Is extracorporeal shockwave therapy evidence‑based for chronic plantar fasciitis, lateral epicondylitis, calcific rotator‑cuff tendinitis, and fracture non‑unions?

Evidence-Based Status of Extracorporeal Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) has FDA approval and strong evidence for chronic plantar fasciitis and lateral epicondylitis, but should NOT be used for calcific rotator-cuff tendinitis, fracture non-unions, or diabetic foot ulcers. 1

FDA-Approved Indications with Strong Evidence

Plantar Fasciitis

• ESWT is recommended for chronic plantar fasciitis that has failed at least 3 months of conservative treatment (stretching, orthotics, NSAIDs, corticosteroid injections). 1, 2
• Both focused ESWT (F-ESWT) and radial pulse therapy (RPT) demonstrate effectiveness for plantar fasciitis pain reduction. 3
• Treatment should only be considered after failure of multiple conservative measures including calf-muscle stretching, heel cushions, arch supports, and limited corticosteroid injections. 2
• If ESWT fails, surgical plantar fasciotomy may be considered as the next step. 2

Lateral Epicondylitis (Tennis Elbow)

• ESWT has FDA approval for lateral epicondylitis, though the evidence shows mixed results depending on treatment protocols and energy levels used. 1
• Higher-dose F-ESWT regimens show greater success rates, suggesting a dose-dependent effect. 3
• Evidence from randomized controlled trials is conflicting—approximately half show statistically significant pain improvement, while half show no benefit over placebo. 4

Conditions Where ESWT Should NOT Be Used

Calcific Rotator-Cuff Tendinitis

• ESWT should NOT be used for rotator-cuff tendinopathy lacking calcification. 1
• Low-level evidence shows lack of benefit for low-dose F-ESWT and RPT in non-calcific rotator cuff disease. 3
• While F-ESWT shows effectiveness for calcific tendinitis specifically, this is distinct from non-calcific rotator cuff pathology. 3

Fracture Non-Unions

• ESWT should NOT be used for acute fracture healing, as there is no compelling anatomical or physiological rationale for benefit. 1
• No high-quality evidence supports its use in fracture management. 1

Diabetic Foot Ulcers

• ESWT is strongly contraindicated for diabetic foot ulcers based on 2024 International Working Group on the Diabetic Foot guidelines. 5, 1, 2
• Multiple studies at moderate-to-high risk of bias failed to demonstrate benefit, and the intervention was deemed unlikely to be cost-effective compared to standard wound care. 5

Treatment Optimization When ESWT Is Indicated

Technical Parameters for Maximum Efficacy

• Deliver 60–90 impulses per minute (not 120/min) to improve clinical results and reduce tissue damage. 1
• Use stepwise energy ramping—gradually increase intensity during each session to minimize injury risk. 1
• Ensure adequate acoustic coupling between the applicator head and skin for effective energy transmission. 1
• Operator experience significantly affects outcomes—procedures should be performed by clinicians trained in ESWT technique. 1

Dose-Dependent Effects

• Higher energy doses (>0.12 mJ/mm²) demonstrate superior outcomes compared to low-dose or sham therapy. 3
• Moderate-dose ESWT (0.12 mJ/mm²) showed no significant difference from sham treatment in one double-blind RCT, suggesting efficacy is highly dependent on energy levels and protocols. 6

Absolute Contraindications

• Pregnancy—when the focal zone would involve the fetus or embryo. 1
• Bleeding disorders or severe coagulopathy—high-energy ESWT must be avoided. 1
• Uncontrolled urinary tract infection—active infection must be treated first. 1
• Arterial aneurysm near the treatment site—risk of rupture. 1

Common Pitfalls to Avoid

• Do not use ESWT for acute tendon injuries—the underlying pathology in chronic cases is degenerative tendinopathy (tendinosis), not acute inflammation, which explains why it may work in chronic but not acute conditions. 7
• Do not bypass conservative treatment—ESWT should only be offered after documented failure of first-line therapies for at least 3–6 months. 2, 7
• Do not use ESWT for Peyronie's disease to improve penile curvature or plaque size—it does not work for these outcomes and carries substantial patient burden. 1
• Avoid low-dose protocols—evidence suggests benefit is dose-dependent, and subtherapeutic energy levels may produce results no better than placebo. 3, 6

Mechanism of Action

• The primary mechanism is mechanotransduction—biological effects through cellular signaling rather than purely mechanical disruption. 8
• ESWT may accelerate healing in degenerative tendon tissue through tenocyte activation and collagen remodeling, though the exact pathways remain incompletely understood. 7, 9