What is the effectiveness of Extracorporeal Shockwave Therapy (ESWT)?

Effectiveness of Extracorporeal Shockwave Therapy (ESWT)

The effectiveness of ESWT depends entirely on the clinical indication: it should NOT be used for reducing penile curvature or plaque size in Peyronie's disease, but may be considered for pain relief in select musculoskeletal conditions and possibly for penile pain in Peyronie's disease, though its overall utility remains low. 1

For Peyronie's Disease

Penile Curvature and Plaque Size - NOT EFFECTIVE

Clinicians should not use ESWT for the reduction of penile curvature or plaque size. 1

• The American Urological Association (AUA) provides a Moderate Recommendation with Evidence Strength Grade B against using ESWT for these outcomes. 1
• Multiple randomized trials demonstrate no benefit:
  • Chitale et al. reported no effects of ESWT to improve curvature and/or plaque size. 1
  • Hatzichristodoulou et al. found curvature was reduced similarly in active and sham treatment groups, with statistically similar percentages experiencing improvement and worsening. 1
  • Palmieri et al. (2009) showed only small non-significant decreases in curvature and plaque for ESWT versus small increases in placebo groups. 1
  • A 2004 study confirmed mean angulation before (40°) and after (37°) ESWT did not change significantly. 2

Penile Pain - POSSIBLY EFFECTIVE BUT LIMITED UTILITY

Clinicians may offer ESWT to improve penile pain (Conditional Recommendation; Evidence Strength Grade B), though the AUA panel notes the overall utility of ESWT in Peyronie's disease management is low. 1

• Hatzichristodoulou et al. and Palmieri et al. (2009) reported mean pain scores on visual analog scale decreased more among ESWT patients than placebo/sham patients. 1
• One study showed pain reduction in 93% of patients, with complete relief in 63%, and mean pain score dropping from 4.2 to 1.3. 2
• Critical caveat: Penile pain commonly resolves over time spontaneously, and ESWT poses a substantial patient burden (typically 4-6 weeks of weekly sessions with 2,000-3,000 shock waves per session at 0.25-0.29 mJ/mm²). 1

For Musculoskeletal Conditions - EFFECTIVE

ESWT is an effective and safe non-invasive treatment option for chronic treatment-resistant tendinopathies and other musculoskeletal pathologies. 3, 4, 5

Proven Indications

• Insertional tendinopathies: plantar fasciitis, Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow. 4
• Bone conditions: pseudoarthrosis, delayed fracture healing, bone marrow edema, and early-stage osteonecrosis. 4
• Chronic wounds: delayed healing and chronic wound problems. 4
• Randomized controlled trials for shoulder, elbow, and heel tendinopathies show consistent positive results in favor of ESWT over placebo in individuals who have failed conservative therapy. 5

Optimal Treatment Protocol

The evidence supports three treatment sessions at 1-week intervals, with 2,000 impulses per session and the highest energy flux density the patient can tolerate. 3

• The distinction between radial ESWT as "low-energy" and focused ESWT as "high-energy" is not scientifically correct and should be abandoned. 3
• There is no scientific evidence favoring either radial or focused ESWT with respect to treatment outcome. 3

Safety Profile

ESWT is a safe therapy with only minor side effects and no severe complications when performed as recommended. 4, 6

Common Side Effects

• Pain during treatment and minor hematomas are the primary side effects. 4
• For urological applications: macroscopic hematuria occurs in 17.2% (typically self-limiting), pain/discomfort in 12.1%, and minimal skin bruising. 7, 2

Absolute Contraindications

• Severe coagulopathy for high-energy ESWT. 4
• Pregnancy (focus on fetus or embryo). 7, 4
• Severe infection in the treatment area. 4
• Malignant tumors in the treatment area (though cancer as an underlying disease elsewhere is not a contraindication). 6
• Bleeding disorders and uncontrolled urinary tract infection. 7

Important Caveats

• Cardiovascular dysrhythmias occur in 11-29% of patients, particularly those with pacemakers or defibrillators, requiring cardiac monitoring. 7
• Patients on anticoagulation have significantly increased bleeding risk; ESWL is classified as a high-risk bleeding procedure. 7
• The relationship between ESWT and long-term hypertension or diabetes remains unclear with no conclusive evidence of adverse effects to date. 7

Clinical Decision Algorithm

1. Identify the indication: Peyronie's disease versus musculoskeletal condition
2. For Peyronie's disease:
   • If goal is curvature/plaque reduction → Do NOT use ESWT 1
   • If goal is pain relief AND pain is severe AND patient understands spontaneous resolution is common → May consider ESWT but counsel about low overall utility 1
3. For musculoskeletal conditions:
   • If chronic tendinopathy with failed conservative therapy → ESWT is effective 3, 5
   • Use protocol: 3 sessions weekly, 2,000 impulses/session, maximum tolerable energy 3
4. Screen for contraindications: coagulopathy, pregnancy, infection, malignancy in treatment area, cardiac devices 7, 4, 6