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Shock Wave Therapy. Shock Wave Therapy: Objectives . Following completion of this lecture the student will be able to: Describe the mechanical characteristics of ESW. Identify musculoskeletal pathology that may benefit from ESWT.

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Shock wave therapy objectives
Shock Wave Therapy: Objectives

Following completion of this lecture the student will be able to:

  • Describe the mechanical characteristics of ESW.

  • Identify musculoskeletal pathology that may benefit from ESWT.

  • Discuss the biological effects of ESW on soft tissue and bone .

Shock wave therapy outlines
Shock Wave Therapy: Outlines

  • Essential and History

  • Principle of Production

  • Characteristics of ESW &Energy production

  • Physiological Effects &Mechanism of Action

  • Clinical Applications

  • Adverse effects of ESW

  • Evidence-Base of ESWT

Eswt essential and history
ESWT: Essential and History

  • Therapeutic shockwave was first introduced into medicine over 30years ago for kidney stones .

  • Recently, ESW was used for musculoskeletal disorders in the early 1980's.

  • By the early 1990s, reports to start to appear in the journals and conference about use of ESW for soft-tissue problems.

  • Although becoming much more popular (especially in Europe and to some extent in the UK), it is still a relatively new technology for musculoskeletal intervention.

Eswt definition
ESWT: Definition

  • Shock-waveis an acoustic large-amplitude compression wave, which is made by high pressure peak, adjustable in a limited frequency range with on the wave side, the positive pressure increases in a short time follows at negative pressure.

Esw characteristic
ESW: Characteristic

The characteristics of a shock wave are:

  • HIGH Peak pressure typically ≈100MPa

    • 50-80MPa

    • 35 - 120MPa

  • Fast pressure rise (usually less than 10 ns

  • Short duration ≤10 microseconds

  • Narrow effective beam (2-8mm diameter)

  • Frequency range 16-20Hz

  • Pause of negativepressure

Esw principles of production
ESW: Principles of Production

  • Four principle to generate ESW

Esw comparison of different types
ESW: Comparison of different types

Shock wave principles of production
Shock Wave : Principles of Production

The amount of space over which the ESW induces therapeutic effects

The amount of acoustic energy delivered in one SW pulse

Measure of peak pulse energy within a focal volume

Measure of the energy flux /square area (mm2)

Shock wave energy flux density
Shock Wave : Energy Flux Density

LOW: Up to 0.08mJ/mm2

MEDIUM :Up to 0.28mJ/mm2

HIGH : > 0.28mJ/mm2

Rompe et al,1998

Shock wave therapy



ESW: Physiological Effects &Mechanism of Action




Shock wave therapy


ESW: Physiological Effects &Mechanism of Action


Molecular ionization

Increasing of membrane permeability.

Esw physiological effects mechanism of action
ESW: Physiological Effects &Mechanism of Action

Esw physiological effects mechanism of action1
ESW: Physiological Effects &Mechanism of Action

  • 1-Mechanical stimulation

  • 2-Increased local blood flow

  • 3-Increase in cellular activity: release of

    • Substance P,

    • Prostaglandin E2

    • NO, TGF β, VEGF, and inflammatory cytokines

  • 4-Transient analgesic effect on afferent nerves

  • 5-Break down calcific deposits (primarily, but not exclusively in tendon)

Esw clinical application
ESW: Clinical Application

Treatment Dose Issues

  • Applied energy (mJ/mm2)

  • Number of shocks

  • Number of treatment session repetitions

Esw clinical application1
ESW: Clinical Application

Applied Energy

  • LOW (up to 0.08mJ/mm2)

  • MEDIUM (up to 0.28mJ/mm2 )

  • HIGH (> 0.28mJ/mm2)

Esw clinical application2
ESW: Clinical Application

Shock Number

  • Shock number usually between 1000 and 2000,

    • Some research has tried as few as 100-500

    • 500 more effective than 100

    • 1000-2000shocks/session is most commonly applied range

Esw clinical application3
ESW: Clinical Application

Number of Treatment Sessions

Some evidence for a single session BUT only for High level treatment – using local anesthesia – not physiotherapy.

Most clinical research has used 3–5 sessions at low energy levels, for the majority of patients.

There have been no RCT trials yet to determine the maximally effective therapy session number and interval (3days-3weeks).

Esw clinical application4
ESW: Clinical Application

  • Plantar fasciitis

  • Achilles tendinopathy

  • Patellar tendonipathy

  • Tennis and Golfers elbow (medial & lateral epicondylalgia)

  • Biceps tendinopathy

  • Supraspinatus tendinopathy

  • Trochanteric bursitis

Orthopaedic indications for eswt 2
Orthopaedic indications for ESWT (2)

Common extensor tendon

Supraspinatus tendon

Achilles tendon

Plantar fascia

Patella tendon

Achilles tendinopathy
Achilles Tendinopathy

Achilles tendinopathy

  • Insertional: within 2 cm of its insertion.

  • Mid-substance: 2-6 cm proximal to its insertion


    Pain, swelling, and impaired performance

Esw contraindications dangers precautions
ESW: Contraindications, Dangers & Precautions

  • Lung tissue appears to be damaged and should be avoided

  • The epiphysis it would make sense to avoid

  • Patients who are haemophiliac/ on anticoagulant therapy.

  • Malignancy

  • Metal implants

  • Infection in the local area should be treated with strong caution

  • Joint replacements - come up with a mixed result

Esw adverse events
ESW: Adverse Events

Adverse events are equivalent to those of conventional ESWT –

  • Transient pain

  • Subcutaneous hematoma (up to 4%)

    Local symptoms are much more common in RSWT due to lower penetration energy area.

  • Local irritation does not appear to be of lasting clinical significance.