#treatment - Foot & Ankle

Shockwave Therapy

Extracorporeal Shockwave therapy or ESWT is a non-surgical and non- invasive treatment for musculoskeletal soft tissue injuries. “Extracorporeal” means “outside of the body” and refers to the way the therapy is applied. Essentially, high energy acoustic (shock) waves deliver a mechanical force to the targeted tissue to initiate a biological response. Currently ESWT can be delivered both by a “focused” or “radial” machine. The differences are primarily technical with little research focused on the differences between the forms.

Proposed mechanism of action:

At a microscopic and cellular level, shock waves cause interstitial and extracellular biological responses and tissue regeneration. Shockwaves exert a mechanical pressure and tension force on the targeted tissue. This has been shown to create an increase in cell membrane permeability and therefore increasing circulation at a microscopic level and thus metabolism within the effected tissues. Alterations of cell activity through cavitation and acoustic micro-streaming occur. Cavitation bubbles are simply small empty cavities created behind an energy front. They tend to expand to a to a maximum size, then collapse, much like a bubble popping. The two primary effects that ESWT has on tendon tissue can be summarised as

1) Effects on pain. It achieves this through hyperstimulation of pain fibres, dispersion of substance P (an important pain signaller) and destruction of small pain fibres (Type C)

2) Stimulation of tendon cell metabolism to stimulate fibroblasts to lay down more normal collagen and matrix within the tendon, thus initiating a repair process.

Who is ESWT for?

ESWT may be considered as a therapeutic option for any patient whose pain has not resolved with conservative treatment over a period of a couple of months. Many therapies such as non-steroidal anti-inflammatories, steroid injections, physical therapies, massage and acupuncture can help during the acute phase of an injury. However, they are much less effective in improving outcomes when tendinopathy becomes chronic. ESWT should not be used in patients with active infection in the area, pregnancy or in adolescents. Other cautions can include those with diabetes, nerve injury or bleeding problems.

Potential side effects are rare and tend to be transient. They include bruising, skin breakdown, temporary increase in pain and very rarely tendon tear/rupture which is reported at <1:5000 treatments.

What conditions can be treated?

• Plantar Fasciitis

• Achilles tendinopathy

• Calcific tendinosis of the shoulder

• Lateral epicondylitis

Hamstring tendinopathy

• Patella tendinopathy

Greater trochanteric pain syndrome

• There is also evidence to show that ESWT encourages bone healing in some fractures such as metatarsals.

How effective is ESWT?

The answer to this question depends upon which study you read, what methods were used in the study and how “success” is measured in the study. However, there is a growing evidence base for its effectiveness in what are renowned to be stubborn conditions to treat.

At present there is no consensus as to the definition of ‘high and ‘low’ energy but a number of studies are currently looking at what is the optimal dose, number of treatments and method. ESWT has been deemed a safe procedure by NICE (National Institute for Health and Clinical Excellence) and is now part of the treatment pathway for musculoskeletal injuries.

What does treatment involve?

One of the Sports Medicine/Orthopaedic team will assess the tendon and likely undertake either ultrasound or MRI to confirm the diagnosis. Ultrasound is rapidly becoming the investigation of choice given its superior resolution.

A standard course of treatment involves 3 treatment sessions that last around 15 minutes including assessment, treatment and advice post treatment. Currently all major insurance companies, except AXA (currently under review), fund ESWT treatment.

Patient info

Find out important information before your treatment.

Shockwave Treatment NICE Guidance

NICE patient guidance notes on Shockwave therapy for heel pain