Benefits of Ultrasound Guided ESWT for Musculoskeletal Pain and Rehab

Benefits of Ultrasound

Extracorporeal Shockwave Therapy (ESWT) is a popular non-invasive tool used in sports medicine to treat musculoskeletal pain and injuries in both athletes and non-athletes. It works by delivering shock waves to injured soft tissues, to reduce pain and promote healing.

Shockwave therapy is often done “blind,” where the practitioner takes an educated guess to target damaged tissues. Ultrasound guidance takes the guesswork out of ESWT by providing real-time images of tissues buried deep beneath the skin’s surface.

ESWT Types and Uses

ESWT Types and Uses

There are two basic types of ESWT: Radial (soft) and focused (hard).

Radial shock wave therapy is the most common form of ESWT, used for a larger treatment area at a more superficial level. Radial shock waves emit their greatest energy at the skin’s surface, and lose power as their energy penetrates deeper tissues. Radial shock waves are most often used for superficial tendinopathies and trigger points, myofascial pain, plantar fasciitis and hip pain at the greater trochanter.

Focused shock wave therapy uses a cylindrical coil to generate electromagnetic waves that penetrate deeper tissues. They cause tissue membranes to vibrate and create pressure waves in their surrounding fluids without losing energy. Focused shock waves target a smaller focal area. They are used to treat acute injuries, bone fractures, shin splints, groin pain, Achilles tendon injuries, tibial pain, ankle sprains and healing wounds.

Focused and radial shock waves are often used in combination to treat acute and repetitive overuse injuries in athletes.

Benefits of US Guided ESWT

Benefits of US Guided ESWT

Using ultrasound technology to help guide ESWT has many advantages:

  • Accurate body positioning: Without ultrasound imaging, deep tissues are difficult to target. Practitioners use anatomical markers to position patients for blind treatment, but individual anatomy varies greatly from one patient to the next. Ultrasound takes the guesswork out of patient positioning and allows us to accurately target deep tissue injuries.
  • More accurate diagnosis: The clinical exam gives limited insight into the true nature of injuries. Ultrasound guidance gives the practitioner a clear image of damaged tissues, for more accurate diagnosis of the nature and severity of injury.
  • More effective treatment: Being able to view damaged tendons gives us a better idea of which type and level of shockwave treatment will be most effective. A degenerated tendon may have partial thickness tears or calcifications, calling for higher energy shock waves.
  • Better timing: Beginning ESWT too soon after an acute injury, when tissues are still inflamed, can increase the patient’s pain and discomfort. Ultrasound lets us assess whether inflammation has subsided enough to begin therapy.
  • Reduced risk to sensitive tissues: Nerves, blood vessels and other sensitive tissues should be avoided when conducting ESWT. Ultrasound guidance lets us avoid sensitive tissues while accurately targeting damaged tissues with the correct power settings.
  • Safe spinal treatment: The facet joints are set deep in the spine, surrounded by sensitive neural tissue. Ultrasound helps the practitioner accurately calculate the depth of facet joints, to ensure correct power settings and avoid sensitive nerves.
  • Focused shoulder treatment: Calcifications in the rotator cuff tendons impede shoulder movement and cause pain. Ultrasound lets us accurately target calcifications at the right depth, to break them up and eliminate them.
  • Effective followup: Ultrasound lets us view the outcomes of ESWT treatment, to assess patient progress and modify the treatment protocol.
  • Improved patient compliance: One of the best features of ultrasound technology is that the patient becomes an active participant in the diagnosis and treatment processes. They are able to view images of their injured tissues in real time, give feedback to the practitioner, understand the purpose and benefits of treatment, and view the recovery process from session to session. As participants in their own treatment, patients are more likely to comply with exercise protocols designed to restore functional recovery.

Who Should Get US Guided ESWT?

If you are athletic or physically active, you are no stranger to sore muscles and overuse injuries. Ultrasound guided ESWT can get to the source of pain and accurately target affected tissues, to speed up healing and recovery. ESWT offers a safe and effective treatment option for conditions like plantar fasciitis, carpal tunnel syndrome, tennis elbow, golfer’s elbow, and rotator cuff pain and dysfunction.

ESWT is not recommended for children, pregnant women, people with blood clots or taking blood thinners, people with pacemakers, anyone with tumors or infections at the treatment site, or if you have had a steroid injection in the past 6 weeks.

US Guided ESWT in NYC

If you suffer from chronic pain, tendinopathies, athletic overuse injuries or other musculoskeletal issues, ESWT may be an effective solution for relieving pain and accelerating the healing process. At NYDNRehab, we have the most sophisticated technologies available in a private rehab clinical setting. We provide a number of innovative treatments geared to the unique needs of each individual patient. Contact us today, and discover what it feels like to move like a pro at NYDNRehab.

Research at NYDNRehab

Comparative Study of Dry Needling under Ultrasound Guidance and Extracorporeal Shock Wave Therapy for Myofascial Pain and Spasticity Management Meeting: 2019 International Congress R. Bubnov, L. Kalika (Kyiv, Ukraine)
Comparative Study of Dry Needling under Ultrasound Guidance and Extracorporeal Shock Wave Therapy for Myofascial Pain and Spasticity Management Meeting: 2019 International Congress R. Bubnov, L. Kalika (Kyiv, Ukraine) (part2)

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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