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SECTION I SYMPOSIUM: Extracorporeal Shock Wave Therapy in Orthopaedics

Shock Wave Therapy (Orthotripsy®) in Musculoskeletal Disorders

Ogden, John A. MD*; Alvarez, Richard G. MD**; Levitt, Richard MD; Marlow, Marie RN

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Clinical Orthopaedics and Related Research: June 2001 - Volume 387 - Issue - p 22-40
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Since the initial therapeutic introduction of shock waves to the human body to noninvasively treat kidney stones (lithotripsy), this technology has evolved to be considered the procedure of primary choice for urolithiasis. 5,25,62,105,152 In contrast, surgery to extricate urinary calculi now is reserved for those few patients who do not respond to treatment with extracorporeal shock waves, or those patients who, because of certain medical disorders, are not appropriate candidates for the technology. Other types of stones (biliary, salivary) also have been addressed with shock waves. 73

In some of the experimental studies to assess the effects of extracorporeal shock waves on various animal tissues, it became evident that if the ilium was in the wave propagation pathway a demonstrable effect was initial, focal osteocyte death followed by significant recruitment of osteoblasts within 72 hours. 15,37,40,41,61 Because of these observations and other analyses of the effects of extracorporeal shock waves on urinary stones of differing hardness and composition, many studies were undertaken to assess the effects of shock waves on similar hard tissues such as bone and contiguous, near bone tissues (cartilage, tendon, fascia). 2,3,25,37,55,60,61,72,85,89,92,120,135,166,170,175,176,185,186

Valchanou et al 185,186 showed that high extracorporeal shock wave energy actually would fracture rat bones, whereas lower applied energy levels stimulated osteogenesis, especially the elaboration of callus. A subsequent study confirmed the osteogenic potential of shock waves and the possibility of reactivating osteogenesis in fracture nonunions that could lead to healing by noninvasive methods. 25 Ekkernkamp and coworkers 53–55 were able to show dose-dependent osteoblast recruitment and osteogenesis and the production of callus in a fracture pseudarthrosis model. This led to early clinical applications for patients with delayed union and nonunion. These studies showed a positive effect of extracorporeal shock waves on initiating fracture healing in patients in whom the natural biologic fracture healing process had failed.

It became evident that lithotripsy technology had to be modified for appropriate use on musculoskeletal tissues. The energy characteristics and delivery systems applicable to urologic applications have limitations, if not possible contraindications, when used on musculoskeletal tissues. Accordingly, numerous manufacturers have developed devices specifically for bone and contiguous soft tissue applications. Three such devices, OssaTron® (High Medical Technologies, Lengwil, Switzerland), Epos (Dornier, Germering, Germany) and Sonocur (Siemens, Erlangen, Germany), have instituted United States Food and Drug Administration-approved, randomized, double-blind studies. To date the Food and Drug Administration has approved only the OssaTron for the treatment of chronic proximal plantar fasciitis.

The aforementioned devices rely on different methods to generate the shock waves. The OssaTron produces shock waves electrohydraulically, whereas the Epos and Sonocur generate shock waves electromagnetically. These methods produce different volumes and amounts of energy, and different depths of penetration into human tissue. Whether treatment efficacy differences will be evident still needs to be determined from the ongoing studies being conducted under Food and Drug Administration sanction and through future studies comparing machines in a randomized study with each other. At least one other generational mechanism, piezoelectricity, is available, but is not currently undergoing Food and Drug Administration-approved testing.

The increasing potential and importance of extracorporeal shock waves to the treatment of musculoskeletal disorders has led to not only an increasing number of publications, but also to the formation of the International Society for Musculoskeletal Shock Wave Therapy. This organization particularly is concerned with encouraging the conduct of credible efficacy studies and standards of application of the technology, while recognizing the need for interaction with medical practice regulations specific to each country or region.

To prove that extracorporeal shock wave treatment is clinically equal to or even more effective than treatment modalities that currently are used, appropriate efficacy analyses must be conducted. 124,125,134,161 Unfortunately, for many of the potential applications similar studies have not been conducted even for currently accepted nonoperative treatment preferences. For example, there are no documented studies comparing the relative benefits of oral drugs (nonsteroidal antiinflammatory agents) compared with injection of cortisone, and, in turn, compared with placebo treatment, for a disorder such as plantar fasciitis. Additionally, endoscopic or open surgical release of the plantar fascia also lacks such comparison and placebo studies. Surgery and cortisone injections have significant complication risks, delayed healing, and recurrence.

Extracorporeal shock wave therapy for musculoskeletal use is an emerging technology that has been used principally in Europe for less than a decade. The emphasis has been on clinical application, without a great deal of experimental evaluation of the mechanisms of action on different musculoskeletal tissues or contiguous neurovascular structures. Many of the published clinical studies lack significant data generating parameters that would allow credible outcome analysis.

Because of the proliferation of articles dealing with the application of extracorporeal shock waves to musculoskeletal tissues, Heller and Niethard 82 did a metaanalysis of those studies published as of early 1997. They classified articles based on the methodology of the study and thought that only a limited number of studies warranted comparison for analysis of extracorporeal shock waves effectiveness. Only approximately 20% of the published treatment cases fit such selective criteria. They thought the results of treatment for plantar fasciitis were credible, whereas all other indications warranted additional study. Haist et al 65 and Haupt 73 also presented an overview of emerging musculosketal applications of extracorporeal shock waves as of 1997.

Because the literature proliferated after 1997, and with the publication of proceedings of focused meetings (such as the annual meeting of the International Society for Musculoskeletal Shock Wave Therapy), the authors have upgraded and reassessed the data of Heller and Niethard to additionally evaluate the potential clinical use and efficacy of extracorporeal shock waves as applied to musculoskeletal disorders. The authors also have revised the study classification system to reflect differences between ongoing and completed Food and Drug Administration-approved extracorporeal shock waves studies and types of studies previously reported in the literature.


Because the current metaanalysis is an update of additional material published after the review article of Heller and Niethard, 82 and a reassessment of data in their article, the authors have used a similar classification scheme to that proposed by the American Association for Spine Surgery. 183 In this previous classification, Type A studies were prospective studies including control groups and having adequate followup data, whereas Type B studies also were prospective, but lacked control groups. However, neither the Type A or Type B category fits the specific criteria required of a randomized, double-blind crossover study, as have been and are being conducted under Food and Drug Administration scrutiny to assess the efficacy of extracorporeal shock waves for musculoskeletal applications. Such studies blind the treating and evaluating physicians and the patients, and include validated outcome assessments. 13,24 The authors have classified such randomized, double-blind studies as Type A, and reassigned designations to the previous classification. In addition, the authors have added another classification (Type F) that would include studies using retrospective data, with or without recall of patients for up to date clinical assessment. Finally, the last classification, abstracts, has been broken down to discern abstracts published in proceedings of meetings from verbal presentations not accompanied by written proceedings. The last two categories (Types G, H) reflect the number of podium presentations that eventually may or may not be published in peer-reviewed journals. Publication rates vary considerably among societies, with rates of 20% or less occurring in some societies. As an additional example, the papers presented at the London meeting of the International Musculoskeletal Shockwave Therapy Society in 1999 were published in book form. 29 The papers varied considerably in their format and often presented minimal study details, results, or statistical analyses. This book, and abstracts, often lack peer-review and have inaccessability to Medline retrieval. This makes Types G and H studies the least credible for citation, even though they may be excellently conducted studies. Realistically, Types G and H studies should not be compiled numerically for metaanalysis, but certainly may be cited for new ideas or trends pending their eventual peer-reviewed publication.

Accordingly, the quality of published clinical outcome studies is as follows: (A) prospective study with randomized, double-blind crossover, statistically validated differences between patients who are treated and patients who receive a placebo and followup studies of sufficient scope and duration, with all patients being treated by exactly the same protocol; (B) prospective study with appropriate control group (nonrandomized), adequate analysis and followups of sufficient scope and duration in which neither study subjects nor treating and evaluating physicians are blinded to actual treatment and the treating and evaluating physician may be the same individual; (C) prospective study without a control group, but with adequate analysis and followup of sufficient scope and duration; (D) prospective study with a control group, but with a followup of insufficient duration or inadequate followup protocol; (E) all other published prospective studies, with the exception of abstracts, with such studies having a hard-to-understand study protocol with inadequate followup of the patient cohort; (F) retrospective data analysis studies that may include patients treated by one or more physicians, and often have variations in treatment that the patient receives, which may or may not involve an attempt to actually assess the patients to obtain accurate, up to date outcome data, and may include metaanalyses and evidence-based medicine reviews; (G) published abstract (in the meeting proceedings or a society journal) of an invited presentation to a recognized scientific society; and (H) unpublished presentation (in the meeting proceedings) to a recognized scientific society or group.

Under this reclassification only the currently approved Food and Drug Administration study on plantar fasciitis, 126 and the currently ongoing studies of extracorporeal shock wave treatment of plantar fasciitis, lateral epicondylitis, and delayed union or nonunion of tibial fractures conform to the Type A category. All other studies fit the Types B to H classifications.

Because the published material covers a wide-spectrum of musculoskeletal conditions, the published data will be analyzed by specific topic: (1) heel spur or plantar fasciitis; (2) lateral epicondylitis; (3) delayed union or nonunion of fractures; (4) calcific tendinitis of the shoulder; (5) other enthesopathies; and (6) additional skeletal applications. Articles that only relate to the basic science of shock waves will be reviewed in the Discussion section.


More than 8000 cases of musculoskeletal problems treated with extracorporeal shock wave therapy have been documented. Patients with a wide variety of musculoskeletal indications have been treated, with considerable variation in the validity of the studies. Although the total number of reported cases seems to be large, the actual number decreases when the quality and scientific rigidity of the published studies are ranked by the aforementioned study classification system. If only studies fitting the criteria of Types A to C are analyzed, the number of cases is at least 2723, which represents approximately 34% of the published cases.

For plantar fasciitis or heel pain, the first musculoskeletal indication of extracorporeal shock waves approved by the Food and Drug Administration, there are published and abstracted studies involving at least 1131 patients. 18,25,29,95,110,126,144,146–148,160,182 Of these studies, one of which is included in this symposium, 126 736 patients fit the category of Types A to C studies, with approximately 300 being the only patients in a published Type A study. The data in these studies strongly support a positive response to extracorporeal shock wave treatment, and that such response usually lasted to at least 1 year. The results certainly were comparable with those attained by surgery, but did not have the expected morbidity and delayed healing associated with surgery. Success rates from 34% to 88% were achieved in these studies. The Type A study included in this symposium 126 used one treatment in approximately 80% of the patients, and two treatments in approximately 20% of the patients to achieve a successful result. In contrast to the studies with an electrohydraulic extracorporeal shock wave device, the other reported studies used multiple treatments (usually three or more) with electromagnetic or piezoelectric devices.

For lateral epicondylitis, which is under active study, using approved Food and Drug Administration protocols for at least two extracorporeal shock wave devices, there are published and abstracted studies involving at least 1672 patients. 18,69,70,78,88,94,96,97,114,133,140,142,143 There are no published Type A studies. Eleven of the studies involving 763 patients are Types B and C studies. The success rates range from 48% to 73%. All of these reported studies have involved electromagnetic or piezoelectric extracorporeal shock wave devices, which invariably have involved multiple treatments (several days apart) to achieve final success.

Delayed union and nonunion of fractures in long bones and the smaller bones of the hand and foot involve studies involving at least 1737 patients. 8,18,20–23,25,32–34,50–52,63–67,76–78,81,98,134,135,151,156,157,162–164,189–192,198 These studies are easier to document as far as an end point of successful treatment, which is established by fracture healing by radiographic studies, rather than the soft tissue disorders (enthesopathies) that rely on more subjective analytical data. Types B and C studies report at least 714 patients with well documented healing success rates of 62% to 83%. Poor results were achieved with electromagnetic devices. The electrohydraulic (high energy device) appears requisite to achieve single treatment union of fracture nonunions.

The presence of implanted hardware (rod, plate) does not seem to interfere with the likelihood of a successful response. Hypertrophic nonunion is more likely to be treated successfully than an atrophic nonunion. A nonunion gap greater than 5 mm has a less likely chance of success than a gap less than 5 mm. These studies have involved long bones and small bones in the hand (scaphoid) and foot. At least one Type A study (Food and Drug Administration approved) has been started.

Calcific tendinitis of the rotator cuff is also relatively easy to document radiographically relative to presence of the lesion before treatment and its diminution in size or disappearance after treatment. As with other enthesopathies, there is a subjective aspect (lessening or disappearance of pain) that also factors into the end result. There are published studies involving at least 916 patients. 19,31,52,69,78,88,90,106–109,115–117,137,149–154,169,180,193,194 More than 510 of these patients are in Types B or C studies, in which the success rates range from 47% to 70%. Approximately all the studies equated success with either diminution in the size or complete disappearance of the calcific deposit, and subjective symptomatic improvement. These studies support the positive effect on the pathologic calcification, but should not be extrapolated to patients with shoulder pain (impingement syndrome, rotator cuff disease without a tear) who do not have radiographic evidence of calcification.

Maier et al 116 studied the outcome of extracorporeal shock waves for calcific tendinitis of the shoulder by magnetic resonance imaging (MRI). They used pretreatment contrast enhanced MRI to document the size and morphologic features of calcifications and the presence of inflammation (positive contrast reaction) around the lesion. Lesion size did not affect outcome. However, patients with more chronic tendinitis, as evident by the absence of contrast uptake around the calcific deposit, had the best outcome.

Other enthesopathies that have been treated include medial epicondylitis, patellar tendinitis, trochanteric bursitis, Achilles tendinitis, and noncalcific shoulder problems. 25,29 Dahmen et al 4 reported treatment of patients with back pain, although this is the only reported study of spinal column application. Until the effect of extracorporeal shock waves on large nerves and spinal cord tissue has been documented, this indication probably is contraindicated. Other skeletal applications include treatment of osteochondritis dissecans, osteonecrosis of the femoral head, and reversal of heterotopic bone formation in patients with spinal cord injury or head injury. 23,25,29,139,184 These other indications only have been explored recently, and statistically valid results are not yet available. These studies are Types D, E, G and H categories. In many cases, the patients were treated with lithotripsy devices, rather than the aforementioned devices modified for orthopaedic applications.


Heller and Niethard 82 undertook a metaanalysis of 105 articles. The study included articles written up to 1997, although some were not published until 1998, that assessed the outcome of extracorporeal shock wave therapy for musculoskeletal disorders. They specifically evaluated 4825 patients who were reported in 55 published articles and abstracts. However, only 24 articles describing 1585 patients (33%) satisfied their standards of an adequate scientific evaluation and only 978 (20%) involved their Type A or Type B study classification. From the current review of more recent studies, the number of reported cases has approximately doubled. More importantly, the percentage of high level studies (Types A to C) has increased from 20% to 34%. This reflects the realization of the current need for valid study design and outcome analysis. Heller and Niethard 82 thought that only the data concerning treatment of plantar fasciitis supported its unequivocal clinical use to avoid the recognized risks and complications of heel surgery. The Food and Drug Administration-approved study reported elsewhere in this symposium 126 corroborates the efficacy of extracorporeal shock waves for chronic proximal plantar fasciitis. All other disorders (lateral epicondylitis, calcific tendinitis of the shoulder, Achilles tendinitis, and osseous delayed union and nonunion) were documented insufficiently relative to their evaluation criteria, although they thought that the data suggested at least the equivalency of treatment effect without potential surgical morbidity. They stressed the need for continuing evaluation of all musculoskeletal indications, and particularly emphasized the need for more studies. The authors agree conceptually, but suggest that the current Type A category (double blind with placebo control or alternate treatment) should be the goal of future clinical prospective studies.

Since the initially sporadic application of shock waves to musculoskeletal conditions in the 1980s, there has been a rapid and widespread application in the last ½ of the 1990s, especially throughout Europe. The rapid application has not been accompanied by an acceptable number of well-conceived and promulgated studies, which has led to some skepticism regarding the actual efficacy of extracorporeal shock waves for musculoskeletal disorders. As an example, in 1996, more than 30,000 patients were sent to European (principally German and Italian) health insurance providers to request coverage of such treatments. 18 In turn, the health authorities expressed the need to justify such coverage (reimbursement) by conducting studies to statistically corroborate the efficacy of such treatments compared with nonoperative and operative treatments that currently are considered acceptable treatments for any given musculoskeletal condition. Such considerations currently involve the cost-benefit aspects of a treatment when applied to a specific need. For example, should extracorporeal shock wave treatment of heel pain or plantar fasciitis at 3 months of symptoms that traditionally has been treated to that point with heel cord stretching, orthotics, and nonsteroidal antiinflammatory drugs be applied before cortisone injections, which have a serious recognized risk of rupture of the plantar fascia, to restore a patient to normal work or recreational activities.

Perhaps the most variable areas in the published studies have been the type of applied energy (low versus high energy), the number of treatments (one versus multiple), the need for anesthesia or sedation, and the total number of applied shocks. Particularly for fracture nonunions, the number of recommended or shocks that are used has increased substantially. 157 Because of differing devices, differing energy outputs and inputs at the first focal point and the second focal point, and differing energy generation, it is difficult to compare treatments for the same musculoskeletal indication. Attempts are being made to standardize the analysis of energy per shock and total treatment energy to create some type of standard.

Rompe and coworkers 145 attempted to define the concepts of low-, medium-, and high-energy shock waves. According to their criteria, low energy waves had an energy density of 0.08 mJ/mm2 at the second focal point2, whereas an energy density up to 0.28 mJ/mm2 constituted medium energy, and an energy density exceeding 0.6 mJ/mm2 was high energy.

Additional differences among the available devices in the United States under Food and Drug Administration approval study and additional devices being used in Europe and the Pacific Rim relate to the size of the actual energy toroid and whether effective treatment can result from one treatment or requires multiple sessions. Patient preference would seem to favor one treatment, although the energy effect on human tissues usually necessitates some type of anesthesia (local, regional block, or general), especially at the energy levels most effective to accomplish osseous healing. In fact, of the three machines currently under Food and Drug Administration study only the OssaTron is capable of producing the high energy necessary for fracture healing (and possibly for the more severe tendinopathies).

When considering the applicability of extracorporeal shock waves to musculoskeletal conditions, early concepts were to alleviate pain using the low energy levels, and to use the medium and high levels to either disintegrate or crush calcific deposits or to cause osteoinduction. The definition of what constitutes low, medium, and high energy has been the subject of intense discussion. As presented elsewhere in this symposium, 126 measurement of energy and energy flux density to allow device comparisons is not easy. This procedure requires specialized devices termed hydrophones. 173 Without interdevice comparison criteria for energy applied per dose (per shock wave) and total energy applied per treatment, effective comparisons of devices cannot be done. Additionally, the appropriate dosage (number of shocks, kV or the mJ/mm2 setting) cannot be effectively determined statistically. Attempts to cross-quantify and compare energy outputs of devices have been made by groups such as the German and International Study Group for Extracorporeal Shock Wave Therapy 59 and the International Society for Musculoskeletal Shockwave Therapy. 87 Both organizations have web sites that document completed comparison studies of energy outputs by numerous devices including those participating in Food and Drug Administration-approved studies and additional devices used outside of the United States.

An additional comparison relates to the direct and indirect effects of shock waves. The direct effect is caused by the conversion of shock waves into kinetic energy at impedance interfaces. The impedance differences (muscle or fat versus bone) further alters energy through reflection and transmission. The bone or implanted rod may redirect the wave (echogenic effect), which may amplify the effect by a double hit to the target tissue. The shock wave indirect effect is achieved by cavitations within the target tissues.

Another important, if not essential aspect, of extracorporeal shock was treatment relates to the transmission of the shock waves through the generation device into the target tissue. Because shock waves transmit poorly in air (lose their potential therapeutic effect), the generating device must be coupled acoustically to the target tissue. This can be accomplished easily with readily available ultrasound gel, although other substances have been evaluated. 7,117

The actual biologic mechanism of action of clinically applied shock waves within human and animal tissue has received a paucity of attention. Studies to date have assessed basic biologic tissue effects and more germane topics such as the potential for neurovascular injury. 38,146 There is no question that lung tissue is highly susceptible to disruption by shock waves, minimizing the applicability to thoracic disorders (stress fractures of the first rib). Such susceptibility also necessitates specific targeting of shock waves to avoid lung tissue when treating shoulder disorders.

Cavitation is the generation and movement of bubbles in a fluid or tissue caused by changing gases normally dissolved in fluids back into their gaseous phase. 1,27,28,36,39,46,56,79,101,118,155,197,205–208 Such phase conversion is a very powerful process that may be a factor, even in hard materials. 36 Such a mechanism may induce surface erosion in ship propellers or turbine blades. 181 A comparable cavitation in bone or relatively hard tissue (cartilage, tendon) also may occur consequent to extracorporeal shock wave application. 181

Cavitation is a very fast process with crucial events occurring in the microsecond range. A moving cavity generated near a solid surface collapses asymmetrically under formation of a water jet at the impedance surface. This surface impairs the flow of water in the direction of the bubble center. 30 A surface pit (microdisruption) generated by such collapse has the same diameter as the water jet and is considered the primary damaging event. Cell damage may occur from the production of free radicals. 177 The process of cavitation produces free radicals that may affect the cellular antioxidative defense status. When a shock wave hits an already present stable gas bubble within a fluid, it also induces a strong jet in this bubble. This interaction between a shock wave and a preexisting bubble is an even stronger mechanism of microdamage formation. 39,41

Although initial studies showed no damaging effects of shock waves on organs and tissues, Brümmer and coworkers 15 gathered numerous reports that documented severe acute effects and chronic complications after shock wave treatments in humans and experimental animals. 129,132 This study was published in 1990, before the advent of musculoskeletal applications of shock waves. Lung tissue especially is susceptible to profound damage if extracorporeal shock waves are directed toward the chest. 26,42 Whether similar or other complications will surface in musculoskeletal tissues remains to be seen. 171,203

Petechial bleeding may be observed in approximately 10% of patients being treated for renal stones. 123 This complication has been observed in patients who were treated for fracture nonunions, and certainly occurred in all the patients in a Food and Drug Administration feasibility study of 21 patients treated for fracture nonunions (Unpublished data, Ogden JA: The use of shock waves in musculoskeletal disorders. Presented at the American Orthopaedic Association, West Palm Beach, FL 1998). In contrast, in the treatment of more than 200 patients for chronic plantar fasciitis, 26 petechial hemorrhage virtually was nonexistent. The differences undoubtedly related to the number of shocks applied and the finite energy per shock. 120

Neural damage is of concern with the use of applied energy forms. 35,121,136 Miller et al 122 showed that heating, rather than cavitation, was responsible for mouse hindlimb paralysis by ultrasound. Similar tissue heating does not occur during shock wave therapy. Schelling et al 158 showed that shock waves stimulated frog sciatic nerves in a manner similar to electrically-induced compound action potentials. They thought cavitation was the causal excitatory factor, and that such cavitation was the underlying mechanism of shock wave related pain in clinical medicine. They also reported that shock waves do not directly stimulate nerves, despite high pressure and short rise times. Another effect of the shock waves seems to be a distortion of axonal contents, straining of the cell membrane, and a resulting increase in permeability, leading to depolarization, factors that effect mechanosensibility. Lohse-Busch and coworkers 111,112 assessed neuromuscular dysfunction disorders (cerebral palsy); however, the results were not dramatic. Obviously, additional animal and clinical studies are essential.

Another aspect of shock wave treatment is pain. 160 In lithotripsy, there are two general patterns: superficial discomfort at the skin surface and deep pain within the kidney. Similar problems occur with high-energy shock waves for musculoskeletal applications. The skin delivery site, when coupled with gel, is painful to most patients. Some patients will feel pain or discomfort in the underlying bone when plantar fasciitis or lateral epicondylitis is being treated. Generally deep bone pain is more likely when 20 kV or greater is used. The low-energy machines (electromagnetic generation are reported to cause no pain 141; however, some patients experience pain even when these devices are used. Local anesthesia, conscious sedation, or a nerve block are ways of alleviating treatment pain or discomfort. In seeming contrast, extracorporeal shock waves have been used for the alleviation of musculoskeletal pain in high performance athletes. 68,141,200 This effect may be similar to transcutaneous neuromuscular stimulation. 121 The initial analgesic effect that many patients have may be attributable to altered or increased cell membrane permeability. The nocioceptors lose their ability for generation potential, which is necessary to elicit a pain signal response (the gate control mechanism).

Brümmer et al 15 tabulated the reported complications of shock waves, including those that could occur by direct exposure of organs and tissues to shock waves. Kidney and liver damage and heart arrhythmia may occur. 43–45,131 Certain chemical markers (S100aO protein, C-reactive protein) may be used as tissue markers for abdominal organ damage. 71,201 However, these are unlikely with distant musculoskeletal extracorporeal shock wave applications.

In the hamster and mouse there was microhemorrhage and leakage of macromolecules within muscle. 15,172 In immature rat bone and rabbit bone, there was evidence of local physeal dysplasia in approximately 50% of the animals. Mature bone (rat) may have dose-dependent hemorrhagic lesions. Brümmer et al 15 additionally showed that extracorporeal shock wave application to multicellular spheroid suspensions caused considerable cellular agitation. 16 This probably is the result of cavitation and jet streams, which occur as a consequence of local acceleration of fluid in the shock wave focus. These rapid accelerations expose cells to shear forces and cause collisions that may be responsible for cellular damage. Placement of the cellular spheroid suspensions in gelatin, effectively duplicating solid organ structure, essentially protected the cells, which showed no detectable cellular damage in this experimental construct.

Seidl et al 167,168 and Steinbach et al 174,175 determined the energy-dependent extent of vascular damage caused by high-energy (electromagnetic) shock waves on vascular tissues. Other researchers also have assessed the effects of extracorporeal shock waves on blood vessels. 14 During treatment (using umbilical cords) macroscopically visible hematomata and superficial holes appeared. In some areas, there was separation of normally adherent endothelial cells. A local energy density of 0.3 mJ/mm2 appeared to be the lower threshold for occurrence of severe vascular damage in their model. In other studies, umbilical cords from humans were exposed to focal energy densities of 0.4 and 0.6 mJ/mm2. 2,167 The degree of tissue change ranged from the induction of stress fibers and intercellular gaps to complete detachment of endothelial cells combined with basement membrane damage. The increased number of stress fibers seemed to correlate with increased vessel wall permeability. 14,49,84 Gaps in the vessels might promote the diffusion of cytokine molecules through the vessel wall. Such a mechanism may be active in the symptom relief experienced after extracorporeal shock wave therapy for plantar fasciitis or epicondylitis.

There are some contraindications to the use of extracorporeal shock waves. Because of microvascular disruption that leads to transient cutaneous petechiae (especially with high energy and large numbers of shocks for fracture treatment) patients with any type of disease-related (hemophilia) or physician-induced coagulopathy should be excluded. The effect of shock waves on infected tissue and bacteria are unknown. Lung tissue is particularly sensitive, and must be avoided from being in the beam pathway. Thus, treatment of rib and clavicular fractures is excluded. The effect of energy on distant coronary stents or implanted heart valves is unknown. Malignancy is a relative contraindication, although some research suggests a tumor may be more receptive to chemotherapy or radiation therapy when initially subjected to extracorporeal shock wave therapy. 130,131 The growth plate is an unknown; experimental studies suggest possible physeal damage, but the studies have involved lithotripsy devices, and not the newer orthopaedic machines. 113,185,187 Heterotopic bone, once mature, probably will not respond (by resorption) to extracorporeal shock wave therapy. However, there is a suggestion that extracorporeal shock wave therapy in the early phases of development (often detectable by bone scan) may reverse the process, not unlike current treatments with drugs or low-dose radiation. 29

Extracorporeal shock waves have been delivered to tumor cells in vitro and tumors in vivo to study the possibility of enhanced tumor treatment. 12,16,17,47,48,127,128,130,131,152,176,196,202 Combining extracorporeal shock waves with biologic response modifiers, such as tumor necrosis factor alpha, led to complete tumor regression in bone xenograft models. The reason for the synergistic effect is unknown, although vascular damage is thought to be a factor especially contributing to tumor necrosis. 48 Most studies have involved soft tissue tumors. Whether musculoskeletal primary or metastatic tumors would respond has yet to be studied. Genetic manipulation also has explored the potential benefits of extracorporeal shock waves. 6,103

Haupt and Chvapil 74 studied the effect of shock waves on the healing of partial-thickness wounds in piglets. They found that wounds treated with 100 shock waves at 14 kV and 10 shock waves at 18 kV had similar rates of reepithelialization as nontreated control wounds. With increased numbers of shock waves (500–1000 at 14 kV; 100 at 18 kV) healing was inhibited significantly. In contrast, low-dose treatment (10 shock waves at 14 kV) led to significant enhancement of reepithelialization. Histologically, the upper dermis in the animals that received low-dose treatment had increased numbers of dilated microvessels and increased macrophages in the perivascular spaces. They thought their observations could be applied more broadly to activation of cellular healing (fracture healing) by promoting the repair process and changing cell kinetics.

At the beginning of the 1990s, the musculoskeletal applications of extracorporeal shock waves attracted significant interest. Valchanou and Michailov 185 showed high energy could fracture rat (rabbit) bones, but that lower applied energy levels stimulated osteogenesis, and, in particular, elaboration of callus. A subsequent study confirmed the osteogenic potential of shock waves but also the possibility of stimulating an osteogenic response in fracture nonunions that could lead to healing by noninvasive nonsurgical methods. 186 Ekkernkamp and coworkers 55 were able to show dose-dependent (high versus low extracorporeal shock waves) osteoblast recruitment and osteogenesis and elaboration of bridging and solidifying callus in a fracture pseudarthrosis model (sheep) using standard fluorescent histologic methods. This subsequently led to early clinical applications for patients with delayed union and nonunion. These studies definitely showed a positive effect of extracorporeal shock waves on initiating fracture healing in patients. Many investigators also have evaluated the effect of extracorporeal shock waves on the stimulation of bone function. 4,11,40,57,58,60,61,63–67,75,89,99,100,138,158–164,178,179,181,182,184,199

Haupt and coworkers 76 used multiple (five) treatments of 100 shocks generated by an experimental early lithotripter (XL-1). Their assessment, based on radiographic, histologic, and biochemical evaluations, showed that fracture healing was initiated. Graff et al 61 concomitantly assessed the effects of shock waves on the various tissues through which they traversed to reach a urethral or renal stone. These experiments used bone from rabbits, pigs, and dogs. Hematomas and petechial bleeding were evident; such findings are comparable with those of blunt trauma. No obvious fractures were found. However, there were no magnetic resonance imaging studies for bone bruising or selective histologic stains that would elucidate intertrabecular hemorrhage. Short-term effects were bleeding and necrosis with the effect being related to the energy imparted. Early changes were aseptic necrosis within the marrow tissue and osteocyte damage and, in some cases, death (although the latter process was not all-enveloping in the shock wave pathway). Subsequently, there was evidence of new bone formation, de novo, and against existing trabeculae. This observation was confirmed by Johannes et al 89 in a canine model.

Ikeda and coworkers 86 applied extracorporeal shock waves to canine bone. Their extracorporeal shock wave generator produced shock waves by explosion of a silver azide pellet at the first focal point, a generational method not being explored clinically in the United States. Their first group of animals were sacrificed immediately after shock wave application. The relevant findings were periosteal detachment and microfractures on the inner surface of the cortex. In a second group, the femurs were studied 2 months after extracorporeal shock wave treatment. There was marked callus formation under the displaced periosteum. They also treated six patients with delayed union or nonunion of fractures, achieving union in four. Of the two patients who did not achieve union, one patient with humeral nonunion with a 1-cm fracture gap and no internal stabilization did not achieve union, whereas the other patient had avascular necrosis of a vascularized fibular graft. In retrospect, they thought neither patient was an appropriate candidate for extracorporeal shock wave treatment.

In a previous study, Ikeda and coworkers 85 applied extracorporeal shock waves to rabbit bone. This led to cortical fracture and saucerization of the inner surface of the opposite cortex. However, similar opposite cortex saucerization was not observed in the canine bones. 86 This may have occurred because of size differences in the overall bone and the thickness of the cortex. The extracorporeal shock waves caused gross fractures in rabbit femurs, but only microfailures in the canine femur. They also found a transient increase in creatinine kinase, probably attributable to damage to muscles in the extracorporeal shock wave path. These values returned to normal within a week.

Other investigators have found osteogenesis may be stimulated by extracorporeal shock wave treatment. 83 Saisu and coworkers 153 reported local increase in bone mineral content and overgrowth of immature rabbit bone. Kusnierczak and others 99,100 studied the effect of extracorporeal shock waves on osteocyte cell cultures. They observed that although there was a short-time effect of cell destruction, the subsequent effect, 3 to 8 days later, was cell stimulation. These studies suggest additional evaluation should be done to assess the possibility of focal bone augmentation (in the osteoporotic femoral neck or radius) or the stimulation of longitudinal bone growth in a congenitally or posttraumatically shortened long bone. Interestingly, the longitudinal growth stimulation in the study by Saisu et al 153 applied extracorporeal shock waves to the middiaphysis of the femur, rather than near the physis (that may be affected adversely by extracorporeal shock waves).

Additional osseous applications have included osteochondroses (femoral and talar osteochondritis dissecans) and early stages of osteonecrosis. 29 Currently, insufficient data are available, although preliminary results are promising.

The effects of extracorporeal shock waves on the physis must be explored in much more detail. 113,187 One study showed no overt damage to the rabbit physis. 185 However, the shock waves were not focused specifically on the physis. In another study, 44% of the animals (rats) had moderate to severe dysplastic changes in the physis. 204 Again, specific studies must be done to evaluate application of extracorporeal shock waves to large physes reasonably similar to human physes. Because the local volume of the second focal point is well controlled, the use of extracorporeal shock waves for a lesion such as a bone cyst (instead of grafting or cortisone injection) might be feasible as long as the energy was directed at least 1 to 2 cm away from the physis within the metaphysis.

Extracorporeal shock wave treatments have been applied experimentally to the distal femurs in rabbits. 188 There were no pathologic changes in the articular cartilage. In a small clinical study, extracorporeal shock waves were applied to osteochondritis dissecans lesions to accomplish healing of the lesion to the underlying bone. 29

Given the difficulty in the removal of cemented prosthetic implants, several researchers have assessed whether the preoperative or intraoperative use of extracorporeal shock waves could disrupt the cement-bone interface to allow easier removal of the prosthesis and the cement mantle during revision surgery. 9,10,91,104,119,165,195 The results suggest extracorporeal shock waves may loosen the cement-bone and cement-prosthesis interfaces, making extraction of prosthesis and cement easier. Another prosthesis-related potential application is the loosened noncemented prosthesis. Because extracorporeal shock waves have been shown to cause new bone formation, there is a potential for its use to the bone surrounding an unstable (clinically symptomatic or painful) implant. Coombs et al 29 and Vogel et al 192 have shown elaboration of new bone and symptomatic relief in a small number of patients. Both applications, easier removal of cemented implants and encouragement of osseous ingrowth to stabilize a press-fit implant, deserve well-designed clinical studies. The stimulation of osseous ingrowth and incorporation of a noncemented prosthesis even may benefit from early extracorporeal shock wave application.

After the fracture applications the problem of calcific tendinitis was addressed, with the specific aim of disrupting the calcific intratendinous deposit to encourage resorption, which was reasonably well documented as an outcome phenomenon. 32–36,105–109 Low-energy and high-energy treatments were studied. The responsiveness of shoulder pathologic disorders gradually led to applications in other tendinopathies not usually characterized by grossly evident calcification (lateral epicondylitis, plantar fasciitis). These include medial and lateral epicondylitis, patellar tendinitis, Achilles tendinitis, and plantar fasciitis.

One of the important aspects of treating soft tissue impairments is the basic concept of etiology. The prevailing concept of disorders such as plantar fasciitis and lateral epicondylitis is that they are inflammatory disorders. The fact that many patients do not, accordingly, respond to treatment with antiinflammatory medications has led to suggestions that other pathologic processes may play a role in the patient’s disorder. 80,102 Detailed evaluation in these aforementioned disorders suggests inflammation may be a concomitant, rather than the primary, aspect of the painful condition. 116

The application of extracorporeal shock waves to the rabbit Achilles tendon causes dose-dependent changes in the tendon and paratenon. 145 The application of impulses with an energy flux density of 0.08 or 0.28 mJ/mm2 caused only minor changes. In contrast, the application of impulses at 0.60 mJ/mm2 (high energy) caused formation of paratendinous fluid and swelling of the tendon. Histologic assessment showed fibrinoid necrosis and infiltration of inflammatory cells. Rompe et al recommended caution in the application of high energy extracorporeal shock waves to patients with tendinopathies (Achilles, patellar).

Although the tissue effects in bone (cell death followed by osteoblast elaboration and recruitment) to reinitiate the fracture healing response, the mechanism in soft tissues has yet to be determined. 37,38 Presumably a similar microdisruption of dense, fibrotic, poorly vascularized tissue allows initial microvascular ingrowth, followed by tissue-appropriate stem cells. In bone and contiguous tissues, the focal microinjury also undoubtedly causes tissue changes and responses that concentrate autologous growth factors (platelet-derived) conducive to establishing more appropriate target tissue healing. There is a distinct paucity of (and obvious need for) animal studies, cellular studies or both of the specific tissue effects of the clinically applied shock waves (high-and low-energy intensity).

Although there is obvious enthusiasm to apply extracorporeal shock waves to various musculoskeletal conditions, there still are many unanswered questions. It is unclear as to which parameters of extracorporeal shock wave delivery may cause detrimental changes in tissues such as muscle, nerve, or even fat in the shock wave pathway. Tissue damage may correlate with one or more factors alone, or with multiple parameters in a combined effect. It is not clear which body tissues or organs are damaged acutely or chronically by shock waves, and which are most susceptible to cellular or organ injury (lung tissue is damaged unequivocally). Many acute changes have not been followed chronically to determine when and if the changes resolve, or whether they lead to subsequent chronic changes. There has been limited assessment of extracorporeal shock wave application to cell cultures to determine direct cell response acutely (often cell death) and subsequently (osteocyte proliferation). Extracorporeal shock waves may affect lysosomes and mitochondria, interfering with metabolic activity within the cell. Metabolic activity of the osteoblast (phosphate turnover, elaboration of extracellular matrix components) may be altered by extracorporeal shock waves.

Future applications in orthopaedics may rely on modification of the extracorporeal shock wave devices. Bailey and coworkers 5 found that dramatically different cavitation was produced by acoustic pulses that had different shapes but similar duration, frequency content and peak positive and negative pressure. The main effect involved cavitation, which was 50 times longer and 3 to 13 times stronger in one device versus the other. A better understanding of the differences between orthopaedic extracorporeal shock wave devices, particularly as based on the Gilmore equation, 207,208 may help to better understand tissue effects and device response differences.

In other studies, Zhong et al 207 used the Gilmore formulation coupled with zeroth-order gas diffusion to investigate cavitation. They found that cavitation dynamics could be enhanced when a slightly different antecedent shock wave and interpulse delay were used before the primary shock wave. Kodama and coworkers 93 developed a shock wave device that can be used in an arbitrary position in the human body percutaneously. This device might have application such as introduction, by a drilled channel, into a region of ischemic necrosis within the femoral head.


1. Apfel RE: Acoustic Cavitation. Methods of Experimental Physics. In Edmonds P (ed). Methods of Experimental Physics. Vol 19. New York, Academic Press 355–411, 1981.
2. Arbeitsgruppe “Orthopädische Stoßwellenbehandlungen”: Standortbestimmung. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Die Stoßwelle-Forschung und Klinik. Tübingen, Germany, Attempto Verlag 137–142, 1995.
3. Arbeitsgruppe “Technische Entwicklungen”: Standortbestimmung. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Die Stoßwelle-Forschung und Klinik. Tübingen, Germany, Attempto Verlag 15–20, 1995.
4. Augat P, Claes L, Sugar G: In vivo effect of shock waves on the healing of fractured bone. Clin Biomech 10:374–378, 1995.
5. Bailey MR, Blackstock DT, Cleveland RO, et al: Comparison of electro-hydraulic lithotripters with rigid and pressure-release ellipsoidal reflectors: II. Cavitation fields. J Acoust Soc Am 106:1149–1160, 1999.
6. Bao S, Thrall BD, Miler DL: Transfection of a reporter plasmid into cultured cells by sonoporation in vitro. Ultrasound Med Biol 23:953–959, 1997.
7. Becker AJ, Stiel CG, Truss MC, et al: Petroleum jelly is an ideal contact medium for pain reduction and successful treatment with extracorporeal shock wave lithotripsy. J Urol 162:18–22, 1999.
8. Boxberg W, Perlick L, Giebel G: Stoßwellenbehandlung bei therapieresistenten weichteilschmerzen. Chirurg 67:1174–1178, 1996.
9. Braun W, Claes A, Rüter A, et al: Effects of extracorporeal shock waves on the stability of the interface between bone and polymethylmethacrylate: An in vitro study on human femoral segments. Clin Biomech 7:47–54, 1992.
10. Braun W, Claes A, Rüter A, et al: Untersuchungen zur wirksamkeit von stowellen auf die pestigkeit der verbundes von knochen und polymethylmethacrylat. Eine in vitro studie an menschlichen femursegmenten. Z Orthop 130:236–243, 1992.
11. Braun W, Rüter A: Frakturheilung: Morphologische und physiologische gesichtspunkte. Unfallchirurg 99:59–67, 1996.
12. Bräuner T, Brümmer F, Hülser DF: Histopathology of shock wave treated tumor cells suspensions and multicell tumor spheroids. Ultrasound Med Biol 15:451–460, 1989.
13. Brazier JE, Harper R, Jones NM, et al: Validating the SF-36 health survey questionnaire: New outcome measure for primary care. Br Med J 305:160–164, 1992.
14. Brendel W, Delius M, Goetz A: Effect of shock waves on the microvasculature. Prog Appl Microcirculation 12:41–50, 1987.
15. Brümmer F, Bräuner T, Hulser D: Biological effects of shock waves. World J Urol 8:224–232, 1990.
16. Brümmer F, Brenner J, Bräuner T, et al: Effect of shock waves on suspended and immobilized L1210 cells. Ultrasound Med Biol 15:229–239, 1989.
17. Brümmer F, Suhr D, Hulser D: Sensitivity of normal and malignant cells to shock waves. Stone Dis 4:243–248, 1992.
18. Brunner W, Thuringer R, Ascher G, et al: Die extrakorporelle stoßwellentherapie in der orthopadie– Drei-monats-ergebnisse in 443 fallen. Orthop Prax 33:461–464, 1997.
19. Buch M, Schlengmann B, Trager D, et al: Prospektiver Vergleich der niedrig–und hochenergetischen Stoßwellentherapie und Needling neider Behandlung der Tendinosis calcarea der Schulter. 45 Jahrestagung der Vereinigung Suddeutscher Orthopäden. Abstractband 101–102, 1997.
20. Burger RA, Witzsch U, Haist J, et al: Die Extracorporale Stoßwellentherapie (ESWT)–Eine Neue Moglichkeitder Behandlung von Pseudarthrosen. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Stoßwellenlithotripsie–Aspekte und Prognosen. Tübingen, Germany, Attempo Verlag 127–130, 1993.
21. Burger RA, Witzsch U, Haist J, et al: Extracorporale stoßwellenbehandlung bei pseudarthrose und aseptischer knochennekrose. Urologe 30:48–50, 1991.
22. Burger RA, Witzsch U, Haist J, et al: Extracorporal shockwave therapy of pseudoarthrosis. J Urol 147:260–263, 1992.
23. Burger RA, Witzsch U, Haist J, et al: Extracorporal shock wave therapy of pseudo-arthrosis and aseptic osteonecrosis. J Endourol 5 (Suppl 1):48–50, 1991.
24. Carlsson AM: Assessment of chronic pain. 1. Aspects of the reliability and validity of the visual analogue scale. Pain 16:87–101, 1983.
25. Chaussy C, Eisenberger F, Jocham D, et al (eds): High Energy Shock Waves in Medicine. Stuttgart, Thieme 1997.
26. Child SZ, Hartman C, Schery LA, et al: Lung damage from exposure to pulsed ultrasound. Ultrasound Med Biol 16:817–825, 1990.
27. Church C: A theoretical study of cavitation generated by an extracorporeal shock wave lithotripter. J Acou Soc Am 86:215–227, 1989.
28. Coleman AJ, Saunders JE: A review of the physical properties and biological effects of the high amplitude acoustic field used in extracorporeal lithotripsy. Ultrasonics 31:75–89, 1993.
29. Coombs R, Schaden W, Zhou SSH: Musculoskeletal Shockwave Therapy. London, Greenwich Medical Media 2000.
30. Crum L: Tensile strength of water. Nature 278:148–149, 1979.
31. Daecke W, Loew M, Schuhknecht B, et al: Der Einfluß der applikationsdosis auf die wirksamkeit der ESWA bei der tendinosis calcarea der schulter. Orthop Prax 33:119–123, 1997.
32. Dahmen GP, Franke R, Gonchars V, et al: Die Behandlung Knochennahem Weichteilschmerzen mit Extracorporaler Stoßwellentherapie (ESWT), Indikation, Technik, und Bisberige Therapie. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Die Stoßwelle-Forschung und Klinik. Tübingen, Germany, Attempo Verlag 175–86, 1995.
33. Dahmen GP, Meiss L, Nam VC, et al: Extracorporale stoßwellentherapie (ESWT) zur behandlung von knochennahem weichteilbereich an der schulter. Extracta Orthop 11:25–27, 1992.
34. Dahmen G, Nam V, Meiss I: Extrakorporale Stoßwellentherapie (ESWT) zur Behandlung von Knochennaben Weichteilschmerzen: Indikation, Technik, und Voraufige Ergebnisse. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Stoßwellenlithotripsie–Aspekte und Prognosen. Tübingen, Germany, Attempo Verlag 142–147, 1993.
35. Deam RK, Scott DA: Neurological damage resulting from extracorporeal shock wave lithotripsy when air is used to locate the epidural space. Anaesth Intensive Care 21:455–457, 1993.
36. Dear JP, Field JE: A study of the collapse of arrays of cavities. J Fluid Mech 190:409–425, 1988.
37. Delius M: Medical applications and bioeffects of extracorporeal shock waves. Shock Waves 4:55–72, 1994.
38. Delius M: Biologische wirkung von stoßwellen-mehr als nur steinzertrümmerung? Zentralbl Chir 120:259–273, 1995.
39. Delius M, Brendel W: A model of extracorporeal shock wave action: Tandem action of shock waves. Ultrasound Med Biol 14:515–518, 1988.
40. Delius M, Draenert K, Al Dieck Y, et al: Biologic effects of shock waves: In vitro effect of high energy pulses on rabbit bone. Ultrasound Med Biol 21:1219–1225, 1995.
41. Delius M, Draenert K, Draenert Y, et al: Effects of Extracorporeal Shock Waves on Bone: A Review of Shock Wave Experiments and the Mechanism of Shock Wave Action. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 91–107, 1997.
42. Delius M, Enders G, Heine G: Biologic effects of shock waves: Lung hemorrhage by shock waves in dogs: Pressure dependence. Ultrasound Med Biol 13:61–67, 1987.
43. Delius M, Hoffmann E, Steinbeck G, et al: Biological effects of shock waves: Induction of arrhythmia in piglet hearts. Ultrasound Med Biol 20:279–285, 1994.
44. Delius M, Jordan M, Eizenhoefer H, et al: Biological effects of shock waves: Kidney hemorrhage by shock waves in dogs: Administration rate dependence. Ultrasound Med Biol 14:689–694, 1988.
45. Delius M, Jordan M, Liebich H, et al: Biological effects of shock waves: Effect of shock waves on the liver and gallbladder wall of dogs: Administration rate dependence. Ultrasound Med Biol 16:459–466, 1990.
46. Delius M, Ueberle F, Eisenmenger W: Extracorporeal shock waves act by shock wave–gas bubble interaction. Ultrasound Med Biol 24:1055–1059, 1998.
47. Delius M, Weiss N, Gambihler S, et al: Tumor therapy with shock waves requires modified lithotripter shock waves. Naturwißenschaften 76:573–574, 1989.
48. Dellian M, Walenta S, Gamarra F, et al: Ischemia and loss of ATP in tumors following treatment with focused high energy shock waves. Br J Cancer 68:26–31, 1993.
49. Di Silverio F, Galluci M, Gambardella P, et al: Blood cellular and biochemical changes after extracorporeal shock wave in lithotripsy. Urol Res 18:49–54, 1990.
50. Diesch R, Haupt G: Anwendung der hochenergetischen extracorporalen stoßwellentherapie bei pseudarthrosen. Orthop Prax 33:470–471, 1997.
51. Diesch R, Haupt G: Use of Extracorporeal Shock Waves in the Treatment of Pseudarthrosis. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme 136–139, 1997.
52. Diesch R, Haupt G: Extracorporeal Shock Wave Treatment of Pseudarthrosis, Tendinosis Calcarea of the Shoulder and Calcaneal Spur. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 131–135, 1997.
53. Ekkernkamp A: Extrakorporale stoßwellen. Deutsches Arzteblatt 95:1035–1043, 1998.
54. Ekkernkamp A, Bosse A, Haupt G, et al: Der Einfluß der Extracorporalen Stoßwellen auf die Standardisierte Tibiafraktur am Schaf. In Ittel T, Siebert G, Matthias F (eds). Aktuelle Aspekte der Osteologie. Berlin, Springer Verlag 307–310, 1992.
55. Ekkernkamp A, Haupt G, Knopf HJ, et al: Effects of extracorporeal shock waves on standardized fractures in sheep. Urology 145:257–261, 1991.
56. Field JE: The physics of liquid impact, shock wave interactions with cavities, and the implications to shock wave lithotripsy. Phys Med Biol 36:1475–1484, 1991.
57. Forriol F, Solchage T, Moreno JL, et al: The effect of shockwaves on mature and healing cortical bone. Int Orthop 18:325–329, 1994.
58. Fukada E, Yasuda I: On the piezoelectric effect of bone. Phys Soc Jpn 12:1158–1162, 1957.
59. German and International Group for Extracorporeal Shock Wave Therapy. http://www.digestev.da.
60. Graff J, Pastor J, Richter KD: Effect of high energy shock waves on bony tissue. Urol Res 16:252–258, 1988.
61. Graff J, Richter KD, Pastor J: Wirkung hochenergetischer stoßwellen auf knochengewebe. Verb Deut Ges Urologie 39:76–78, 1989.
62. Greenstein A, Matzkin H: Does the rate of extracorporeal shock wave delivery affect stone fragmentation? Urology 54:430–432, 1999.
63. Haist J: Die Osteorestauration via Stoßwellenauwendung: Eine Neue Moglichkeit zur Therapie der Gestorten Knochernen Konsolidierung. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Die Stowelle–Forschung und Klinik. Tübingen, Germany, Attempo Verlag 157–161, 1995.
64. Haist J: Osteorestoration Via Shock Wave Application: A New Possibility of Treating Disturbed Bone Nonunion. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 119–129, 1997.
65. Haist J, Reichel W, Burger R, et al: Einsatz der extracorporalen stoßwelle bei der osteosyntheisch versorgten pseudarthrose: Eine experimentelle studie. Orthop Prax 29:345–347, 1993.
66. Haist J, Reichel W, Witzsch U, et al: Die extracorporale stoßwellenbehandlung der gestorten frakturheilung: Eine alternative zu operativen verfahren? Orthop Prax 29:842–844, 1993.
67. Haist J, von Keitz-Steeger D: Stoßwellentherapie Knochernaber Weichteikchmerzen: Ein Neues Behandlungskonzept. In Chaussy C, Eisenberger F, Jochum D, Wilbert D (eds). Die Stoßwelle–Forschung und Klinik. Tübingen, Germany, Attempo Verlag 162–165, 1995.
68. Haist J, von Keitz-Steeger D: Shock wave therapy in the treatment of near to bone soft tissue pain in sportsmen. Int J Sports Med 17:79–81, 1996.
69. Haist J, von Keitz-Steeger D, Mohr G, et al: The Orthopaedic Shock Wave Therapy in the Treatment of Chronic Insertion Tendopathy and Tendinosis Calcarea. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 159–163, 1997.
70. Hammer DS, Rupp S, Ensslin S, et al: Extracorporal shock wave therapy in patients with tennis elbow and painful heel. Arch Orthop Trauma Surg 120:304–307, 2000.
71. Hasegawa S, Kato K, Takashi M, et al: S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy. Eur Urol 24:393–396, 1993.
72. Haupt G: Stoßwellen in der orthopädie. Urologe 36:233–238, 1997.
73. Haupt G: Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases. J Urology 158:4–11, 1997.
74. Haupt G, Chvapil M: Effect of shock waves on the healing of partial-thickness wounds in piglets. J Surg Res 49:45–48, 1990.
75. Haupt G, Ekkernkamp A, Püllenberg A, et al: Einflu extrakorporal erzeugter stoßwellen auf standardisierte tibiafrakturen in schafmodell. Urologe 31:43–46, 1992.
76. Haupt G, Haupt A, Ekkernkamp A, et al: Influence of shock waves on fracture healing. Urology 39:529–532, 1992.
77. Haupt G, Haupt A, Senge T: Die Behandlung von Knochen mit Extrakorproalen Stoßwellen–Entwicklung Einer Neuen Therapie. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Stowellenlithotripsie–Aspekte und Prognosen. Tübingen, Germany, Attempo Verlag 120–126, 1993.
78. Haupt G, Katzmeier P: Anwendung der Hochenergetischen Extrakorporalen Stoßwellentherapie bei Pseudarthrosen, Tendinoisis Calcarea der Schulter und Amatztendinosen (Fersensporn, Epicondylitis). In Chaussy C, Eisenberger F, Jocham D, Wilbert (eds). Die Stoßwelle-Forschung und Klinik. Tübingen, Germany, Attempo Verlag 143–146, 1995.
79. Häusler E, Kiefer W: Anregung von stoßwellen in flüssigkeiten durch hochgeschwindigkeits wassertropfen. Verhand Dtsch Physikal Gesellsch 6:786–789, 1971.
80. Hefti F, Stoll TM: Healing of ligaments and tendons. Orthopäde 24:237–245, 1995.
81. Heinrichs W, Witzsch U, Bürger R: Extrakorporale stoßwellentherapie (ESWT) von pseudarthrosen. Anaesthesist 42:361–364, 1993.
82. Heller KD, Niethard FU: Der Einsatz der extrakorparalen stoßwellen therapie in der orthopäde: Eine metaanalyse. Z Orthop 136:391–401, 1998.
83. Hirachi K, Minami A, Kato H, et al: Osteogenic potential of the shock wave: Experimental study in rabbit model. Trans Orthop Res Soc 45:558, 1999.
84. Holmes RP, Yeaman LD, Taylor RG, et al: Altered neutrophil permeability following shock wave exposure in vitro. Urol 147:733–737, 1992.
85. Ikeda K, Tajiri K, Nakatani A, et al: Extracorporeal shock wave induced bone formation. Jpn J Med Electron Biol Eng 31:21–28, 1993.
86. Ikeda K, Tomita K, Takayama K: Application of extracorporeal shock wave on bone: Preliminary report. J Trauma 47:946–950, 1999.
87. International Society for Musculoskeletal Shockwave therapy.
88. Jakobeit C, Welp L, Winiarski B, et al: Ultrasound-Guided Extracorporeal Shock Wave Therapy of Tendinosis Calcarea of the Shoulder, of Symptomatic Plantar Calcaneal Spur (Heel Spur) and of Epicondylopathia Radialis and Ulnaris. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 165–180, 1997.
89. Johannes EJ, Kaulesar-Sukul DM, Metura E, et al: High energy shock waves for the treatment of nonunions: An experiment on dogs. J Surg Res 57:246–254, 1994.
90. Jurgowski W, Lowe M, Cotta H, et al: Extracorporal shockwave treatment of calcareous tendonitis of the shoulder. J Endurol 7 (Suppl 1):14–17, 1993.
91. Karpman RR, Magee FP, Gruen TW, et al: The lithotriptor and its potential use in the revision of total hip arthroplasty. Orthop Rev 16:81–85, 1987.
92. Kaulesar-Sukul DM, Johannes EJ, Pierek EG, et al: The effect of high energy shock waves focused on cortical bone: An in vitro study. J Surg Res 54:46–51, 1993.
93. Kodama T, Uenohara H, Takayama K: Innovative technology for tissue disruption by explosive-induced shock waves. Ultrasound Biol Med 24:1459–1466, 1998.
94. Krischek O, Hopf C, Nafe B, et al: Shock-wave therapy for tennis and golfer’s elbow: 1 year follow-up. Arch Orthop Trauma Surg 119:62–66, 1999.
95. Krischek O, Rompe J-D, Herbsthofer B, et al: Symptomatische niedrig-energetische stowellentherapie bei fersenschmerzen und radiologisch nachweisbaren plantaren fersenspora. Z Orthop 136:169–174, 1998.
96. Krischek O, Rompe J-D, Hopf C, et al: 1st die extracorporelle stowellentherapie bei epicondylitis humei ulnaris indiziert? Kurzfristige ergebnisse einer vergleichenden, prospektiven studie. Orthop Prax 33:465–469, 1997.
97. Krischek O, Rompe J-D, Hopf C, et al: Die extrakorporale stoßwellentherapie bei epicondylitis humeri ulnaris oder radialis: Eine prospecktive, kontronierte, vergleichende studie. Z Orthop 136:3–7, 1998.
98. Kuner EH, Berwarth H, Lücke SV: Behandlungsprinzipien bei aseptischen pseudarthrosen. Orthopäde 25:394–404, 1996.
99. Kuznierczak DR, Brocai DRC, Vettel U, et al: Der Einfluß der extrakorpalen stowellen application (ESWA) auf das biologische verhalten von knochenzellen in vitro. Z Orthop 138:29–33, 2000.
100. Kuznierczak D, Loew M: Enfluuß von Stoßwellen auf das Wachstums-und Expressionsverbeiten von Knochenzellkulturen: Eine Pilotstudie. In Siebert W, Buch M (eds). Stowellenanwendungen am Knochen–Klinische und Experimentelle Ehrfarungen. Hamburg, Kovac 12–13, 1997.
101. Kuwahara M, Ioritani N, Kambe K, et al: Hyperechoic region induced by focused shock waves in vitro and in vivo: Possibility of acoustic cavitation bubbles. J Litho Stone Dis 1:282–288, 1989.
102. LaBelle H, Guibert R, Joncas J: Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: An attempted meta-analysis. J Bone Joint Surg 74B:646–651, 1992.
103. Lauer U, Bürgeit E, Squire Z, et al: Shock wave permeabilization as new gene transfer method. Gene Therapy 4:710–715, 1997.
104. Lewis G: Effect of Lithotriptor treatment in the fracture toughness of acrylic bone cement. Biomaterials 13:225–229, 1992.
105. Lingeman JE, McAteer JA, Kempson SA, et al: Bioeffects of extracorporeal shock-wave lithotripsy Strategy for research and treatment. Urol Clin North Am 15:507–514, 1988.
106. Loew M, Daecke W, Kuznierczak D, et al: Shock-wave therapy is effective for chronic calcifying tendonitis of the shoulder. J Bone Joint Surg 81B:863–867, 1999.
107. Loew M, Jurgowski W: Erste Erfahrungen mit der extrakorporalen stoßwellen-lithotripsie (ESWT) in der behandlung der tendinosis calcarea der schulter. Z Orthop 131:470–473, 1993.
108. Loew J, Jurgowski W, Mau HC, et al: Die Wirkung Extrakorporal Erzengter Hochenergetischer Stoßwellen auf den Klinischen, Röntgenologischen und Histologischen Verlauf der Tendinosis Calcarea der Schulter: Eine Prospective Studie. In Chaussy C, Eisenberger D, Jochum D, Wilbert D (eds). Die Stoßwelle–Forschung und Klinik. Tubingen, Germany, Attempo Verlag 153–156, 1995.
109. Loew M, Jurgowski W, Mau H, et al: Treatment of calcifying tendinitis of rotator cuff by extracorporeal shock waves: A preliminary report. J Shoulder Elbow Surg 4:101–106, 1995.
110. Loew M, Rompe JD: Stoßwellenbehandhung bei orthopidischen Erkrankungen. In Gifka J (ed). Band 71 Bucherei des Orthopäden. Stuttgart, Enke Verlag 92–96, 1998.
111. Lohse-Busch H, Kraemer M, Reime U: The Use of Extracorporeal Shock Wave Fronts for Treatment of Muscle Dysfunction of Various Etiologies: An Overview of First Results. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 215–230, 1997.
112. Lohse-Busch H, Kraemer M, Reime U: Pilotuntersuchung zur wirkung von niederenergetischen, extrakorporalen stoßwellen auf muskelfunktionßtörungen bei spastischen bewegungßtörungen von kindern. Schmerz 11:108–113, 1997.
113. Lüssenhop S, Seeman D, Hahn M, et al: The Influence of Shock Waves on Epiphyseal Growth Plates: First Results of an In Vivo Study With Rabbits. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. New York, Springer Verlag 109–118, 1997.
114. Maier M, Dürr HR, Köhler S, et al: Analgetische wirkung nieder energetischer extrakorpaler stowellen bei tendinosis calcarea, epikondylitis humeri radialis und plantar fasziitis. Z Orthop 138:34–38, 2000.
115. Maier M, Lienemann A, Refior HJ: Gibt es magnetresonantztomographie verändrungen nach stowellenbehandlungen bei tendinitis calcarea? Z Orthop 35:20–21, 1997.
116. Maier M, Stäbler A. Lienemann A, et al: Shockwave application in calcifying tendinitis of the shoulder: Prediction of outcome by imaging. Arch Orthop Trauma Surg 120:43–48, 2000.
117. Maier M, Staupendahl D, Dürr HR, et al: Castor oil decreases pain during extracorporeal shock wave application. Arch Orthop Trauma Surg 119:423–427, 1999.
118. Maier M, Ueberle F, Rupprecht G: Physikalische parameter extra-korpaler stoßwellen. Biomed Tech 43:269–274, 1998.
119. May TC, Krause WR, Preslar AJ, et al: Use of high energy shock waves for bone cement removal. J Arthroplasty 10:19–27, 1990.
120. McCormack D, Lane H, McElwain J: The osteogenic potential of extracorporeal shock wave therapy: An in vivo study. Isr J Med Sci 165:20–22, 1996.
121. Melzack R: Prolonged relief of pain by brief, intense transcutaneous somatic stimulation. Pain 1:357–373, 1975.
122. Miller DL, Creim JA, Gies RA: Heating vs. cavitation in the induction of mouse hind limb paralysis by ultrasound. Ultrasound Med Biol 25:1145–1150, 1999.
123. Miller MW, Thomas RM: Thresholds for hemorrhages in mouse skin and intestine induced by lithotripter shock waves. Ultrasound Med Biol 21:249–257, 1995.
124. Niethard FU: Wißenschaftlichkeit und wirtschaftlichkrit in orthopädie und physiotherapie. Z Orthop 135:1–2, 1997.
125. Niethard FU: “Qualitatsmicherung”. Z Orthop 135:93–94, 1997.
126. Ogden JA, Alvarez R, Levitt R, et al: Extracorporeal shockwave therapy for chronic proximal plantar fasciitis. Clin Orthop 387:xxx–xxx, 2001.
127. Oosterhof G, Cornel EB, Smits GA, et al: The influence of high energy shock waves on the development of metastases. Ultrasound Med Biol 22:339–344, 1996.
128. Oosterhof G, Smits GA, de Ruyter A, et al: Effects of high energy shock waves combined with biological response modifiers in different human kidney cancer xenografts. Ultrasound Med Biol 17:391–399, 1991.
129. Prat F, Ponchon T, Berger F: Hepatic lesions in the rabbit produced by acoustic cavitation. Gastroenterol 100:1345–1350, 1991.
130. Prat F, Sibille A, Luccioni C, et al: Increased chemocytotoxicity to colon cancer cells by shock wave induced cavitation. Gastroenterol 106:937–944, 1994.
131. Randazzo RF, Chaussy C, Fuchs GJ, et al: The in vitro and in vivo effects of extracorporeal shock waves on malignant cells. Urol Res 16:419–426, 1988.
132. Rawat B, Wolber R, Burhenne HJ: Long-term soft tissue effects of biliary extracorporeal shock waves: An animal study. Am J Roentgenol 156:73–76, 1991.
133. Richter D, Ekkernkamp A, Muhr G: Die extracorporale stoßwellentherapie-ein alternative konzept zur behandlung der epicondylitis humeri radialis? Orthopäde 24:303–306, 1995.
134. Rompe JD (ed): Extrakorporale Stoßwellentherapie–Grundlagen, Indikation, Anwendung. London, Chapman and Hall 1997.
135. Rompe JD: Stoßwellentherapie: Therapeutische wirkung bei spekulativen mechanismes. Z Orthop 134:13–19, 1996.
136. Rompe JD, Bohl J, Riehle HM, et al: Überprüfung der Läsionsgefahr des nervus ischiadicus des kaninchens durch die applikation neidrig und mittelenergetischer extrakorporaler stowellen. Orthop Prax 136:407–411, 1997.
137. Rompe JD, Burger R, Hopf C, et al: Shoulder function after extracorporeal shock wave therapy for calcific tendonitis. J Shoulder Elbow Surg 7:505–509, 1998.
138. Rompe JD, Eysel P, Hopf C, et al: Extrakorporae stowellenapplikation bei gestörter Knochenheilung: Eine kritische bestandsaufnahme. Unfallchirug 100:845–849, 1997.
139. Rompe JD, Eysel P, Kullmer K, et al: Extracorporale stoßwellentherapie in der orthopadie aktueller stand. Orthop Prax 32:558–561, 1996.
140. Rompe JD, Hopf C, Eysel P, et al: Extracorporale Stoßwellentherapie des Therapieresistenten Tennisellenbogens–Erste Ergebnisse von 150 Patienten. In Chaussy C, Eisenberger F, Jochum D, Wilbert D (eds). Die Stowellen Forschung und Klinik. Tubingen, Germany, Attempo Verlag 152–174, 1995.
141. Rompe JD, Hopf C, Kullmer K, et al: Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. J Bone Joint Surg 78B:233–237, 1996.
142. Rompe JD, Hopf C, Kullmer K, et al: Low-energy extracorporeal shock wave therapy for persistant tennis elbow. Int Orthop 20:23–27, 1996.
143. Rompe JD, Hopf C, Kullmer K, et al: Extracorporale stowellentherapie der epicondylopathia humeri radialis: Ein alternatives behandlungskonzept. Z Orthop 134:63–66, 1996.
144. Rompe JD, Hopf C, Nafe B, et al: Low-energy extracorporeal shock wave therapy for painful heel: A prospective controlled single-blind study. Arch Orthop Trauma Surg 115:75–79, 1996.
145. Rompe JD, Kirkpatrick CJ, Kullmer K, et al: Dose-related effects of shock waves on rabbit tendo Achilles. J Bone Joint Surg 80 B:546–552, 1998.
146. Rompe JD, Kullmer K, Eysel P, et al: Niederengenergetische extrakorporale stowellentherapie (ESWT) beim plantaren fersensporn. Orthop Prax 32:271–275, 1996.
147. Rompe JD, Kullmer K, Riehle HM, et al: Effektiveness of low-energy extracorporal shock waves for chronic plantar fasciitis. J Foot Ankle Surg 2:215–221, 1996.
148. Rompe JD, Kullmer K, Vogel J, et al: Extracorporale stoßwellentherapie: Experimentelle grundlagen, klinischer Einsatz. Orthopäde 26:215–228, 1997.
149. Rompe JD, Rumler F, Hopf C, et al: Shoulder function after extra-corporal shock wave therapy (ESWT) for calcifying tendonitis. J Shoulder Elbow Surg 6:317–320, 1997.
150. Rompe JD, Rumler F, Hopf C, et al: Extracorporal shock wave therapy for calcifying tendinitis of the shoulder. Clin Orthop 321:196–201, 1995.
151. Russo S, Gigliotti S, de Durante C, et al: Results with Extracorporeal Shock Wave Therapy in Bone and Soft Tissue Pathologies. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 149–155, 1997.
152. Russo S, Stephenson RA, Mies C, et al: High energy shock waves suppress tumor growth in vitro and in vivo. Urology 135:626–628, 1986.
153. Saisu T, Goto S, Wada Y, et al: Irradiation of the extracorporeal shock wave to the immature long bone causes overgrowth and local increase in bone mineral content. Trans Orthop Res Soc 45:34, 1999.
154. Salinas AS, Lorenzo-Romero J, Segura M, et al: Factors determining analgesic and sedative drug requirements during extracorporeal shock wave lithotripsy. Urol Int 63:92–101, 1999.
155. Saß W, Bräunlich M, Dreyer H, et al: The mechanisms of stone disintegration by shock waves. Ultrasound Med Biol 17:239–243, 1992.
156. Schaden W: Clinical Experience With Shock Wave Therapy of Pseudarthrosis, Delayed Fracture Healing, and Cement-Free Endoprosthesis Loosening. In Siebert W, Buch M (eds): Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 137–148, 1997.
157. Schaden W, Kuderna H: Extracorporeal Shock Wave Therapy (ESWT) in 37 Patients With Non-Union or Delayed Osseous Union in Diaphyseal Fractures. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 121–126, 1997.
158. Schelling G, Delius M, Gschwender M, et al: Extracorporeal shock waves stimulate from sciatic nerves indirectly via a cavitation mediated mechanism. Biophysical J 66:133–140, 1994.
159. Schleberger R: Anwendung der Extrakorporalen Stoßwelle am Stutz und Bewegungsapparat im Mittelenergetischen Bereich. In Chaussy C, Eisenberger F, Jochum D, Wilbert D (eds). Die Stoßwelle–Forshung und Klinik. Tubingen, Attempo Verlag 166–174, 1995.
160. Schleberger R, Dahm K, Werner T: Two-Center Comparison of Extracorporeal Shockwave Therapy (ESWT) in Calcaneal Spurs. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 117–120, 1997.
161. Schleberger R, Delius M, Dahmen GP, et al: Orthopaedic Extracorporeal Shockwave Therapy (ESWT): Method Analysis and Suggestions of Prospective Study Design–Consensus. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 108–111, 1997.
162. Schleberger R, Diesch R, Schaden W, et al: Four-Center Result Analysis of Extracorporeal Shockwave Treatment (ESWT) of Long Bone Non-Unions. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 112–116, 1997.
163. Schleberger R, Senge T; Non-invasive treatment of long-bone pseudarthrosis by shock waves (ESWT). Arch Orthop Trauma Surg 111:224–227, 1992.
164. Schleberger R, Senge T: Nichtinvasive Behandlung diaphysaren Pseudarthrosen mit der Stoßwelle. In Irtel T, Sieberth G, Matthiaß H (eds). Aktuelle Aspekte in der Osteologie. Berlin, Springer Verlag 311–317, 1992.
165. Schreuers BW, Bierkens AF, Huiskes R, et al: The effect of the extracorporeal shock wave lithotripter on bone cement. Biomed Mater Res 25:157–164, 1991.
166. Seeman O, Rassweiler J, Chvapil M, et al: Effect of low dose shock wave energy on fracture healing: An experimental study. J Endourol 6:219–223, 1992.
167. Seidl M, Steinback P, Hofstädter F: Shock wave induced endothelial damage: In situ–analysis by confocal laser scanning microscopy. Ultrasound Med Biol 20:571–578, 1994.
168. Seidl M, Steinback P, Wörle K, et al: Induction of stress fibers and intercellular gaps in human vascular endothelium by shock waves. Ultrasonics 32:397–400, 1994.
169. Seil R, Rupp S, Hammer DS, et al: Extrakorporale stoßwellentherapie bei der tendinosis calcarea der rotatorenmanschette: Vergleich zweier behandlung protokolle. Z Orthop 137:310–315, 1997.
170. Siebert W, Buch M (eds): Extracorporeal Shockwaves in Orthopaedics. New York, Springer Verlag 1997.
171. Sistermann R, Kathagen BD: Komplikationen, nebenwirkungen und kontraindikationen der anwendung mittel-und hochenergetischer extrakorporaler stoßwellen im orthopädischen bereich. Z Orthop 136:175–181, 1998.
172. Smits GA, Jap PH, Heerschap A, et al: Biological effects of high energy shock waves in mouse skeletal muscle: Correlation between 31P magnetic resonance spectroscopic and microscopic alterations. Ultrasound Med Biol 19:399–409, 1993.
173. Staudenraus J, Eisenmenger W: Fiber optic probe hydrophone for ultrasonic and shock wave measurements in water. Ultrasonics 31:267–273, 1993.
174. Steinbach P, Hofstädter F, Nicolai H, et al: Determination of the energy dependent extent of vascular damage caused by high-energy shock waves in an umbilical cord model. Urol Res 21:279–282, 1993.
175. Steinbach P, Hofstädter F, Nicolai H, et al: In vitro investigations on cellular damage induced by high energy shock waves. Ultrasound Med Biol 18:691–699, 1992.
176. Steinbach P, Wörle K, Seidl M, et al: Effekte Hochenergetischer Ultraschallstoßwellen auf Tumorzellen In Vitro und Humane Endothelzellen In Situ. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). Stoßwellenlithotripsie–Aspekte und Prognosen. Tübingen, Germany, Attempto Verlag 104–109, 1993.
177. Suhr D, Brummer F, Hulser DF: Cavitation-generated free radicals during shock wave exposure investigations with cell-free solutions and suspended cells. Ultrasound Med Biol 17:761–768, 1992.
178. Sukul-Kaulesar DM, Johannes EJ, Pierik EG, et al: Effect of shock wave application on bone: An in vitro study. J Surg Res 53:110–116, 1992.
179. Sukul-Kaulesar DM, Johannes EJ, Pierik EG, et al: The effect of high energy shock waves focused on cortical bone: An in vitro study. Surg Res 54:46–51, 1993.
180. Thiele R, Hartmann T, Helbig K, et al: Primary Results of a Long Term Observation of the Treatment of Tendinosis Calcarea of the Shoulder Using Extracorporeal Shock Wave Therapy. In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 127–128, 1997.
181. Tomita Y, Shima A: Mechanisms of impulsive pressure generation and damage pit formation by bubble collapse. J Fluid Mech 169:535–564, 1986.
182. Tsironis K, Burger C, Meurer A, et al: Langzeitergebniße der extrakorporalen stoßwellentherapie bei ansatztendopathien der schulter des ellenbogens und der ferse. Orthop Prax 10:669–672, 1997.
183. United States Department of Health and Human Services: Acute Low Back Problems in Adults. Clinical Practice Guideline. Washington, DC, United States Department of Health and Human Services 14, 1994.
184. Usle M, Bozdogan Ö, Güney S, et al: The effect of extracorporeal shock wave treatment (ESWT) on bone defects: An experimental study. Bull Hosp Jt Dis 58:114–118, 1999.
185. Valchanou VD, Michailov P: High energy shock waves in the treatment of delayed and non union of fractures. Int Orthop 15:181–184, 1991.
186. Valchanou VD, Michailov P, Kerin T, et al: Extracorporeal exposure with shock waves on bone tissue as a factor for local osteogenesis. Endourology 5 (Suppl 1):22–26, 1991.
187. Van Arsdalen KN, Kurzweil S, Smith J, et al: Effect of lithotripsy on immature rabbit bone and kidney development. J Urol 146:213–216, 1991.
188. Väterlein N, Lussenhop S, Hahn M, et al: The effect of extracorporeal shock waves on joint cartilage: An in vivo study in rabbits. Arch Orthop Trauma Surg 120:403–406, 2000
189. Vogel J, Eysel P, Hopf C, et al: Lithotripsy in Non-Unions of the Lower Extremities: An Alternative to Surgery? In Chaussy C, Eisenberger F, Jocham D, Wilbert D (eds). High Energy Shock Waves in Medicine. Stuttgart, Thieme Verlag 129–135, 1997.
190. Vogel J, Hopf C, Eysel P, et al: Application of extracorporeal shock-waves in the treatment of pseudarthrosis of the lower extremity: Preliminary results. Arch Orthop Trauma Surg 116:480–483, 1997.
191. Vogel J, Krischek O, Rompe JD: Die prognostische bedeutung der skelettszintigraphie in der behandlung von pseudarthrosen mit hochenergetischen extracorporalen stoßwellen. Z Orthop 135:94–98, 1997.
192. Vogel J, Rompe JD, Hopf C, et al: Die hochenergetinche extracorporale stowellentherapie (ESWT) in der behandlung von pseudarthrosen. Z Orthop 135:145–149, 1997.
193. von Daecke W, Loew M, Schuknecht B, et al: Der einfluß der applikationsdosis auf die wirksamkeit der ESWA bei der tendinosis calcarea der schulter. Orthop Prax 2:119–123, 1997.
194. von Hasselbach C: Therapy Resistant Insertion Tendinosis: Indication for Extracorporeal Shock Wave Therapy or Surgery. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 201–212, 1997.
195. Weinstein JN, Oster DM, Park JB, et al: The effects of extracorporeal shock wave lithotripter on the bone-cement interface in dogs. Clin Orthop 235:261–267, 1988.
196. Weiss N, Delius M, Gambihler S, et al: The in vivo effects of shock waves and cisplatin on cisplatin sensitive and resistant rodent tumors. Int J Cancer 58:693–699, 1994.
197. Williams JC, Stonehill MA, Colmenares K, et al: Effect of macroscopic air bubbles on cell lysis by shock wave lithotripsy in vitro. Ultrasound Med Biol 25:473–479, 1999.
198. Wirth CJ: Pseudarthrosen. In Jäger M, Wirth CJ (eds). Praxis der Orthopädie. Stuttgart, Thieme Verlag 284–291, 1992.
199. Wolf T, Breitenfelder J: Erste erfahrungen mit der extrakorporalen stoäwellentherapie (ESWT) bei schmerzzustlinden des bewegungsapparates mit unschriebener lokalisation. Orthop Prax 32:480–483, 1996.
200. Wolf T, Breitenfelder J: Course Observations After Extracorporeal Shock Wave Therapy (ESWT) in Cases of Pain in the Locomotor System with Circumscribed Localization. In Siebert W, Buch M (eds). Extracorporeal Shock Waves in Orthopaedics. Berlin, Springer Verlag 181–188, 1997.
201. Wolff JM, Mattelaer P, Boeckmann W, et al: Evaluation of possible tissue damage in patients undergoing extracorporeal shock wave therapy employing C-reactive protein. Scand J Urol Nephrol 31:31–34, 1997.
202. Wörle K, Steinbach P, Hofstädter F: The combined effects of high-energy shock waves and cytostatic drugs or cytokines on human bladder cancer cells. Br J Cancer 69:58–65, 1994.
203. Yang C, Heston WDW, Gulati S, Fair WR: The effect of high energy shock waves (HESW) on human bone marrow. Urol Res 16:427–429, 1988.
204. Yeaman J, Jerome DCP, McCullough DL: Effects of shock-waves on the structure and growth of the immature rat epiphysis. J Urol 141:670, 1989.
205. Yount DE: On the evolution, generation and regeneration of gas cavitation nuclei. J Acoust Soc Am 71:1473–1481, 1982.
206. Yount DE, Gillary EW, Hoffman DC: A microscopic investigation on bubble formation nuclei. J Acoust Soc Am 76:1511–1521, 1984.
207. Zhong P, Cioanata S, Zhu L, et al: Effects of tissue constraint on shock wave-induced bubble expansion in vivo. J Acoust Soc Am 104:3126–3129, 1998.
208. Zhu S, Zhong P: Shock wave-inertial micro bubble interaction: A theoretical study based on the Gilmore formulation for bubble dynamics. J Acoust Soc Am 106:3024–3033, 1999.

Section Description

John A. Ogden, MD; and Richard R. Alvarez, MD, Guest Editors

© 2001 Lippincott Williams & Wilkins, Inc.