In an era where many passive therapy modalities are falling out of favor, one modality is bucking that trend. Extracorporeal Shock Wave Therapy (ESWT) is a relatively new modality that has rapidly growing research support for a variety of musculoskeletal conditions. A September 2018 meta-analysis of 29 RCT’s concluded:
“Extracorporeal shock wave therapy exerted a positive overall effect on pain and function for lower-limb tendinopathy.” (1)
Another recent study suggested that ESWT is not only an option for tendinopathy, but possibly the BEST option:
“Shockwave therapy significantly reduced the pain that accompanies tendinopathies and improves functionality and quality of life. It might be the first choice (for treating tendinopathies) because of its effectiveness and safety.” (2)
Check out this video demonstration of Shockwave Therapy in action, then read on to learn more about the evidence-based integration of this promising technology.
Considering our current understanding of tendinopathy, the ESWT seems to be an ideal management concept.
Unlike acute injuries that cause inflammation, tendinopathy is characterized by repeated overloading, micro-tearing, failed healing, and subsequent tendon degeneration. (3-6). The process begins with collagen fiber disruption and ends in a disorganized healing process that fails to regenerate a “normal” tendon.
For more insight about how chronic tendonitis is a misnomer for “tendinopathy”, check out this past ChiroUp blog.
Shockwave Therapy has shown promise for the management of several disorders including:
- Carpal tunnel syndrome (7,20,21)
- Lateral epicondylopathy (8,22)
- Achilles tendinopathy (10,11)
- Plantar fasciitis (12,13,14)
- Greater trochanteric pain syndrome (15)
- Medial tibial stress syndrome (16)
- ITB syndrome (17)
- Hamstring tendinopathy (18)
- Patellar tendinopathy (19)
- Rotator cuff tendinopathy (23)
Shock Wave Therapy is reportedly safe and quite simple to perform. Regarding delivery parameters, a recent systematic review concluded: “An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.” (24) A procedure lasts only a couple of minutes. Depending on state and carrier regulations, the application may generally be delegated to a trained assistant.
Shock Wave Therapy is considered investigational and is not currently reimbursed by third-party health insurance carriers. However, any associated myofascial release may be reimbursable when it is provided as a separate and distinct service from the shockwave therapy. Clinicians are forced to choose between providing Shock Wave Therapy at no additional cost vs. cash billing the patient with procedure codes 0101T or 97039 (when allowed).
Shock Wave Therapy units deliver energy in either a “focused” or “radial” fashion. Technically, only “focused” ESWT units are considered true “shockwave” modalities. Radial Pressure Wave (RPW) devices i.e. “radial” units are considered “pulse wave”. The designation may be splitting hairs since both devices share a similar treatment concept of tissue disruption for similar conditions – with differing delivery technology. Focused units have the ability for greater penetration; however, radial (pressure wave) units seem to produce similar outcomes for many musculoskeletal conditions. (25,26,28) Radial units are substantially less expensive than focused varieties.
The major Shock Wave and Radial Pulse Wave therapy manufacturers are Zimmer, Mettler, and Storz. The Chattanooga unit used in the accompanying video is manufactured by Storz. ChiroUp members are eligible for a substantial discount on Chattanooga units purchased through Scrip Hessco. If you are interested in learning more, email or call Larry Knutson directly at (309) 258-1038. (ChiroUp receives no compensation for this or any other subscriber-benefit discount.)
Do you have experience with or additional information about Shock Wave Therapy? We would love to hear about it. Email your input to support@ChiroUp.com.
* Special thanks to Bruce Zilka, Regional Sales Manager from DJO Chattanooga for assisting with the accompanying video, and Chattanooga Clinical Consultant, Dr. Christopher M. Proulx, DC, PhD(abd), ATC, CSCS for his expert editorial contributions, and compliance expert Mario Fucinari for providing billing and coding clarification. Click here to see Dr. Fucinari’s upcoming course schedule.
- Liao CD et al. Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2018 Sep;97(9):605-619. doi: 10.1097/PHM.0000000000000925.
- Dedes V et al. Effectiveness and Safety of Shockwave Therapy in Tendinopathies. Mater Sociomed. 2018 Jun;30(2):131-146. doi: 10.5455/msm.2018.30.141-146.
- Gibbon, W.W., Cooper, J.R., Radcliffe, G.S. (1999). Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis. British Journal of Sports Medicine 33, 129–30.
- Kvist M. Achilles tendon injuries in athletes. Sports Med1994;18:173–201.
- Kader, D., Saxena, A, Movin, T, and Maffulli, N. (2002) Achilles tendinopathy: some aspects of basic science and clinical management. British Journal of Sports Medicine 36, 239-249.
- Astrom M. On the nature and etiology of chronic achilles tendinopathy. PhD thesis, Lund University, Sweden, 1997.
- Bionka M. Huisstede, Peter Hoogvliet, Thierry P. Franke, Manon S. Randsdorp, Bart W. Koes Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials Archives of Physical Medicine and Rehabilitation 2018;99:1623-34
- Aydın A , Atiç R. Comparison of extracorporeal shock-wave therapy and wristextensor splint application in the treatment of lateral epicondylitis: a prospective randomized controlled study. J Pain Res. 2018 Aug 2;11:1459-1467. doi: 10.2147/JPR.S166679. eCollection 2018
- Saxena A, Ramdath S Jr, O’Halloran P, Gerdesmeyer L, Gollwitzer H. Extra-corporeal pulsed-activated therapy (“EPAT” sound wave) for Achilles tendinopathy: a prospective study. Foot Ankle Surg. 2011;50(3):315-9.
- Rompe, Furia, Maffulli et al, Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy. A Randomized Controlled Trial. Am J Sports Med. 2009 Mar;37(3):463-70.
- Lou J, Wang S, Liu S, Xing G. Effectiveness of Extracorporeal Shock Wave Therapy Without Local Anesthesia in Patients With Recalcitrant Plantar Fasciitis: A Meta-Analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2017 Aug;96(8):529-534.
- Ibrahim MI, Donatelli RA, Hellman M, Hussein AZ, Furia JP, Schmitz C. Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: A prospective, randomized, placebo-controlled trial with two years follow-up. J Orthop Res. 2017 Jul;35(7):1532-1538.
- Eslamian F, Shakouri SK, Jahanjoo F, Hajialiloo M, Notghi F. Extra Corporeal Shock Wave Therapy Versus Local Corticosteroid Injection in the Treat- ment of Chronic Plantar Fasciitis, a Single Blinded Randomized Clinical Trial. Pain Med. 2016 Sep;17(9):1722-31.
- Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home Training, Local Corticosteroid Injection, or Radial Shock Wave Therapy for Greater Trochanter Pain Syndrome. Am J Sports Med. 2009 Oct;37(10):1981-90.
- Rompe JD, Cacchio A, Furia JP, Maffulli N. Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Medial Tibial Stress Syndrome. Am J Sports Med. 2010 Jan;38(1):125-32.
- Weckström K, Söderström J. Radial extracorporeal shockwave therapy compared with manual therapy in runners with iliotibial band syndrome. J Back Musculoskelet Rehabil. 2016;29(1):161-70.
- Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave Therapy for the Treatment of Chronic Proximal Hamstring Tendinopathy in Professional Athletes . Am J Sports Med. 2011 Jan;39(1):146-53.
- van der Worp H, Zwerver J, Hamstra M, van den Akker-Scheek I, Diercks RL. No difference in effectiveness between focused and radial shockwave therapy for treating patellar tendinopathy: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2014 Sep;22(9):2026-32.
- Atthakomol P, Manosroi W, Phanphaisarn A, Phrompaet S, Iammatavee S, Tongprasert S. Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial. BMC Musculoskelet Disord. 2018 Jan 25;19(1):32.
- Wu YT, Ke MJ, Chou YC, Chang CY, Lin CY, Li TY, Shih FM, Chen LC. Effect of radial shock wave therapy for carpal tunnel syndrome: A prospective randomized, double-blind, placebo-controlled trial. J Orthop Res. 2016 Jun;34(6):977-84.
- Beyazal MS, Devrimsel G. Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis. J Phys Ther Sci. 2015 Dec;27(12):3755-8.
- Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Santilli V. Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months’ follow-up: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013 Sep;94(9):1699-706.
- Schmitz C, Császár NB, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015;116(1):115-38.
- Król P, Franek A, Durmała J, et al. Focused and Radial Shock Wave Therapy in the Treatment of Tennis Elbow: A Pilot Randomised Controlled Study. J Hum Kinet. 2015;47:127-35. Published 2015 Oct 14. doi:10.1515/hukin-2015-0068
- Worp et al. No difference in effectiveness between focused and radial shockwave therapy for treating patellar tendinopathy: a randomized controlled trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. (2013). 22. 10.1007/s00167-013-2522-z.
- Cristina d’Agostino M, Craig K, Tibalt E, Respizzi S. Shock wave as biological therapeutic tool: From mechanical stimulation to recovery and healing, through mechanotransduction. Int J Surg. 2015 Dec;24(Pt B):147-53.
- Schmitz, C. Focused and radial extracorporeal shock wave therapy: more similarities than differences. Physiotherapy , Volume 101 , e1346 – e1347
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
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