The current treatment option for patients with Dupuytren contracture is open needle aponeurotomy or fasciectomy, which has been shown to weaken the fibrous tissue architecture
5 and routinely results in recurrence rates higher than those of other, less invasive treatment options.
8,9 Furthermore, patients who experience recurrent disease are 10 times more likely to suffer complications including digital nerve and artery injury.
10 Moreover, surgical intervention is associated with a long recovery period, which often includes splint casting and physical therapy.
11,12 Alternatively, needle aponeurotomy techniques, which have been used in Europe since the 1970s,
13 have proven to be a safe and effective substitute to open surgical procedures. Combining needle aponeurotomy with ultrasound guidance and biphasic Doppler technology produces superior visualization of cord fibers in Dupuytren contracture, detecting structural abnormalities and allowing accurate needle placement during treatment (
Figure 3). Ultrasonography is also cost effective, widely available, and easy to use in clinical practice.
14
In addition, adjunct therapy with OMT likely provides greater release of the fascial tissues than would be accomplished with ultrasound-guided needle injections alone. Specifically, muscle energy techniques address the muscular tissues of the hand flexors by creating a reciprocal inhibition reflex arc that directly affects agonist muscles, presumably via activation of the peritendinous structures termed the Golgi tendon organs.
15 Furthermore, to be most effective with the application of muscle energy, the physician should follow the activation and engagement of the flexor tendons, with special attention to the palmaris longus muscle. This technique is accomplished by having the patient provide direct tension through isometric contraction for 2 to 3 seconds. The patient then relaxes, and the physician brings the tendons into gentle and slow extension while carefully avoiding rebound flexion. This series of movements should be repeated 3 to 5 times to allow greater resting muscle length and to provide greater extension (
Figure 4).
16
Direct myofascial release should be administered immediately after muscle energy. This treatment protocol provides maximum correction of the fascia contracture by engaging the restrictive barriers of the palmar fascia with continuous palpatory feedback to achieve free movement of the tissues.
15 Myofascial pain syndrome of the palmaris longus muscle may be addressed by targeting and inactivating the trigger points within the muscle itself with prolonged ischemic pressure, needle injection of the triggers, and stretch and spray techniques.
18 Cumulatively, these factors support the use of ultrasound-guided dry-needle aponeurotomy in conjunction with ultrasound-guided lidocaine injections and OMT as potential alternatives to open surgical aponeurotomy or fasciectomy.