In our ‘Condition of the Month’ series for June 2024, we are featuring Shockwave Therapy. Although this is a service instead of a condition, shockwave therapy is a unique treatment that benefits more than one problem. What shockwave therapy tackles best is ‘scar tissue’, so really that is the condition that shockwave is addressing, and scar tissue has a role to play in lots of problems we see in clinic including achilles tendinopathy, plantar fasciopathy, medial tibial stress syndrome (shin splints) and much more, so read on to learn what shockwave therapy is and how it might be of benefit to you.
What is shockwave therapy?
Extracorporeal shockwave therapy (ESWT) is a safe, non-surgical treatment that is often used when other methods of treatment have not been effective. It works by passing high energy acoustic waves through the skin to the damaged tissue via a handheld probe, stimulating the body’s natural healing response and promoting regeneration and normal healing processes.
Benefits include (1):
- Reduction in pain
- Nerve desensitisation
- Breaking the cycle of chronic inflammation
- New blood vessel formation
- Collagen production
ESWT shows positive outcomes in a wide range of chronic musculoskeletal conditions, although some evidence in certain conditions is less robust. Common conditions in the lower limb where ESWT has shown to improve symptoms and function include:
- Plantar fasciopathy (3)
- Achilles tendinopathy (9)
- Medial tibial stress syndrome (shin splints) (11)
- Other conditions involving scar tissue such as tendons or muscle where other treatment has failed
What does shockwave therapy involve?
An initial consultation is required to ensure the treatment is appropriate and safe for you. The delivery of ESWT takes around 5 minutes and can be uncomfortable, but this is normal. The practitioner will find and mark the painful area and apply a coupling gel. A handheld device is then applied to the skin and pulses of acoustic waves are then delivered.
A course of treatment is typically one appointment every 5-10 days for 4 sessions. Another 4 sessions may be beneficial if symptoms have improved, but not resolved 3 months after the last appointment within the first session. Prior to your first appointment it is advised that you do not take non-steroidal anti-inflammatories, such as ibuprofen, 2 weeks prior to your appointment and during your course of treatment as they may reduce your body’s response to the treatment.
Who cannot have extracorporeal shockwave therapy?
- Under 18 years of age (unless for Osgood-Schlatters disease)
- Pregnancy
- Disease or disorders of peripheral blood vessels / nerves
- Major blood vessels or nerves in area to be treated
- Bleeding disorders (blood clotting disorders or treatment with oral anticoagulants)
- Within 12 weeks of corticosteroid injection to the area being treated
- Previously ruptured tendons
- Malignant (cancerous) disease \ infection in treatment area
- Prosthetic device in the area to be treated e.g. artificial limb
- Treatment site over lungs or bowel
When is shockwave therapy advised?
ESWT is used more and more commonly now in Sports & Exercise Medicine. It is used in both short-term and long-term injury, however, most of the research base for the conditions we use ESWT for supports its use in longer-term injury. Therefore, if you have a condition such as plantar fasciopathy, achilles tendinopathy or medial tibial stress syndrome and haven’t had other treatments such as exercise therapy, gait re-training or changes to the way you walk or run with footwear changes or foot orthoses, we would assess your need for those treatments first and continue those treatments whilst shockwave therapy takes place. It is the case, however, that the sooner shockwave is done, the more likely it is to be effective during the first of the 4 sessions. Therefore, if the condition has been present for 6-12 weeks or more, shockwave may be suggested at the initial assessment in order to get the best benefit from it.
What happens after a course of shockwave therapy?
After treatment most patients will immediately feel a reduction in symptoms, however, others can take several weeks or months to respond so you can’t get straight back into ultra-marathoning after the last session, but you will be more likely to get back there eventually! We advise patients not to undertake any significant activity that stresses the affected area for up to 48hrs after treatment and to avoid non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen. This ensures optimal treatment outcomes and reduces the likelihood of complications.
Some potential minor complications to treatment include pain during and after treatment (typically 24 hours), local skin reddening, swelling, headache and bruising. Very rare but more serious complications to treatment could include temporary or permanent damage to blood vessels / nerves or tendon rupture (10). A follow up appointment will normally be arranged for 6 weeks after the last session to assess the response to treatment and change any other therapy that is happening at the same time such as exercises, gait re-training, foot orthoses, footwear changes and occupational activity management (8).
If you would like to know more about shockwave therapy and whether it is appropriate for your issue, please contact us and we can let you know more.
1. Cinteza, D., Poenaru, D. and Ioana Sandulescu, M. (2022). Biological effects of extracorporeal shockwave therapy in tendons: A systematic review. Biomed Rep, 18 (2), pp.15.
2. Gerdesmeyer, L., Frey, C., Vester, J., Maier, M., Weil, L., Weil, L., Russlies, M., Stienstra, J., Scurran, B., Fedder, K., Diehl, P., Lohrer, H., Henne, M. and Gollwitzer, H. (2008) Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicentre study. The American Journal of Sports Medicine, 36(11), pp.2100-2109.
3. Gollwitzer, H., Saxena, A., DiDomenico, L.A., Galli, L., Bouché, R.T., Caminear, D.S., Fullem, B., Vester, J.C., Horn, C., Banke, I.J., Burgkart, R. and Gerdesmeyer, L. (2015) Clinically Relevant Effectiveness of Focused Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery-American Volume, 97(9), pp.701-708.
4. Hocaoglu, S., Vurdem, U.E., Cebicci, M.A., Sutbeyaz, S.T., Guldeste, Z. and Yunsuroglu, S.G. (2017) Comparative Effectiveness of Radial Extracorporeal Shockwave Therapy and Ultrasound-Guided Local Corticosteroid Injection Treatment for Plantar Fasciitis. Journal of the American Podiatric Medical Association, 107(3), pp.192-199.
5. Ibrahim, M.I., Donatelli, R.A., Hellman, M., Hussein, A.Z., Furia, J.P. and Schmitz, C. (2016) Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: A prospective, randomized, placebo-controlled trial with two years follow-up. Journal of Orthopaedic Research, 35(7), pp.1532-1538.
6. NICE. (2016) Overview | Extracorporeal shockwave therapy for Achilles tendinopathy | Guidance | NICE. [online] www.nice.org.uk. Available at: https://www.nice.org.uk/Guidance/IPG571.
7. NICE. (2009) Overview | Extracorporeal shockwave therapy for refractory plantar fasciitis | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ipg311.
8. Pavone, V., Vescio, A., Mobilia, G., Dimartino, S., Di Stefano, G., Culmone, A. and Testa, G. (2019). Conservative Treatment of Chronic Achilles Tendinopathy: A Systematic Review. Journal of Functional Morphology and Kinesiology, 4(3), p.46.
9. Roerdink, R.L., Dietvorst, M., van der Zwaard, B., van der Worp, H. and Zwerver, J. (2017) Complications of extracorporeal shockwave therapy in plantar fasciitis: Systematic review. International Journal of Surgery, 46, pp.133–145.
10. Winters, M., Eskes, M., Weir, A., Moen, M.H., Backx, F.J.G. and Bakker, E.W.P. (2013) Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Medicine, 43(12), pp.1315–1333.
