A New Approach To Treating Painful Diabetic Neuropathy

By David Lambarski, DPM, and Martin E. Wendelken, DPM, RN

      The use of musculoskeletal ultrasound provides podiatric practitioners with non-invasive diagnostic capabilities in the office setting. In addition, this diagnostic tool can also assist with interventional medical techniques for treating a number of pathologic conditions. One may also combine ultrasound with duplex imaging and color Doppler to provide a vascular assessment tool.       For this article, we will offer a closer look at the potential of combining musculoskeletal ultrasound with cryosurgery to treat tarsal tunnel syndrome. Before we discuss this new application via an intriguing case study, let us offer a quick review of the advances and evolution of cryotherapy and musculoskeletal ultrasound.       For more than 10 years, some podiatric professionals have been using non-invasive diagnostic ultrasound. The schools of podiatric medicine now teach musculoskeletal ultrasonography and have scanners in their radiology departments. This imaging modality enables one to diagnose and discover occult pathology in the musculoskeletal system.       In the beginning, clinicians mainly utilized this technology to image the plantar fascia and web space neuromas. Now podiatrists may utilize diagnostic ultrasound to diagnose most soft tissue pathology of the lower extremity. This includes tendons (tendonitis, tendon tears and ruptures), joint capsule and plantar plate tears, soft tissue masses (ganglions), stress fractures and more. In 1998, Wendelken, et. al., patented a method of imaging wounds using diagnostic ultrasound.1       Diagnostic ultrasound has many other uses in podiatry. Combining duplex imaging along with Doppler capability provides a non-invasive method to determine the status of the vascular system of the lower extremity. Color Doppler imaging of the venous system can reveal damage to the valves in veins. Duplex imaging may also show the presence of a thrombus within a vein, which is a potentially life-threatening condition. One may also use this same scanner to detect abnormalities in the arterial system. The measurement of velocities can reveal areas of stenosis within an artery, which, in turn, yield the percentage of closure.       Today, skilled podiatrists are now using ultrasound to assist in visualizing invasive treatments. Practitioners can use ultrasound for guidance as it allows for the visualization of trigger point injections. One can use this technique to inject into areas that are difficult to reach anatomically.       Ultrasound can also detect and locate foreign bodies. Skilled podiatrists can also perform needle-guided biopsies and guided aspirations using these same guidance techniques. One may also utilize ultrasound to guide plantar fasciotomies and assist in the sclerosing of web space neuromas (using 4% alcohol). These methods of using diagnostic ultrasound have advanced the podiatric profession through technology.

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