International Journal of Surgery 51 (2018) 184–190

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International Journal of Surgery

journal homepage: www.elsevier.com/locate/ijsu

Original Research

Comparative outcomes of extracorporeal shockwave therapy for shoulder T

tendinitis or partial tears of the rotator cuff in athletes and non-athletes:
Retrospective study
Wen-Yi Choua, Ching-Jen Wanga,b,∗, Kuan-Ting Wua, Ya-Ju Yanga, Jai-Hong Chengb,
Shih-Wei Wangc
a
Department of Orthopedic Surgery, Section of Sports Medicine, Taiwan
b
Center for Shockwave Medicine and Tissue Engineering, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College
of Medicine, Kaohsiung, Taiwan
c
Department of Medicine, Mackay Medical College, New Taipei City, Taiwan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Refractory shoulder tendinitis or partial thickness rotator cuff tears (PTRCTs) are common findings
Extracorporeal shockwave therapy in overhead athletes. Previous studies have examined the effectiveness of extracorporeal shockwave therapy
Shoulder tendinitis (ESWT) for shoulder tendinitis.
Athletes Materials and methods: In the current study, we recruited 36 shoulders and performed a comparison between the
Partial thickness rotator cuff tear
professional athletes (13 shoulders, athletic group; AG) and the non-athletic population (23 shoulders, non-
athletic group, NAG) with PTRCTs or shoulder tendinitis of the shoulder after ESWT. Patients with symptomatic
tendinitis of the shoulder with or without a partial tear of the rotator cuff tendon and failed oral medication and
physical therapy for more than 3 months were treated with electrohydraulic mode of ESWT. All patients that met
the inclusion criteria were categorized into two groups according to their pre-treatment activity level.
Results: We found that NAG exhibited significant aging and degenerative change around the glenohumeral joint
and subacromial space. After ESWT treatment, the patients in AG were with 53.8% high satisfaction rating and
patients in NAG were 52.1% by one-year followed up.
Conclusion: The results showed ESWT was equally effective treatment in both AG and NAG. In light of its efficacy
and less-invasive nature, we suggest ESWT can be used to treat athletes with refractory tendinitis or PTRCTs
before proceeding to arthroscopic intervention.

1. Introduction
Overhead-throwing athletes, especially baseball or softball players,
subject their shoulders to an extremely high repetitive force that often
compromises the rotator cuff tendon underneath the acromion.
Refractory shoulder tendinitis or partial thickness rotator cuff tears
(PTRCTs) are common findings in baseball pitchers [1,2], with a re-
ported incidence of 40% in dominant shoulders as compared with 0% in
non-dominant shoulders in high-level pitchers [3]. Different from
aging-related degenerative tears, rotator cuff tears in throwing athletes
are closely related to repetitive high-tensile loading during the late
cocking and early acceleration phases of the throwing motion. Tradi-
tionally, treatment consists of activity modification with avoidance of
overhead or painful motions. Non-steroidal anti-inflammatory drugs
(NSAIDs) are used to alleviate pain and suppress inflammation,
although there is a lack of strong evidence to prove the efficacy of these
medications. Physical therapy is also a common modality used to re-
lieve pain and improve the shoulder range of motion [4,5]. Pathologic
posterior capsular tightness with rotator cuff myotendinous contracture
can be managed with specific stretching, such as sleeper's stretch and
horizontal adduction stretches [6,7]. Occasional intra-articular corti-
sone injections are often administered alongside the treatment men-
tioned above. Although platelet-rich plasma (PRP) injection has shown
promising results for the treatment of rotator cuff tendinitis or PTRCTs,
the overall efficacy remains uncertain, and opinions are diverse [8,9].
Many papers have been published that report encouraging clinical
outcomes of operative management of PTRCTs in the general popula-
tion, but these results should not be applied to competitive overhead
athletes.
Following studies conducted within the last decade, extracorporeal

∗
Corresponding author. Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta Pei Road, Niao Sung Dist., Kaohsiung, Taiwan.
E-mail address: w281211@adm.cgmh.org.tw (C.-J. Wang).

https://doi.org/10.1016/j.ijsu.2018.01.036
Received 22 September 2017; Received in revised form 20 November 2017; Accepted 25 January 2018
Available online 02 February 2018
1743-9191/ © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
W.-Y. Chou et al.
shockwave therapy (ESWT) has been reported to be beneficial in
treating various musculoskeletal disorders, such as plantar fasciitis
[10,11], medial/lateral epicondylitis [4,12,13], nonunion of fractures
[14–16], and avascular necrosis of the femoral head [17,18]. Ad-
ditionally, ESWT has also been applied in cases of calcified/noncalcified
tendinitis of the shoulder, with promising results. A review of 16 stu-
dies, including 5 randomized controlled trials, found moderate evi-
dence that high-energy ESWT is effective for treatment of chronic cal-
cific tendinitis when the shock waves are applied to the calcification
[19]. Previous reports have revealed favorable outcomes regarding
sports medicine application, including use for the treatment of tibial
stress syndrome [20], plantar fasciitis [21] and muscular micro-
circulation [22]. However, few studies of the clinical outcomes of ESWT
in throwing athletes with PTRCTs/tendinitis of the shoulders have been
performed.
Therefore, we conducted a comprehensive clinical analysis to clarify
the outcomes of ESWT in professional overhead athletes with PTRCTs
or tendinitis of the shoulder and performed a comparison with the non-
athletic population.
2. Material and methods
2.1. Participants
Since January 2014, patients with symptomatic tendinitis of the
shoulder with or without a partial tear of the rotator cuff tendon, who
failed oral medication and physical therapy for more than 3 months,
were treated with an electrohydraulic mode shockwave. The diagnosis
was initially made from plain X-rays, followed by either shoulder so-
nography or magnetic resonance imaging (MRI) to confirm the diag-
nosis as well as to exclude the possibility of a complete rotator cuff tear
or malignancy. Patients with the conditions such as pregnancy, acute
infection, malignant tumor or coagulopathy were excluded from study.
In addition, affected shoulders with fractures were also excluded. To
improve accuracy in the comparative study between the athletic group
and non-athletic group, the calcific tendinitis was excluded because
there were no calcific tendinitis patient in the athletic group.
2.2. ESWT
Patients undergoing ESWT were asked to discontinue current
treatments, including NSAIDs and aspirin, for 2 weeks prior to ESWT.
The patients were placed in either the supine or beach-chair position.
The electrohydraulic shockwave mode was delivered using either
Ossatron (High Medical Technology) or Orthospec equipment
(Medispec Ltd., Yehud, Israel). 3000 impulses of the shockwave at
0.28–0.32 mJ/mm2 energy flux density in Ossatron or Orthospec Level
7 (0.32 mJ/mm2) were applied to the affected shoulder under ultra-
sonographic guidance in line with the point of tenderness. Patients who
needed a second ESWT underwent a repeated procedure 3 months later
after the index procedure.
2.3. Study design
The Institutional Review Board in human study approved this study.
The methods section states that the work has been reported in line with
the STROCSS criteria [23]. All patients that met the inclusion criteria
were categorized into 2 groups according to their pre-treatment activity
level. Patients who were active athletes that participated in a profes-
sional ball club or national team for at least 1 year were recruited into
the athletic group (AG), while those who were not athletes were en-
rolled into the non-athletic group (NAG). Comparative analysis in-
cluded examination of demographic characteristics, radiographic
parameters and clinical outcomes. Radiographic analysis included ac-
romion index (AI), subacromial space (SAS) and critical shoulder angle
(CSA) on the plain film. The AI is believed to be associated with
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International Journal of Surgery 51 (2018) 184–190
degenerative rotator cuff tears [24,25]. The distance between the lat-
eral extremity of the acromion and the plane of the glenoid cavity was
designated as the GA. The distance between the lateral extremity of the
humerus and the plane of the glenoid cavity was referred to as the GU.
The ratio of the values of the GA and GU formed the AI. The sub-
acromial space (SAS) was measured from the dense cortical bone
marking the inferior aspect of the anterior acromion at a point directly
above the head of the humerus. The critical shoulder angle is a newly-
described radiographic parameter that could be of high diagnostic value
for the prediction of rotator cuff tears and osteoarthritis of the gleno-
humeral joint [26,27]. This angle is formed between the glenoid and
lateral border of the acromion. Subacromial spurs and osteoarthritis
(OA) of the glenohumeral joint was also recorded. OA of the gleno-
humeral joint was noted when narrowing of the joint space of the
glenohumeral space or marginal spur formation around the proximal
head or glenoid were observed. A subacromial spur was regarded as
present when a bird-beak or significant curve-like morphology was
identified. All of these items have been reported to be predictors of
rotator cuff lesions or osteoarthritic change of the shoulders, and were
used as referential parameters in this comparative study for the as-
sessment of degenerative effects. Soft-tissue images were obtained using
either magnetic resonance imaging (MRI) or sonography of the
shoulder for analysis. The locations and degrees of tears were recorded
according to the classification system proposed by Ellman [28].
2.4. Clinical evaluation parameters
The clinical evaluation parameters included the duration of symp-
toms prior to ESWT, Visual Analogue Scale (VAS) and Constant score
which contains pain (0–15, which was divided into pain score 0–10 and
night pain 0-5), power (0–25), activity (0–20) and motion (0–40).
Besides, a global rating was also recorded to represent degree of sa-
tisfaction with treatment. We defined patients with symptom im-
provement of more than 80% as complaint-free, 50–79% as sig-
nificantly better, 25–49% as slightly better, and lower than 24% as
unchanged. Patients who were considered “complaint-free” and “sig-
nificantly better” at the final follow-up were regarded as having a high
level of satisfaction. Each patient was followed-up 3, 6 and 12 months
after ESWT. Recurrence of symptoms was also routinely monitored at
each follow-up.
2.5. Statistical analysis
Descriptive statistics (means and standard deviations, numbers, and
percentages) were used to describe the AG and NAG and the outcome
variables at the 4 follow-up time points. The p < 0.05 was regarded as
indicating statistical significance. 95% confidence intervals (CIs) were
also calculated. A 2-sided x 2 test was carried out to compare the
number of patients who were able to return to their pre-injury level of
sports activity. Statistical analysis was performed using SPSS for
Windows (Statistical Package for the Social Sciences, version 22.0; SSPS
Inc.).
3. Results
From March 2014 to June 2015, 114 shoulders were treated with
ESWT for tendinitis or a partial tear of the rotator cuff tendon.
Following the exclusion of 64 shoulders who had calcified tendinitis
and 14 shoulders who were lost to follow-up, 36 shoulders in 35 pa-
tients were reviewed in this retrospective analysis. Of these 36
shoulders, 13 were allocated to the AG, including 10 professional
baseball players and 3 weightlifters who participated in national teams
as well as the other 23 shoulders were assigned to the NAG (Fig. 1).
Comparisons of demographic characteristics showed significant differ-
ences in age and gender predominance between groups, the NAG sub-
jects being older (52.7 ± 10.3 vs 26.6 ± 5.6, p < 0.001) and more
W.-Y. Chou et al. International Journal of Surgery 51 (2018) 184–190

Fig. 1. Flow chat of participants through the ESWT.

predominantly female.
3.1. Radiographic parameters
Regarding the X-ray parameters, there were no differences in the AI
and SAS, indicators of rotator cuff tears, between groups (Table 1). The
critical shoulder angle was significantly larger in the AG than in the
NAG (33.5 ± 2.1 vs 30.2 ± 3.7, p = 0.005). The CSA is now known to
be an indicator of rotator cuff tears when the CSA is greater than 35°,
and of osteoarthritis of the shoulder when it is less than 30°. A sig-
nificant difference in the CSA implied that osteoarthritis was prominent
in the NAG, a result compatible with the differences in subacromial
spurs (NAG: AG = 65.2%: 30.7%, p = 0.047) and osteroarthritis of the
glenohumeral joint (NAG: AG = 39.1%: 0%, p = 0.014). There were no
significant differences between groups with regards to the degree of
rotator cuff tendon lesions (Table 1). In addition, the NAG showed
significant differences in subject age and degenerative changes around
the glenohumeral joint and subacromial space.

Table 1
Comparisons of radiographic results in the AG and NAG before ESWT.

AG NAG p value

(n = 13) (n = 23)

(I) X-ray of shoulder

(1) AI (acromion index) 0.8 ± 0.1 (0.64–0.92) 0.8 ± 0.1 (0.53–0.96) 0.745
(2) SAS (subacromial space) 8.7 ± 1.7 (6.53–12.29) 8.1 ± 2.7 (0.57–12.27) 0.795
(3) CSA (critical shoulder angle) 33.5 ± 2.1 (31–37) 30.2 ± 3.7 (23–36) 0.005
(4) Subacromial spur 4/13 (30.7%) 15/23 (65.2%) 0.047
(5) Osteoarthritis of glenohumeral joint 0/13 (0%) 9/23 (39.1%) 0.014
(II) Location of tendon lesion
(1) Bursitis/tendinitis 5/13 (38.4%) 14/23 (60.9%) 0.169
(2) Articular tear 4/13 (30.7%) 4/23 (17.4%) 0.422
(3) Bursal tear 1/13 (7.6%) 4/23 (17.4%) 0.634
(4) Intractendinous tear 3/13 (23.1%) 1/23 (4.3%) 0.115
(III) Degree of partial tear
(1) Gr. I < 3mm/25% 3/8 (37%) 6/9 (67%) 0.347
(2) Gr. II < 3–6mm/25–50% 1/8 (13%) 1/9 (11%) 0.929
(3) Gr. III > 6mm/ > 50% 4/8 (50%) 2/9 (22%) 0.335

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Table 2 4. Discussion
Demographics characteristics of the patients.
The most common rotator cuff tear pattern in overhead or throwing
AG NAG p value
athletes involves a partial thickness tear on the articular side cuff. The
Number of patients/shoulders 13/13 22/23 0.446 exact mechanism is still under debate. Andrews et al. theorized that
Average age (years) articular side tears result from repetitive large eccentric tensile stress to
Mean ± SD 26.6 ± 5.6 52.7 ± 10.3 < 0.001
the supraspinatus and infraspinatus during the deceleration phase of
(Range) (17–34) (32–78)
Gender (Male/Female) 9/4 7/15 0.032 throwing [29,30]. Walch et al. reported that internal impingement
Side of lesion occurs while the humerus is in the 90-degree abduction and 90-degree
Right/Left 7/6 12/11 0.923 external positions, which led to direct contact of the posterosuperior
Bilateral shoulder 0 1 0.435 cuff tendon and posterosuperior glenoid labrum by pinching of the
Duration of symptoms (months)
greater tuberosity and labrum. This causes intratendinous extension of
Mean ± SD 7.9 ± 2.6 14.7 ± 15.5 0.267
(Range) (4–12) (6–50) the articular side tear into the middle layer of the infraspinatus tendon
Athlete category and leads to dissection into two layers [31]. Some investigators believe
Weightlifter 3 that contact of the undersurface of the posterosuperior cuff with the
Baseball pitcher 10
glenoid is a natural element in a throwing shoulder, even with an
asymptomatic PTRCT [1,32]. Although the extrinsic mechanical com-
3.2. Clinical parameters pression and irritation of the rotator cuff caused by the acromial mor-
phology have been well-studied, significant evidence exists to indicate
There was no significant difference in the average duration of that intrinsic degeneration is an important cause of PTRCTs. Brewer
symptoms prior to ESWT between groups (AG vs NAG = 7.9 ± 2.6 vs et al. studied rotator cuff autopsy specimens, and observed age-related
14.7 ± 15.5 months, p = 0.267) but the subjects were older in the changes, including a loss of cellularity, disorganization, and fragmen-
NAG (Table 2). Among the other clinical parameters, which included tation, that led to dissolution of the cuff in older subjects [33]. The
VAS and Constant score which contains pain score, night pain, power, blood supply to the cuff is compromised with aging, most notably at the
activity and motion, pain score, night pain, power, activity, motion, articular side of the supraspinatus tendon, and histologic studies sup-
there were significant improvements after ESWT in both AG and NAG port the concept of intrinsic degeneration as the primary etiology of
groups during follow-up, as assessed at 3, 6 and 12 months, but no PTRCTs [34,35]. Both intrinsic degeneration and impingement of the
significant differences were observed between the two groups (Table 3). cuff tendon lead to compromise of blood supply to the cuff tendon, and
The global rating (Table 4) and overall symptoms improvement (Fig. 2) result in inadequate tissue repair accompanied by chronic pain. ESWT
revealed progressive improvement of the rate of satisfaction from the has been proved to have positive effects in the neovascularization of
3rd to the 12th month after ESWT in both AG and NAG, with no sig- tendons and bone junctions. Previous studies also showed that ESWT
nificant differences between groups. The percentage of subjects with a stimulates the ingrowth of neo-vessels associated with early release of
high satisfaction rating was 53.8% in the AG and 52.1% in the NAG one angiogenic and proliferating growth factors at the tendon-bone junction
year after ESWT (Table 4). In addition, the athletes in the AG with a [13,36]. A representative patient showed regression of inflammation
high satisfaction rating had all returned to their previous competitive and healing of a partial tear of the supraspinatus tendon 6 months after
level within 3 months after ESWT. However, the recurrence rate was ESWT (Fig. 3). The recurrence rate was 62% and 18% in the AG and
62% and 18% in the AG and NAG, respectively, although there were no NAG, respectively. The higher recurrence tendency in the AG indicated
statistically significant differences between groups. In addition, 15% that repetitive and high-tensile overhead activity is a prominent nega-
and 17% of patients were referred for arthroscopic debridement at the tive factor in relation to tendon healing as compared with chronic de-
final follow-up. No major complications were found in this study. generation in a period of a few months. Despite treatment, adequate
rest and overhead activity restriction are all essential for tendon re-
covery.
Non-operative treatment is always favored in patients or athletes

Table 3
Comparison of clinical outcomes in the AG and NAG.

AG (n = 13) NAG (n = 23)

Pre-treatment 3 months 6 months 12 months Pre-treatment 3 months 6 months 12 months Difference Difference Difference

Mean Mean Mean Mean Mean Mean Mean Mean (95% CI) (95% CI) (95% CI)

(SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD) at 3 months at 6 months at 12 months

VAS 5.1 (0.9) 3.8 (1.5) 3.0 (2.5) 2.0 (2.8) 5.6 (0.8) 4.3 (1.6) 3.9 (2.2) 2.6 (2.9) −1.3 −1.2 −2.6
(0–10) (-0.9 to 0.9) (-3.1 to 0.4) (-2.3 to 2.0)
Pain score 4.5 (1.0) 5.9 (1.1) 6.9 (0.2) 7.6 (2.7) 4.6 (0.9) 5.5 (1.4) 6.6 (1.6) 7.7 (2.1) 1.1 2.2 5.4
(0–10) (-0.4 to 0.6) (-1.2 to 2.3) −7.8 to −3.3
Night pain 3.1 (0.5) 3.7 (0.6) 4.2 (1.1) 4.2 (1.3) 2.5 (0.8) 2.9 (1.0) 3.5 (0.9) 4.2 (1.0) 0.4 0.4 0.8
(0–5) (-0.2 to 1.0) (-1.1 to 1.2) (-1.9 to 0.7)
Power 12.9 (4.5) 15.8 (3.8) 18.7 (3.7) 21.3 (10.0) 12.7 (3.5) 14.7 (3.7) 16.6 (4.2) 19.2 (5.2) 2.4 4.4 7.3
(0–25) (-1.3 to 3.0) (-2.0 to 5.3) (-3.9 to 5.8)
Activity 12.4 (3.5) 14.9 (3.2) 16.8 (2.3) 17.9 (2.7) 10.8 (3.0) 13.0 (3.4) 14.8 (3.5) 16.1 (4.2) 2.4 4.0 5.2
(0–20) (-1.7 to 2.3) (-2.9 to 3.4) (-3.6 to 3.9)
Motion 25.1(6.0) 28.9(3.7) 32.4(5.6) 35.8(5.2) 22.1(8.3) 26.4(7.1) 29.7(7.1) 31.7(7.2) 4.3 7.5 10.1
(0–40) (-4.6 to 3.5) (-6.9 to 6.9) (-6.3 to 9.2)
Constant 57.9(12.9) 69.2(10.1) 79.0(10.5) 86.8(12.4) 52.7(14.2) 62.5(14.0) 71.1(15.7) 78.8(18.3) 10.8 19.1 26.8
Score (0–100) (-7.0 to 9.9) (-12.6 to 17.9) (-15.0 to 21.2)

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Table 4
Global rating and status of recurrence.

3 months 6 months 12 months

AG NAG p AG NAG p AG NAG p

n (%) n (%) n (%) n (%) n (%) n (%)

Complaint-free 0 (0) 0 (0) 2 (15) 3 (13) 0.845 4 (30) 4 (17) 0.422

Significantly better 2 (15) 7 (30) 0.438 3 (24) 8 (35) 0.708 3 (24) 8 (35) 0.708
Slightly better 6 (46) 6 (26) 0.281 2 (15) 4 (17) 0.877 1 (7) 2 (8) 0.917
Unchanged 5 (39) 10 (44) 0.769 6 (46) 8 (35) 0.501 5 (39) 9 (40) 0.968

Recurrence rate 5 (39) 2 (9) 0.030 3 (23) 2(9) 0.308 0(0) 0(0)

Referred for surgery 2 (15) 4 (17) 0.877

arthroscopic debridement or repair would be considered. The reported

Fig. 2. Symptoms improvement rate.
with refractory tendinitis or a partial tear of the rotator cuff tendon.
Correction of the throwing mechanism should be considered a pre-
vention strategy. Several phases of rehabilitation are utilized, which
progress from anti-inflammation, regaining of range of motion, mus-
cular strengthening and soft tissue flexibility, to proprioception
training. Specific posterior stretches such as the “sleeper's stretch” and
horizontal adduction stretch have also been recommended [6,7]. These
modalities are accepted in line with the concept of damage control and
passive self-recovery as well as none of them can promote or accelerate
tissue regeneration. The benefits of ESWT are seen in tissue regenera-
tion and anti-inflammation. Compared with other non-operative treat-
ment, ESWT has important potential for the promotion of tissue re-
growth. Previously, following failure of nonoperative treatments,
success rate of arthroscopic debridement of PTRCTs in competitive
throwing athletes ranges from 50% to 85% [29,37]. However, recovery
from surgical intervention varies from person to person. The duration to
a return to the previous activity level is usually longer than 6 months.
Therefore, a modality that is more aggressive than conventional non-
operative treatment but less invasive than arthroscopic surgery may be
favored. According to present study, ESWT resulted in a satisfaction
rate greater than 50% in patients with PTRCTs or tendinitis, both in
overhead athletes and in the general population. Despite the high re-
currence rate in the athletic group, ESWT is an appropriate alternative
after failure of other conservative treatments owing to non-invasive
nature of the treatment and the fact that there are no treatments con-
flicts should conversion to arthroscopic surgery be necessary.
Based on prolific basic and clinical research into shockwave medi-
cine, ESWT has been introduced in the clinical application of sports
medicine, including the treatment of tibial stress syndrome [20],
plantar fasciitis [21] and muscular microcirculation [22]. Although
unsuccessful results regarding treatment for patellar tendinopathy in
jumping athletes have been reported [16] but the most studies are re-
ported a positive efficacy. In this study, 53.8% of the subjects in the AG
returned to their previous activity level, which was similar to the re-
ported outcome of surgical intervention. ESWT has advantages in terms
of evidence-based tissue regeneration effectiveness and non-violation of
regulations. However, few studies have assessed the application of
ESWT for shoulder tendinitis or partial tears in professional athletes. To
the best of our knowledge, this was the first report to assess the effec-
tiveness of ESWT in overhead athletes and present a comparative
analysis of the outcome of treatment in athletes and non-athletes. Based
on the result of a success rate greater than 50% and the non-invasive
characteristic, ESWT is favored for tissue regeneration treatment over
PRP treatment.

Fig. 3. Representative case showing regression of inflammation and healing of partially-torn supraspinatus tendon 6 months after ESWT. (A) Before ESWT; (B) 6 months after ESWT.

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Limitations of this study exist. First, the retrospective analysis
contains selection bios. Second, the limited patient numbers may lead
to results of lower significance. Third, details regarding ESWT remained
under debate, including the optimal dosage and treatment interval for
different degrees of tendon lesion, which may be closely related to the
less satisfaction rates of 46.2% and 47.9% in the AG and NAG, re-
spectively.
5. Conclusions
In this study, ESWT was found to be equally effective in the athletic
group and the non-athletic group, with rates of patients with a high
level of satisfaction of 53.8% and 52.1%, respectively. In light of early
return to sport, treatment efficacy and less invasive nature with early
recovery, we recommend ESWT for athletes with refractory tendinitis
or a partial tear of the rotator cuff tendon before proceeding to ar-
throscopic intervention.
Ethical approval
Chang Gung Medical Foundation
Institutional Review Board
199, TUNG HWA NORTH ROAD,
TAIPEI, TAIWAN, 10507
REPUBLIC OF CHINA
Tel: (03) 3196200
Fax: (03) 3494549
Date 2016/08/19,
was approved by the Institutional Review Board (the “IRB”) of
Chang Gung Medical Foundation on 2016/08/19. The IRB is organized
and operates according to Good Clinical Practice and the applicable
laws and regulations.
Protocol Title: Comparative outcomes of Extracorporeal Shockwave
Therapy for the tendinitis of the Shoulder in athletes and non-athletes
IRB No.: 201600905B0
Principal Investigator(s): Wen-Yi Chou
Co-Investigator(s): CHING-JEN-WANG
Duration of Approval: From 2016/08/19 TO 2016/09/19
Approved Protocol: Version I,105/8/8
Date of Approval: 2016/08/19
Sincerely Yours,
Tsang-Tang Hsieh, MD
Chairman
Institutional Review Board
Chang Gung Medical Foundation
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Author contribution
Wen-Yi Chou, Ching-Jen Wang, Kuan-Ting Wu, Ya-Ju Yang, Jai-
Hong Cheng, Shih-Wei Wang, contributed to this paper for conception
and design, acquisition of data, and interpretation of data. Wen-Yi Chou
is writing and drafting the article and Ching-Jen Wang revising it cri-
tically for important intellectual content, and final approval of the
version to be published.
Conflicts of interest
The authors declared that they did not receive any honoraria or
consultancy fees in writing this manuscript. No benefits in any form
have been received or will be received from a commercial party related
directly or indirectly to the subject of this article. One author (CJW)
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International Journal of Surgery 51 (2018) 184–190
serves as a member of the advisory committee of Sanuwave, (Suwanee,
GA) and this study is performed independent of the appointment. The
remaining authors declared no conflict of interest.
Trial registry number
Researchregistry2996.
Guarantor
Wen-Yi Chou, Ching-Jen Wang, Kuan-Ting Wu, Ya-Ju Yang, Jai-
Hong Cheng, Shih-Wei Wang.
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