The role of shockwave therapy in tendon pain
What is shockwave therapy?
Extracorporeal Shockwave Therapy (ESWT), also known as shockwave was first used in clinical settings in the 1980s for the management of various urologic conditions. Its early success led to it being used to improve fracture healing due to its ability to improve bone remodelling. Most recently, shockwave has been found to be an effective adjunct for tendinopathies, fasciopathies, and other soft tissue conditions.
How does extracorporeal Shockwave Therapy work?
The shockwave device is essentially a gun with a sealed barrel, inside the barrel is a ball bearing. Air blasts the ball bearing into the sealed barrel at a predetermined rate such as 10 Hz (10 bangs a second) and each time it bangs it creates a pressure wave. These pressure waves are delivered energy to a body part to try to bring about a biological response.
There is a short term and a longer-term biological response. In the short term there is a stimulation of free nerve endings and a release of local pain killing chemicals at the treatment site, such as substance P, which can cause a pain killing effect.
The longer-term biological response is thought to be the promotion of localised growth of blood vessels, the release if nitric oxide (NO – a vasodilator and growth promoter) and growth factors. It also increases the activity of tendon cells, leukocytes (immune cells that help fight infection), and bone cells. This increased cellular activity is thought to increase collagen formation with the result being remodelling and regeneration of the tissue in question.
What can shockwave therapy be used for?
Shockwave therapy is primarily used in the treatment of common musculoskeletal conditions. These include the following:
- Shockwave for upper and lower extremity tendinopathies (golfer’s / tennis elbow, patella, proximal hamstring, Achilles)
- Shockwave for greater trochanteric pain syndrome
- Shockwave for medial tibial stress syndrome
- Shockwave for plantar fasciopathy
- Shockwave for adhesive capsulitis
- Shockwave for non-union of long bone fracture
- Shockwave for calcific tendinopathy
Are there different types of shockwave?
Yes, the two main types are radial shockwave (RPW) and focussed shockwave (FPW). The most common type of shockwave used is RPW. The pressure waves delivered by this type of device have their greatest effect at or near to the surface – at a depth of 6-16mm depending on which type of devices are used. RPW will be more effective for superficial tendon such as the lateral elbow (tennis elbow) or Achilles. They may be less effective for deeper tendons. At Wandsworth Physiotherapy and Osteopathy we use RPW and our clinical experience is that it is still effective for deeper tendons.
Does health insurance cover for shockwave treatment?
Yes, most major health insurance companies will cover ESWT as evidence is increasing about its effectiveness.
Is shockwave therapy a safe non-invasive procedure?
Yes, shockwave is a safe, clinically effective and non-invasive procedure that carries no more risk when compared to more mainstream forms of interventions such as ultrasound, massage or manual therapy.
Does shockwave hurt?
It is not a painless treatment as is meant to cause localised micro-trauma to the tissue that is being treated. However, there is a pressure dial on the machine where we can increase or decrease the bar pressure. During a shockwave treatment we expect the level of discomfort to be less than 5 out of 10 on a pain scale. It is typical for it to be a bit sore to start with, especially on bony areas such as the elbow, but you will accommodate to this and we can normally increase the pressure within the session, and with each successive session. In fact, more recent suggestions are they you must feel the discomfort to have a treatment effect.
There shouldn’t be any lingering effects after treatment with most patients feeling fine once the treatment has finished. If there is a little soreness it should settle within 24 hours.
Can I train on the same day I get shockwave treatment?
Generally, it’s best to not do any type of intense training that loads the treated area 24 hrs prior or after shockwave treatment is carried out. Daily normal activities such as driving and light exercise will be able to be completed.
How many shockwave sessions do I need?
The number of treatments needed will vary depending on the diagnosis, duration of symptoms, location and previous activity levels. Research shows that patients should have a minimum of three treatment sessions over a period of three to four weeks. It is not unusual that more than three sessions are required but this is decided depending on the response to treatment. Most research does not study the effects of more than 6 sessions, so we generally do not use more than 6 sessions. However, in recalcitrant tendinopathy it’s not unusual to repeat another course of shockwave within 3-6 months as symptoms start to increase again, especially in combination with other modalities such as PRP injection.
How is a shockwave treatment delivered?
For the session, it may be worth wearing comfortable clothing that allows for the injured part to be uncovered. The session will last approximately 10 minutes during which you and the therapist can have a conversation to catch up on how the injury is progressing. An important thing to note is that shockwave therapy works most effectively as part of a complete rehabilitation programme, thus you are likely to leave the appointment with exercises tailored to you and any other recommendations the therapist has made (massage, running analysis, biomechanics modification) to aid in your recovery. This holistic approach ensures we cover the injury from all angles to achieve the best, long-term results.
As shockwave is meant to cause localised micro-trauma to the tissue that is being applied to, it can be tender at times, particularly if the painful area is near a bony prominence. This lasts only for the duration of the treatment. Afterwards, particularly if it’s the first time, it can be sore but should settle within 24 hrs and often much sooner than that. During treatment, the physiotherapist will be in constant communication with you regarding any pain and the intensity can be adjusted if necessary.
Are there any risks associated with shockwave?
Your physiotherapist will discuss these with you before carrying out the procedure. Rare side effects include redness, bruising and tenderness in the treated area. Very rare side effects include tendon tear or rupture.
Are there any instances when I should not have shockwave?
Yes, we wouldn’t use shockwave on major blood vessels and nerves, if a person has ac pacemaker or other implanted device, on open wounds or infected areas, over a joint replacement or over cancerous tissue.
How much faster will it heal with shockwave compared to without?
It is hard to put an exact timeframe on this as everybody is different and time to recovery depends on several factors including age, fitness level, location of injury, severity of injury, exercise adherence, stress, nutrition and goals. However, what we do know is that there are a wide number of studies that have demonstrated its superiority when used as an adjunct to physiotherapy compared to physiotherapy alone. Most patients will feel a significant clinical benefit in their pain 6 to 8 weeks after treatment, however it can take 12 weeks after the last shockwave treatment to see the maximum positive effect.
References
Moya, et al (2018) The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders.
Dedes et al, (2018) Effectiveness and Safety of Shockwave Therapy in Tendinopathies
Reilly et al (2018) Narrative Review on the Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions
