After ESWT, a comprehensive post-treatment schedule, individualized for each pathology and each patient’s clinical status, should be given to the patient including avoidance of the use of the anatomic structure, a specific exercise program, and instructions to avoid overload.
ESWT has emerged as an alternative therapy prior to invasive procedures when conservative treatment has failed as described for Gärtner type-I or II rotator cuff calcifications54,55 (Fig. 3). The rate of successful reabsorption reported by different authors has a very wide range56-66.
Several systematic reviews and meta-analyses have demonstrated that high-energy F-ESWT is a safe, effective treatment for CTS61-66.
Unlike CTS, the treatment of noncalcified tendinopathies with shockwaves is controversial71. Both favorable and poorly performing studies in many cases present inadequate inclusion criteria (wide age ranges, heterogeneous populations, and insufficient diagnostic evaluations). It is inadmissible to consider “subacromial pain”72 or “non-specific shoulder pain”73 as a diagnosis of shoulder disease if all possible differential diagnoses have not been ruled out. This confusion is reflected in the results of the meta-analyses and systematic reviews62,63,65.
We are unable to recommend the use of ESWT in noncalcific tendinopathy of the shoulder because of the lack of compelling evidence.
There are many therapeutic options for treating lateral epicondylopathy. The existing evidence does not clearly support the efficacy of any of the available treatment methods for this clinical condition74-79. ESWT is not the exception79, although it was approved by the U.S. Food and Drug Administration (FDA) for treating this disease in 200280.
Although the strength of the supporting evidence is not strong, no method to treat lateral epicondylopathy is backed by studies with a high level of evidence. As the benefits largely exceed any potential harm, we recommend the use of radial or focused ESWT technologies when conventional rehabilitation treatment has failed.
There is no agreement about the optimal management for greater trochanteric pain syndrome88. Numerous conservative treatments (nonsteroidal anti-inflammatory drugs, physiotherapy, and corticosteroid injections) have been recommended88.
Two studies provided Level-II and III evidence for RPW effectiveness in 74% of patients at 15 months88 and 78.8% at 12 months89, respectively.
Although the available evidence on ESWT in greater trochanteric pain syndrome is limited, RPW appears more effective than a home exercise program and local corticosteroid injection after short-term and mid-term follow-up (up to 15 months) of greater trochanteric pain syndrome88-90.
New therapies, such as prolotherapy, dry-needling, platelet-rich plasma (PRP), cell therapy, or hyaluronic acid, may offer alternatives to standard treatments93,94.
However, these studies describing poor results with the use of ESWT included certain features and methodological errors such as: no complementary studies were performed to rule out calcification or partial rupture with a different prognosis101,102; applying ESWT with a piezoelectric device101,102; adapting the ESWT intensity to patient tolerance instead of a specific therapeutic energy level101; high energy levels101; allowing for training and competition during and after ESWT treatment instead of removing the patient from sports101,102; and ESWT as a solitary treatment not combined with exercise101.
Review of the literature shows that ESWT is safe and effective in the treatment of patellar tendinopathy90,91,98. Current evidence supports the use of F-ESWT and RPW for patellar tendinopathy with moderate or low-intensity protocols, especially in patients attempting to avoid an invasive intervention.
Achilles tendinopathy affects active athletes as well as the sedentary population103. According to its anatomical location, it is classified into 2 categories, insertional and noninsertional or midportion tendinopathy.
Conservative treatment includes pain medication, heel lifts, eccentric exercises, physiotherapy, steroid and platelet-rich plasma injections, low-level laser therapy, and radiofrequency, among others104-109. Different shockwave sources and protocols have been used. A Level-I study with 48 patients compared piezoelectric F-ESWT and placebo ESWT and found better results for the ESWT group110. Furia reported good results for insertional111 and noninsertional112 Achilles tendinopathies with RPW.
Since then, several studies with a high level of evidence have supported both focused121,122 and radial123,124 technologies for this disorder. Gollwitzer et al.125, in a study of the treatment of recalcitrant plantar fasciitis with an electromagnetic device, reported pain reduction in 69.2% of the patients in the ESWT group compared with 34.5% in the control group. Ogden et al.126, in an RCT, concluded that electrohydraulic F-ESWT is effective and safe and that the clinical improvement lasts beyond 1 year. In a Level-I study, Wang et al.122 compared F-ESWT with conservative treatment modalities. The shockwave group had excellent or good results in 82.7% of the patients compared with 55% in the control group at a follow-up of between 60 and 72 months; also, the shockwave group had a much lower recurrence rate.
Since 2010, the American College of Foot and Ankle Surgeons has recommended ESWT as a treatment of choice for plantar fasciitis with or without a plantar spur when nonoperative treatment has failed135.
The use of ESWT for nonhealing fractures was first reported, to our knowledge, in 1991 by Valchanou and Michailov142. Since then, several observations and trials have supported the efficacy of ESWT for nonunion and delayed fracture-healing143-157 (Table IV).
As some Level-I and II evidence has demonstrated that the efficacy of ESWT is comparable with that of surgery for the treatment of nonunions152,154,155, and ESWT is practically free of adverse effects and more economic, it may progressively be considered as the first choice in the treatment of stable nonunions with a gap of <5 mm in long bones (Fig. 4). For bone treatment, the basic principles of acute fracture management should be implemented after F-ESWT (immobilization, casting, and weight-bearing restrictions).
We acknowledge that it is currently difficult to obtain reimbursement for ESWT in the United States. We hope that heightened awareness as to the efficacy of ESWT, as well as recognition of how ESWT can be a cost-saving measure, will lead to changes in reimbursement coverage.
Shockwave treatment is indicated when standard conservative treatment has failed, so its cost should be compared with the cost of surgery. Dubs161 compared the efficacy and costs of ESWT with the usual treatments for CTS. In addition to demonstrating that ESWT was more efficacious, it also allowed for an average savings of US$2,000 per patient in comparison with alternative therapies.
ESWT is considered to be an alternative to surgery for several chronic tendinopathies and nonunions because of its efficacy, safety, and noninvasiveness. The best evidence supporting the use of ESWT was obtained with low to medium levels of energy for tendon disorders as well as with a high energy level for tendon calcification and bone pathologies in a comprehensive rehabilitation framework.
Because of the variability in the treatment protocols, the methodological quality of many ESWT studies is limited. Further research from well-designed, high-quality studies is required to standardize the treatment parameters and demonstrate the optimal ESWT approach for health-care decision-making.
With adequate patient selection, appropriate indications, homogeneous ESWT therapeutic protocols, and proper application, ESWT could make a paramount contribution to noninvasive treatment of certain musculoskeletal disorders.
Note: The authors thank Dr. Achim M. Loske Mehling for his important contribution on the subject of physical principles and wave generation, and John Furia, MD, for his kind contribution on Achilles tendinopathy and on economic and administrative considerations.
Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/E569).
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