Shockwave Therapy is a modern and highly effective treatment option in orthopaedic and rehabilitation medicine. The terms Shockwave refers to mechanical pressure pulses that expand as a wave in the body. Simply put, extracorporeal shockwaves stimulate certain processes and cells within the body – so the body is able to heal where it had previously failed to do so.
Shock Wave Therapy can be used to treat a wide variety of musculoskeletal conditions – particularly those involving issues where major connective tissues attach to bone like tendonosis and fasciosis.
The basic science behind ESWT is analogous to lithotripsy, the technology that uses acoustic shockwaves to break up kidney stones without surgery. The technique of using shockwaves to break up kidney stones has been around for a nearly a quarter century now, and in the process of treating thousands and thousands of patients, it was found that many people undergoing the procedure had other unrelated aches and pains disappear.
Specialized machines were then developed specifically with the idea of using these shockwaves on other parts of the body, and this is the origin of Shockwave Therapy.
The type of shockwave therapy we use in our clinic in Bath is highly specialised, state of the art machine, to specifically help treat musculoskeletal conditions.
Complaints involving attachment points for tendons and ligaments in major joints like the shoulder (such as the rotator cuff), elbow (epicondylitis – tennis or golfer’s elbow), hip, and knee (tendinitis or “jumper’s knee) are common sites for Shock Wave Therapy (ESWT).
One of the areas most frequently treated with ESWT however, is the foot, especially Plantar Fasciitis. This is one of our specialties. Some conditions in the foot that have been treated with Shockwave Therapy include:
- Plantar Fasciitis or Fasciosis (Strained Arch)
- Achilles Tendinitis or Tendinosis
- Calcific Tendinitis or Tendinosis
- Connective Tissue Pain and degeneration
- Muscle Pain and Injuries
- Joint Injuries
- Morton’s Neuromas
And as shock wave therapy encourage bone healing, it has been used to help treat:
- Stress Fractures
- Avascular Necrosis (A dead portion of bone)
- Slow-healing bone (Delayed unions)
- Non-healing bone (Non-unions)
There are also urological conditions that respond to Shockwave Therapy, such as Peyronie’s Disease but we do not specialise in the treatment of any urological condition here at Active Health in Bath as we are a Chiropractic and Physiotherapy clinic specialising in the treatment of all musculoskeletal injuries and complaints.
Shock Wave Therapy is generally considered when the following criteria are met:
- When patient has a diagnosis that is considered to be responsive to ESWT
- When simpler and less expensive treatment alternatives have failed or aren’t appropriate for some reason
- When surgery or other more invasive treatments are alternatives
- When the patient fully understands the procedure
- When there are no known contraindications to the procedure
Shockwave Therapy is not typically used in the presence of bone tumours, certain metabolic bone conditions, and certain nerve or circulation disorders. SWT isn’t typically used in pregnant patients and locations of an open growth plate, (where the bone is still growing). It’s not currently used in areas where an infection is present, (though there is some early research suggesting SWT may actually help with infection). It also shouldn’t be used in conditions or locations where gas or air is present in the body (rare in the locations where SWT is typically used), or for other conditions as determined by your doctor.
Like any medical tool, its only as good as the person who uses it and the strength of their diagnosis. Problems that mimic insertional tendonopathy or fasciopathy will likely not get better. This is why we only administer Shockwave Therapy after a proper diagnoses has been made.
The answer to this question depends upon which study you read, what methods were used in the study, how “success” is measured in the study, the patients selected to be included in the study, the condition being treated, and the machine being used.
While there are some studies (usually quoted by an insurance company trying to find a way to justify not paying for ESWT treatment) that suggest that shockwave hasn’t been proven to be effective, the vast majority of recent studies suggest that shockwave is highly effective. See the research tab for more detailed research information.
Assuming you have an injury appropriate to extra-corporeal shockwave technology treatment, most recent independent studies suggest somewhere between a 65% and a 95% “success” range, with values around 80% being the most commonly cited number. And it’s important to note that most of these studies have success rates as determined by the patient, himself, in terms of pain and function.
We find that our results with the highly accurate piezoelectric technology, are at least this successful. The most important factor in getting a good result with ESWT appears to be in selecting appropriate patients most likely to benefit from this technology. However, we can’t guarantee which patients will respond successfully to ESWT and which ones won’t.
We find that many patients get an initial degree of improvement almost immediately following treatment. This effect is usually (but not always) temporary, and is associated with an anesthesia effect from the hyperstimulation of the tissue from the ESWT. Check out the How It Works tab for more information on this phenomenon.
It takes several days for injuries to begin to heal, and many patients see an improvement before the end of the second week. Depending upon your diagnosis, the healing process may take several weeks or even months to be completed, but pain relief often precedes the completion of the healing process. For more information contact us to arrange a quick phone call from one of our practitioners to discuss the likely time it may take for your condition to recover.
The basic technology involved with extracorporeal shockwave technology has been used for decades now on quite literally millions of people. The technology has been used most extensively in Europe, particularly the German-speaking countries, where this technology originates. In all its use, ESWT of the musculoskeletal system has been found to have virtually no serious side-effects. In fact, even mild side effects like tingling, aching, redness, or bruising are relatively rare, modest and short-lived.
Further, effects like these appear to be more common with higher energy treatments, particularly those from earlier generations of ESWT technology than that which we use.
“Whilst other professions are concerned with changing the environment to suit the weakened body, Chiropractic is concerned with strengthening the body to suit the environment”
~ B.J. Palmer, the Developer of Chiropractic
A shockwave is an intense, but very short energy wave traveling faster than the speed of sound. In modern pain therapy, Shockwave energy is conducted from the point of origin through the skin, penetrating deeply if needed, to where the painful tissue lies. When the shock wave hits the dysfunctional tissue, healing is stimulated by the side effects of the tissue transducing and absorbing the energy of the wave. Simply put, extracorporeal shockwaves stimulate certain processes and cells within the body – so the body is able to heal.
In addition to stimulating the healing process, ESWT seems to have a direct effect on nerves, diminishing pain.
Shockwave works when you have a chronic degenerative soft tissue issue. Many traditional therapies such as anti-inflammatory medications, steroid injections, massage, acupuncture, and so forth–can assist the body during the early, acute phase of an injury. However, they are much less effective in assisting the body to heal when an injury becomes chronic. As an example, many patients can relate to a history where a steroid injection (cortisone) seemed to be effective in resolving pain early in their healing process, but subsequent injections were much less effective. This isn’t really surprising when you realize that a chronic-state, degenerative injury isn’t likely to respond well to a medication designed to affect an acute-phase, inflammatory condition. The body deals with acute inflammatory problems very differently to chronic inflammatory ones, yet currently modern medicinal treatments appear to largely only focus on the acute phase.
There are many biological mechanisms activated by Musculoskeletal Shockwaves. Some of which are:
- Tissue regeneration via stem cell activation and migration
- Improved blood circulation initiating healing in treated area
- Long-term stimulation of metabolism
- Pain relief in only a few treatment sessions
- Changes in cell membrane permeability
- Growth factor (VEGF, etc.) promotion
- Mitochondrial changes
- Neurotransmitter dilution (Substance P)
- Nitric Oxygen (NO) promotion
- Free radical liberation
True ESWT produces a very strong energy pulse (5-100 MPa) for a very short length of time, (approximately 10 milliseconds).
The energy pulse quite literally breaks the sound barrier, and this is what creates the shockwave.
To the right is a photograph of a plane flying faster than the speed of sound and creating shockwaves. Shockwaves produced by an extracorporeal shockwave machine are identical, only on a smaller scale.
One difference with the shockwaves our machine is able to produce is that the shockwave is generated, controlled, and focused precisely.
First, this shockwave exerts a mechanical pressure and tension force on the afflicted tissue. This has been shown to create an increase in cell membrane permeability, thereby increasing microscopic circulation (right) to the tissues and the metabolism within the treated tissues, both of which promote healing and subsequent dissolution of pathological calcific deposits.
Second, the ESWT shock waves pressure front creates behind it what are known as “cavitation bubbles”. An example of a single cavitation bubble is pictured to the right.
Cavitation bubbles are simply small empty cavities created behind an energy front. They tend to expand to a to a maximum size, then collapse, much like a bubble popping.
As these bubbles burst, a resultant force is created. In the human body, this force is strong enough to help break down pathological deposits of calcification in soft tissues.
Third, as cavitation bubbles collapse, they create smaller, secondary energy waves known as microjets. You can see how a microjet forms in the diagram to the right, and you can see it pictured in the center of the cavitation bubble in the photograph immediately above.
These microjets also create a lot of force that also breaks down pathological deposits of calcification in the soft tissues through direct, mechanical means.
In the application of an ESWT treatment in a medical setting, however, it’s not just one cavitation bubble or just a few cavitation bubbles being produced, but hundreds and thousands.
To the right you can see what hundreds of cavitation bubbles formed from a single shockwave looks like.
Multiply this by several thousand shockwaves being administered to an injured tissue through a course of ESWT treatment and you can imagine the forces that can be mustered to break down deposits of calcification that are found in joints, soft tissues and spurs.
The beginning is the most important part of any work”
It’s actually very simple for the patient.
We just need adequate access to the area of concern.
Reviews and General Papers
Boddeker, R. et al. (2001). “Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis–a biometrical review.” Clin Rheumatol 20(5): 324-330.
Ogden, J. et al. (2001). “Shock Wave Therapy (Orthotripsy(R)) in Musculoskeletal Disorders.[Report].” Clinical Orthopaedics & Related Research 387: 22-40.
Thiel, M. (2001). “Application of shock waves in medicine.” Clin Orthop Relat Res(387): 18-21.
Buchbinder, R. et al. (2002). “Shock wave therapy for lateral elbow pain.” Cochrane Database Syst Rev(1): CD003524.
Chung, B. and J. P. Wiley (2002). “Extracorporeal shockwave therapy: a review.” Sports Med 32(13): 851-865.
Ogden, J. A. et al. (2002). “Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.” Foot Ankle Int 23(4): 301-308.
Strash, W. W. and R. R. Perez (2002). “Extracorporeal shockwave therapy for chronic proximal plantar fasciitis.” Clin Podiatr Med Surg 19(4): 467-476.
Cheing, G. L. and H. Chang (2003). “Extracorporeal shock wave therapy.” J-Orthop-Sports-PhysTher. 33(6): 337-343.
Perez, M. et al. (2003). “Extracorporeal shock wave therapy for plantar fasciitis.” Clin Podiatr Med Surg 20(2): 323-334.
Wang, C. J. (2003). “An overview of shock wave therapy in musculoskeletal disorders.” Chang Gung Med J 26(4): 220-232.
Harniman, E. et al. (2004). “Extracorporeal shock wave therapy for calcific and noncalcific tendonitis of the rotator cuff: a systematic review.” J Hand Ther 17(2): 132-151.
Speed, C. A. (2004). “Extracorporeal shock-wave therapy in the management of chronic soft-tissue conditions.” Journal of Bone & Joint Surgery 86(2): 165-171.
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): 411-422
Burton, A. 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.” Physical Therapy Reviews 10(3): 152-162.
Roehrig, G. J. et al. (2005). “The role of extracorporeal shock wave on plantar fasciitis.” Foot Ankle Clin 10(4): 699-712, ix.
Saw, A. (2005). “Extracorporeal shock wave therapy for musculoskeletal pathology–a literature review.” Med J Malaysia 60 Suppl C: 8-10.
Stasinopoulos, D. and M. I. Johnson (2005). “Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis).” Br J Sports Med 39(3): 132-136.
Thomson, C. E. et al. (2005). “The effectiveness of extracorporal shock wave therapy for plantar heel pain: a systematic review and meta-analysis.” BMC Musculoskeletal Disorders 6: 19-.
Shockwave as effective as Surgery for Chronic Calcific Supraspinatus Tendinitis
Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. J Orthop Traumatol. 2008 Dec; 9(4): 179–185.
Buchbinder, R. et al. (2006). “Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain.” J Rheumatol 33(7): 1351-1363.
Seil, R. et al. (2006). “Extracorporeal shock wave therapy for tendinopathies.” Expert Rev Med Devices 3(4): 463-470.
Sems, A. et al. (2006). “Extracorporeal shock wave therapy in the treatment of chronic tendinopathies.” J Am Acad Orthop Surg 14(4): 195-204.
Ho, C. (2007). “Extracorporeal shock wave treatment for chronic rotator cuff tendonitis (shoulder pain).” Issues Emerg Health Technol(96 (part 3)): 1-4.
Ho, C. (2007). “Extracorporeal shock wave treatment for chronic plantar fasciitis (heel pain).” Issues Emerg Health Technol(96 (part 1)): 1-4.
Mouzopoulos, G. et al. (2007). “Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review.” Skeletal Radiol 36(9): 803-811.
Rompe, J. D. et al. (2008). “Mid-portion Achilles tendinopathy–current options for treatment.” Disabil Rehabil 30(20-22): 1666-1676.
Alves, E. M. et al. (2009). “The use of extracorporeal shock waves in the treatment of osteonecrosis of the femoral head: a systematic review.” Clinical Rheumatology 28(11): 1247-1251.
Petrisor, B. et al. (2009). “Extracorporeal shockwave therapy: A systematic review of its use in fracture management.” Indian journal of orthopaedics 43(2): 161-167.
Schmitz, C. and R. DePace (2009). “Pain relief by extracorporeal shockwave therapy: an update on the current understanding.” Urol Res 37(4): 231-234.
van Leeuwen, M. T. et al. (2009). “Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature.” Br J Sports Med 43(3): 163-168.
Xu, Z. H. et al. (2009). “Extracorporeal shock wave treatment in nonunions of long bone fractures.” Int Orthop 33(3): 789-793.
Furia, J. P. et al. (2010). “Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures.” Foot Ankle Clin 15(4): 651-662.
Zelle, B. A. et al. (2010). “Extracorporeal shock wave therapy: current evidence.” J Orthop Trauma 24 Suppl 1: S66-70.
Huisstede, B. M. et al. (2011). “Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis–a systematic review.” Man Ther 16(5):419-433.
Qureshi, A. A. et al. (2011). “Shock wave therapy in wound healing.” Plast Reconstr Surg 128(6):721e-727e.
Chang, K. V. et al. (2012). “Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis.” Arch Phys Med Rehabil 93(7): 1259-1268.
Foldager, C. B. 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.
Mittermayr, R. et al. (2012). “Extracorporeal shock wave therapy (ESWT) for wound healing:technology, mechanisms, and clinical efficacy.” Wound Repair Regen 20(4): 456-465.
Wang, C.-J. (2012). “Extracorporeal shockwave therapy in musculoskeletal disorders.” Journal of Orthopaedic Surgery and Research 7(1): 11.
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.
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.
Ioppolo, F. et al. (2013). “Clinical Improvement and Resorption of Calcifications in Calcific Tendinitis of the Shoulder After Shock Wave Therapy at 6 Months’ Follow-Up: A Systematic Review and MetaAnalysis.”Archives of Physical Medicine and Rehabilitation 94(9): 1699-1706.
Reznik, J. E. et al. (2013). “Extracorporeal shock wave therapy as a treatment for heterotopic ossification.” Physical Therapy Reviews 18(4): 300-307.
Schmitz, C. et al. (2013). “Treatment of chronic plantar fasciopathy with extracorporeal shock waves (review).” J Orthop Surg Res 8(1): 31.
van der Worp, H. et al. (2013). “ESWT for tendinopathy: technology and clinical implications.” Knee Surgery Sports Traumatology Arthroscopy 21(6): 1451-1458.
Romeo, P. et al. (2014). “Extracorporeal Shock Wave Therapy in Musculoskeletal Disorders: A Review.” Medical Principles and Practice 23(1): 7-13.
Yin, M. C. et al. (2014). “Is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized placebo or activetreatment controlled trials.” Arch Phys Med Rehabil 95(8): 1585-1593.