In adult patients without infection, coagulopathy, malignancy at the treatment site, or pregnancy, which musculoskeletal and soft‑tissue conditions respond to extracorporeal shock‑wave therapy?

Musculoskeletal Conditions Responding to Extracorporeal Shock Wave Therapy

Extracorporeal shock wave therapy (ESWT) is effective for specific tendinopathies and soft-tissue conditions, with FDA approval for plantar fasciitis and lateral epicondylitis, but should NOT be used for penile curvature, plaque reduction in Peyronie's disease, acute fractures, diabetic foot ulcers, or most rotator cuff conditions without calcification. 1, 2, 3

Established Indications with Strong Evidence

Tendinopathies (Level 1+ to 1- Evidence)

• Plantar fasciitis/calcaneal spurs: FDA-approved in 2000, with success rates of 65-91% 3, 4, 5
• Lateral epicondylitis (tennis elbow): FDA-approved in 2002, appears safe and effective though requires further research 6, 3, 5
• Calcific tendonitis of the shoulder: Well-established indication with strong evidence 3, 4, 5
• Patellar tendinopathy: Demonstrated efficacy in multiple studies 3, 5
• Achilles tendinopathy: Standard approved indication 3, 4, 5

Other Musculoskeletal Conditions

• Trochanteric tendinopathy: Solid evidence supports pain improvement 5
• Myofascial pain syndrome: Recommended by ISMST for common empirically tested clinical use 4, 5
• Coccygodynia: Evidence supports use for axial pain 5

Emerging Indications (Level 2- to 3 Evidence)

Bone Pathologies

• Delayed fracture healing and pseudoarthrosis: Positive effects demonstrated, though NOT for acute fracture healing 2, 5, 7
• Osteonecrosis of femoral head (early stages): Beneficial effects reported 3, 5, 7
• Bone marrow edema syndrome: Evidence supports use 5, 7
• Kienbock's disease: Emerging indication 5
• Pubic osteitis: Demonstrated efficacy 5

Chronic Pain Conditions

• Low back pain: Recent systematic reviews show promise 5
• Carpal tunnel syndrome: Evidence for nerve entrapment treatment 5
• Osteoarthritis: Emerging evidence for pain improvement 5

Wound Healing

• Chronic diabetic and non-diabetic ulcers: Positive effects reported, though IIWGDF recommends against use specifically for diabetic foot ulcers 2, 3, 7

Absolute Contraindications

Do NOT use ESWT in these scenarios:

• Pregnancy: Absolute contraindication when focus is on fetus/embryo 1, 7
• Bleeding disorders/severe coagulopathy: Particularly for high-energy ESWT 1, 7
• Uncontrolled urinary tract infection: Must be treated first 1
• Arterial aneurysm near treatment site: Risk of rupture 1
• Malignancy at the treatment site: Tumor in treatment area is contraindication, though cancer elsewhere is not 4
• Active infection at treatment site: Severe infection is contraindicated 7

Specific Conditions Where ESWT Should NOT Be Used

Peyronie's Disease

• Do NOT use for penile curvature or plaque size reduction (Moderate Recommendation, Grade B) 1
• Randomized trials show no improvement in curvature or plaque size compared to sham treatment 1
• May offer ESWT only for penile pain improvement (Conditional Recommendation, Grade B), though pain commonly resolves spontaneously and ESWT poses substantial patient burden 1

Other Contraindicated Uses

• Acute fracture healing: No compelling anatomical or physiological rationale 2
• Rotator cuff tendinopathy without calcification: No high-quality evidence supports use 2
• Peroneal tendinopathy: Insufficient evidence 2
• Patellar tendinopathy (per ACP guidelines): No high-quality evidence 2

Mechanism of Action

ESWT works through mechanotransduction rather than tissue disintegration 5, 8:

• Mechanical energy triggers cellular skeleton changes 7
• Provokes cell nucleus reactions (mRNA release) 7
• Produces pain relief, neovascularization, protein biosynthesis, cell proliferation, and neuro/chondroprotection 8
• Destroys calcium deposits in musculoskeletal structures 8

Safety Profile and Complications

ESWT is generally safe with minimal complications:

• Pain during treatment: 12.1% 9
• Minor hematomas: common but negligible 3, 7
• No severe complications expected when performed as recommended 7

For urological applications (different context):

• Macroscopic hematuria: 17.2% 9
• Steinstrasse: 4% 9
• Renal colic: 2-4% 9

Treatment Optimization

To maximize outcomes:

• Slower shockwave rate (60-90/min vs 120/min) improves results and reduces tissue damage 1
• Stepwise energy ramping minimizes injury 1
• Proper acoustic coupling between treatment head and skin is crucial 1
• Operator experience significantly impacts outcomes 1
• Can be combined with eccentric strengthening exercises or static stretching to enhance therapeutic effect 5

Clinical Algorithm for Conservative Management

Before considering ESWT for tendinopathies:

1. Implement relative rest and activity modification for 3-6 months 2, 6
2. Apply ice therapy for short-term pain relief 6
3. Use topical or oral NSAIDs (topical preferred to avoid GI complications) 2, 6
4. Prescribe eccentric strengthening exercises as cornerstone of rehabilitation 2, 6
5. Consider ESWT only after conservative measures fail 6
6. Reserve surgical evaluation for persistent pain after 3-6 months of well-managed conservative treatment 6

Note: Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 6