Shockwave - The Essentials

 

A SHOCKWAVE is essentially a PRESSURE DISTURBANCE that propagates rapidly through a MEDIUM. It can be defined thus : A large-amplitude compression wave, as that produced by an explosion or by supersonic motion of a body in a medium  which just a formal version of the first sentence.

 

Although the adjacent image is from a plane flying at supersonic speed, it clearly illustrates the principle.

Shockwaves generated from supersonic aircraft in flight (CNN / NASA)

Obvious examples of shock waves are the sonic boom from an aircraft, thunder or the sound following an explosion. A shockwave is, put simply, an acoustic wave, as is a means of transmitting energy.

A clinically useful shockwave is effectively a controlled explosion (Ogden et al 2001), and when it enters the tissues, it will be reflected, refracted, transmitted and dissipated like any other energy form. The energy content of the wave will vary and the propagation of the wave will vary with tissue type. Just like an ultrasound wave, the shock wave consists of a high pressure phase followed by a low pressure (or relaxation) phase. When a shock wave reaches a 'boundary', some of the energy will be reflected and some transmitted.

General profile of a shockwave (Gymna Uniphy

 
A Brief History

 

Shock waves were initially employed as a non invasive treatment for kidney stones (from the early 1970's, with treatment proper starting in the 1980's), and it has become a first line intervention for such conditions. In the process of the animal model experimentation associated with this work, it was identified that shockwaves could have an effect (an adverse one initially) on bone.

This led to a series of experimental investigations looking at the effect of shockwaves on bone, cartilage and associated soft tissues (tendon, ligament, fascia) resulting in what is now becoming an intervention of increasing popularity, most especially for the recalcitrant lesions of these tissues, though the clinical uses are expanding and now include wound management, treatment of fractures and numerous additional applications. The use of shock waves to treat bone problems was researched through the early 1980's. with the earliest clinical work (that I can easily identify) being around the middle of that decade on delayed and non unions. By the early 1990's, reports start to appear in the journals and conference papers where shockwave is being employed to deal with soft tissue problems, most commonly calcific tendinitis in the first instance, and then on to a variety of other long term problems in tendon, ligament and similar tissues.

 

Although becoming much more popular (especially in Europe and to some extent, in the UK), it is still a relatively new technology for musculoskeletal intervention, and although the publication volume is steadily increasing, some of the published trials are of doubtful methodological quality and need to be considered with some caution.

The treatment goes by several names, the most popular being SHOCK WAVE THERAPY or EXTRACORPORAL SHOCKWAVE THERAPY, though, as ever, there are several variations, often linked to the names of particular machines. Some have recently suggested that the therapy version of shockwave therapy might be usefully called RADIAL SHOCKWAVE THERAPY to distinguish the nature of the wave from the focused versions employed elsewhere in medical practice though more recently, it has been suggested that a preferred term would be RADIAL PRESSURE WAVE. A very readable but succinct history of the development of shock waves for medical applications can be found in Thiel (2001).

Shockwave - Principles of Production

 

There are basically four different way to produce the 'shock wave', which, without getting technical about it are : spark discharge; piezoelectric; electromagnetic and pneumatic (or electrohydrualic). The wave that is generated will vary in its energy content and also will have different penetration characteristics in human tissue. In therapy the most commonly employed generation method is based on the pneumatic system, and the key reason for this is that a radial (dispersive) wave results. Radial Pressure Wave is most commonly generated by means of the Pneumatic / Ballistic method though some Electromagnetic applicators now in production

 

The Focussed waves are essential for 'surgical' interventions, but given their potentially destructive nature, they have been considered less appropriate for therapeutic uses, though this is a rapidly changing standpoint. Focussed waves are sometimes also referred to as 'hard' shockwaves, the radial or dispersive wave sometimes called a 'soft' shockwave (another twist in the terminology).

 

Shockwave production (Eaton and Watson 2020)

Shockwave - Characteristics

 

The characteristics of a shock wave are (typically) :
 

  • Peak pressure - typically 50-80MPa (according to Ogden et al, 2001) and 35 - 120MPa (according to Speed, 2004)

  • Fast pressure rise (usually less than 10 ns (nanoseconds)

  • Short duration (usually about 10 microseconds)

  • Narrow effective beam (2-8mm diameter)
    (more detailed descriptions can be found in Ogden et al 2001, Speed, 2004)

 

Shockwave characteristics (after Chung and Wiley, 2002)

Shockwaves are divided in terms of their energy content and although there is some controversy, it is generally accepted that the following groups would be reasonable (after Rompe et al, 1998):

LOW (up to 0.08mJ/mm2)

MEDIUM (up to 0.28mJ/mm2 - though some authorities elect for a higher value)

HIGH (over 0.6mJ/mm2)

(EFD – Energy Flux Density - mJ/mm2) appears to be one of several critical ‘dose’ parameters)

Though almost all authors, manufacturers and others divide the range into these energy bands, there is (as yet) no universal agreement with regards the boundary values.

Focussed Shockwave & Radial Pressure Wave - how are they different?

As the names would imply, with Focussed Shockwave (historically has been called HARD SHOCKWAVE and EXTRACORPOREAL SHOCKWAVE THERAPY - ESWT) the shockwave energy is (a) 'stronger (more intense) and (b) comes to a point of focus at a level deeper in the tissue than it is at the skin surface.

 

Focussed Shockwave profile (after Eaton and Watson, 2020)

It is suggested that the focussed shockwave can potentially reach effective tissue penetration depths of up to 12cm in the tissue

Radial Pressure Wave (Radial Shockwave) is (a) less 'strong' (intense), (b) the beam is divergent - and thus the energy density diminishes with increasing depth into the tissue - the pressure wave is never 'stronger' at depth than it is at the skin surface. This mode of shockwave has, in the past, also been called SOFT SHOCKWAVE, though this is a term which is uncommonly encountered in the current literature

Radial Pressure Wave (Radial Shockwave) profile (after Eaton and Watson, 2020)

It is suggested that the radial pressurewave can potentially reach effective tissue penetration depths of up to 4cm in the tissue.

Due to the smaller size of the devices and lower costs the RADIAL SHOCKWAVE (Radial Pressure Wave) technology has been widely embraced in therapy clinical applications (Lohrer et al. 2016).

Both Radial and Focused modes are employed in current practice and both have clinical evidence to support their application. In the past it was said that Focussed mode was the domain of surgeons and medical professions only and Radial was for the therapists - this differentiation is largely irrelevant in current practice

Shockwave Energy Transmission

 

A shockwave will quickly weaken when travelling through air. In WATER (or GEL) the attenuation will be approximately 1000 times less. Medical applications use water (and more recently gel) to help the energy reach the tissues. The use of OIL as a coupling medium is suggested (Maier et al, 1999) but not widely employed clinically

Shockwave - Physiological Effects and Mechanisms of Action

 

The pressure wave causes direct effects (as one would expect) and also 'indirect' effects associated with the subsequent low pressure part of the cycle (often referred too as the tensile phase), and during this phase, cavitation will occur (as with therapeutic ultrasound). The collapse of these cavitations (bubbles) is in part at least, responsible for the efficacy of the therapy (in focussed mode). The waves are focused in order to achieve the effects in a volume limited zone of tissue, though the focus does not actually come to a 'point' in therapy devices - more like a zone or small volume typically several mm across (2 - 8mm), and thus the destructive effects are eliminated. There is no evidence of tissue destructive effects at therapy level doses or with radial pressure wave.

 

As the shock wave travels through a medium and comes to an interface, part of the wave will be reflected and part transmitted. There are equations around for calculating this proportional relationship, but effectively, the dissipation of the energy at the interface is almost certainly responsible for the generation of the physical, physiological and thus the therapeutic effects.

 

The full details of physiological and therapeutic mechanisms are yet to be identified, though a range of effects have been confirmed and several others postulated.

It is now most commonly considered to be a form of mechanotherapy which Huang et al (2013) define as " . . . all therapeutic interventions that reduce and reverse injury to damaged tissues or promote the homeostasis of healthy tissues by mechanical means at the molecular, cellular or tissue level”

Some of the effects relate to an increase in local blood flow which has been clearly evidenced, even in relatively avascular tissues. This increased flow includes an angiogenic response rather than simply increasing the flow in existing vessels. [Calcagni et al 2011; Goertz et al 2014; Ha et al 2013; Huang et al 2016; McKay et al 2021; Mittermayr et al 2012; Notarnicola et al 2012; Scroppo et al 2021; Song et al 2020; Sung et al 2022].

 

It is suggested that the beneficial effects are partly also due to a stimulation of an inflammatory response – therefore enhancing tissue repair responses, which is especially relevant when dealing with recalcitrant tissues, such as some chronic tendinopathies and delayed and non unions in bone.  [Chamberlain and Colbourne 2016; Chen et al 2019; de Girolamo et al 2014; Feichtinger et al 2019; Feng et al 2021; Frairia et al 2012; Liao et al 2022; Mariotto et al 2009; Mittermayr et al 2012; Modena et al 2022; Ozkan et al 2019; Peng et al 2020; Song et al 2021; Waugh et al 2015]. As with other modalities (such as ultrasound and laser/photobiomodulation) this will effectively stimulate or 'enhance' the tissue repair response. At least part of this enhanced inflammation & repair process is achieved by enhanced expression and release of cytokines and chemical mediators such as :

  • VEGF (Vascular Endothelial Growth Factor) (Chen et al 2018; Heimes et al 2020; Modena et al 2022; Schnurrer et al 2018; Sung et al 2022)

  • MMP (Matrix Metalloproteinase) (Che et al 2021; Heimes et al 2020)

  • Interleukins (Chen et al 2020; Kim et al 2019; Notarnicola et al 2012)

  • Nitric Oxide (NO) (Hayashi et al 2012; Wang et al 2011)

  • FGF (Fibroblast Growth Factor) (de Lima Morias et al 2019; Rodriguez-Merchan et al 2021)

  • TGFb (Transforming Growth Factor Beta) (Fan et al 2018; Li et al 2021; Wang et al 2009)

  • PGE2 (Benson et al 2007; Chen et al 2016; Xing et al 2021)

There is a steadily growing body of evidence which identifies the shockwave stimulates various cells associated with tissue repair [Chao et al 2009; Chi et al 2021; Kuo et al 2009; Manganotti et al 2012; Mittermayr et al 2012; Rinella et al 2016, 2018; Saggini et al 2015; Yang et al 2022; Zhao et al 2021].

In addition to the effects identified above, there is also evidence for a transient analgesic effect (via afferent nerves) and the capacity of focused shockwave to breakdown (or instigate the breakdown) of calcific deposits.

One of the strongest arguments for the use of shockwave in therapy is that it effectively takes a tissue from a more chronic to a more acute state (Eaton and Watson, 2020), and in doing so, provides a stimulus (trigger) to a 'stalled' repair sequence. This is actually consistent with other approaches employed in therapy - such as some manual therapies (e.g. transverse frictions), some exercise based approaches (e.g. eccentric loading) and some electrotherapy interventions (e.g. provocative ultrasound or laser treatments). The following are the most strongly established treatment effects at therapy shockwave levels.

Energy Levels for Detrimental Effects

 

High energy shockwave (considered to be over 0.6 mJ/mm2) have been shown to have detrimental effects in soft tissues, though it is proposed that this is not a dose that would normally be employed in therapy, and is likely to require at least some form of local analgesia to be able to tolerate the treatment! There is some evidence that energy densities greater than 0.4 mJ/mm2 may have detrimental effects, though this has yet to be confirmed. In tendon (using an animal model), shockwave at 0.6 mJ/mm2 was demonstrated to have a damaging effect on local blood vessels (Rompe et al 1998). Several authors (Rompe et al, 1998; Gerdesmeyer et al, 2007) have suggested that energy (EFD) levels over 0.28 mJ/mm2 are not employed in tendon disorders.

 

Adverse Effects

 

Provided that the applied energy levels are in the therapy range (LOW and ?possibly MEDIUM), there have been no significant adverse effects reported. Some reports of pain or discomfort during, and sometimes after the treatment, but this usually subsides within a relatively short period (1-2 days). It is worth advising the patient of this possibility when discussing the treatment, prior to application. There can be minor skin irritation, and sometimes numbness or paraesthesia, but all are temporary. The potential for and the incidence of adverse effects is included in the Wang et al (2012) review.

 
 
Shockwave - Clinical Applications

[a range of clinical application trials and literature is included in the reference list at the end of this material]

Treatment Dose Issues

  • In addition to the applied energy (mJ/mm2) – in therapy we are using the LOW (up to 0.08mJ/mm2 ) and possibly the MEDIUM (up to 0.28 mJ/mm2) energy levels, the other significant factors are

  • a) number of shocks and

  • b) number of treatment session repetitions

 

Shock Number

  • Shock number usually between 1500 and 2000 in a treatment session, (this is an increase on the previously suggested number of 1000 - 1500)

  • Some research has tried as few as 100 and also 500 : 500 more effective than 100

  • 1500 – 2000 have been used in the clinical trials with the best (most significant) outcomes

  • Anecdotally, 1000-2000 shocks per session appears to be the most commonly applied range

 

 

Number of Treatment Sessions

  • Some evidence for a single session BUT only for high level treatment – using local anaesthesia – not a standard therapy application

  • Most clinical research has used between 3 – 5 sessions at low energy levels (typical therapy application), suggested up to 7 may be needed in the more recalcitrant lesions

  • Some patients will gain significant benefit in 2 - 3 sessions

  • There have been no RCT trials yet to determine the maximally effective therapy session number though there are several in the pipeline

  • Treatment sessions are most commonly delivered at 1 x weekly intervals

  • Some have tried higher treatment frequency, but the results are, thus far, equivocal

  • Typically 3 - 5 session appears to be effective for the majority of patients, spaced such as to let the tissue 'reaction' at least partly subside from the first session before the next treatment is delivered.

Treatment Time

Treatment time is NOT the critical parameter – the number of pulses IS

  • If you want to deliver 2000 shocks in a session at set your machine at 10Hz, will get 600 shocks in a minute (assuming you don’t give the patient a break!)

  • Therefore will take 3.3 min (i.e. 3 min 20 sec) to deliver the 2000 shocks

  • If set machine to 20Hz will take 1min 40sec

  • Machine at 8Hz will take just over 4 min

The TREATMENT OUTCOME is the same

 
Clinical Application - Conditions

In terms of specific lesions that have been supported by the research evidence, the chronic tendinopathies (and associated lesions) are certainly the most frequently reported in the literature. Of the chronic and especially recalcitrant tendon lesions, those with strongest research support include :

Plantar Fasciitis

Achilles Tendinopathy (insertional and mid portion)

Patellar Tendinopathy

Greater Trochanter Pain Syndrome

Lateral Epicondylalgia (Tennis Elbow)

Medial Epicondylalgia (Golfers Elbow)

Supraspinatus Tendinopathy (calcific and non calcific)

Other rotator cuff tendinopathies/lesions

Bicipital tendinitis/tendinopathy

This is not an EXCLUSIVE set of clinical presentations for which shockwave has been shown to be effective - just the most strongly supported. In addition to the Chronic Tendinopathy type presentations, the following are either already established as clinically responsive lesions or are being investigated for the potential benefit. This is a dynamic list and it is expected to change - some currently listed will become mainstream and some being investigated are likely to be 'dropped' if they are identified as not sufficiently responsive This is NOT claimed to be a complete listing - just the applications and research that I am aware of) :

Emerging Applications

Delayed and non union long bone fractures (e.g. Alvarez et al (2011); Birubaum et al 2002; Cacchio et al 2009; Elster et al 2010; Furia et al (2010); Kobayashi et al 2020; Notarnicola et al 2020; Sansone et al 2022; Schleusser et al 2020; Shimozono et al 2022; Wang (2012) + Stress Fractures (Moretti et al 2009)

Avascular necrosis femoral head (e.g. Cheng et al 2021; Furia et al 2010; Wang et al 2008; Zhao et al 2021)

Chronic venous ulcers (diabetic and non diabetic) (e.g. Larking et al 2010; Saggini et al 2008; Wang et al 2011; Wolff et al 2011) and other Chronic Wounds (e.g. Antonic et al 2011; Mittermayr et al 2012)

Complex Regional Pain Syndrome (e.g. Notarnicola et al 2010)

OA Knee (e.g. Chen et al 2020; Frisbie et al 2004; Liao et al 2022; Ma et al 2020; Mostafa et al 2022; Oliveira et al 2022; Wang et al 2013, 2014; Zhao et al 2013; Zhang et al 2021)

 

Post spinal fusion (e.g Lee et al 2008)

Spasticity in CP children (e.g. Corrado et al 2019; El-Shamy et al 2014; Park et al 2015; Vidal et al 2011; 2020; Wardhani et al 2022)

 

Hypertonicity post stroke (e.g. Cabanas-Valdes et al 2020; Jia et al 2020; Leng et al 2020; Manganotti et al 2005; Ou-Yang et al 2022; Zhang et al 2022)

Post Carpal Tunnel pillar pain (e.g. Haghighat et al 2019; Romeo et al 2011) + Carpal Tunnel Syndrome (Li et al 2020; Raissi et al 2017; Seok et al 2013; Xie et al 2022; Xu et al 2020)

 

Trigger point application (e.g. Gleitz et al 2012; Luan et al 2019; Ramon et al 2015; Tognolo et al 2022; Zhang et al 2020)

 

Cellulite management (e.g. Angehrn et al 2007; Schlaudraff et al 2014; Troia et al 2021)

 

Frozen Shoulder : Saldrian et al 2022; Zhang et al 2022;

 

(Medial) Tibial Stress Syndrome (e.g. Moen et al 2012; Rompe et al 2010; Menendez et al 2020)

 

Various DENTAL related applications (e.g. Elisetti 2021; Goker et al 2019; Li et al 2010; Song et al 2020)

 

Chronic Low Back Pain (e.g. Lee et al 2014; Rajfur et al 2022; Taheri et al 2021; Yue et al 2022)

 

Myositis Ossificans (e.g. Buselli et al 2010; Reznik et al 2013)

 

Coccydynia (Ahadi et al 2021; Marwan et al 2014)

 

Myofascial Pain Syndrome (Cho et al 2012; Joshi et al 2020; Jun et al 2021; Kamel et al 2020; Rahbar et al 2020; Sugawara et al 2021; Wu et al 2022; Yalcin 2021; Yoo et al 2020; Zhang et al 2020)

 

Erectile Dysfunction (various causes) + Peryroine’s (e.g. Kim et al 2020; Ladegaard et al 2021; Liu et al 2021; Sokolakis et al 2021; Towe et al 2021; Yao et al 2022)

 

(Neuro related) Muscle Contractures (e.g. Svane et al 2021)

 

Trigger Finger (e.g. Chen et al 2021; Ferrara et al 2020; Shen et al 2020; Yildrim et al 2016; Zyluk et al 2020)

 
Research Evidence

This is problematic to summarise. I now have the best part of 5000 shockwave papers in my database - you are not going to want to read through that lot and this page would take up the whole website. My interpretation of these papers in terms of clinical applications is included in the previous section(s).

Of those 5000 papers, almost 900 of them are reviews of some kind or another. I will summarise some of the more recent reviews below - which will get you started if you want to delve into the literature.

Reviews

Zhang et al (2022) Extracorporeal Shockwave Therapy as an Adjunctive Therapy for Frozen Shoulder: A Systematic Review and Meta-analysis Orthop J Sports Med 10(2): 23259671211062222 : ESWT seems to be beneficial to patients with frozen shoulder by alleviating pain and improving function

Zhang et al (2022) Extracorporeal Shock Wave Therapy on Spasticity After Upper Motor Neuron Injury: A Systematic Review and Meta-analysis Am J Phys Med Rehabil 101(7): 615 :  Extracorporeal shock wave therapy may be an effective and safe treatment for spasticity after upper motor neuron injury.

Yao et al (2022) Systematic Review and Meta-Analysis of 16 Randomized Controlled Trials of Clinical Outcomes of Low-Intensity Extracorporeal Shock Wave Therapy in Treating Erectile Dysfunction Am J Mens Health 16(2): 15579883221087532 :  The results of this meta-analysis suggest that treatment plans with an energy density of 0.09 mJ/mm(2) and pulses number of 1,500 to 2,000 are more beneficial to IIEF in ED patients

Yang et al (2022) Safety and efficacy of treating post-burn pathological scars with extracorporeal shock wave therapy: A meta-analysis of randomised controlled trials Wound Repair Regen 30(5): 595 : Available data preliminarily suggested that the combination of extracorporeal shockwave therapy and comprehensive rehabilitation therapy had better therapeutic effect on post-burn pathological scars than comprehensive rehabilitation therapy alone, without obvious side effects

Xie et al (2022) Effects of shock wave therapy in patients with carpal tunnel syndrome: a systematic review and meta-analysis Disabil Rehabil 44(2): 177 : Shock wave therapy is beneficial for alleviating syndrome and improving hand function of carpal tunnel syndrome patients.Radial shock wave therapy seems superior to focused shock wave therapy on syndrome alleviation and functional recovery of hand in carpal tunnel syndrome patient

Wu et al (2022) Efficacy of extracorporeal shock waves in the treatment of myofascial pain syndrome: a systematic review and meta-analysis of controlled clinical studies Ann Transl Med 10(4): 165 :  ESWT can avoid the adverse effects of invasive procedures on patient tolerance and compliance; compared with trigger point injection (TPI), dry needling, ultrasound-guided pulsed radiofrequency (US), and other methods, ESWT can more effectively relieve pain in patients with MPS

Sansone et al (2022) Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis J Clin Med 11(7) : ESWT is a promising approach for treating nonunions

Ou-Yang et al (2022) The Effect and Optimal Timing of Extracorporeal Shock-wave Intervention to Patients with Spasticity After Stroke: A Systematic Review and Meta-Analysis Am J Phys Med Rehabil : ESWT is an effective method for reducing spasticity in patients with stroke, and the effect could be maintained for up to 3 months

Melese et al (2022) Extracorporeal shock wave therapy on pain and foot functions in subjects with chronic plantar fasciitis: systematic review of randomized controlled trials Disabil Rehabil 44(18): 5007 : Extracorporeal shock wave therapy (ESWT) exerted beneficial effects on pain and functional outcomes for chronic plantar fasciitis.ESWT could be effectively performed with no side effects.ESWT could be an alternative to the conventional management of chronic plantar fasciitis.

Liu et al (2022) Extracorporeal Shock Wave Therapy Shows Superiority Over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis Arthroscopy 38(6): 2018 : ESWT outperformed placebo for short-term and medium term pain relief. DPT and ESWT were the best two treatment options for pain control and ESWT was the best treatment option for grip strength recovery

Hsu et al (2022) Comparative Effectiveness of Botulinum Toxin Injections and Extracorporeal Shockwave Therapy for Post-Stroke Spasticity: A Systematic Review and Network Meta-Analysis EClinicalMedicine 43: 101222 : BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options.

Feeney (2022) The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review Cureus 14(7): e26960 : ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone

Zhi et al (2021) Nonoperative treatment of insertional Achilles tendinopathy: a systematic review J Orthop Surg Res 16(1): 233 : Current evidence for nonoperative treatment specific for insertional Achilles tendinopathy favors ESWT or the combined treatment of ESWT plus eccentric exercises

Yue et al (2021) Extracorporeal Shockwave Therapy for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials Biomed Res Int 2021: 5937250 : The use of ESWT in CLBP patients results in significant and quantifiable reductions in pain and disability in the short term.

Nazim et al (2022) Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis J Am Podiatr Med Assoc 112(3) : ESWT can help manage plantar fasciitis, calcaneal spur, Achilles tendinopathy and Morton's neuroma. Meta-analysis of the change in pre- to post-VAS overall scores for plantar fasciitis significantly favored ESWT compared to placebo/conservative treatment

Morrissey et al (2021) Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values Br J Sports Med 55(19): 1106 : 

Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.

Jun et al (2021) The Effect of Extracorporeal Shock Wave Therapy on Pain Intensity and Neck Disability for Patients With Myofascial Pain Syndrome in the Neck and Shoulder: A Meta-Analysis of Randomized Controlled Trials Am J Phys Med Rehabil 100(2): 120 : Extracorporeal shock wave therapy is superior to other treatments in terms of alleviating the pain intensity and pressure pain threshold of patients with myofascial pain syndrome in the neck and shoulder at postintervention
 

 . . . . and that is just a selection of the reviews from the last 18 months . . . . . 

 
 
References

 

There is a chapter in the new edition of the textbook which covers this material

Eaton, C.  and Watson, T. (2020) Chapter 13 : Shockwave

IN:  Watson, T. and Nussbaum, E. Electrophysical Agents: Evidence Based Practice. Elsevier

In addition to the recent reviews (previous section) the other references cited on this page are listed below

(2005). "Extracorporeal shock wave treatment for chronic plantar fasciitis." Technol Eval Cent Asses Program Exec Summ 19(18): 1-4.

Albert, J. D. et al. (2007). "High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: A RANDOMISED TRIAL." J Bone Joint Surg Br 89(3): 335-41.

Alper, B. S. (2007). "Evidence-based medicine. Extracorporeal shock wave therapy appears ineffective for lateral elbow pain." Clinical Advisor 10(3): 181.

Aqil, A. et al. (2013). "Extracorporeal Shock Wave Therapy Is Effective In Treating Chronic Plantar Fasciitis: A Meta-analysis of RCTs." Clinical Orthopaedics and Related Research 471(11): 3645-3652.

 

Bisset, L. et al. (2005). "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia." Br J Sports Med 39(7): 411-22; discussion 411-22.

Borchers, J. R. and T. M. Best (2006). "Corticosteroid injection compared with extracorporeal shock wave therapy for plantar fasciopathy." Clin J Sport Med 16(5): 452-3.

Buchbinder, R. et al. (2005). "Shock-wave therapy for plantar fasciitis." J Bone Joint Surg Am 87(3): 680-1; author reply 682-4.

Buchbinder, R. et al. (2005). "Shock wave therapy for lateral elbow pain." Cochrane Database Syst Rev(4): CD003524.

Buchbinder, R. et al. (2006). "Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain." J Rheumatol 33(7): 1351-63.

Buchbinder, R. et al. (2006). "Shock wave therapy for lateral elbow pain." The Cochrane Library 4.

Burton, A. M. and T. J. Overend (2005). "Low-energy extracorporeal shock wave therapy: a critical analysis of the evidence for effectiveness in the treatment of plantar fasciitis." Phys-Ther-Rev. 10(3): 152-62.

 

Buselli, P. et al (2010). "Shock waves in the treatment of post-traumatic myositis ossificans." Ultrasound Med Biol 36(3): 397-409.


Cacchio, A. et al. (2006). "Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study." Phys-Ther. 86(5): 672-82.
 

Cacchio, A. et al (2011). "Shockwave Therapy for the Treatment of Chronic Proximal Hamstring Tendinopathy in Professional Athletes." Am J Sports Med 39(1): 146-153.


Chow, I. H. W. and G. L. Y. Cheing (2007). "Comparison of different energy densities of extracorporeal shock wave therapy (ESWT) for the management of chronic heel pain." Clinical Rehabilitation 21(2): 131-41.

Chung, B. et al. (2005). "Long-term effectiveness of extracorporeal shockwave therapy in the treatment of previously untreated lateral epicondylitis." Clin J Sport Med 15(5): 305-12.

Cook, J. (2007). "Eccentric exercise and shock-wave therapy benefit patients with chronic Achilles tendinopathy." Aust J Physiother 53(2): 131.

Costa, M. L. et al. (2005). "Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial." Clin Orthop Relat Res 440: 199-204.

Crawford, F. and C. Thomson (2006). "Interventions for treating plantar heel pain." The Cochrane Library 4.
 

Csaszar, N. B. and C. Schmitz (2013). "Extracorporeal shock wave therapy in musculoskeletal disorders." J Orthop Surg Res 8(1): 22.

Dizon, J. N. et al. (2013). "Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis." Am J Phys Med Rehabil 92(7): 606-620.

 

Dorotka, R. et al. (2006). "Location modalities for focused extracorporeal shock wave application in the treatment of chronic plantar fasciitis." Foot Ankle Int 27(11): 943-7.

 

Foldager, C et al (2012). "Clinical Application of Extracorporeal Shock Wave Therapy in Orthopedics: Focused versus Unfocused Shock Waves." Ultrasound in Medicine & Biology 38(10): 1673-1680.

 

Fridman, R. et al (2008). "Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospective study." J Am Podiatr Med Assoc 98(6): 466-468.


Furia, J. F. (2005). "The safety and efficacy of high energy extracorporeal shock wave therapy in active, moderately active, and sedentary patients with chronic plantar fasciitis." Orthopedics 28(7): 685-92.

Furia, J. P. (2005). "Safety and efficacy of extracorporeal shock wave therapy for chronic lateral epicondylitis." Am J Orthop 34(1): 13-9; discussion 19.

Furia, J. P. (2005). "The safety and efficacy of high energy extracorporeal shock wave therapy in active, moderately active, and sedentary patients with chronic plantar fasciitis." Orthopedics 28(7): 685-92.

 

Furia, J. P. et al. (2013). "A single application of low-energy radial extracorporeal shock wave therapy is effective for the management of chronic patellar tendinopathy." Knee Surgery Sports Traumatology Arthroscopy 21(2): 346-350.

 

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