The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

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Extracorporeal shockwave therapy in musculoskeletal disorders

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

BackgroundResults of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.PurposeTo compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.Study DesignRandomized controlled trial; Level of evidence, 1.MethodsSixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule...

/pdf/eccentric-loading-versus-eccentric-loading-plus-shock-wave-266mqg8wcy.pdf

Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy A Randomized Controlled Trial

Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. "Conventional "treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key pointsThe word "tendinopathy "is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon.The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination.US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms.Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.Many interesting new treatments are now being developed to treat tendinopathy, but currently there is little evidence to support their use in clinical practice.

Current Opinions on Tendinopathy

Background ‘Shock wave’ therapies are now extensively used in the treatment of musculoskeletal injuries. This systematic review summarises the evidence base for the use of these modalities. Methods A thorough search of the literature was performed to identify studies of adequate quality to assess the evidence base for shockwave therapies on pain in specific soft tissue injuries. Both focused extracorporeal shockwave therapy (F-ESWT) and radial pulse therapy (RPT) were examined. Results 23 appropriate studies were identified. There is evidence for the benefit of F-ESWT and of RPT in a number of soft tissue musculoskeletal conditions, and evidence that both treatment modalities are safe. There is evidence that F-ESWT is effective in the treatment of plantar fasciitis, calcific tendinitis, and that RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. There is low level evidence for lack of benefit of low-dose F-ESWT and RPT in non-calcific rotator cuff disease and mixed evidence in lateral epicondylitis.

https://bjsm.bmj.com/content/bjsports/48/21/1538.full.pdf

A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence

Background and purpose Chronic Achilles tendinopathy is a painful condition and there are often unsatisfactory results with conservative treatment. Extracorporal shock-wave therapy (ESWT) has been ...

https://www.tandfonline.com/doi/pdf/10.1080/17453670710015058

Ole Simonson

Papers

Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy.