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Extracorporeal
Shockwave Therapy

Original Editor - Ayushi Tomer

Top Contributors - Cindy John-Chu, Sue

Safadi, Amanda Ager, Ayushi Tomer and Kim
Jackson

Online Course: Introduction to…

History of Extracorporeal
Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT)

otherwise referred to as shockwave therapy, was
first introduced into clinical practice in 1982 for
the management of urologic conditions [1]. The
success of this technology for the treatment of
urinary stones quickly made it a first-line,
noninvasive, and effective method [2].
Subsequently, ESWT was studied in orthopedics
where it was identified that it could loosen the
cement in total hip arthroplasty revisions[3].
Further, animal studies conducted in the 1980s
revealed that ESWT could augment the bone-
cement interface, enhance osteogenic response
and improve fracture healing [4][5]. While
shockwave therapy has been shown to be
beneficial in fracture healing, most orthopedic
research has focused on upper and lower
extremity tendinopathies, fasciopathies, and soft
tissue conditions.

Physiology of ESWT

Shockwaves are sound waves that have specific

physical characteristics, including nonlinearity,
high peak pressure followed by low tensile
amplitude, short rise time, and short duration
(10 ms). They have a single pulse, a wide
frequency range (0-20 MHz), and a high pressure
amplitude (0-120 MPa)

These characteristics produce a positive and

negative phase of shockwave. The positive phase
produces direct mechanical forces, whereas the
negative phase generates cavitation and gas
bubbles that subsequently implode at high
speeds, generating a second wave of shockwaves.
[6]

In comparison to ultrasound waves, the

shockwave peak pressure is approximately 1000
times greater than the peak pressure of an
ultrasound wave.[7]

Mechanism of Action

The effects of ESWT treatment are unknown[8].

However, the proposed mechanisms of action for
ESWT include the following: promote
neovascularization at the tendon-bone junction
[9], stimulate proliferation of tenocytes [10] and
osteoprogenitor differentiation [11], increase
leukocyte infiltration [12], and amplify growth
factor and protein synthesis to stimulate collagen
synthesis and tissue remodeling [10] [11] [13] [14].

Principles of Sho ck wave

Therapy

Shockwaves are transient pressure disturbances

that propagate rapidly in three-dimensional
space. They are associated with a sudden rise
from ambient pressure to their maximum
pressure. Significant tissue effects include
cavitation, which are consequent to the negative
phase of the wave propagation.

Direct shockwave and indirect cavitation effects

cause hematoma formation and focal cell death,
which then stimulate new bone or tissue
formation.

Indications for Shockwave

Therapy

Shockwave therapy is primarily used in the

treatment of common musculoskeletal
conditions. These include:

Upper and lower extremity tendinopathies

Greater trochanteric pain syndrome
Medial tibial stress syndrome
Patellar tendinopathy
Plantar fasciopathy.
Adhesive capsulitis[15]
Non-union of long bone fracture
Avascular necrosis of femoral head[7]
Osteoarthritis of the knee[16]

There is no standardized ESWT protocol for the

treatment of musculoskeletal conditions.

Contraindications to ESWT in
Physiotherapy

1. Pregnancy
2. Over major blood vessels and nerves
3. Pacemakers or other implanted devices
4. Open wounds
5. Joint replacements
6. Epiphysis
7. Blood clotting disorders including
thrombosis
8. Infection
9. Cancerous tissues
10. A compromised mental status of the patient
and/or the inability to cooperate.

Differences between ESWT and

Therapeutic Ultrasound

Therapeutic ultrasound utilises high

frequency sound waves, while ESWT
utilises lower frequency waves.
Ultrasound may produce either thermal or
non-thermal effects in tissues, while ESWT
does not result in heating effects.

Similarities between Therapeutic

Ultrasound and ESW T

Both modalities employ acoustic waves to

produce therapeutic benefits.
They both make use of a coupling medium
to transmit sound waves to the tissues
being treated.
They are both non-invasive forms of
treatment.

Evidence-based

According to a study performed by Rompe and

coworkers[17], stretching exercises in
combination with radial shock wave therapy is
more efficient for the treatment of chronic
symptoms of proximal plantar fasciopathy than
repetitive radial pressure wave therapy alone.
Patients were subjected to three sessions of 2000
radial pressure pulses (EFD = 0.16 mJ/mm 2) in
weekly intervals, generated with a ballistic
device (air compressor pressure 4 bar; rate 8 Hz)
manufactured by Electro Medical Systems.

A study to investigate the clinical outcomes of

ESWT on calcaneal spurs of 108 patients and its
correlation with radiologic changes were
reported by Yalcin et al. [18]. All the patients
underwent radial pressure wave therapy once a
week for 5 weeks (2000 pressure waves starting
at an EFD of 0.05 mJ/mm 2 and increasing up to
0.4 mJ/mm 2). After the therapy, approximately
67 % of the patients reported no pain; however,
there was no correlation between clinical
outcome and radiologic changes. The authors
concluded that even without radiologic change.

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Knee Electrotherapy - Physiopedia
evidence for you to read. Extracorporeal Shockwave
Introduction This page will look at popular methods
Therapy (ESWT)[edit | edit source] ESWT has been
of electrotherapy and the evidence to support it in
researched as a conservative treatment option for
the use of knee conditons specifically. Pulsed
various tendinopathies.[1][2][3][4] There is
Shortwave Therapy [edit | edit source] Pulsed
Therapeutic
conflicting evidence Modalities for and - Physiopedia
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patient
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of Achilles | edit source]
tendinopathy. Although Ultrasound
uncomfortable experience, that is expensive with
utilises
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