ULTRASOUND-GUIDED CRYONEUROLYSIS: A NOVEL APPROACH TO PAIN MANAGEMENT IN RHEUMATOID ANKLE AND FOOT ARTHRITIS

A. Allam¹, M. Hassanien², A.O.M. Abdallah³, K.H.S. Lam^4|5|6, T.K. Ng^7|8|9|10, T. Ergönenç¹¹, F. Occhigrossi¹² | ¹Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta, Egypt; ²Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assuit University, Assuit, Egypt; ³Department of Anesthesia and Intensive Care, Faculty of Medicine, New Valley University, New Valley, Egypt; ⁴Department of Family Medicine, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong; ⁵Department of Family Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong; ⁶Department of Clinical Research, The International Association of Musculoskeletal Medicine, Kowloon Bay, Kowloon, Hong Kong, China; ⁷Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China; ⁸Department of Anaesthesia, Boxhill Hospital, Melbourne, Australia; ⁹Frankston Pain Management, Melbourne, Australia; ¹⁰Department of Anaesthesia and Operating Theatre Services, Tuen Mun Hospital, Tuen Mun, Hong Kong, China; ¹¹Anesthesia and Reanimation, Pain and Palliative Care, Akayazi Hospital, Sakarya, Turkey; ¹²Pain Therapy Unit, San Giovanni-Addolorata Hospital, Rome, Italy

Abstract

Background and Aims. Rheumatoid arthritis (RA) is a systemic autoimmune disease that frequently affects the foot and ankle. More than 90% of patients develop symptoms in these regions during the course of the disease, leading to pain, deformity, and disability. Chronic ankle and foot pain in RA may persist despite pharmacological and surgical interventions, severely impairing daily activities and professional duties. This case report aims to demonstrate the efficacy of ultrasound‑guided cryoneurolysis in refractory RA‑related ankle and foot pain, emphasizing its impact on pain relief, functional recovery, and preservation of gait and proprioception.
Methods. A 45-year-old female pediatric physician with a 15-year history of rheumatoid arthritis and prior subtalar and talo-navicular arthrodesis presented with severe chronic left ankle and foot pain (VAS 10/10). Over five years, she received multiple systemic and local therapies, including NSAIDs, gabapentin, pregabalin, duloxetine, intra-articular steroids, hyaluronic acid, ozone, botulinum toxin, and rehabilitation modalities, without improvement. Prior to definitive cryoneurolysis, an ultrasound-guided (USG) diagnostic block was performed targeting the superficial fibular, sural, saphenous, and deep peroneal nerves, resulting in >90% pain relief that was sustained for 24 hours. On August 17, 2025, USG cryoneurolysis was subsequently carried out on the same nerves.
Results. The procedure resulted in immediate and complete pain relief (VAS 0/10). The patient resumed activities of daily living and professional work without limitations. Importantly, gait and proprioception were not affected. Pain relief persisted for six months, with no reported complications.
Conclusions. Ultrasound-guided cryoneurolysis of ankle nerves is a safe and effective minimally invasive option for refractory RA-related ankle and foot pain. This case demonstrates sustained analgesia, functional recovery, and preservation of gait and proprioception, underscoring its potential role in patients unresponsive to conventional therapies