Extracorporeal shockwave therapy (ESWT) uses high energy acoustic waves to help stimulate healing and decrease pain in patients with tendinopathy and bone injuries. Unlike more invasive interventions for these types of injuries, ESWT typically involves fewer post-procedure restrictions, allowing patients to continue training or participating in sports during treatment.
While ESWT has been a mainstream treatment in Europe for some time, it is relatively newer in the United States, and has lacked official standardized protocols. Evidence is steadily growing regarding its effectiveness in treatment of musculoskeletal and sports injuries that do not improve with standard care.
Jennifer Soo Hoo, M.D., a sports medicine physiatrist at NewYork-Presbyterian and Weill Cornell Medicine, was joint senior coauthor on a paper recently published in the British Journal of Sports Medicine that presents 69 new consensus statements on using ESWT for tendon and bone injuries. Below, Dr. Soo Hoo discusses the new consensus statements and how they can help providers feel more confident offering ESWT to their patients.
How ESWT Works and What Conditions It Can Help Treat
ESWT uses high energy acoustic waves to stimulate interstitial and extracellular responses, promoting healing and helping provide pain relief for certain musculoskeletal conditions. This type of technology has been used for years to treat kidney stones via lithotripsy. In recent years, researchers have modified it for use in treating musculoskeletal and sports injuries. While ESWT’s exact mechanism of action remains unknown, it is thought to be through cellular mechanotransduction, where mechanical stimuli lead to cellular migration and proliferation to increase vascularity and blood flow as well as modulate pain pathways to decrease pain.
There are two main forms of ESWT used in clinical practice:
- Focused Shockwave Therapy: Generates sound waves that penetrate deeper structures at the application site — this is considered "true shockwave" therapy.
- Radial Pressure Wave Therapy: Produces pressure waves that affect more superficial structures.
It is important to distinguish between these two, as many patients who say they have had "shockwave therapy" may have only received radial pressure wave therapy, which is less intense and not true ESWT. In many cases, a combination of focused shockwave and radial pressure wave therapy provides optimal results.
We wanted to create a clear protocol for providers that clarifies when it is appropriate to use ESWT to treat tendon and bone injuries.
— Dr. Jennifer Soo Hoo
While ESWT has long been popular in Europe, it is still emerging in the United States. The FDA has approved ESWT for treating plantar fasciitis and lateral epicondylopathy (tennis elbow). Physicians at NewYork-Presbyterian and Weill Cornell Medicine began offering ESWT to patients in 2020. Common conditions treated with ESWT include:
- Tendinopathies (Achilles, hamstring, elbow, gluteal, and rotator cuff)
- Plantar fasciitis
- Bone injuries (stress injuries or fractures with delayed healing)
There are a few contraindications for the use of ESWT. Providers should not perform ESWT over an area of active malignancy or over the thoracic cavity. We avoid using ESWT on pregnant patients and on anyone who has a pacemaker or any other electronic implanted device. Providers who are pregnant should also avoid performing ESWT because the exposure to prolonged loud noise of the machine could damage fetal hearing especially during 18-30 weeks of gestation.
Establishing Expert Consensus for ESWT
Given the growing use of ESWT, our research team aimed to create clearer recommendations for providers. We conducted a three-stage, modified Delphi questionnaire completed by a panel of 41 international clinical and research experts from 13 countries. There were a wide variety of disciplines represented on the panel, including nonoperative musculoskeletal sports medicine specialists, orthopedic surgeons, podiatrists, and physical therapists.
We reached consensus on 69 out of 118 statements. The new consensus statements include recommendations on ESWT terminology and concepts, indications, procedural aspects for tendinopathy and bone pathologies, periprocedural and postprocedural considerations, contraindications, and potential side effects.
Most of the statements where we did not reach consensus involve procedural aspects of bone pathology and large tendon tears. More high-quality research is needed to study the effects of ESWT on these injuries before we can reach international consensus on the best way to use this approach to treat these conditions.
Treatment Expectations
Especially among our patient population of on-the-go New Yorkers, we found that ESWT is an attractive intervention for patients with bone and tendon injuries because it requires much less activity restriction than any other interventional procedure offered. Patients can expect to feel some discomfort during the session which on average lasts about 5-10 minutes. We always start with lower energy and work our way up according to the patient’s tolerance.
For tendon injuries, patients can expect to undergo three to five ESWT sessions about one to two weeks apart. For bone injuries, patients undergo three to four ESWT sessions on average typically one week apart. We usually do a combination of radial pressure wave and focused ESWT for tendon injuries and focused ESWT for bone.
The procedure is not associated with any major side effects. Most common side effects include pain at application site, skin erythema, and skin bruising. Patients generally do not have any long-term activity restrictions or range of motion restrictions, but this is dependent on the severity of the injury being treated. On average, it takes about 6 to 12 weeks for patients to feel significant clinical benefit.
My advice to providers who are interested in incorporating ESWT is to attend a course to learn from physicians who already use ESWT and ask them questions. I field questions daily from providers across the country asking about my experience with ESWT. Those of us who have experience using this technology should make ourselves readily available so that other physicians can help promote its use more broadly.
