The group of soft tissue problems often referred to as tendinopathies has always presented a clinical challenge for practitioners of physical medicine because they are often slow to heal, easy to aggravate, and can be very resistant to treatment interventions. This group includes;
Chronic tendinopathies, those that have been there for a long time, can be especially challenging. Pain can be severe, and this often causes serious limitation in activities of daily living, work capacity and in sport and leisure activities. Problems with over-consumption of analgesics and non-steroidal anti-inflammatories are common in patients with chronic tendinopathies.
Steroid injection, although often producing a short term positive result, has been shown by meta analysis to have little long term benefit and may inhibit full recovery compared to placebo. (1,2,3)
I use Swiss Dolorclast Radial Shockwave Therapy (RSWT) combined with a range of other interventions in the treatment of these chronic tendinopathies and related disorders. Other interventions include manual treatment of muscles, tendons and connective tissue, acupuncture, low level laser therapy, joint mobilisation, taping and bracing, as well as exercise to strengthen and rehabilitate dysfunctional muscle.
Radial Shockwave Therapy is an evidence based treatment that has been shown in numerous published studies, including randomized controlled trials, to be a safe and effective treatment for tendinopathies and related soft tissue problems. (4-28)
The technology behind Radial Shock Wave Therapy was developed by the Swiss company EMS. This is the same company that developed Swiss Lithoclast technology, using shock waves and ultrasound for destruction and removal of kidney stones, a process known as lithotripsy.
RSWT treatment of tendinopathy and associated soft tissue disorders is widely used in Europe and North America.
Radial shockwaves are high energy acoustic waves transmitted from a probe held against the painful site. The acoustic shock waves pass through the skin and spread outwards into the underlying tissues. This is believed to induce increased blood flow, activate mesenchymal stem cells and increase metabolic activity around the site of pain, thus activating or accelerating the healing process. RSWT has been shown to effectively reduce pain associated with tendinopathy. It is suggested that this pain reduction effect is a result of over-stimulation of C nerve fibres, these are associated with pain sensation. This over-stimulation at first stimulates, then reduces the production of substance P. Substance P is a neuropeptide associated with pain and inflammation that is found in the brain and spinal cord.
I use EMS Swiss Dolorclast RSWT device. There are a number of less expensive shockwave therapy devices available however the EMS is the only one with numerous published studies showing safety and efficacy.
After examination, painful sites are identified. Shockwaves are applied via a hand piece or applicator held firmly against the skin. The initial phase of treatment may cause some deep pain however this indicates correct targeting of the problem area. This is usually followed by numbness or heaviness in the area and the latter phase of the treatment feels less painful. The treatment sessions are around 10 minutes duration during which the patient may receive up to 2000 pulses. Many patients get pain relief just days after the first treatment. The usual protocol is to deliver 3 to 5 treatments a week apart, depending on the nature of the problem and patient response.
Some soreness may be felt, which may intensify on the night of the treatment. Simple analgesia and icing may be required to control this pain. There may also be some minor bruising in the treatment area. As far as possible, the patient should refrain from aggravating activities over the treatment period.
Transient post- treatment pain as above.
Local bruising – uncommon and usually minor.
Tendon rupture has not been reported following Radial Shockwave Therapy, unlike cortisone injection and surgery.
There is no single treatment that is guaranteed to work for everybody. This is especially so in the case of chronic tendinopathies. RSWT has however been shown by high-level evidence to be an effective treatment for a large proportion of patients with tendinopathies. *
Each patient is monitored for their response to treatment and changes to the treatment program are made on a case by case basis. As mentioned above I will often use acupuncture, low level laser therapy (LLLT), manual soft tissue treatment and taping or bracing where indicated to augment RSWT treatment of tendinopathy. Management of tendinopathies almost always incorporates a program of targeted stretching and/or strengthening exercise.
*All but three of the publications 4-28 below demonstrate level 1 evidence of efficacy and safety.
16, 17 and 22 below reached level 3 evidence.
1. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Coombes, BK., Bisset L., Vicenzino, B (2010) Lancet, 2010:376 9754: 1751-1767.
2. Corticosteroid injection for lateral epicondylalgia is helpful in the short term, but harmful in the longer term; data for non-corticosteroid injections and other tendinopathies are limited. Orchard J. Evidence-Based Medicine 2011;16:116-117.
3. Corticosteroids improve short-term outcomes but worsen longer-term outcomes in some types of tendinopathy. Margo KL. Ann Internal Med. 2011 Feb 15;154(4)
4. Comparison of different energy densities of extracorporeal shock wave therapy
(ESWT) for the management of chronic heel pain. Chow IH, Cheing GL. Clin Rehabil 2007;21:131-141
5. Radial extracorporeal shock wave therapy is safe and effective in the treatment of
chronic recalcitrant plantar fasciitis: results of a confirmatory randomized
placebo-controlled multicenter study. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H. Am J Sports Med 2008;36:2100-2109
6. Extracorporeal shock-wave therapy (ESWT) with a new generation pneumatic
device in the treatment of heel pain. A double blind randomised controlled trial. Marks W, Jackiewicz A, Witkowski Z, Kot J, Deja W, Lasek J. Acta Orthop Belg 2008;74:98-101
7. Successful treatment of chronic plantar fasciitis with two sessions of radial
extracorporeal shock wave therapy. Ibrahim Ibrahim M, Donatelli R, Schmitz C, Hellman M, Buxbaum F. Foot Ankle Int 2010;31:391-397
8. Comparison of three different treatment protocols of low-energy radial
extracorporeal shock wave therapy for management of chronic plantar fasciitis. Shaheen AAM. Ind J Physiother Occup Ther. 2010;4:8-12
9. One-year treatment follow-up of plantar fasciitis: radial shockwaves vs. conventional physiotherapy. Grecco MV, Brech GC, Greve JM. Clinics 2013;68:1089-1095
10. Radial shock wave treatment alone is less efficient than radial shock wave
treatment combined with tissue-specific plantar fascia-stretching in patients with
chronic plantar heel pain. Rompe JD, Furia J, Cacchio A, Schmitz C, Maffulli N. Int J Surg 2015;24(Pt B):135-142
11. A comparison of the effectiveness of radial extracorporeal shock wave therapy
and ultrasound therapy in the treatment of chronic plantar fasciitis: a randomized
controlled trial. Konjen N, Napnark T, Janchai S. J Med Assoc Thai. 2015 Jan;98 Suppl 1:S49-56.
12. Long-term results of radial extracorporeal shock wave treatment for chronic
plantar fasciopathy: A prospective, randomized, placebo-controlled trial with two
years follow-up. Ibrahim MI, Donatelli RA, Hellman M, Hussein AZ, Furia JP, Schmitz C.
J Orthop Res. 2016 Aug 27. doi: 10.1002/jor.23403.
13. Eccentric loading versus eccentric loading plus shock-wave treatment for
midportion achilles tendinopathy: a randomized controlled trial. Rompe JD, Furia J, Maffulli N.
Am J Sports Med 2009;37:463-470
14. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. Rompe JD, Furia J, Maffulli N. J Bone Joint Surg Am 2008;90:52-61
15. Eccentric loading, shock-wave treatment, or a wait-and-see policy for
tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Rompe JD, Nafe B, Furia JP, Maffulli N. Am J Sports Med 2007;35:374-383
16. Low-energy extracorporeal shock wave therapy as a treatment for medial tibial
stress syndrome. Rompe JD, Cacchio A, Furia JP, Maffulli N. Am J Sports Med 2010;38:125-132
17. A single application of low-energy radial extracorporeal shock wave therapy is
effective for the management of chronic patellar tendinopathy. Furia JP, Rompe JD, Cacchio A, Del Buono A, Maffulli N. Knee Surg Sports Traumatol Arthrosc 2013;21:346-350
18. Efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a
randomized controlled trial. Zhao Z, Jing R, Shi Z, Zhao B, Ai Q, Xing G. J Surg Res 2013;185:661-666
19. Radial extracorporeal shock wave therapy for disabling pain due to severe
primary knee osteoarthritis. Imamura M, Alamino S, Hsing WT, Alfieri FM, Schmitz C, Battistella LR.
J Rehabil Med. 2016 Nov 31. doi: 10.2340/16501977-2148.
20. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy
in professional athletes. Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F.
Am J Sports Med 2011;39:146-153
21. Home training, local corticosteroid injection, or radial shock wave therapy for
greater trochanter pain syndrome. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N.
Am J Sports Med 2009;37 1981-1990
22. Low-energy extracorporeal shock wave therapy as a treatment for greater
trochanteric pain syndrome. Furia JP, Rompe JD, Maffulli N. Am J Sports Med 2009;37:1806-1813
23. Effectiveness of initial extracorporeal shock wave therapy on the newly
diagnosed lateral or medial epicondylitis. Lee SS, Kang S, Park NK, Lee CW, Song HS, Sohn MK, Cho KH, Kim JH. Ann Rehabil Med 2012;36:681-687
24. The use of a mobile lithotripter in the treatment of tennis elbow and plantar
fasciitis. Mehra A, Zaman T, Jenkin AI. Surgeon 2003;1:290-292
25. Radial extracorporeal shock wave therapy is effective and safe in chronic distal
biceps tendinopathy. Furia JP, Rompe JD, Maffulli N, Cacchio A, Schmitz C. Clin J Sport Med. 2016 Nov 23.
26. Radial extracorporeal pressure pulse therapy for the primary long bicipital
tenosynovitis a prospective randomized controlled study. Liu S, Zhai L, Shi Z, Jing R, Zhao B, Xing G.
Ultrasound Med Biol 2012;38:727-735
27. Radial extracorporeal shock wave therapy (rESWT) in the treatment of spasticity
in cerebral palsy: a randomized, placebo-controlled clinical trial. Vidal X, Morral A, Costa L, Tur M.
28. A prospective case-control study of radial extracorporeal shock wave therapy for
spastic plantar flexor muscles in very young children with cerebral palsy. Wang T, Du L, Shan L, Dong H, Feng J, Kiessling MC, Angstman NB, Schmitz C, Jia F. Medicine (Baltimore). 2016 May;95(19):e3649