospital de la Santísima Trinidad, Madrid, Spain

Case Report
Calcifying tendonitis (CT) is the deposit of hydroxyapatite within tendons. CT is multifactorial and it could affect the rotator cuff, Achilles, patella, forearm extensors biceps brachi and tibialis posterior tendons. The etiology is unclear, playing degeneration and important role. Three stages with clinical/histological and radiological correlation are described:
A. Pre-calcification: tenocyte metaplasia/chondrocyte transformation;
B. Calcification: a)formative, b)resorptive (spontaneous resorption/phagocytosis);
C. Post-calcification: collagen remodeling/tendon repair. The diagnosis is clinical and radiological. Conservative treatment includes NSAIDs, physiotherapy, electrotherapy (micro-waves, short-waves, TENS, ultrasounds, iontophoresis, interferential and pulsed electromagnetic therapy). Advanced treatment includes shock-waves, eco-guided aspiration and arthroscopy [1-3].
Iontophoresis is a non-invasive technique that increases the penetration of transdermal substances through the skin with the help of electric current, based on physical-chemical properties of attraction and repulsion of charges. Psaki and Carroll introduced acetic acid iontophoresis as an effective treatment for shoulder
CT [4]. However, there are controversial results on CT, and limited case reports on effectiveness in other tendons such as gluteus medium and minimum and Achilles’ tendon [5]. To the best of our knowledge, there is no report on the effectiveness of acetic acid iontophoresis and ultrasound in calcific tendonitis of the elbow.
We present the case of a 48 years old woman, who presented a 2-months history of elbow pain which increased with hand movements. She was a right-handed nurse, with no important medical history, but used to smoke 10 cigarettes/day. NSAIDs did not alleviate pain and the use of an elbow orthosis decreased pain slightly, so she decided to quit. Radiography showed a formative calcification of 12 mm length in its longer axis, at the insertion of the forearm extensor tendon at the elbow (Figures 1 & 2).
After 30 sessions of 5% acetic acid iontophoresis (2cc, 4.7mA x 10 minutes) and continuous Ultrasound (1W/cm2/1MHz x 5 minutes) over the calcification, pain decreased from 10/10 to 4/10 on Visual Analogical Scale (VAS), and calcification disappeared after treatment (from 12 mm to 0mm), evaluated by a 100%-size posterior/ anterior radiography of the elbow.

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Calcific Tendinopathy of the Rotator Cuff Treated With Acetic Acid Iontophoresis

MARYCRIS MEDINA-GANDIONCO, PT, DPT, Physical Therapy Service, Brigadier General Crawford F. Sams US Army
Health Clinic/Medical Department Activity-Japan, Camp Zama, Japan.
ROBERT A. BRIGGS, PT, DPT, PhD, OCS, Army-Baylor University/US Army Medical Center of Excellence, Fort Sam Houston, TX.

A 62-year-old right hand–dominant man with a 20-year history
of left shoulder pain and 6-month insidious, progressively worsening symptoms was referred to physical therapy with clinical and radiographic evidence of left supraspinatus tendon calcification. The patient enjoyed tennis, push-ups, and resistance training but had discontinued these activities because of his increasing shoulder symptom severity.

At evaluation, the patient reported pain ranging from 7/10 to 9/10 on the visual analog scale, and scored 54% on the Shoulder Pain and Disability Index (SPADI). Left shoulder active range of motion was limited to 60° of flexion and abduction, with empty end feel due to muscle guarding. Passively, the patient tolerated 90° of shoulder flexion with increasing pain.
Due to severity and irritability of pain, the patient was prescribed rest, isometrics, and pain-free range of motion. He was treated with iontophoresis, utilizing 3% acetic acid, for 3 visits per week for 5 weeks. Radiographs, repeated 1 week post treatment and 9 weeks since his initial
radiographs, demonstrated marked resorption of the calcific deposit. At that point, the patient demonstrated 160° of active left shoulder flexion, 2/10 pain, and a SPADI score of 28% disability. A progressive resistive exercise
program was initiated.

At 16 weeks post evaluation, the patient demonstrated full active range of
motion of the left shoulder, 4+/5 shoulder girdle strength, a SPADI score of 5% disability, and reported a pain-free return to prior activities.

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Astym Patient Information Sheet

Astym is one of the most researched and effective therapy
treatments available. It is unmatched in its ability to resolve tendinopathies, scar tissue problems, and other
soft tissue dysfunctions.

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