Extracorporeal shockwave therapy

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Extracorporeal shockwave therapy
Gerät zur extrakorporalen Stoßwellentherapie.JPG
ESWT device (EMS Swiss DolorClast)
ICD-10-PCS 6A93

Extracorporeal shockwave therapy (ESWT) is a treatment used in physical therapy, orthopedics, urology and cardiology.[1][2] The shock waves are abrupt, high amplitude pulses of mechanical energy, similar to soundwaves, generated by an electromagnetic coil or a spark in water. Similar technology using focused higher energies is used to break up kidney and gallstones, and is termed lithotripsy. “Extracorporeal” means that the shockwaves are generated externally to the body and transmitted from a pad through the skin.

Medical uses[edit]

Extracorporeal shockwave therapy is used to treat a growing number of tendon, joint and muscle conditions. These include tennis elbow,[3] where results in double blind studies are reported as excellent; chronic tendinitis of the knee[4] and shoulder rotator cuff pain,[5] achilles tendinitis,[6] hamstring tendinitis[7] and plantar fasciitis have also been treated successfully.[8][9]

The above conditions are often difficult to treat using other methods and can become chronic. With ESWT patients report reduced pain and faster healing, without significant adverse side effects. However, the treatment has proven challenging to verify categorically in large controlled studies, in part because the therapist and patient are aware whether or not they are in the treatment cohort or the sham cohort[citation needed]. ESWT is also used to promote bone healing and treat bone necrosis.[10] It is an effective alternative to surgical treatment of non-healing fractures.[11][12]

ESWT is used for wound healing and has shown positive results in short-term and long-term outcomes in diabetic patients suffering from foot ulcers.[13]

Chest pains associated with heart disease, known as angina have been treated successfully with ESWT. Studies have shown that the shockwaves promote the growth of new blood vessels or revascularization.[14]

Since 2010 shockwaves have been used in urology, to treat chronic pelvic pain syndrome[15] and erectile dysfunction. Unlike drugs, ESWT is non-invasive, does not have side effects, and promotes long-term healing. There are a growing number of double blind sham controlled studies that show success rates of up to 80%.[16]

Physiological mechanisms[edit]

Shock waves stimulate angiogenesis (new blood vessels) and neurogenesis (new nerve cells).[17] The exact physiological mechanisms at this stage are poorly understood, but it appears that the cells undergo microtrauma which promotes the inflammatory and catabolic processes that are associated with removing damaged matrix constituents and stimulating wound healing mechanisms.[18]


Shockwave therapy on a patient.

When ESWT was used for plantar fascia treatment, the procedure used to be performed in an out-patient setting, under local anesthesia, taking up to 30 minutes. Now with newer and more portable technology, it can be done without anesthesia in the physician's office in less than 10 minutes. There are a variety of ESWT devices - manufacturers include Storz Medical, Dornier, EMS Swiss and Richard Wolf. Recent developments in applicator technology have led to additional indications such as back pain and fascia treatment[citation needed].

Patient receiving radial ESWT for lateral epicondylitis

Research indicates that there is significant reduction in intensity of application pain with the use of castor oil rather than ultrasound jelly.[19] The positive effect of castor oil can be explained by its cavitation-free quality. The patient is afterwards able to walk out, the major complaint being of a thumping feeling on the heel. Because re-inflammation is being introduced, the patient cannot take anti-inflammatory medication afterwards, and nor should the area be iced. Acetaminophen/Paracetamol with codeine may be utilized[citation needed].

Contraindications for this procedure include: neurological and vascular disease of the foot; history of rupture of the plantar fascial ligament; open bone growth plates; pregnancy, implanted metal in the area (bone screws and pins); and people on medication that interferes with blood clotting, such as coumadin and prophylactic aspirin[citation needed].


ESWT is approved in the US by the Food and Drug Administration (FDA) for treatment of only plantar fasciitis and tennis elbow. There is an FDA study to treat recalcitrant diabetic wounds[citation needed].

Shockwave devices have been approved for the treatment of erectile dysfunction in most jurisdictions other than the United States[citation needed].

The UK advisory body, the National Institute for Health and Care Excellence (NICE), have issued guidance on ESWT to UK clinicians for a number of clinical indications including calcific tendinitis of the shoulder,[20] refractory plantar fascitiis,[21] refractory Achilles tendinopathy,[22] refractory tennis elbow,[23] and refractory greater trochanteric pain syndrome.[24] NICE state ESWT raises no major safety concerns however the current evidence for ESWT in the majority of indications is conflicting, as such ESWT should only be used where there are special arrangements for clinical governance and audit. NICE guidance has led to the launch in 2012 of the Assessment of the Effectiveness of ESWT for Soft Tissue Injuries.[25] ASSERT facilitates the clinical governance and audit function of NICE's guidance for clinicians wishing to offer ESWT to patients. Through the use of validated outcome score measurement tools ASSERT has facilitated access for patients to ESWT in the UK and has become globally one of the largest collections of data over a 2-year period. ASSERT 1 ceased actively recruiting patients in 2014 however the follow ups will continue into 2016 at which the data will be published. ASSERT 2 superseded the original ASSERT Protocol in May 2014 and continues to actively collect data of patients who have received ESWT.


ESWT is commonly used for treating orthopedic problems in horses, including tendon and ligament injuries, kissing spine, navicular syndrome, and arthritis. Because it can produce temporary analgesia, usually around 4 days, care must be taken not to push the horse too hard after treatment, since the animal may not guard the injury as well as they did previously. ESWT is often used in conjunction with rest and other therapies to help return the horse to soundness. Since the treatment is slightly uncomfortable, horses are sedated for treatments.

Extracorporeal pulse activation therapy[edit]

Extracorporeal pulse activation therapy or EPAT, also called extracorporeal acoustic wave therapy or extracorporeal shock wave therapy is a non-invasive medical treatment used for many purposes, including improving skin elasticity, body shaping,[26] treating cellulite, and combating weakness of connective tissue.[27][28]

See also[edit]


  1. ^ Wang, Ching-Jen (2012). "Extracorporeal shockwave therapy in musculoskeletal disorders". Journal of Orthopaedic Surgery and Research. 7 (1): 11. ISSN 1749-799X. doi:10.1186/1749-799X-7-11. 
  2. ^ Chung, Bryan; Wiley, J. Preston (2002). "Extracorporeal Shockwave Therapy". Sports Medicine. 32 (13): 851–865. ISSN 0112-1642. doi:10.2165/00007256-200232130-00004. 
  3. ^ Thiele S, Thiele R, Gerdesmeyer L (2015). "Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy". International Journal of Surgery. PMID 26455532. doi:10.1016/j.ijsu.2015.09.034. 
  4. ^ Wang CJ, Ko JY, Chan YS, Weng LH, Hsu SL (2007). "Extracorporeal shockwave for chronic patellar tendinopathy". The American Journal of Sports Medicine. 35 (6): 972–8. PMID 17307892. doi:10.1177/0363546506298109. 
  5. ^ Louwerens JK, Sierevelt IN, van Noort A, van den Bekerom MP (2014). "Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis". Journal of Shoulder and Elbow Surgery. 23 (8): 1240–9. PMID 24774621. doi:10.1016/j.jse.2014.02.002. 
  6. ^ Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN (2013). "Treatment for insertional Achilles tendinopathy: a systematic review". Knee Surgery, Sports Traumatology, Arthroscopy. 21 (6): 1345–55. PMID 23052113. doi:10.1007/s00167-012-2219-8. 
  7. ^ Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F (2011). "Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes". The American Journal of Sports Medicine. 39 (1): 146–53. PMID 20855554. doi:10.1177/0363546510379324. 
  8. ^ Wang CJ, Wang FS, Yang KD, Weng LH, Ko JY (2006). "Long-term results of extracorporeal shockwave treatment for plantar fasciitis". The American Journal of Sports Medicine. 34 (4): 592–6. PMID 16556754. doi:10.1177/0363546505281811. 
  9. ^ Yin MC, Ye J, Yao M, Cui XJ, Xia Y, Shen QX, Tong ZY, Wu XQ, Ma JM, Mo W (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 active-treatment controlled trials". Archives of Physical Medicine and Rehabilitation. 95 (8): 1585–93. PMID 24662810. doi:10.1016/j.apmr.2014.01.033. 
  10. ^ Cheng JH, Wang CJ (2015). "Biological mechanism of shockwave in bone". International Journal of Surgery. PMID 26118613. doi:10.1016/j.ijsu.2015.06.059. 
  11. ^ Schaden W, Mittermayr R, Haffner N, Smolen D, Gerdesmeyer L, Wang CJ (2015). "Extracorporeal shockwave therapy (ESWT) - First choice treatment of fracture non-unions?". International Journal of Surgery. PMID 26454164. doi:10.1016/j.ijsu.2015.10.003. 
  12. ^ Kong FR, Liang YJ, Qin SG, Li JJ, Li XL (2010). "[Clinical application of extracorporeal shock wave to repair and reconstruct osseous tissue framework in the treatment of avascular necrosis of the femoral head (ANFH)]". Zhongguo Gu Shang (in Chinese). 23 (1): 12–5. PMID 20191955. 
  13. ^ Wang CJ, Cheng JH, Kuo YR, Schaden W, Mittermayr R (2015). "Extracorporeal shockwave therapy in diabetic foot ulcers". International Journal of Surgery. PMID 26079500. doi:10.1016/j.ijsu.2015.06.024. 
  14. ^ Zuoziene G, Leibowitz D, Celutkiene J, Burneikaite G, Ivaskeviciene L, Kalinauskas G, Maneikiene VV, Palionis D, Janusauskas V, Valeviciene N, Laucevicius A (2015). "Multimodality imaging of myocardial revascularization using cardiac shock wave therapy". International Journal of Cardiology. 187: 229–30. PMID 25838218. doi:10.1016/j.ijcard.2015.03.306. 
  15. ^ Vahdatpour B, Alizadeh F, Moayednia A, Emadi M, Khorami MH, Haghdani S (2013). "Efficacy of extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome: a randomized, controlled trial". ISRN Urology. 2013: 972601. PMC 3755541Freely accessible. PMID 24000311. doi:10.1155/2013/972601. 
  16. ^ http://sonicwave.ca/shockwave-estw-evidence/[full citation needed]
  17. ^ Wang CJ, Ko JY, Kuo YR, Yang YJ (2011). "Molecular changes in diabetic foot ulcers". Diabetes Research and Clinical Practice. 94 (1): 105–10. PMID 21742400. doi:10.1016/j.diabres.2011.06.016. 
  18. ^ Waugh CM, Morrissey D, Jones E, Riley GP, Langberg H, Screen HR (2015). "In vivo biological response to extracorporeal shockwave therapy in human tendinopathy". European Cells & Materials. 29: 268–80; discussion 280. PMID 25978115. 
  19. ^ Maier M, Staupendahl D, Duerr HR, Refior HJ (1999). "Castor oil decreases pain during extracorporeal shock wave application". Archives of Orthopaedic and Trauma Surgery. 119 (7): 423–7. PMID 10613232. doi:10.1007/s004020050013. 
  20. ^ "Extracorporeal shockwave lithotripsy for calcific tendonitis (tendinopathy) of the shoulder - Guidance and guidelines - NICE". 
  21. ^ "Extracorporeal shockwave therapy for refractory plantar fasciitis - Guidance and guidelines - NICE". 
  22. ^ "Extracorporeal shockwave therapy for refractory Achilles tendinopathy - Guidance and guidelines - NICE". 
  23. ^ "Extracorporeal shockwave therapy for refractory tennis elbow - Guidance and guidelines - NICE". 
  24. ^ "Extracorporeal shockwave therapy for refractory greater trochanteric pain syndrome - Guidance and guidelines - NICE". 
  25. ^ Maffulli G, Hemmings S, Maffulli N (2014). "Assessment of the Effectiveness of Extracorporeal Shock Wave Therapy (ESWT) For Soft Tissue Injuries (ASSERT): An Online Database Protocol". Translational Medicine. 10: 46–51. PMC 4140430Freely accessible. PMID 25147767. 
  26. ^ Adatto, Maurice A.; Robin Adatto-Neilson; Pavel Novak; Alexander Krotz; Gerd Haller (2011). "Body shaping with acoustic wave therapy AWT®/EPAT®: Randomized, controlled study on 14 subjects". Journal of Cosmetic and Laser Therapy. 13 (6): 291–296. ISSN 1476-4172. doi:10.3109/14764172.2011.630089. 
  27. ^ Adatto, Maurice; Adatto-Neilson, Robin; Servant, Jean-Jacques; Vester, J.; Novak, Pavel; Krotz, Alexander (2010). "Controlled, randomized study evaluating the effects of treating cellulite with AWT®/EPAT®". Journal of Cosmetic and Laser Therapy. 12 (4): 176–182. ISSN 1476-4172. doi:10.3109/14764172.2010.500392. 
  28. ^ Christ, C; R Brenke; G Sattler; W Siems; P Novak; A Daser (2008). "Improvement in Skin Elasticity in the Treatment of Cellulite and Connective Tissue Weakness by Means of Extracorporeal Pulse Activation Therapy" (PDF). Aesthetic Surgery Journal. 28 (5): 538–544. ISSN 1090-820X. doi:10.1016/j.asj.2008.07.011. 

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