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Extracorporeal shockwave therapy
Extracorporeal shockwave therapy
Extracorporeal shockwave therapy
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Extracorporeal shockwave therapy
ESWT device (EMS Swiss DolorClast)
ICD-10-PCS6A93
ICD-9-CM98.5
ESWT device

Extracorporeal shockwave therapy (ESWT) is a treatment using powerful acoustic pulses which is mostly used to treat kidney stones and in physical therapy and orthopedics.[1][2]

Medical uses

[edit]
Some of the passed fragments of a 1-cm calcium oxalate stone that was smashed using lithotripsy

The most common use of extracorporeal shockwave therapy (ESWT) is for lithotripsy to treat kidney stones[3] (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic pulse. It is also reported to be used for salivary stones[4] and pancreatic stones.[5]

In the UK, the National Institute for Health and Care Excellence (NICE) found that the evidence for ESWT in the majority of indications is conflicting, and therefore ESWT should only be used where there are special arrangements for clinical governance and audit.[6] Two 2017 reviews had similar findings, with moderate level evidence at best.[7][8]

Extracorporeal shockwave therapy is used as a second line measure to treat tennis elbow,[9][10][11] shoulder rotator cuff pain,[12][13] Achilles tendinitis,[14][15] plantar fasciitis,[16][17] and greater trochanteric pain syndrome.[18]

ESWT is also used to promote bone healing and treat bone necrosis.[19] It is an effective alternative to surgical treatment of non-healing fractures.[20]

ESWT is used for wound healing and has shown positive results in short-term and long-term outcomes in diabetic patients with foot ulcers.[21] Randomised controlled trials into the use of ESWT for healing venous leg ulcers are needed as there is a lack of evidence in this area.[22]

Low-intensity extracorporeal shock wave therapy (LI-ESWT) has been used as a treatment for erectile dysfunction.[23] It differs from palliative options by aiming to restore natural erectile function by inducing cellular microtrauma, triggering the release of angiogenic factors and promoting neovascularization in treated tissue. This mechanism is distinct from the high-intensity shock waves used in lithotripsy and medium-intensity shock waves used for anti-inflammatory purposes in orthopedics. Clinical studies, including double-blind randomized trials, have demonstrated LI-ESWT's ability to significantly improve erectile function and penile hemodynamics in men with vasculogenic ED.[24][25]

Procedure

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The lithotripter attempts to break up the stone with minimal collateral damage by using an externally applied, focused, high-intensity acoustic pulse. The patient is usually sedated or anesthetized for the procedure in order to help them remain still and reduce possible discomfort.[26] Sedation is not required in its application for soft tissue injuries.

History

[edit]

Beginning in 1969 and funded by the German Ministry of Defense, Dornier began a study of the effects of shock waves on tissue. In 1972, on the basis of preliminary studies performed by Dornier Medical Systems, an agreement was reached with Egbert Schmiedt, director of the urologic clinic at the University of Munich. The development of the Dornier lithotripter progressed through several prototypes, ultimately culminating in February 1980 with the first treatment of a human by shockwave lithotripsy (SWL). The production and distribution of the Dornier HM3 lithotripter began in late 1983, and SWL was approved by the U.S. Food and Drug Administration in 1984.[27]

In the 1980s people using ESWT for kidney stones noticed that it appeared to increase bone density in nearby bones, leading them to explore it for orthopedic purposes.[28]

Research

[edit]

In response to concerns raised by NICE, in 2012 a study called the Assessment of the Effectiveness of ESWT for Soft Tissue Injuries was launched (ASSERT).[6]

As of 2018 use of ESWT had been studied as a potential treatment for chronic prostatitis/chronic pelvic pain syndrome in three small studies; there were short-term improvements in symptoms and few adverse effects, but the medium-term results are unknown, and the results are difficult to generalize due to the low quality of the studies.[29]

Veterinary use

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ESWT is commonly used for treating orthopedic problems in horses, including tendon and ligament injuries, kissing spine, navicular syndrome, and arthritis. The evidence for these uses is weak.[28]

Physiotherapy use

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ESWT is used in physical therapy for pain reduction, increase in metabolism at the cellular level, revascularisation, and recovering normal muscle tone following various disorders.[30] The use of ESWT was demonstrated in patients with frozen shoulders compared to therapeutic ultrasound with exercises.[31]

Research suggests that ESWT can accelerate the blood flow, facilitating the healing of the inflamed Achilles tendon.[citation needed] In one study involving 23 patients with chronic Achilles tendinopathy, 20 reported improvement in their condition and pain scores after ESWT; three saw no change, and none reported any worsening.[32]

See also

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References

[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Extracorporeal shockwave therapy

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from Grokipedia
Extracorporeal shock wave therapy (ESWT) is a non-invasive medical procedure that delivers high-energy acoustic waves from an external source to targeted body tissues, primarily to alleviate pain, promote tissue regeneration, and facilitate healing in musculoskeletal and certain neurological conditions. Originating in the early 1980s as extracorporeal shock wave lithotripsy (ESWL) for the fragmentation of kidney stones, ESWT evolved in the 1990s and 2000s to address orthopedic and rehabilitative needs, with initial applications in Germany and Bulgaria for bone-related treatments. The operates through two primary modalities: focused ESWT, which generates concentrated shock waves using electromagnetic, piezoelectric, or electrohydraulic methods to penetrate up to 10-12 cm deep with pressures reaching 50 MPa, and radial ESWT (or pressure wave therapy), which employs a pneumatic mechanism to produce lower-energy waves (up to 0.5 MPa) that disperse more superficially, up to 4-5 cm in depth. At the cellular level, ESWT induces mechanotransduction, triggering biological responses such as the release of growth factors (e.g., VEGF, BMPs), increased neovascularization, enhanced cellular proliferation, and modulation of , which collectively support tissue repair without surgical intervention. Clinically, ESWT is applied to a range of musculoskeletal disorders, including chronic tendinopathies (such as , Achilles tendinopathy, and lateral epicondylitis), of the shoulder, delayed fracture healing, nonunions, and of the . It has also shown promise in neurological contexts, such as reducing in patients with , multiple sclerosis, or by modulating and improving function. Evidence from randomized controlled trials and meta-analyses supports its efficacy for specific indications; for instance, high-energy ESWT demonstrated superior pain reduction and functional improvement in calcifying tendinitis compared to , while studies on report success rates of around 70% in resolving symptoms. However, outcomes vary across conditions, with Medicare coverage limited due to inconsistent long-term data and lack of standardization in protocols, emphasizing the need for further high-quality randomized trials. ESWT is generally safe, with common transient side effects including localized pain, swelling, or during or after sessions, and rare serious complications like ; contraindications encompass , active infections, and severe coagulopathies at treatment sites. Ongoing research explores optimized dosing, combination therapies, and expanded uses in , positioning ESWT as a valuable adjunct in conservative management strategies.

Fundamentals

Definition and principles

Extracorporeal shockwave therapy (ESWT) is a non-invasive medical treatment that involves the generation of high-energy acoustic shockwaves outside the body, which are then directed toward targeted tissues to induce controlled mechanical stress and promote therapeutic responses. These shockwaves are produced by specialized devices and propagate through the skin and underlying tissues without requiring surgical intervention, distinguishing ESWT from invasive procedures. The fundamental principles of ESWT rely on the physical properties of shockwaves, which are characterized by a rapid rise in positive pressure (typically 10-100 MPa) occurring over nanoseconds, followed by a brief tensile (negative) phase of about -20 MPa, with the entire lasting microseconds (up to 10 μs). Shockwaves propagate either in a focused manner, concentrating at a specific depth, or radially, dispersing more broadly; key parameters include energy flux , ranging from 0.001 to 0.70 mJ/mm², which determines the intensity of the mechanical impact, and tissue , reaching up to 12 cm for focused waves. These deliver that interacts with biological tissues through wave propagation, creating localized pressure gradients without significant heat generation. Biologically, ESWT initiates responses via mechanotransduction, where mechanical stimuli from the shockwaves are converted into biochemical signals within cells, activating pathways that modulate and enhance tissue repair. Primary effects include — the formation and implosive collapse of gas bubbles during the negative pressure phase, generating microjets—and at tissue interfaces, which disrupt cellular membranes and stimulate release of growth factors. These processes promote neovascularization by upregulating factors such as (VEGF) and endothelial (eNOS), fostering improved blood supply and supporting regeneration without causing widespread damage.

Types and mechanisms

Extracorporeal shockwave therapy (ESWT) is classified into several types based on the generation method, wave propagation, and energy application, each suited to specific tissue depths and therapeutic goals. Focused ESWT employs high-energy acoustic waves concentrated at a precise focal point deep within tissues, generated through electrohydraulic (via underwater spark discharge), electromagnetic (using a coil and membrane), or piezoelectric (via ceramic crystal deformation) mechanisms, enabling targeted treatment up to 12 cm in depth. In contrast, radial pressure wave therapy (R-PWT), also known as radial ESWT, produces unfocused, ballistic pressure waves using pneumatic accelerators that propel projectiles against an applicator, dispersing energy superficially for depths up to 3-6 cm, commonly applied to musculoskeletal conditions. Low-intensity ESWT (LI-ESWT) represents a subset using reduced energy levels across focused or radial modalities, primarily for regenerative applications such as promoting tissue repair without significant disruption; a notable example is its use in treating erectile dysfunction, where it induces mechanical stress waves to promote neovascularization, endogenous stem cell recruitment, and endothelial function improvement via VEGF and NO release, thereby addressing underlying vascular and fibrotic issues in urological contexts. Key parameters of ESWT include energy flux density (EFD, measured in mJ/mm²), pulse frequency (), and number of pulses per session, which vary by type and indication to optimize therapeutic effects while minimizing risks. EFD is categorized as low (<0.09 mJ/mm²), medium (0.09-0.38 mJ/mm²), or high (>0.38 mJ/mm²), with low and medium levels favoring regenerative outcomes and high levels used for mechanical disruption. Frequency typically ranges from 1-20 to control wave delivery rate, while sessions involve 500-4000 pulses, adjusted based on the target area and device type for cumulative biomechanical stimulation. At the cellular level, ESWT induces mechanotransduction, triggering biological responses that promote healing; low- to medium-energy applications upregulate (VEGF) to enhance , bone morphogenetic protein-2 (BMP-2) to stimulate osteogenesis, and (NO) release via endothelial activation for and anti-inflammatory effects. Tissue-level mechanisms include controlled microtrauma that recruits mesenchymal stem cells, fosters remodeling through increased synthesis, and reduces by modulating profiles. Mechanistic differences arise primarily from energy levels: high-energy ESWT (>0.38 mJ/mm²) generates bubbles that cause mechanical fragmentation, as in urological for stones, leading to direct tissue disruption and rapid debris clearance. In opposition, low-energy ESWT (<0.09 mJ/mm²) elicits non-destructive mechanosensitive responses, emphasizing regenerative pathways like differentiation and neovascularization without -induced damage.

Clinical Applications

Urological uses

Extracorporeal shock wave lithotripsy (ESWL), a high-energy form of extracorporeal shockwave therapy (ESWT), is primarily used in to fragment , ureteral, biliary, salivary, and pancreatic stones non-invasively. This application targets calculi by generating acoustic shock waves that propagate through body tissues to induce and mechanical stress on the stone surface, leading to fragmentation into passable particles. Success rates for ESWL typically range from 70% to 90% for stones smaller than 2 cm, with higher efficacy observed for renal and proximal ureteral calculi compared to distal ureteral ones. However, success rates vary by stone location, with lower efficacy for distal ureteral calculi, highlighting the importance of individualized treatment planning. In urological procedures, ESWL employs focused high-energy shock waves, often delivering 3000 to 4000 shocks per session at a rate of 60 to 120 shocks per minute to optimize fragmentation while minimizing tissue damage. Imaging guidance, such as or , is essential for precise targeting of the stone location and monitoring during treatment. This outpatient approach avoids incisions, allowing most patients to resume normal activities shortly after the session, though multiple treatments may be required for complete stone clearance. Beyond stone fragmentation, low-intensity ESWT (LI-ESWT) has emerged as a therapeutic option for , where it induces mechanical stress waves that promote neovascularization through the release of vascular endothelial growth factor (VEGF), recruit endogenous stem cells, and improve endothelial function via nitric oxide (NO) release, thereby addressing underlying fibrosis and vascular issues. This promotes penile blood flow improvement through and neovascularization. Protocols typically involve 4 to 12 sessions, administered over several weeks, targeting the corpora cavernosa to enhance endothelial function and vascular repair. This approach has shown particular promise for vasculogenic ED, including cases of venous leak, with success rates of approximately 50-70%, better outcomes in mild-to-moderate cases, and 5-10 point improvements in International Index of Erectile Function (IIEF) scores; effects persist up to 2 years in about 60% of responders. Noticeable improvements are often observed within 6-12 weeks and optimal results following the completion of 6-12 sessions over several months. However, efficacy may be limited in moderate to severe venous leak cases that cannot be compensated with other treatments. The use of unregulated at-home shockwave therapy devices for ED is not recommended, as they can cause skin lesions or burns, unnecessary pain, and often have no effect due to insufficient energy output and lack of clinical evidence; these devices are not regulated as proper medical equipment. For chronic prostatitis/chronic syndrome (CP/CPPS), LI-ESWT reduces and alleviates symptoms by modulating local tissue repair and pain pathways, often showing sustained benefits in refractory cases. A 2023 Cochrane systematic review supports ESWL's role as a first-line non-invasive treatment for select kidney stones up to 20 mm, though it notes lower stone-free rates compared to more invasive procedures like percutaneous nephrolithotomy for larger calculi. Recent 2024 studies on LI-ESWT for ED report significant improvements in International Index of Erectile Function (IIEF) scores, with mean increases of 4 to 6 points in erectile function domains post-treatment, indicating moderate clinical benefit in vasculogenic cases. A 2018 prospective study specifically on LI-ESWT for ED, including venous leak cases, reported significant IIEF-5 score improvements from baseline to 6 weeks and 3 months post-treatment after 6 weekly sessions, with 100% improvement in venous leak patients at 3 months. Similarly, evidence for LI-ESWT in CP/CPPS highlights symptom score reductions persisting up to 12 weeks, positioning it as a safe adjunctive therapy.

Musculoskeletal uses

Extracorporeal shockwave therapy (ESWT) is widely applied in musculoskeletal medicine to treat various orthopedic and disorders, particularly those involving and impaired function in tendons, ligaments, bones, and . Key indications include lateral epicondylitis (), where ESWT targets enthesopathies of the extensor tendons; , affecting the plantar aponeurosis; Achilles tendinopathy, involving mid-portion or insertional degeneration; rotator cuff tendinopathy, for shoulder impingement and calcific tendinitis; non-union fractures, to promote bone healing in delayed or non-healing cases; and of the or , addressing and stiffness. These applications leverage ESWT's non-invasive nature to avoid surgical intervention in cases. In musculoskeletal contexts, ESWT exerts its effects through biomechanical and biological mechanisms that promote tissue repair and modulation. Acoustic shockwaves induce microtrauma, stimulating remodeling by enhancing synthesis and organization while reducing pathological in tendinopathies and calcific deposits. For bone-related conditions, it stimulates osteogenesis via upregulation of growth factors like and VEGF, fostering and callus formation in non-union fractures. In , ESWT mitigates and improves dynamics, contributing to . Typical treatment protocols involve 3-5 sessions spaced 1-2 weeks apart, delivering 1500-2500 pulses per session at an density of 0.12-0.35 mJ/mm², adjusted based on focused or radial ESWT type and tolerance. Clinical efficacy is supported by meta-analyses demonstrating substantial pain relief and functional improvements across indications. For plantar fasciitis, systematic reviews indicate 60-80% reduction in visual analog scale (VAS) pain scores at 3-12 months post-treatment compared to or conservative therapies, with success rates up to 73% in chronic cases. Recent 2024 studies on frozen (adhesive ) report ESWT yielding significant enhancements in internal rotation (Hand Behind Back score improvement) and VAS reductions of approximately 2 points, outperforming alone in short-term follow-up. Similarly, for knee , 2024 meta-analyses show ESWT improving ROM by approximately 18 degrees and lowering VAS scores by 2 points, alongside better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcomes. These benefits are attributed to sustained tissue regeneration observed at 6-12 month follow-ups. In , ESWT has gained prominence for managing injuries, with the 2025 British Journal of Sports Medicine (BJSM) international consensus guidelines standardizing parameters for optimal use. These recommendations endorse focused ESWT at 0.12-0.35 mJ/mm² for 2000 pulses over 3-4 sessions in Achilles and tendinopathies, emphasizing patient-specific dosing to minimize rupture risk while maximizing neovascularization and pain relief. The guidelines highlight ESWT's role in accelerating return-to-play, with low adverse event rates (<5% minor bruising). ESWT is often integrated briefly with physiotherapy, such as eccentric exercises, to enhance long-term loading capacity.

Other medical uses

Extracorporeal shockwave therapy (ESWT) has shown potential in cardiovascular applications, particularly for refractory , where it improves myocardial through neovascularization and collateral vessel growth. In patients with chronic refractory , cardiac ESWT typically involves nine sessions delivered over three months, leading to reduced symptoms and enhanced myocardial function without invasive procedures. Similarly, for , ESWT promotes and improves limb , offering a non-invasive option for symptomatic relief in patients unsuitable for , though evidence remains limited to small-scale studies. In , ESWT accelerates tissue repair in ulcers and chronic wounds by stimulating formation, , and cellular proliferation. A 2025 systematic of 47 clinical studies from 2005 to 2025 demonstrated that ESWT significantly enhances wound closure rates compared to standard care, with faster healing observed across various modalities including focused and radial waves. This therapy is particularly beneficial for non-healing ulcers, reducing treatment duration and recurrence risk while maintaining a favorable profile. Neurological applications of ESWT focus on pain modulation through anti-inflammatory effects and nerve regeneration, showing efficacy in conditions like , , and . For , a 2025 study reported significant reductions in pain and pruritus scores following ESWT sessions, attributing benefits to decreased neural hypersensitivity and improved local blood flow. In , focused ESWT combined with conservative measures improves nerve conduction, hand function, and symptom severity in moderate-to-severe cases. For , radial ESWT has been effective in alleviating refractory pain via targeted nerve stimulation, as evidenced in case reports and small trials. Beyond these, ESWT addresses by targeting trigger points to reduce muscle stiffness and , with a 2025 review highlighting its role in improving pain and functionality through biomechanical and neurophysiological mechanisms. A 2025 comparing ESWT to therapy for musculoskeletal pain found ESWT superior in certain conditions, such as those involving deeper tissues, due to its delivery enhancing tissue remodeling more effectively than photobiomodulation. These regenerative effects stem from ESWT's ability to upregulate growth factors and modulate across diverse tissues.

Procedure and Administration

Preparation and equipment

Patient preparation for extracorporeal shockwave therapy (ESWT) begins with a thorough pre-treatment assessment to ensure suitability and safety. This includes screening for contraindications such as , , active infections, or implanted devices like pacemakers, as these conditions can increase risks of adverse effects. Diagnostic imaging, such as or , is essential to confirm the , identify the target area, and plan accurate treatment placement, particularly for musculoskeletal or urological applications. For high-energy ESWT procedures like in , patients require fasting after midnight and may receive intravenous or general to manage discomfort and ensure immobility. In contrast, low-energy sessions for musculoskeletal conditions typically do not necessitate , but patients are advised to avoid non-steroidal drugs (NSAIDs) for 1-2 weeks prior to avoid interfering with the therapeutic response, and to wear loose clothing for accessibility. Hydration is encouraged, and arrangements for transportation home should be made if is involved. ESWT equipment consists of a shockwave generator, applicator, and ancillary components to deliver and monitor the therapy effectively. Generators produce shockwaves through three primary methods: electrohydraulic (using an underwater spark discharge), electromagnetic (via a coil and ), or piezoelectric (employing crystal deformation), each determining the wave's characteristics like energy flux density. Applicators are categorized as focused, which concentrate energy at a precise depth for deeper tissues (e.g., in urological ), or radial, which disperse pressure waves superficially for broader musculoskeletal coverage. A or medium is applied between the applicator and to facilitate acoustic transmission and eliminate air gaps that could attenuate the waves. Monitoring systems, such as (ECG) for cardiac applications or real-time for targeting, ensure precise delivery and during setup. Facility requirements vary by ESWT energy level and application. Low-energy focused or radial ESWT for musculoskeletal uses is typically performed in outpatient clinics or physiotherapy settings, allowing for quick sessions without overnight stays. High-energy procedures, such as extracorporeal shockwave for urinary stones, often require hospital-based facilities equipped for and potential complications. Costs generally range from $200 to $500 per session, influenced by device type, location, and number of impulses delivered, with 3-5 sessions commonly recommended. Setup prerequisites include ergonomic adjustments, such as adjustable treatment tables and visible device screens, to maintain posture and procedural accuracy.

Treatment delivery

During extracorporeal shockwave therapy (ESWT), the treatment area is precisely targeted using imaging guidance such as or to ensure accurate delivery of shockwaves to the affected tissue. Patient positioning is adjusted for comfort and accessibility, typically for upper body or anterior sites and prone for posterior or lower extremity areas, allowing stable alignment with the shockwave generator. This setup facilitates effective energy transmission while minimizing discomfort during the procedure. The delivery process begins with the application of ultrasound gel as a medium to the skin over the target site, which eliminates air gaps and enables efficient propagation. The shockwave applicator is then placed in direct contact, delivering a series of pulses—typically 1500 to 4000 per session—at frequencies of 3 to 10 Hz, with each session lasting 10 to 20 minutes depending on the total impulses administered. during treatment is managed through real-time adjustment of energy levels based on patient tolerance, and is rarely required except in high-energy applications. Session variations depend on the energy level and therapeutic goal; high-energy focused ESWT, often used in applications like , involves higher flux densities (0.35–0.6 mJ/mm²) and is typically completed in a single session of 3000–4000 pulses to achieve fragmentation. In contrast, low-energy radial ESWT for regenerative purposes employs lower intensities (0.08–0.25 mJ/mm² or 2–4 bar) over multiple sessions, usually 3 to 8 treatments spaced 1 to 2 weeks apart, to promote tissue without . Throughout the session, monitoring involves real-time imaging via or to verify focus and adjust positioning as needed, supplemented by patient feedback on and sensation to titrate the dose and ensure safety. Periodic checks, such as every 500 pulses in high-energy protocols, confirm ongoing accuracy and prevent deviations.

Risks and contraindications

Extracorporeal shockwave therapy (ESWT) is generally regarded as a safe procedure with a low incidence of serious complications, typically less than 5% across various applications. Common adverse effects include transient pain at the treatment site, skin erythema, mild bruising or hematoma, and localized swelling, which occur in approximately 10-20% of patients and usually resolve within days without intervention. Additionally, the use of unregulated home shockwave therapy devices, particularly for erectile dysfunction, carries heightened risks such as skin burns, blisters, lesions, unnecessary pain, bruising, nerve damage, and ineffectiveness due to insufficient energy output and lack of clinical validation; these devices are not regulated as proper medical equipment and lack professional oversight, potentially leading to severe complications like tissue ulceration. Rare complications encompass nerve irritation, edema, headache, and, in high-energy applications, potential tendon rupture or tissue damage, with reported incidences below 1% when parameters are appropriately managed. For instance, post-lithotripsy Steinstrasse, a ureteral obstruction from stone fragments, has been noted in urological uses but remains uncommon with modern protocols. High-energy ESWT carries a higher risk profile, including risks of hemorrhage or arrhythmia in cardiac-adjacent treatments, necessitating careful energy flux density limits (e.g., below 0.6 mJ/mm² to avoid necrosis). Absolute contraindications for ESWT include (due to potential fetal exposure), active or in the treatment field, lung or pleural tissue in the shockwave path (risking or bleeding), severe , and the presence of pacemakers or defibrillators in the field. Relative contraindications encompass anticoagulant therapy (e.g., or NSAIDs, requiring assessment), active at the site, epiphyseal plates in growing individuals, or proximity (for high-energy focused waves), and metal implants that could be damaged. These restrictions are outlined in the International Society for Medical Shockwave Therapies (ISMST) guidelines, updated in 2024, which emphasize pre-treatment screening to mitigate risks. Safety profiles are supported by extensive clinical data, showing minimal systemic effects and a complication rate of 3-7% in procedural contexts like , with even lower rates for low- to medium-energy musculoskeletal applications. The 2025 ISMST-aligned recommendations, including those from recent consensus studies, stress adhering to energy limits (0.08-0.55 mJ/mm²), pulse counts (1500-3000 per session), and session intervals (1-2 weeks) to further reduce adverse events. Post-treatment monitoring for 24-48 hours is advised to detect any immediate issues, alongside activity restrictions such as avoiding heavy lifting or high-impact sports for 2-6 weeks, depending on the site, to support recovery and prevent exacerbation. Patients are typically encouraged to continue gentle and follow-up assessments at 4-12 weeks.

History and Development

Invention and early adoption

Extracorporeal shockwave therapy (ESWT) originated in the late 1960s at Dornier Medizintechnik, a German company, where engineers investigated the effects of shockwaves on materials and tissues, inspired by the structural damage caused by shockwaves from encountering rain and hailstones. Initial research, funded by the German Ministry of Defense starting in 1968, focused on animal studies to assess shockwave impacts on biological tissues, with early experiments in 1971 demonstrating kidney stone fragmentation using underwater spark discharges. By 1974, Dornier collaborated with urologists at Ludwig-Maximilians University in , including Christian Chaussy, to develop the first prototype lithotripter (TM1), which generated focused shockwaves via electrohydraulic means for targeted stone destruction. Animal testing advanced in the mid-1970s, with 1975 studies on dogs confirming effective fragmentation of implanted human kidney stones using ultrasound localization, though challenges with precise targeting persisted until X-ray integration in later prototypes like the TM4 by 1979. The breakthrough came in 1980 with the HM1 clinical prototype, when urologist Christian Chaussy, alongside Bernd Forssmann and Dieter Jocham, performed the first human ESWT treatment on February 7 in Munich, successfully disintegrating a renal calculus in a patient under general anesthesia. This marked the inception of extracorporeal shockwave lithotripsy (ESWL), a non-invasive alternative to surgery for urolithiasis, with results published in The Lancet later that year. Early adoption centered on urology, with the refined HM3 device—the first commercial lithotripter—installed in 1983, enabling broader clinical use despite initial hurdles like severe pain requiring general anesthesia for most procedures. The U.S. Food and Drug Administration approved ESWL in December 1984, following the installation of the first American device in Indianapolis earlier that year, which accelerated global dissemination for renal stone treatment. By the late 1980s, applications expanded beyond urology; in 1988, the first ESWT treatment for non-union fractures was successfully performed in Bochum, Germany, signaling its potential in orthopedics. Chaussy's pioneering role as a urologist bridged engineering and clinical practice, overcoming early pain management issues that limited patient tolerance during high-energy sessions.

Evolution and regulatory milestones

In the early 1990s, extracorporeal shockwave therapy (ESWT) shifted toward orthopedic applications, building on its established use in from the 1980s, as initial trials explored its effects on and conditions like tendinopathies. Researchers in and conducted pivotal studies demonstrating ESWT's potential to stimulate neovascularization and tissue regeneration in chronic tendinopathies, marking the therapy's diversification beyond . Regulatory progress accelerated in the late and early . In , ESWT devices for musculoskeletal indications received , enabling broader clinical adoption across the continent for conditions such as and non-union fractures. The U.S. (FDA) granted the first approval in 2000 for high-energy focused ESWT treatment of chronic proximal using the OssaTron device, following clinical trials showing significant pain reduction in refractory cases. This was followed by FDA clearance in 2002 for lateral epicondylitis () with devices like the Epos and Sonocur systems. Further global milestones included the UK's National Institute for Health and Care Excellence () issuing interventional procedure guidance in 2009, recommending ESWT for refractory (IPG311) and (IPG313) based on evidence of short-term efficacy and low complication rates, though long-term outcomes required more research. In the , low-intensity ESWT (LI-ESWT) emerged for , with FDA-cleared devices adapted for this after pilot studies reported improved vascular function in vasculogenic cases. Technological advancements complemented these approvals, particularly the introduction of radial pressure wave devices in the early 2000s, which generated ballistic waves for shallower penetration and reduced discomfort compared to focused systems, expanding for superficial tendinopathies. In veterinary applications, ESWT saw early adoption for equine musculoskeletal issues around 2000, with studies validating its use for proximal suspensory desmitis and showing improved lameness scores without invasive procedures. Despite these developments, ESWT encountered early skepticism in the orthopedic community due to inconsistent reports across trials, attributed to variations in energy levels and patient selection. Standardization efforts gained momentum by 2010, led by the International Society for Medical Shockwave Treatments (ISMST), which advocated for uniform dosing protocols (e.g., energy flux density of 0.08–0.35 mJ/mm²) to enhance and quality. These efforts continued, with ISMST updating its guidelines in 2024 and international expert consensus recommendations published in 2025 to standardize terminology, parameters, and procedures for ESWT in and conditions.

Evidence and Research

Clinical efficacy studies

In urological applications, a 2005 randomized controlled trial evaluated extracorporeal shock wave lithotripsy (ESWL), a form of ESWT, for treating kidney stones, demonstrating stone-free rates of 35% compared to 50% for ureteroscopy for small lower pole stones up to 10 mm (p=0.2), with ESWL associated with shorter operative times but similar complications and higher potential for retreatment in some cases. Earlier NICE guidance from 2019 highlighted conflicting evidence on ESWL efficacy for ureteric stones, recommending it primarily for stones under 10 mm due to variable success rates. These discrepancies were addressed in a 2023 Cochrane review, which concluded that ESWL is effective for stones smaller than 20 mm, achieving stone-free rates of approximately 70-90% in appropriately selected cases, particularly in the lower pole, while noting lower success compared to more invasive options like percutaneous nephrolithotomy for larger stones. For musculoskeletal conditions, a 2025 and synthesized data from multiple randomized controlled trials and found moderate supporting ESWT for relief in tendinopathies, such as those affecting the and , with significant reductions in visual analog scale (VAS) scores observed at 3-6 months post-treatment compared to sham interventions (standardized mean difference -1.02, 95% CI -1.45 to -0.59). In contrast, for ESWT in treating non-unions remains limited, with meta-analyses reporting success rates of 50-85% in promoting union for non-unions, though outcomes vary widely based on type and factors, and overall healing rates hover around 73% across studies. Beyond and musculoskeletal uses, a 2025 CADTH review assessed low-intensity ESWT for , concluding it improves erectile function in 50-70% of mild to moderate cases, as measured by the International Index of Erectile Function, with sustained benefits up to 12 months in responsive patients. For erectile dysfunction due to venous leak, a subset of urological applications, noticeable improvements have been observed in 6-12 weeks, with optimal results after a full course of 6-12 sessions over several months, particularly in milder cases. A 2018 prospective study reported significant enhancements in IIEF-5 scores and penile hemodynamics at 6 weeks and 3 months post-treatment in a small cohort of venous leak patients following 6 weekly sessions, with 100% showing improvement; however, efficacy is mixed for moderate to severe cases. For , 2025 clinical studies reported ESWT achieving greater than 50% VAS pain reduction after 4-6 sessions, outperforming conventional therapies in alleviating neuropathic symptoms. Clinical studies on ESWT face limitations, including high heterogeneity in protocols—such as shockwave levels and session —which complicates direct comparisons across trials. Additionally, effects are notable in pain-focused studies, with some meta-analyses showing ESWT's benefits diminishing when rigorous sham controls are used. Overall, the is rated as level B (moderate) in the 2025 APTA practice advisory, reflecting consistent but not definitive support for select indications. Early trials established foundational baselines but often lacked , influencing modern interpretations.

Guidelines and recent advancements

Professional guidelines for extracorporeal shockwave therapy (ESWT) have evolved to standardize its application in musculoskeletal (MSK) conditions. The 2025 British Journal of (BJSM) international consensus, developed via a modified process with experts, recommends specific parameters for ESWT in , including low to medium energy levels (0.10–0.28 mJ/mm²) for tendinopathies and frequencies around 3 Hz for treatments to optimize relief and tissue regeneration while minimizing risks. This consensus emphasizes 3–5 sessions at 1–2 week intervals, with no and monitoring via visual analog scale (VAS ≤6 for tendons). Similarly, the (APTA) 2025 practice advisory supports ESWT integration into physiotherapy for noninvasive and healing in chronic conditions, urging clinicians to assess evidence, , and before adoption. For (ED), the Canadian Agency for Drugs and Technologies in Health (CADTH) 2025 evaluates low-intensity ESWT as a potential adjunct to standard therapies, noting moderate evidence for improved erectile function scores but calling for larger trials to confirm durability. Recent advancements highlight ESWT's expanding role beyond MSK applications. A 2024 systematic review and meta-analysis found that ESWT combined with standard care significantly increased complete healing rates of ulcers (RR 1.57, 95% CI 1.26-1.95) by promoting and reducing , with faster wound closure observed in randomized trials compared to controls. In neural conditions, 2024–2025 trials on (CTS) report ESWT improves and reduces symptoms, with one randomized study showing sustained enhancements in function at 6 months post-treatment versus alone. Emerging trends include combination therapies and technological enhancements. Studies from 2025 indicate that ESWT paired with (PRP) yields superior outcomes in ED and tendinopathies, with meta-analyses showing greater improvements in pain and function at 6-month follow-up compared to ESWT monotherapy. Advanced targeting methods, such as ultrasound-guided ESWT, enhance precision for calcific tendinopathies, outperforming landmark-based approaches in accuracy and . Recent randomized controlled trials (RCTs) from 2024–2025 on (OA) demonstrate long-term benefits, including reduced knee pain and improved function persisting up to 12 months, building on prior meta-analyses. As of November 2025, the FDA has cleared additional radial ESWT devices for chronic , while Medicare coverage remains restricted to specific indications like due to variable long-term evidence. Despite progress, gaps persist in ESWT research. The 2025 BJSM consensus underscores the need for standardized reporting of parameters and outcomes to facilitate comparisons across studies. Areas like Achilles tendinopathy remain outdated since early 2000s reviews, with a 2025 RCT revealing no added benefit of radial ESWT over sham for insertional cases, highlighting the urgency for updated, high-quality trials.

Specialized Applications

Physiotherapy uses

In physiotherapy, extracorporeal shockwave therapy (ESWT) is commonly integrated with exercise and regimens to manage tendinopathies, promoting regeneration and improving functional outcomes beyond monotherapy approaches. This combination leverages ESWT's ability to reduce and enhance tissue repair, allowing patients to engage more effectively in eccentric loading or heavy slow resistance exercises. The (APTA) Practice Advisory describes ESWT as a noninvasive treatment using sound waves to reduce and promote healing, encouraging physical therapists to understand its evidence and scope of practice. Specific protocols often involve radial ESWT delivered before exercise sessions to alleviate and minimize protective guarding, thereby optimizing tolerance and adherence to or strengthening activities. For instance, in frozen shoulder rehabilitation, radial ESWT combined with targeted exercises has demonstrated improved shoulder mobility, with significant increases in active for flexion, abduction, and internal observed in 12-week programs. These protocols typically apply 2000 pulses per session at densities of 0.16–0.25 mJ/mm², focusing on the affected area to facilitate progressive functional gains. Clinical outcomes emphasize short-term pain relief, with visual analog scale (VAS) scores commonly decreasing by 2–4 points following ESWT sessions in rehabilitation contexts, enabling faster return to daily activities and reduced reliance on analgesics. ESWT positions itself as a valuable non-invasive alternative to surgical interventions for persistent tendinopathies, offering comparable efficacy in pain reduction and functional restoration while avoiding operative risks. Physiotherapists must obtain through specialized programs to safely operate ESWT devices, ensuring proper patient selection, dosing, and integration with overall rehabilitation plans. Typical protocols involve 3 sessions spaced 1 week apart to allow for tissue response and recovery. This approach is particularly integrated in rehabilitation for musculoskeletal conditions such as , where ESWT supports exercise progression and long-term symptom management.

Veterinary uses

Extracorporeal shockwave therapy (ESWT) has gained prominence in , particularly for treating musculoskeletal conditions in and small animals, where it promotes tissue regeneration and pain relief through acoustic waves that stimulate biological responses such as and effects. In equine practice, ESWT is primarily applied to and injuries, including proximal suspensory desmitis, with studies showing that approximately 62% of horses with involvement return to full work within six months following treatment. For hindlimb cases, the success rate is lower at around 41%, highlighting challenges in bilateral or rear-limb pathologies. ESWT is also used for equine , where three sessions administered two weeks apart have been shown to increase mechanical nociceptive thresholds over a 56-day period, indicating sustained analgesia without altering muscle cross-sectional area. In small animals, particularly dogs, ESWT addresses conditions like and associated , with one study demonstrating significant improvements in vertical impulse and peak vertical force at post-treatment compared to baseline. These applications leverage similar mechanisms to human musculoskeletal therapy, such as enhanced neovascularization, but are tailored to animal-specific anatomies and performance demands. Treatment protocols typically involve radial or focused shock waves, with 500–4,000 pulses per session at energy flux densities of 0.11–0.89 mJ/mm², administered over 1–3 sessions spaced 1–4 weeks apart. is often recommended for both equines and small animals to mitigate discomfort and noise from the device, though newer radial systems may allow awake treatments in tolerant patients. Evidence supporting these protocols emerged in the early , with initial equine applications following a 1996 introduction in and a 2000 symposium on veterinary uses, though regulatory approvals focused on device clearance rather than specific indications. Systematic reviews note limited randomized controlled trials (RCTs), with only 7 in equines and 6 in dogs, often rated as low to moderate quality due to small sample sizes and bias risks, leading to weak overall for . ESWT offers key advantages in veterinary settings, including its non-invasive nature, which suits performance animals like racehorses by avoiding surgical downtime, and cost-effectiveness, with treatment courses (typically 2–3 sessions at $200–400 each) recouping device investments after about 120 uses. No major adverse effects are reported, enhancing its safety profile. ESWT has been investigated for in veterinary applications, with experimental models showing shortened equine wound closure times (e.g., 74 versus 90 days) and promise for canine repair through modulated expression, though gaps persist in standardized dosing across .

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