Shockwave Therapy

In orthopedics, extracorporeal shockwave therapy (ESWT) is a form of shockwave therapy designed to repair and regenerate damaged tissue. For over a decade physicians have been using shockwave therapy for Achilles pain, plantar fasciitis of the heel, lateral epicondylitis, tendinitis of the shoulder, patellar tendinopathy, necrosis of the femoral head, and ischemic heart disease. The success rate for healing ranges from between 65 to 91 percent of patients, and complications are minimal.

What is Shockwave Therapy?

A shockwave is a pulse of energy that can pass at near-supersonic speeds through any material. For example, the tremors from an earthquake travel so fast, they can shake the earth’s crust.

The healing advantages of shockwave therapy were discovered when physicians began using them to target and break up kidney stones within the body. Shockwave therapy works by inducing micro-trauma to the tissue which initiates a healing response, causing blood vessel formation, increasing blood flow, delivering nutrients, and lessening pain within the affected area.

Shockwave therapy comes in two forms, one low-energy and the other high-energy. Low-energy shockwaves, which are given as a series of three or more treatments, are at worst only mildly painful. High-energy shockwaves, however, are administered in one session and incredibly painful. Patients undergoing this procedure will need to procure either a regional block or general anesthesia.

Shockwave Therapy for Achilles Pain

In the last decade shockwave therapy for tendinitis and other afflictions of the heel bone (calcaneus) has been overwhelmingly successful. Achilles tendinopathy is a degenerative condition in which the body’s largest tendon becomes strained and ruptured from repetitive walking, jumping, and strenuous exercise. Tendinitis (or tendonitis) is a form of Achilles tendinopathy involving large-scale acute injuries accompanied by inflammation. It’s often confused with tendinosis, which is damage to a tendon at a cellular level because of microtears in the support structure surrounding the tendon. Achilles tendon injuries typically affect distance runners and participants in sports like soccer, basketball, and handball. Achilles tendinopathy affects 11 percent of runners, 9 percent of dancers, 9 percent of dancers, and 5 percent of gymnasts.

In uncontrolled pilot studies, shockwave therapy for Achilles tendinitis and other heel injuries has proven effective. In trials conducted using shockwave therapy on lateral epicondylitis, plantar fasciitis, and Achilles tendinopathy, 1,500-2,000 jolts of low energy were applied to the place of greatest pain without the benefit of anesthesia. This was done three to four times during one weekly session over a period of three to four months. These studies revealed that low-energy shockwave therapy for Achilles pain resulted in healed tendons, while high levels of energy prevented the tendons from healing.

In one study, two separate trials investigated the use of shockwave therapy on Achilles tendinopathy. Single-dose high-energy shockwave therapy was applied to both chronic insertional and non-insertional tendinopathy in 68 patients. One group of 35 received a dose of high-energy shockwave therapy, while another group of 33 received non-operative treatment. Twelve months after treatment, 83 percent of patients receiving shockwave therapy for Achilles tendinitis or tendinosis reported improved symptoms. However, the study also found that local anesthesia may limit the procedure’s effectiveness.

Shockwave therapy has also emerged as an effective treatment for plantar fasciitis, a condition causing pain under the heel bone and the arch of the foot. Plantar fasciitis is an inflammation of the soft tissue on the bottom of the foot, the plantar fascia, that loosens and contracts like a rubber band when the body moves. Because plantar fasciitis may result from excessive exercise or other strenuous activity, runners and athletes are especially susceptible to it. However, plantar fasciitis may also result from prolonged exposure to shoes that don’t fit properly or fail to support the body’s weight.

Most patients with plantar fasciitis experience relief through conventional methods like orthotics (shoe inserts), ice treatment, and non-steroidal anti-inflammatory medications, but increasingly orthopedic surgeons are turning to shockwave therapy when treating plantar fasciitis that doesn’t respond to surgery. The FDA approved the use of shockwaves for plantar fasciitis treatment in 2000, and repeated studies have touted the benefits of low-energy ESWT for patients suffering from plantar fasciitis, especially those who did not improve with more conventional methods.

Shockwave Therapy for Calcific Tendinitis

Calcific tendinitis is a condition characterized by the formation of small calcium deposits within a tendon. In the majority of cases shockwave therapy for calcific tendinitis involves treatment of the rotator cuff in the shoulder blade. Most patients who undergo treatment are over the age of thirty, and a significant number are also diabetic.

The extent of shockwave therapy for calcific tendinopathy will depend on the progression of symptoms. In the earliest stages there are no symptoms. Later, as the calcium is excreted from cells and coalesces into calcium deposits, the patient undergoes a resting phase in which symptoms are not painful. However, this gives way to the resorptive phase, which is intensely painful, and, not coincidentally, when the majority of people seek shockwave therapy for calcific tendinosis.

In a study reported in the Journal of Orthopaedics and Traumatology, undertaken between 2000 and 2005, forty-six patients with chronic calcific tendinitis were treated with non-conservative treatments. None of the patients had responded to six months of conservative treatments. Each of them had undergone clinical examinations, radiographs, sonography, or magnetic resonance imaging.

The patients were given the option of being treated with surgery or with shockwave therapy for calcific tendinosis. Twenty-two patients chose surgery; the rest underwent ESWT. The doctor inserted a needle through the hyperemic area, occasionally finding calcium lodged on the tip of the needle. Then a suture was passed through the needle to mark the position of the deposit and a bursectomy was performed, puncturing the calcium deposit and allowing it to leak out. They then used a motorized shaver to fully remove the deposit. After the operation, the patient was given a sling and began a daily regimen of pendulum exercises.

After twenty-four months of recovery and rehabilitation, both groups were examined again. The study found that there was no significant difference between those who had undergone surgery and those treated with shockwave therapy for calcific tendinopathy. The doctors concluded that both surgery and ESWT are effective in treating calcifying tendinitis, that there’s no clinical advantage to surgery, and that repeated low-energy sessions of ESWT can be effectively given without anesthesia and hospitalization.

Shockwave Therapy for Heel Pain

Shockwave Therapy for heel pain may prove beneficial for those suffering from plantar fasciitis and heel spurs which can cause pain and inflammation in the foot.

Heel spurs are calcium deposits that gradually develop into bony protrusions underneath the heel. As the spur develops, the soft tissue becomes swollen and irritated, placing pressure on the nerves that causes intense pain. Like plantar fasciitis, heel spurs may result from improper motion during walking and running, badly fitted shoes, or excessive body weight which heightens the amount of force hitting the ground when the body impacts it.

Shockwave therapy for heel spurs is essentially the same as shockwave therapy for Achilles tendinosis and shockwave therapy for knee pain, though the site of treatment is different. Patients can expect their shockwave therapy for heel spurs to take about half an hour under local anesthetic. The efficacy of the treatment will become apparent over a period of two or three months. Vigorous activities should be limited for a period of four to six weeks.

Like shockwave therapy for lateral epicondylitis, ESWT for heel spurs should be accompanied by conventional treatments, allowing the patient time to rest and recover. Shoes with shock-absorbent soles should be worn to provide proper support for the body, while shoes with excessive wear, or that don’t have adequate support, should be thrown out. Orthotics may be worn to correct structural imbalances. A physician may recommend a regimen of daily stretching, along with cross-training exercises such as yoga, swimming, and biking.

Shockwave Therapy for Knee Pain

For patients suffering from chronic patellar tendinopathy, the most beneficial treatment may be shockwave therapy for knee pain. Chronic patellar tendinopathy is an overuse syndrome in which the tendons are injured. Medical researchers from Chang Gung University College of Medicine in Taiwan tested the results on 27 patients, over against 23 who underwent more conservative treatments. After three years, the study found significantly more improvement in the shockwave group, where 43 percent of patients experienced “excellent outcomes” and 43 percent reported “good” outcomes.

How Do We Use Shockwave Therapy?

Extracorporeal shockwave therapy is one of the most advanced and effective non-invasive treatments for neuromuscular disorders approved by the FDA. Because there’s no surgical incision, minimal risk is involved. As a consequence, ESWT is frequently recommended before surgery is undertaken. Our trained specialists have performed over 2,000 procedures for tendons throughout the body, and their use of extracorporeal shockwave therapy has been exceptional because they target the site of injury with diagnostic ultrasound. Moreover, we combine shockwave therapy with comprehensive rehabilitation programs such as eccentric strengthening exercises and biomechanical correction.


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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