Shock Wave Therapy. Does it Work?

Extracorporeal Shock Wave Therapy in Musculoskeletal Disorders

Extracorporeal Shock Wave Therapy (ESWT) for the treatment of musculoskeletal disorders is becoming a popular intervention in recent times. It has been reported in the literature as a growing field for the treatment of many orthopaedic conditions such as plantar fasciitis, lateral epicondylitis (tennis elbow), calcific tendinopathies, non-union fractures, etc. (1) Today’s blog will try to shed some light over a few musculoskeletal disorders and the research evidence behind the use of ESWT for each of them.

Lower Limb Tendinopathy

A high quality paper published in 2015 (2) has investigated the available evidence behind ESWT in different lower limb conditions. After a thorough review the authors concluded that there is moderate evidence supporting the use of ESWT in greater trochanteric pain syndrome, a type of lateral hip pain, when compared to home training and corticosteroid injection in the short and long term.

However, for patella tendinopathy (runner’s knee), ESWT compared against other treatments such as physiotherapy care, shows limited evidence in favour of the ESWT. That finding is in line with current evidence which mostly advocates load management to be a crucial feature in tendon pathology.

The same authors report that moderate evidence supports the use of ESWT in Achilles Insertional tendinopathy when compared to eccentric loading training in the short term. It is important to highlight Achilles Tendinopathy is a multifactorial condition and is clinically subdivided into insertional or mid-portion type. When looking into the mid-portion group, ESWT is as effective as Eccentric loading programs; however, combining eccentric loading with ESWT seems to yield superior outcomes according to research.

Others have a different opinion (3). In this Systematic Review, the author found the evidence in favour of the ESWT to be limited when addressing Achilles Tendinopathies. Despite acknowledging there is some research in support of the therapy, it is their opinion more high quality research must be done before deciding on the value of adding ESWT in the management of Achilles Tendinopathy.

Considering the conflicting evidence in the literature, consumers are encouraged to seek professional advice in trying to decide the best course of action when contemplating ESWT for Lower Limb Tendinopathies.

Lateral Elbow Pain

Lateral elbow pain, also known as ‘tennis elbow’, is a recurrent condition seen in the clinic. When looking at the benefits of ESWT regarding pain and function in patients suffering from lateral elbow pain, the evidence is not encouraging. Two high quality studies (3, 4) highlight the lack of positive results in adopting ESWT as a treatment when compared to placebo. To clarify, placebo effect is the negative or positive results attributed to a placebo treatment, for instance, a sugar pill instead of a pill containing an active medication. Therefore, researches commonly compare interventions against placebos in order to establish if the positive or negative results seen with the administration of a given intervention are linked to the intervention itself, or a placebo-effect, by comparing it to a placebo-controlled group.
So, if you are thinking of going ahead with ESWT for the treatment of lateral elbow pain you may want to give it a bit more thought first. Get help from a professional.

Plantar Fasciitis

When we look at plantar fasciitis under the research microscope, the results of adding ESWT to a treatment plan are more encouraging because the literature recognises the benefits of its use. Good quality research is supportive of the ESWT, particularly in recalcitrant plantar fasciitis (3, 5, 6). The authors of those studies agree that in the short term, pain relief and functional outcomes are satisfactory when using ESWT for chronic plantar fasciitis and superior than placebo. It is important to mention that low-dose focused ESWT does not seem to help those patients. In order words, even when compelling research is supportive of a given therapy, due to the variations in ESWT administration, a professional opinion is the best in helping you to clarify not only if a given intervention may be of benefit to your situation, but also how it should be integrated in your care.

In summary, from research perspective we can give thumbs-up to the use of ESWT in patients struggling to recover from plantar fasciitis that does not want to go away.

Calcific Tendinopathies of the Shoulder

As per plantar fasciitis, Calcific Tendinopathies of the Shoulder also have a thumbs-up from the evidence. Three good quality papers (3, 7, 8) are in agreement that ESWT is an effective option in treating this condition. They report decrease in shoulder pain, improvements in shoulder function and quicker reabsorption rate of the calcium deposits within the tendon. Still, these studies have pointed out that in order to achieve those results a regime of high energy shock wave must be applied. Low energy ESWT does not seem to be effective in helping those with calcific tendinopathy of the shoulder.

Take home message, according to the current literature, you may consider high energy ESWT as an option in the management of this pathology.

Non-Calcific Rotator Cuff Tendinopathy

Unfortunately, in the light of current research, non-calcific tendinopathies of the shoulder do not benefit from ESWT (3, 8). Just like lateral elbow pain and patella tendinopathy, to use ESWT in non-calcific shoulder tendinopathy is not better than placebo and; therefore, cannot be recommended. In fact, one author reports on limited evidence for its inefficacy (3).

Non-union Fracture

A systematic review of the literature performed in 2010 reported that ESWT seems to help the healing of delayed and non-union fracture sites (9). Ten studies were included in this review and data from 924 patients analysed. Overall, the conclusion was that ESWT can stimulate the healing process. Nevertheless, due to the moderate to low quality of the available studies included in this review, the authors still believe that further research is still warranted before we can draw stronger conclusions in favour or against the ESWT in these cases.

There are positives, negatives & lots of questions around ESWT as a treatment for musculoskeletal disorders. Click To Tweet

Final Considerations

After reading this blog, you may now realise ESWT is not a straightforward topic. There are positives, negatives and lots of questions around ESWT as a treatment option for musculoskeletal disorders. In summary, ESWT is a safe modality that can be helpful in special circumstances if combined with sound clinical reasoning. If you are still unsure if ESWT is a good option for you problem or not, feel free to contact the Pogo Physio Team.

Bruno Rebello (APAM)

Physiotherapist

References

1. Romeo P, Lavanga V, Pagani D, Sansone V. Extracorporeal Shock Wave Therapy in Musculoskeletal Disorders: A Review. Med Princ Pract Medical Principles and Practice. 2014;23(1):7–13.
2. Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy: A Systematic Review. The American Journal of Sports Medicine. 2014Sep;43(3):752–61.
3. Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. British Journal of Sports Medicine Br J Sports Med. 2013May;48(21):1538–42.
4. Buchbinder R, Green S, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews Reviews. 2005;
5. Yin M-C, Ye J, Yao M, Cui X-J, Xia Y, Shen Q-X, et al. Is Extracorporeal Shock Wave Therapy Clinical Efficacy for Relief of Chronic, Recalcitrant Plantar Fasciitis? A Systematic Review and Meta-Analysis of Randomized Placebo or Active-Treatment Controlled Trials. Archives of Physical Medicine and Rehabilitation. 2014;95(8):1585–93.
6. Dizon JNC, Gonzalez-Suarez C, Zamora MTG, Gambito ED. Effectiveness of Extracorporeal Shock Wave Therapy in Chronic Plantar Fasciitis. American Journal of Physical Medicine & Rehabilitation. 2013;92(7):606–20.
7. Verstraelen FU, N. J. H. M. In Den Kleef, Jansen L, Morrenhof JW. High-energy Versus Low-energy Extracorporeal Shock Wave Therapy for Calcifying Tendinitis of the Shoulder: Which is Superior? A Meta-analysis. Clinical Orthopaedics and Related Research® Clin Orthop Relat Res. 2014;472(9):2816–25.
8. Huisstede BM, Gebremariam L, Sande RVD, Hay EM, Koes BW. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis – A systematic review. Manual Therapy. 2011;16(5):419–33.
9. Zelle BA, Gollwitzer H, Zlowodzki M, Bühren V. Extracorporeal Shock Wave Therapy: Current Evidence. Journal of Orthopaedic Trauma. 2010;24.

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