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Actual State of Research

and Experiences in
Classical Shock Wave Indications

M. Henne, L. Gerdesmeyer
Orthopaedic Departement
Klinikum rechts der Isar
Technical University of Munich/Germany
Shock Waves in Atmosphere
May break window panes.

May damage membranes of the ear.


Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
ESWT History
• 1980 first application for crushing kidney stones (1. generation)
• 1987 use for loosening cemented endoprothesis
• 1991 first treatment of nonunion of bones
• 1992 first treatment of calcified
tendintis of shoulder (2. generation)
• 1993 treatment of pain and
inflammations in enthesiopathies
• since 1999 exists the radial (unfocussed)
shock wave device (3. generation)

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Difference of shock waves
focussed unfocussed
(radial)

2. focus
1. focus

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
rESWT
Technique

• Transformation of kinetic energy


• Emission of shock waves
• Shock waves expand in radial waves

Handpiece (schematic)
projectile
applicator

compressed air

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Shock wave or pressure wave ?
0.9 p p +
+
fallende tr = 5 ... 60 ns
> Shock waves in literature: Flanke
~e -kt
t 50 =100 ... 800 ns

0.5 p + p + = 20 ... 100 MPa


t 50

Schalldruck p / [MPa]
p - = -10 ... -50 MPa

0.1 p +
tr

Zeit t / [µs]
p -

Dornier Epos, sound pressure in the focus, level 1 Swiss DolorClast®

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Parameter
Physical quantities Sign Aplicator Ø 15 mm
Peak positive acoustic pressure P+max 11,92 Mpa
Peak negative acoustic pressure P-max - 5,86 MPa
Rise time tr 3 µs
Compressional pulse duration tp 2.5 µs
max. pos. Energy flux density ED+max 0,18 mJ/mm2
Maximum focal width (-6dB focal size x,y) fx-6 dB 8,0  10-3 mm

Orthogonal focal width (-6dB focal size z) fy-6 dB 8,0  10-3 mm

Focal extent fz-6 dB 8,0  10-3mm


Focal volume fv-6 dB 268  10-9 m3
Distance between the focus and target location N.A. (not a focused device)

Derived focal acoustic pulse energy E-6 dB 5.4 mJ

Derived acoustic pulse energy E 8,6 mJ

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Technique

12 pressure ED+
10
WP 4,0 bar
[bar] [mJ/mm2]
8
1,5 0,03
2,0 0,06
P+[MPa]

6
2,5 0,11
4
3,0 0,13
2
3,5 0,16
0
0 10 20 30 40 50
4,0 0,18
axial distance z [mm]

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Schlierenoptik
technique I
• pressure-/ shock waves
• cavitation

Time

Pressure wave

Pressure wave
Pressure wave

Cavitation Cavitation

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Moleculare effects
• transient denervation of nerve endings
acute pain treatment
• hyperaemia
interruption of inflammatory process
• release of substance P and endorphines
antiinflammatory und analgetic effect
• « Gate-control-theory » pain treatment
• osteogenetic effect treatment of non-union of bones
CAVE: Only superficial defects !
Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tennis elbow I

Patients n = 64
♀:♂ 34 : 30
Age Ø 43.5 years
Dominant arm 87,5 %
Permanent PC use 67,2 %
Aktive tennis player 9,4 %
Period of complain Ø 17,6 months

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tennis elbow II

Impulses 2000
Frequency 8 Hz
Pressure 4 bar
Treatments 3x
Periods 4 weeks
Follow up 6 and 12 weeks
Focusierung Patient controlled
– biofeedback orientated

Local anaesthesia!
Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tenis elbow III
results (VAS)
Pain Baseline 6 weeks 12 weeks

General 7.6 3.4 6.5


activity
Pressure 9.4 6.9 6.5
(Dolormeter)
general activity
10
Thomson- 7.1 5.0 3.0 Pressure
Test (Dolorm eter)
8 Thom son-test
Chair- 8.4 4.9 3.7 Chair-test
Test 6

0
Bas el ine 6 weeks 12 weeks

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tennis elbow IV
results (R&M)
Baseline 6 weeks 12 weeks
excellent 0 5 12
good 0 41 43
satisfied 16 11 4
unsatisfied 48 7 5

50
Baseline

40 6 weeks
12 w eeks
30

20

10

0
unsatis fi ed sati sfi ed good excelle nt

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Achilles tendinopathy I

Patients n = 40 (♀ : ♂ = 9 : 31)
Age 35.8 ± 10.5 ys. (20 - 63)
Distribution right = 22, left = 18
Period 12.0 ± 10.6 months conservative

Preliminary treatment with at least 2 methods


Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Achilles tendinopathy II
running induced pain result
(min)
* p < 0,05
120

96,7
80 87,5 90
75,4

40
* 63
50
43
29,3
14,4 23,4
0

pre 2. 3. 4. 5. 1 4 12 26 52
treatment weeks follow up

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Achilles tendinopathy III
(%) results after one year

60
60 %

40

27,5 %
20
12,5 %
0
pain free better unchanged
Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Jumper´s knee I

Patients n = 45 (♀ : ♂ = 12 : 33)
Age 24.2 ± 9.8 ys
Distribution right = 23, left = 22
Period 21.4 ± 9.4 months conservative

Preliminary treatment with at least 2 methods


Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Jumper´s knee II
Results
Baseline 1 week 4 weeks 12 weeks 26 weeks 52 weeks

Rest pain 1.6 0.8 0.6 0.3 0.3 0.3


(VAS)

Pain level 15.1 28.7 30.6 32.9 34.6 35.3


(N)

Pressure 5.5 2.3 2.2 2.1 1.9 1.7


(30 N, VAS)

Stress pain 5.5 2.8 2.5 2.3 1.9 1.9


(VAS)

Running time 10.4 54.3 57.0 62.8 71.2 70.3


(min)

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Jumper´s knee III

80
running time 71,2 70,3
70
62,8
60 54,3 57
50
40
30
20
10,4
10
0
Baseline 1 week 4 weeks 12 weeks 26 weeks 52 weeks

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Plantar fasciitis I

Placebo-controlled single blind study

Patients n = 70
♀:♂ 45 : 35
Age Ø 57.4 ys
right : left 38 : 32
Heel spur: 68%
BMI (kg/m²): 27.0
Period of complain: Ø 21.4 months

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Plantar fasciitis II
Impulses 2000
Frequency 8 Hz
Pressure 4 bar
EFD 0.18 mJ/mm²
Treatments maximum 3 (Ø 2.4)
Period 2 weeks
Follow up 12 weeks
Focusing Patient controlled
– biofeedback orientated

No local anaesthesia !
Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Plantar fasciitis III
results
8
7 p<0.05
6
5
rESWT
4
Placebo
3
2
1
0
Baseline 3 Mo
rESWT 7,1 2,6
Placebo 6,7 5,9

VAS starting pain in the morning

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Plantar fasciitis IV
results
Baseline R&M FU 3 month R&M

30 20
18
25 16
20 14
12
Placebo
15 10
Verum 8
10 6
5 4
2
0 0
excellent good moderate poor excellent good moderate poor

p<0.05

3 month results Roles- & Maudsley-Score

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tendinitis calcarea I

Patients n = 35
♀:♂ 12 : 23
Age Ø 47.5 years
right : left 22 : 13
Period of complain Ø 28 months

unsuccessful conservative therapy for 6 months

Calcified deposit Gärtner 1 or 2


Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tendinitis calcarea II
Impulses 2000
Frequency 8 Hz
Pressure 2 bar
Treatments 3
Periods 7-10 days
Follow up 4 weeks, 3, 6 und 12 months
Focusing Patient controlled
– biofeedback orientated

No local anaesthesia !
Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –
Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tendinitis calcarea III
results (Constant Score)

Baseline 4 weeks 3 months 6 months 12 months


68.5 80.5 74.7 78.9 79.7

85

80

75

Co nsta nt Score
70

65

60
Ba seline 4 weeks 3 month s 6 months 12 months

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tendinitis calcarea IV
results
4 weeks 3 months 6 months 12 months
No pain 25.7 50 59.3 80.8
Decrease of pain 54.3 14.3 25.9 19.2
Persistent pain / 19.9 41.4 14.8 0
increase
90
80
70
60
50 persistent pain/increase
40 decrease of pain
30 no pain
20
10
0
4 weeks 3 months 6 months 12 months

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tibia-Edge-Syndrom I

Patients n = 17 (♀ : ♂ = 3 : 14)
Age 21.2 ± 4.6 ys.
Distribution right = 9, left = 8
Period 9.5 ± 7.3 months conservative

Preliminary treatment with at least 2 methods

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tibia-Edge-Syndrom II
Baseline 1 week 4 weeks 12 weeks 26 weeks 52 weeks

Rest pain 1,7 0,6 0,6 0,5 0,5 0,1


(VAS)

Pain level 16,1 29,1 31,8 32,9 36,3 40,5


(N)
Pressure 6,2 2,4 2,3 1,7 1,5 0,9
(30 N, VAS)

Stress pain 7,8 1,8 2,2 1,9 1,6 0,9


(VAS)

Running time 11,2 62,9 72,9 91,3 91,3 105,0


(min)

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Tibia-Edge-Syndrom III

120
running time
105
100 91,3 91,3

80 72,9
62,9
60

40

20 11,2

0
Baseline 1 week 4 weeks 12 weeks 26 weeks 52 weeks

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Discussion

• significant effect in enthesiopathies


• well documented effects
• no relevant side effects
• results increase in a period of 1 year
• simple and quick application
• good acceptance of patients
• perfect application in sports medicine
(no doping regulations)

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Suggested parameters
Frequency Pressure Compression Impulses Treatment Intervals
(Hz) (bar) s
Plantar 8 – 10 2.5 – 4 strong 2.000 3–5 1x / week
fasciitis
Tennis elbow 4-8 2.5 - 4 soft 2.000 3-5 1x / week

Tendinosis 4-8 2.5 - 4 middle to 2.000 3–5 1x / week


calcarea strong
Achilles 6 – 10 2–3 soft to 2.000 3–5 1x / week
tendinopathy middle
Jumper´s 6 – 10 2–3 soft to 2.000 3–5 1x / week
knee middle
Trigger- 10 - 12 2–3 middle to 2.000 3–5 2x / week
points strong

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
„It takes profound knowledge
to do simple things.“
A.Turgot, (French Minister of Finances 1774)

Introduction – Technique – Tennis elbow – Achilles tendinopathy – Jumper´s knee –


Plantar fasciitis – Tendinitis calcarea – Tibia-edge-syndrom – Discussion
Thank you !