Extracorporeal shockwave therapy (ESWT)

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History of extracorporeal shockwave therapy

Clinical use of ESWT was first introduced into practice in 1982 for urologic conditions [1]. The success of this technology for the treatment of urinary stones quickly made it a first-line, noninvasive, and effective method[2]. Subsequently, ESWT was studied in orthopedics where is was identified that ESWT could loosen the cement in total hip arthroplasty revisions[3]. Further, animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface and also found an osteogenic response and improve fracture healing [4][5]. While benefits in fracture healing have been shown with ESWT the majority of orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies, and soft tissue conditions.

Physiology of ESWT

Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration (10 ms). They have a single pulse, a wide frequency range (0-20 MHz) and a high pressure amplitude (0-120 MPa)

These characteristics produce a positive and negative phase of shockwave. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves.[6]

In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave.[7]

Mechanism of Action

The effects of ESWT treatment are unknown[8]. The proposed mechanisms of action for ESWT include the following: promote neovascularization at the tendon-bone junction [9], stimulate proliferation of tenocytes [10] and osteoprogenitor differentiation [11], increase leukocyte infiltration [12], and amplify growth factor and protein synthesis to stimulate collagen synthesis and tissue remodeling [10] [11] [13] [14].

Clinical Guidelines

Extracorporeal shockwave therapy (ESWT) is primarily used in the treatment of common musculoskeletal conditions. These include both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, patellar tendinopathy, plantar fasciopathy.

There is no standardized ESWT protocol for the treatment of musculoskeletal conditions.




  1. C. Chaussy, E. Schmiedt, D. Jocham, W. Brendel, B. Forssmann, V. Walther First clinical experience with extracorporeally induced destruction of kidney stones by shock waves J Urol, 127 (1982), pp. 417-420
  2. A.N. Argyropoulos, D.A. Tolley Optimizing shock wave lithotripsy in the 21st century Eur Urol, 52 (2007), pp. 344-352
  3. S.H. Park, J.B. Park, J.N. Weinstein, S. Loening Application of extracorporeal shock wave lithotripter (ECSWL) in orthopedics. I. Foundations and overview J Appl Biomater, 2 (1991), pp. 115-126
  4. J.N. Weinstein, D.M. Oster, J.B. Park, S.H. Park, S. Loening The effect of the extracorporeal shock wave lithotriptor on the bone-cement interface in dogs Clin Orthop Relat Res, 235 (1988), pp. 261-267
  5. G. Haupt, A. Haupt, A. Ekkernkamp, B. Gerety, M. Chvapil Influence of shock waves on fracture healing Urology, 39 (1992), pp. 529-532
  6. H. van der Worp, I. van den Akker-Scheek, H. van Schie, J. Zwerver ESWT for tendinopathy: Technology and clinical implications Knee Surg Sports Traumatol Arthrosc, 21 (2013), pp. 1451-1458
  7. C.J. Wang Extracorporeal shockwave therapy in musculoskeletal disorders J Orthop Surg Res, 7 (2012), p. 11
  8. Reilly JM, Bluman E, Tenforde AS. Narrative Review on the Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions PM R. 2018 May 31 [Epub ahead of print]
  9. C.J. Wang, H.Y. Huang, C.H. Pai Shockwave-enhanced neovascularization at the tendon-bone junction: An experiment in dogs J Foot Ankle Surg, 41 (2002), pp. 16-22
  10. 10.0 10.1 Y.J. Chen, C.J. Wang, K.D. Yang, et al. Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression J Orthop Res, 22 (2004), pp. 854-861
  11. 11.0 11.1 F.S. Wang, K.D. Yang, R.F. Chen, C.J. Wang, S.M. Sheen-Chen Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta1 J Bone Joint Surg Br, 84 (2002), pp. 457-461
  12. J.D. Rompe, C.J. Kirkpatrick, K. Kullmer, M. Schwitalle, O. Krischek Dose-related effects of shock waves on rabbit tendo Achillis. A sonographic and histological study J Bone Joint Surg Br, 80 (1998), pp. 546-552
  13. G. Bosch, Y.L. Lin, H.T. van Schie, C.H. van De Lest, A. Barneveld, P.R. van Weeren Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponies Equine Vet J, 39 (2007), pp. 226-231
  14. C.M. Waugh, D. Morrissey, E. Jones, G.P. Riley, H. Langberg, H.R. Screen In vivo biological response to extracorporeal shockwave therapy in human tendinopathy Eur Cell Mater, 29 (2015), pp. 268-280
  15. Langmore Podiatry. Shockwave Therapy Demonstration. Available from: https://www.youtube.com/watch?v=P5dibaAu7pQ [last accessed 6/17/2018]