Clearing the Fog Around Shockwave Therapy

Shockwaves have been safely used on human tissues since the 1980’s, initially as a tool to break up kidney stones and gallstones. But shockwave technology has dramatically evolved over the past 40 years, transforming extracorporeal shockwave therapy (ESWT) into an evidence-based regenerative solution for eliminating pain and promoting tissue healing at the cellular level.However, not all shockwaves are created equal. Equipment manufacturers riding the wave of shockwave’s popularity have flooded the market with a broad range of shockwave units, many of which are minimally efficient. At the same time, the qualifications and experience of most shockwave providers leaves much to be desired.Learn about the different types of shockwaves, their applications for different tissue types, and what to look for in a shockwave provider.

ESWT: A New Frontier in Regenerative Medicine

The human body comes fully equipped with its own mechanisms for regenerating cells and repairing damaged tissue, but sometimes innate healing factors fall short of fully repairing injured tissues. Regenerative medicine seeks to tap into the body’s healing mechanisms and enhance their performance by stimulating biochemical reactions that accelerate cellular neogenesis.

There are multiple modalities of regenerative medicine:

  • Stem cell injection therapy uses stem cells harvested from the patient’s own fat, blood, or bone marrow. Stem cells are generic cells that are able to develop into different types of cells, depending on the site of injection, such as tendon, ligament, cartilage or bone cells. Stem cells release cytokines – proteins that decrease pain and inhibit tissue degeneration.
  • Platelet rich plasma (PRP) injections use a sample of the patient’s own blood, spun in a centrifuge to extract a concentrated solution of platelets and plasma. PRP therapy releases the natural healing properties of platelets into the targeted tissues. PRP is frequently used to promote tendon healing and enhance joint function after an injury.
Stem cell injection therapy
Stem cell injection therapy
Platelet rich plasma (PRP) injections
Platelet rich plasma (PRP) injections
  • Prolotherapy injects a neutral solution such as dextrose, cellulose or saline into injured tissues as an irritant, with the aim of triggering an inflammatory immune response. The body responds to the irritant by sending immune cells like granulocytes, monocytes, macrophages and fibroblasts to the targeted site, to help repair and heal damaged tissues.
  • Regenerative technologies like extracorporeal shockwave therapy (ESWT), extracorporeal magnetic transduction therapy (EMTT), and other non-invasive technologies are relative newcomers to regenerative medicine, but they are quickly taking the lead as fast and effective treatment modalities for muscles, fascia, connective tissues and nervous tissue, with a growing body of research to support their efficacy.

When it comes to regenerative technologies, shockwave therapy has become the gold standard for regenerative medicine. In addition to tissue regeneration, ESWT is used to treat coronary disease, and is often used intraoperatively during open heart surgery. Shockwave therapy has been successfully used to treat muscle spasticity in cerebral palsy and stroke victims. Its potential for treating neurodegenerative disorders like Parkinson’s disease is currently being explored and shows great promise.

Shockwave Types and Variables

There are many grades and types of shockwave devices marketed to clinicians who treat musculoskeletal disorders, but only the most advanced and highest grade shockwave apparatus provides multiple options for different types of tissues and categories of shockwaves.

Most injuries involve more than one tissue type, and different tissues respond to different types of shockwaves. In addition, some tendon pathologies have multiple components that require a combination of energy waves. For example, the Achilles tendon is an aggregate of tissues that can be injured in different ways. Achilles tendinopathy may require focused waves mid-body, defocused waves at the peritenon, and radial waves at the myotendinous junction.

For optimal results, a combination of shockwave types will yield superior results versus a one-size-fits-all approach. To achieve the best results, clinicians need access to multimodal shockwave devices.

Shockwave Types and Variables

Factors that determine shockwave efficacy include:

  • Energy type and amplitude
  • Required depth of penetration
  • Tissue type (muscle, tendon, bone, etc)
  • Tissue depth – deep vs superficial
  • Patient characteristics (age, health status, obesity, etc)
  • Clinician training and expertise
  • Ability to visualize the tissues and monitor the procedure


There are multiple types of shockwaves with different uses and benefits:

  • Focused shockwaves use high-energy waves that allow for optimal precision. They are the most regenerative wave, being 70% more effective than radial shockwaves, and 50% more effective than defocused shockwaves. Their depth of penetration can be varied, with the capacity to reach deep tissues far below the skin’s surface.
  • Linear shockwaves are low-energy focused shockwaves used to promote angiogenesis – the formation of new blood vessels. Linear shockwaves are used to treat various conditions such as erectile dysfunction, and to encourage blood vessel formation in avascular tissues like tendons and ligaments.
Regenerative technologies
  • Defocused shockwaves, also called softwaves, are a combination of dispersed unfocused waves followed by a smaller focused wave. This type of wave does not penetrate as deeply, is harder to focus,is a bit more painful, and requires more treatment sessions. However, it is effective for larger area pathologies.
  • Radial shockwaves, also known as radial pressure waves, are not true shockwaves. They use extracorporeal pulse activation technology (EPAT) to create pressure waves, and are useful for collagen remodeling in fascia, eliminating fascial densifications, and increasing blood supply to superficial muscle tissues.

It is important to note that most non-medical health care providers use only radial shockwaves, which are often not regenerative enough, and which can be traumatic for certain tissues with an inflammatory component. In addition, few clinicians use imaging to guide their shockwave procedures, making shockwave therapy a hit-or-miss proposition.

Imaging is Foundational to Shockwave Efficacy

Even with the highest grade shockwave equipment, with the most diverse capabilities, it is impossible to efficiently target specific tissue types without being able to see them. Clinicians who advertise shockwave therapy with no means of visualizing the affected tissues are unlikely to be able to deliver satisfactory results.

Of the currently available imaging modalities, only high-resolution diagnostic ultrasonography provides the ability to visualize the body’s tissues in real time as they interact. This enables the shockwave provider to differentiate between different tissue types, their depth, the degree of damage, and other factors that cause pain and inhibit mobility.

Imaging is Foundational to Shockwave Efficacy

Ultrasonography enables the clinician to:

  • Identify which tissues to target
  • Select the depth of penetration
  • Determine the appropriate energy needed for each tissue type
  • Decide which tissue ruptures can be treated with shockwaves, and which should be left alone
  • Guide the shockwave procedure to ensure precise tissue targeting
  • Guide and monitor the rehabilitation process, from initial treatment to full recovery

Get Real Ultrasound-Guided Shockwave Therapy in NYC

Many chiropractic practices and physical therapy clinics advertise shockwave therapy as a service, but the vast majority only offer radial shockwave, which is not a true shockwave. At NYDNRehab, we use the highest resolution diagnostic ultrasound to identify tissue types and determine other factors that contribute to your pain and disability. Our high-performance shockwave equipment gives us a broad range of options for shockwave type, depth of penetration, and amplitude of energy.

get ultrasound-guided shockwave therapy that really works contact NYDNRehab today

Request an appointment » map Our location: 11 West 25th Street 5th floor, New York, NY 10010

Don’t waste your time and money on “shockwave therapy” that doesn’t deliver results. Contact NYDNRehab today, and get true ultrasound-guided shockwave therapy that really works!



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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