TY - JOUR
AU1 - Steere, Hannah K
AU2 - DeLuca, Stephanie
AU3 - Borg-Stein, Joanne
AU4 - Malanga, Gerard A
AU5 - Tenforde, Adam S
AB - ABSTRACT Introduction Extracorporeal shockwave therapy (ESWT) has a wide variety of clinical applications ranging from urology to orthopedics. Extracorporeal shockwave therapy is of particular interest to military medicine in the treatment of diverse musculoskeletal injuries, including recalcitrant tendinopathy. Much of the evidence for ESWT is from studies in the civilian population, including athletes. A few investigations have been conducted within military personnel. Musculoskeletal conditions within military personnel may contribute to pain and physical limitations. Optimal functional outcomes could be achieved through ESWT. The purpose of this narrative review is to summarize the current evidence on the efficacy of ESWT the in management of lower extremity musculoskeletal injuries in the military. Further, we explore the relative efficacy of ESWT compared to regenerative medicine procedures, including studies with treatment using platelet-rich plasma. Materials and Methods A literature review was performed in April 2020 to identify studies evaluating the use of ESWT for lower extremity conditions commonly observed in military personnel, including plantar fasciitis, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, and knee arthritis. The literature search was completed by two researchers independently, using PubMed and Embase databases and same search terms. Disagreements were adjudicated by a senior author. Due to the paucity of relevant search results, the search term parameters were expanded to incorporate active participants. Results Two studies evaluated the use of ESWT in a military population for lower extremity injuries. This included a randomized control trial in active military with medial tibial stress syndrome and an unblinded retrospective study for the chronic plantar fasciitis condition. Both studies in the military had favorable outcomes in the use of ESWT compared to other treatment arms. The remaining studies predominantly included athletes. Although heterogeneity on the quality of the studies may prevent meta-analysis and limit the generalization of the findings, the majority of studies demonstrated an improvement in pain and return to activity using ESWT. Two studies using platelet-rich plasma as a treatment arm identified similar short-term outcomes compared to ESWT for Achilles tendinopathy and patellar tendinopathy. Conclusion Our findings suggest that ESWT is a safe and well-tolerated intervention with positive outcomes for lower extremity conditions commonly seen in the military. The few studies comparing ESWT to PRP suggest regenerative benefits similar to orthobiologics in the shorter term. More robust quality designed research may enable the evaluation of ESWT efficacy within the military population. In summary, the use of ESWT may provide pain reduction and improved function in active populations with lower extremity musculoskeletal injuries. Further research in the military is needed to evaluate shockwave efficacy in order to advance musculoskeletal care and improve outcomes. INTRODUCTION Extracorporeal shockwave therapy (ESWT) is a treatment used for musculoskeletal conditions,1–3 including plantar fasciitis (PF),4 Achilles tendinopathy (AT),5–9 patellar tendinopathy (PT),10 and medial tibial stress syndrome (MTSS).11 Much of the evidence for ESWT in musculoskeletal medicine is in the civilian population, with limited studies in military. Military personnel can be considered a distinct subset of patients because of the high physical demands in training and operations.12–18 Musculoskeletal injuries in the military can lead to missed duty time,19 military discharge,19 medical evacuation,20 increased risk of disability,21,22 psychological comorbidities,23,24 and higher prevalence of musculoskeletal pain later in life compared to similarly aged civilians.25,26 The high prevalence of musculoskeletal disease within the military underscores the need to identify strategies to address pain and physical limitations with a goal to restore function. The exact mechanism(s) through which ESWT affects musculoskeletal conditions is unknown. Proposed mechanisms include increased expression of local growth factors,27 inflammatory cytokines,28 oxygen radicals,29 and enhanced local neovascularization of entheses,27,30 thought to reinitiate the healing cascade. Extracorporeal shockwave therapy may induce the stimulation of osteoprogenitor differentiation31 and tenocyte proliferation.32 It may reduce chondrocyte apoptosis.33 These biological responses are purported to induce tissue regeneration, angiogenesis, and remodeling. Analgesic effects may result from local and central effects, including hyperstimulation and subsequent activation of the descending inhibitory system triggering the release of endorphins and analgesic molecules.34 Analgesia may also be achieved through the reduction of substance P in target tissue,35 reduced substance P synthesis in the dorsal root ganglia,36 and the selective loss of nociceptive C-fibers in target tissue.37 Platelet-rich plasma (PRP) is among the more common forms of regenerative medicine treatments utilized for orthopedic conditions. Platelet-rich plasma is a preparation of autologous plasma consisting of a platelet concentration above baseline blood levels. This preparation is achieved through a centrifugation process that allows for the extraction of platelets and other cell and growth factors, which are then injected into the affected area. Activated platelets are thought to promote the body’s healing response by releasing growth factors and proteins that stimulate angiogenesis, cell growth and differentiation, and tissue regeneration and remodeling.38,39 The mechanisms of effect proposed for ESWT also appear to occur through the activation of growth factors.27 The literature to date has primarily focused on the general population and more recently on the active populations of athletes. To date, one report reviewed the historical use of ESWT in the military.40 This report characterized various shockwave protocols and conditions treated, but did not characterize outcomes that could help guide further use of this technology in the military. The primary aim of our narrative review is to identify studies evaluating efficacy of ESWT on lower extremity conditions as these are the most commonly reported anatomic locations of injury in the military.13,41–44 As a secondary focus, we explore the literature to support ESWT as a regenerative treatment by including studies that compare outcomes to PRP. Technology Two primary types of ESWT are focused (F-SWT) and radial (R-SWT). Focused SWT can generate higher energy at greater penetrative depth,45 using electrohydraulic, electromagnetic, or piezoelectric sources. The biphasic wave created through F-SWT is an initial positive high amplitude phase thought to exert a direct mechanical force on tissue. The negative phase generates cavitation and subsequent formation of acoustic air bubbles, which rapidly collapse to exert a second surge of shockwave.46 Radial SWT does not generate a true shockwave, rather creates energy through pressure waves commonly using pneumatic and ballistic forces with maximum pressure in superficial tissue. Initially, ESWT used expensive equipment, with large spatial requirements because of bulkiness, and often utilized full anesthesia.47 The current commercial devices are smaller and portable, affording capacity for use in most outpatient settings (example in Fig. 1). FIGURE 1. Open in new tabDownload slide An example of radial and focused shockwave devices. Both devices can be easily transported on a cart. Treatments are performed on standard procedure or examination tables in the outpatient clinic or a similar setting. FIGURE 1. Open in new tabDownload slide An example of radial and focused shockwave devices. Both devices can be easily transported on a cart. Treatments are performed on standard procedure or examination tables in the outpatient clinic or a similar setting. METHODS A literature review was conducted in April 2020 through PubMed and Embase databases using a combination of search terms: shockwave, shock wave, ESWT, extracorporeal shockwave therapy, platelet rich plasma, plantar fasciopathy, plantar fasciitis, Achilles tendinopathy, Achilles tendinitis, Medial Tibial Stress Syndrome, patellar tendinopathy, knee pain, knee bone marrow edema, knee osteoarthritis, military, active, and athlete. Primary articles were cross-referenced to identify additional articles. There were limited studies focusing on the military; consequently, the search was expanded to include athletes or an active population and lastly civilian population with unspecified activity if the former were not found. The search was expanded to include retrospective studies. Articles were excluded if they were not published in English. Two authors (HS and SD) independently screened studies, and any disagreements for inclusion were resolved by a third author (AST). RESULTS Literature Search The search resulted in nine randomized controlled trials (RCTs), five prospective cohorts, and seven retrospective studies. Articles are organized by condition and include descriptions of study design, patient population, specifics of ESWT, presence of a control or comparative group, and primary outcomes (Supplement Fig. S1). Tables I–IV provide a detailed description of the articles discussed in the review, with the exception of those pertaining to knee osteoarthritis and bone marrow edema. TABLE I. Detailed Summary of Key Literature Related to the Use of ESWT in Plantar Fasciitis Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Plantar fasciitis Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment 71% met criteria for FAAM for sport subscale Purcell et al. 2018 Retrospective 76 subjects (41 M, 35 F), 73.6% active duty military Refractory to conservative treatment ≥6 months Prior ESWT for other foot-related injuries ESWT (76 subjects): type not specified, 1 session for 75 subjects, 2 sessions for 1 subject, 2,000 pulses, EFD unspecified, under conscious sedation. Posttreatment: no running or strenuous weight-bearing exercise ×4 weeks, no NSAIDs or ice ×6 weeks Mean follow-up 42 months (range 5–73 months) NRS scores demonstrated 68% reduction in pain. Based on R&M score, 74% reported excellent or good outcomes, 87% rated ESWT as successful. 85% non-active military reported clinical improvement compared to 70% active duty military. 76% returned to running, 18% left the military Saxena et al. 2017 Prospective cohort 28 subjects (16 M, 12 F), 92% athletes (42.9% runners, 14.3% tennis, 21.4% walkers, 3.6% dancers, 3.6% golfers, 7.14% hikers, 2 non-active) Pain at plantar fascia origin Prior injections or surgery, neuropathy, chronic pain syndrome, radiculopathy, inflammatory arthropathy Early group (symptoms <3 months, 14 subjects): R-SWT (EnPuls: Zimmer MedizinSysteme) ×1 session/week ×3, 2,500 pulses, EFD 160 mJ/mm2. Posttreatment: return to activities PRN, avoid NSAIDs and new activities that exacerbate symptoms. Control group (symptoms ≥6 months, 14 subjects): no intervention 3, ≥12 months At 3 and 12 months, VAS and R&M scores improved for both groups, no significant difference between 2 groups. At 12 months, no subjects in early group experienced a decrease in desired activity level, whereas 35.7% in the control group reported a decline Saxena et al. 2012 RCT 37 subjects (21 M, 16 F), all athletes (professional, collegiate, high school athletes who practice sport ≥6 h/week, runners completing ≥25 miles/week) PF > 6 months, refractory to ≥3 conservative modalities. All patients in surgical group had to have corticosteroid injection, custom orthoses, and refrain from running/sport for ≥2 months Inflammatory arthropathies, radiculopathy. For shockwave groups, corticosteroid injection <6 weeks ago, use of steroids or NSAIDs, change in shoe gear or orthoses EPF (12 subjects): posttreatment cast boot ×4 weeks, weight-bearing as tolerated after 2 weeks. ESWT (11 subjects): R-SWT (Duolith) ×3 sessions every 7± 3 days, 2,000 pulses, EFD 0.24 mJ/mm2, no anesthesia. Placebo ESWT (14 subjects): special head piece prevented shockwaves from occurring, otherwise same protocol as ESWT group 12 months Improvement in VAS and R&M scores in all groups, but greatest in EPF group. Pre-VAS scores lower in EPF group. Post-ESWT return to activity ranged from immediate to 2 months. Two patients in ESWT group underwent EPF surgery. Placebo group return to activity ranged from immediate to 6 months, 2 did not return to sport. Post-EPF, return to activity averaged 2.8 months Moretti et al. 2006 Prospective cohort 54 subjects (did not specify gender), runners (20 competitive, 34 recreational) Pain at proximal insertion of PF ≥6 months, refractory to conservative treatment, heel spur on imaging Not specified ESWT (54 subjects): F-SWT (MINILITH SL1) ×1 session/week ×4, 2000 pulses, EFD 0.04 mJ/mm2, no local anesthetic 45 days, 6, 24 months Mean VAS score improved from 7.64 pretreatment to 3.55 at 6 weeks, 3.05 at 6 months, and 2.8 at 24 months. 59% reported excellent outcomes (70–100% decrease in pain), 12% reported very good outcomes (30–70% decrease in pain), 21% reported satisfactory results (< 30% decrease in pain), 8% reported unsatisfactory results (worse or unchanged). Association between reduced inflammation on ultrasound in those with better subjective results. 50 subjects resumed running at average 34 days posttreatment. No resolution of heels spurs on imaging Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Plantar fasciitis Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment 71% met criteria for FAAM for sport subscale Purcell et al. 2018 Retrospective 76 subjects (41 M, 35 F), 73.6% active duty military Refractory to conservative treatment ≥6 months Prior ESWT for other foot-related injuries ESWT (76 subjects): type not specified, 1 session for 75 subjects, 2 sessions for 1 subject, 2,000 pulses, EFD unspecified, under conscious sedation. Posttreatment: no running or strenuous weight-bearing exercise ×4 weeks, no NSAIDs or ice ×6 weeks Mean follow-up 42 months (range 5–73 months) NRS scores demonstrated 68% reduction in pain. Based on R&M score, 74% reported excellent or good outcomes, 87% rated ESWT as successful. 85% non-active military reported clinical improvement compared to 70% active duty military. 76% returned to running, 18% left the military Saxena et al. 2017 Prospective cohort 28 subjects (16 M, 12 F), 92% athletes (42.9% runners, 14.3% tennis, 21.4% walkers, 3.6% dancers, 3.6% golfers, 7.14% hikers, 2 non-active) Pain at plantar fascia origin Prior injections or surgery, neuropathy, chronic pain syndrome, radiculopathy, inflammatory arthropathy Early group (symptoms <3 months, 14 subjects): R-SWT (EnPuls: Zimmer MedizinSysteme) ×1 session/week ×3, 2,500 pulses, EFD 160 mJ/mm2. Posttreatment: return to activities PRN, avoid NSAIDs and new activities that exacerbate symptoms. Control group (symptoms ≥6 months, 14 subjects): no intervention 3, ≥12 months At 3 and 12 months, VAS and R&M scores improved for both groups, no significant difference between 2 groups. At 12 months, no subjects in early group experienced a decrease in desired activity level, whereas 35.7% in the control group reported a decline Saxena et al. 2012 RCT 37 subjects (21 M, 16 F), all athletes (professional, collegiate, high school athletes who practice sport ≥6 h/week, runners completing ≥25 miles/week) PF > 6 months, refractory to ≥3 conservative modalities. All patients in surgical group had to have corticosteroid injection, custom orthoses, and refrain from running/sport for ≥2 months Inflammatory arthropathies, radiculopathy. For shockwave groups, corticosteroid injection <6 weeks ago, use of steroids or NSAIDs, change in shoe gear or orthoses EPF (12 subjects): posttreatment cast boot ×4 weeks, weight-bearing as tolerated after 2 weeks. ESWT (11 subjects): R-SWT (Duolith) ×3 sessions every 7± 3 days, 2,000 pulses, EFD 0.24 mJ/mm2, no anesthesia. Placebo ESWT (14 subjects): special head piece prevented shockwaves from occurring, otherwise same protocol as ESWT group 12 months Improvement in VAS and R&M scores in all groups, but greatest in EPF group. Pre-VAS scores lower in EPF group. Post-ESWT return to activity ranged from immediate to 2 months. Two patients in ESWT group underwent EPF surgery. Placebo group return to activity ranged from immediate to 6 months, 2 did not return to sport. Post-EPF, return to activity averaged 2.8 months Moretti et al. 2006 Prospective cohort 54 subjects (did not specify gender), runners (20 competitive, 34 recreational) Pain at proximal insertion of PF ≥6 months, refractory to conservative treatment, heel spur on imaging Not specified ESWT (54 subjects): F-SWT (MINILITH SL1) ×1 session/week ×4, 2000 pulses, EFD 0.04 mJ/mm2, no local anesthetic 45 days, 6, 24 months Mean VAS score improved from 7.64 pretreatment to 3.55 at 6 weeks, 3.05 at 6 months, and 2.8 at 24 months. 59% reported excellent outcomes (70–100% decrease in pain), 12% reported very good outcomes (30–70% decrease in pain), 21% reported satisfactory results (< 30% decrease in pain), 8% reported unsatisfactory results (worse or unchanged). Association between reduced inflammation on ultrasound in those with better subjective results. 50 subjects resumed running at average 34 days posttreatment. No resolution of heels spurs on imaging Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE I. Detailed Summary of Key Literature Related to the Use of ESWT in Plantar Fasciitis Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Plantar fasciitis Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment 71% met criteria for FAAM for sport subscale Purcell et al. 2018 Retrospective 76 subjects (41 M, 35 F), 73.6% active duty military Refractory to conservative treatment ≥6 months Prior ESWT for other foot-related injuries ESWT (76 subjects): type not specified, 1 session for 75 subjects, 2 sessions for 1 subject, 2,000 pulses, EFD unspecified, under conscious sedation. Posttreatment: no running or strenuous weight-bearing exercise ×4 weeks, no NSAIDs or ice ×6 weeks Mean follow-up 42 months (range 5–73 months) NRS scores demonstrated 68% reduction in pain. Based on R&M score, 74% reported excellent or good outcomes, 87% rated ESWT as successful. 85% non-active military reported clinical improvement compared to 70% active duty military. 76% returned to running, 18% left the military Saxena et al. 2017 Prospective cohort 28 subjects (16 M, 12 F), 92% athletes (42.9% runners, 14.3% tennis, 21.4% walkers, 3.6% dancers, 3.6% golfers, 7.14% hikers, 2 non-active) Pain at plantar fascia origin Prior injections or surgery, neuropathy, chronic pain syndrome, radiculopathy, inflammatory arthropathy Early group (symptoms <3 months, 14 subjects): R-SWT (EnPuls: Zimmer MedizinSysteme) ×1 session/week ×3, 2,500 pulses, EFD 160 mJ/mm2. Posttreatment: return to activities PRN, avoid NSAIDs and new activities that exacerbate symptoms. Control group (symptoms ≥6 months, 14 subjects): no intervention 3, ≥12 months At 3 and 12 months, VAS and R&M scores improved for both groups, no significant difference between 2 groups. At 12 months, no subjects in early group experienced a decrease in desired activity level, whereas 35.7% in the control group reported a decline Saxena et al. 2012 RCT 37 subjects (21 M, 16 F), all athletes (professional, collegiate, high school athletes who practice sport ≥6 h/week, runners completing ≥25 miles/week) PF > 6 months, refractory to ≥3 conservative modalities. All patients in surgical group had to have corticosteroid injection, custom orthoses, and refrain from running/sport for ≥2 months Inflammatory arthropathies, radiculopathy. For shockwave groups, corticosteroid injection <6 weeks ago, use of steroids or NSAIDs, change in shoe gear or orthoses EPF (12 subjects): posttreatment cast boot ×4 weeks, weight-bearing as tolerated after 2 weeks. ESWT (11 subjects): R-SWT (Duolith) ×3 sessions every 7± 3 days, 2,000 pulses, EFD 0.24 mJ/mm2, no anesthesia. Placebo ESWT (14 subjects): special head piece prevented shockwaves from occurring, otherwise same protocol as ESWT group 12 months Improvement in VAS and R&M scores in all groups, but greatest in EPF group. Pre-VAS scores lower in EPF group. Post-ESWT return to activity ranged from immediate to 2 months. Two patients in ESWT group underwent EPF surgery. Placebo group return to activity ranged from immediate to 6 months, 2 did not return to sport. Post-EPF, return to activity averaged 2.8 months Moretti et al. 2006 Prospective cohort 54 subjects (did not specify gender), runners (20 competitive, 34 recreational) Pain at proximal insertion of PF ≥6 months, refractory to conservative treatment, heel spur on imaging Not specified ESWT (54 subjects): F-SWT (MINILITH SL1) ×1 session/week ×4, 2000 pulses, EFD 0.04 mJ/mm2, no local anesthetic 45 days, 6, 24 months Mean VAS score improved from 7.64 pretreatment to 3.55 at 6 weeks, 3.05 at 6 months, and 2.8 at 24 months. 59% reported excellent outcomes (70–100% decrease in pain), 12% reported very good outcomes (30–70% decrease in pain), 21% reported satisfactory results (< 30% decrease in pain), 8% reported unsatisfactory results (worse or unchanged). Association between reduced inflammation on ultrasound in those with better subjective results. 50 subjects resumed running at average 34 days posttreatment. No resolution of heels spurs on imaging Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Plantar fasciitis Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment 71% met criteria for FAAM for sport subscale Purcell et al. 2018 Retrospective 76 subjects (41 M, 35 F), 73.6% active duty military Refractory to conservative treatment ≥6 months Prior ESWT for other foot-related injuries ESWT (76 subjects): type not specified, 1 session for 75 subjects, 2 sessions for 1 subject, 2,000 pulses, EFD unspecified, under conscious sedation. Posttreatment: no running or strenuous weight-bearing exercise ×4 weeks, no NSAIDs or ice ×6 weeks Mean follow-up 42 months (range 5–73 months) NRS scores demonstrated 68% reduction in pain. Based on R&M score, 74% reported excellent or good outcomes, 87% rated ESWT as successful. 85% non-active military reported clinical improvement compared to 70% active duty military. 76% returned to running, 18% left the military Saxena et al. 2017 Prospective cohort 28 subjects (16 M, 12 F), 92% athletes (42.9% runners, 14.3% tennis, 21.4% walkers, 3.6% dancers, 3.6% golfers, 7.14% hikers, 2 non-active) Pain at plantar fascia origin Prior injections or surgery, neuropathy, chronic pain syndrome, radiculopathy, inflammatory arthropathy Early group (symptoms <3 months, 14 subjects): R-SWT (EnPuls: Zimmer MedizinSysteme) ×1 session/week ×3, 2,500 pulses, EFD 160 mJ/mm2. Posttreatment: return to activities PRN, avoid NSAIDs and new activities that exacerbate symptoms. Control group (symptoms ≥6 months, 14 subjects): no intervention 3, ≥12 months At 3 and 12 months, VAS and R&M scores improved for both groups, no significant difference between 2 groups. At 12 months, no subjects in early group experienced a decrease in desired activity level, whereas 35.7% in the control group reported a decline Saxena et al. 2012 RCT 37 subjects (21 M, 16 F), all athletes (professional, collegiate, high school athletes who practice sport ≥6 h/week, runners completing ≥25 miles/week) PF > 6 months, refractory to ≥3 conservative modalities. All patients in surgical group had to have corticosteroid injection, custom orthoses, and refrain from running/sport for ≥2 months Inflammatory arthropathies, radiculopathy. For shockwave groups, corticosteroid injection <6 weeks ago, use of steroids or NSAIDs, change in shoe gear or orthoses EPF (12 subjects): posttreatment cast boot ×4 weeks, weight-bearing as tolerated after 2 weeks. ESWT (11 subjects): R-SWT (Duolith) ×3 sessions every 7± 3 days, 2,000 pulses, EFD 0.24 mJ/mm2, no anesthesia. Placebo ESWT (14 subjects): special head piece prevented shockwaves from occurring, otherwise same protocol as ESWT group 12 months Improvement in VAS and R&M scores in all groups, but greatest in EPF group. Pre-VAS scores lower in EPF group. Post-ESWT return to activity ranged from immediate to 2 months. Two patients in ESWT group underwent EPF surgery. Placebo group return to activity ranged from immediate to 6 months, 2 did not return to sport. Post-EPF, return to activity averaged 2.8 months Moretti et al. 2006 Prospective cohort 54 subjects (did not specify gender), runners (20 competitive, 34 recreational) Pain at proximal insertion of PF ≥6 months, refractory to conservative treatment, heel spur on imaging Not specified ESWT (54 subjects): F-SWT (MINILITH SL1) ×1 session/week ×4, 2000 pulses, EFD 0.04 mJ/mm2, no local anesthetic 45 days, 6, 24 months Mean VAS score improved from 7.64 pretreatment to 3.55 at 6 weeks, 3.05 at 6 months, and 2.8 at 24 months. 59% reported excellent outcomes (70–100% decrease in pain), 12% reported very good outcomes (30–70% decrease in pain), 21% reported satisfactory results (< 30% decrease in pain), 8% reported unsatisfactory results (worse or unchanged). Association between reduced inflammation on ultrasound in those with better subjective results. 50 subjects resumed running at average 34 days posttreatment. No resolution of heels spurs on imaging Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE II. Detailed Summary of Key Literature Related to the Use of ESWT in Achilles Tendinopathy Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Achilles tendinopathy Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment VISA-A scores improved from 53.5 pretreatment to 79 at final follow-up for insertional Achilles tendinopathy and from 56.8 pretreatment to 81.4 at final follow-up for noninsertional Achilles tendinopathy Zhang et al. 2020 Retrospective cohort 33 subjects (31 M, 2 F), stratified based on activity level, sports-active group of self-reported joggers with Tegner activity level >3 versus nonsports-active group with Tegner activity level ≤3 Insertional Achilles tendinopathy >3 months, no history of NSAID use or physiotherapy Haglund deformity, Achilles tendon rupture, noninsertional Achilles tendinopathy, ankle deformities or osteoarthritis, peripheral neuropathies, systemic neurological conditions, seronegative diseases ESWT (33 subjects): R-SWT (EMS Swiss Dolor-Clast) ×1 session/week ×5, 2,000 pulses, EVD 0.06–0.1 mJ/mm2, anesthesia unspecified. Posttreatment: restricted NSAID for a few days after each treatment Immediately posttreatment, 5 years VISA-A scores and VAS scores improved in both groups. At 5 years, active group had lower VAS scores (0.3 ± 0.8 versus 1.6 ± 1.3) and higher mean VISA-A scores (90 ± 4 versus 78 ± 7) compared to less-active group. No difference in calcification or neovascularization of Achilles tendinopathy on ultrasound Erroi et al. 2017 Retrospective 45 subjects (30 M, 15 F), required to do physical activity or sport Insertional Achilles tendinopathy ≥6 months, refractory to conservative treatment, washout period of 12 weeks from conservative treatments, age 20–70 years old, could have retrocalcaneal bursitis Bilateral Achilles tendinopathy, coexisting foot injuries, noninsertional AT, Haglund deformity, deformities of knee or ankle, foot surgery or corticosteroid injection ≤3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infection, immunosuppressed, tumor, platelets <150 K, pregnancy PRP (21 subjects): mean platelet concentration of 0.89–1.1 ×109 cc, 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Postinjection: rest for 15 minutes, moderate compressive bandage for remainder of day, permitted full weight-bearing and ADLs, tylenol PRN, restricted NSAID usage ESWT (24 subjects): F-SWT (Modulith SLK) with ultrasound guidance ×1 session/week ×3, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Post-PRP and F-SWT treatment: identical daily home exercise program explained by clinician and executed without physical therapy ×8 weeks until 1st follow-up and 2×/week for 4 following weeks. 4 weeks after treatment, gradual return to previous activity level 2, 4, 6 months VISA-A, VAS, and R&M scores improved for both groups at 2, 4, and 6 months, with no difference between two groups except for greater improvement in VISA-A in F-SWT group at 4 months Vulpiani et al. 2009 Prospective cohort 105 subjects (89 M, 16 F), athletes (9.5% professionals, 60% amateurs, 30.5% practicing sports ≥1×/week) Insertional or noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 months conservative treatment Conservative treatment ≤4 weeks before study, polyneuropathies, Achilles tendon surgery ESWT (105 subjects): F-SWT (STORZ medical AG) × average 4 sessions (minimum 3, maximum 5) with 2 to 7 days rest, 1,500–2,500 pulses, EFD 0.08–0.33 mJ/mm2, no local anesthesia. Posttreatment: did not return to sports for ≥3 weeks, no adjuvant medical treatments 2, 6–12 months, 12–24 months At all follow-up time points, mean VAS score decreased significantly and subjective clinical evaluation improved. Overall, satisfactory results were reported in 47.2% subjects at 2 months, 73.2% at 6–12 months, and 76% at 12–24 months. When stratified into noninsertional Achilles tendinopathy, satisfactory results were reported in 60.5% at 2 months, 77.7% at 6–12 months, 75% at 12–24 months. For insertional, satisfactory results were reported in 43.7% at 2 months, 42.3% at 6–12 months, and 37.4% at 12–24 months. Bone spurs remained unchanged Rompe et al. 2008 RCT 50 subjects (20 M, 30 F), 58% athletes (undefined level) Insertional Achilles tendinopathy > 6 months, refractory to conservative treatment, ages 18–70 years old Peritendinous injections ≤4 weeks, other posterior ankle pain pathology, ankle or knee deformities, prior ankle or Achilles tendon surgery, prior Achilles tendon rupture, dislocation or fracture in the area ≤12 months ago Eccentric loading (25 subjects): 2×/day ×7 days/week, ×12 weeks, not allowed to perform other physical therapy or use innersoles. ESWT (25 subjects): R-SWT (Swiss DolorClast) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.12 mJ/mm2. Both groups to avoid pain-provoking activities during treatment period, light jogging on flat ground allowed after 4–6 weeks 4, 12 months At 4 months, greater improvement in VISA-A score, pain rating, pain threshold, and tenderness. Per Likert scale, 64% ESWT group reported complete resolution or much improvement at 4 months compared to 28% in eccentric loading group Furia et al. 2008 Retrospective case control 68 subjects (22 M, 46 F), 50% recreational athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, cycling, and golf) Noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 forms of nonoperative treatment ≥6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding disorders, tumors, <18 years old, severe endocrine disease, advanced peripheral vascular disease, pain and tenderness at retrocalcaneal bursa, calcifications and/or spurs near retrocalcaneal bursa, Achilles tendon calcifications/spurs/tenderness within <2 cm proximal from insertion, Achilles tendon surgery Control (34 subjects): conservative management ≥6 months. ESWT (34 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, EFD 604 mJ/mm2, anesthesia was patient-dependent (ankle block for 32 subjects, ankle blocks with sedation for two patients). Posttreatment: decrease activity for 24 hours, permitted early range of motion and immediate weight-bearing, return to sport and heavy-labor occupations made on individual basis 1, 3, 12 months At 1, 3, 12 months, mean VAS score significantly decreased and R&M scores significantly increased for SWT, but not for the control group. 78% of the athletes in ESWT group returned to sport compared to 63% of athletes in the control group Furia et al. 2006 Retrospective case–control 68 subjects (24 M, 44 F), 62% athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, golf) Insertional Achilles tendinopathy ≥6 months, refractory to ≥3 types of conservative treatment for ≥ 6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding, tumors, < 18 years old, severe endocrine disease, pain and tenderness at retrocalcaneal bursa, calcifications of Achilles tendon, spurs near retrocalcaneal bursa, advanced peripheral vascular disease, prior Achilles tendon surgery Control (33 subjects): conservative treatment. ESWT (35 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, 604 mJ/mm2, 12 patients received local anesthesia block and 23 patients received a regional block. Posttreatment: immobilization period (walking boot) varied in duration per provider, individualized return to activity 1, 3, 12 months At 1, 3, 12 months, VAS scores improved for ESWT group compared to control. At 12 months, using the R&M score, 82.9% in the ESWT group reported excellent or good results compared to 39.4% in the control group. At 1, 3, 12 months, there was significantly less improvement in VAS for the local anesthetic group versus regional block. No difference in R&M scores between local and nonlocal anesthetic groups Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Achilles tendinopathy Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment VISA-A scores improved from 53.5 pretreatment to 79 at final follow-up for insertional Achilles tendinopathy and from 56.8 pretreatment to 81.4 at final follow-up for noninsertional Achilles tendinopathy Zhang et al. 2020 Retrospective cohort 33 subjects (31 M, 2 F), stratified based on activity level, sports-active group of self-reported joggers with Tegner activity level >3 versus nonsports-active group with Tegner activity level ≤3 Insertional Achilles tendinopathy >3 months, no history of NSAID use or physiotherapy Haglund deformity, Achilles tendon rupture, noninsertional Achilles tendinopathy, ankle deformities or osteoarthritis, peripheral neuropathies, systemic neurological conditions, seronegative diseases ESWT (33 subjects): R-SWT (EMS Swiss Dolor-Clast) ×1 session/week ×5, 2,000 pulses, EVD 0.06–0.1 mJ/mm2, anesthesia unspecified. Posttreatment: restricted NSAID for a few days after each treatment Immediately posttreatment, 5 years VISA-A scores and VAS scores improved in both groups. At 5 years, active group had lower VAS scores (0.3 ± 0.8 versus 1.6 ± 1.3) and higher mean VISA-A scores (90 ± 4 versus 78 ± 7) compared to less-active group. No difference in calcification or neovascularization of Achilles tendinopathy on ultrasound Erroi et al. 2017 Retrospective 45 subjects (30 M, 15 F), required to do physical activity or sport Insertional Achilles tendinopathy ≥6 months, refractory to conservative treatment, washout period of 12 weeks from conservative treatments, age 20–70 years old, could have retrocalcaneal bursitis Bilateral Achilles tendinopathy, coexisting foot injuries, noninsertional AT, Haglund deformity, deformities of knee or ankle, foot surgery or corticosteroid injection ≤3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infection, immunosuppressed, tumor, platelets <150 K, pregnancy PRP (21 subjects): mean platelet concentration of 0.89–1.1 ×109 cc, 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Postinjection: rest for 15 minutes, moderate compressive bandage for remainder of day, permitted full weight-bearing and ADLs, tylenol PRN, restricted NSAID usage ESWT (24 subjects): F-SWT (Modulith SLK) with ultrasound guidance ×1 session/week ×3, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Post-PRP and F-SWT treatment: identical daily home exercise program explained by clinician and executed without physical therapy ×8 weeks until 1st follow-up and 2×/week for 4 following weeks. 4 weeks after treatment, gradual return to previous activity level 2, 4, 6 months VISA-A, VAS, and R&M scores improved for both groups at 2, 4, and 6 months, with no difference between two groups except for greater improvement in VISA-A in F-SWT group at 4 months Vulpiani et al. 2009 Prospective cohort 105 subjects (89 M, 16 F), athletes (9.5% professionals, 60% amateurs, 30.5% practicing sports ≥1×/week) Insertional or noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 months conservative treatment Conservative treatment ≤4 weeks before study, polyneuropathies, Achilles tendon surgery ESWT (105 subjects): F-SWT (STORZ medical AG) × average 4 sessions (minimum 3, maximum 5) with 2 to 7 days rest, 1,500–2,500 pulses, EFD 0.08–0.33 mJ/mm2, no local anesthesia. Posttreatment: did not return to sports for ≥3 weeks, no adjuvant medical treatments 2, 6–12 months, 12–24 months At all follow-up time points, mean VAS score decreased significantly and subjective clinical evaluation improved. Overall, satisfactory results were reported in 47.2% subjects at 2 months, 73.2% at 6–12 months, and 76% at 12–24 months. When stratified into noninsertional Achilles tendinopathy, satisfactory results were reported in 60.5% at 2 months, 77.7% at 6–12 months, 75% at 12–24 months. For insertional, satisfactory results were reported in 43.7% at 2 months, 42.3% at 6–12 months, and 37.4% at 12–24 months. Bone spurs remained unchanged Rompe et al. 2008 RCT 50 subjects (20 M, 30 F), 58% athletes (undefined level) Insertional Achilles tendinopathy > 6 months, refractory to conservative treatment, ages 18–70 years old Peritendinous injections ≤4 weeks, other posterior ankle pain pathology, ankle or knee deformities, prior ankle or Achilles tendon surgery, prior Achilles tendon rupture, dislocation or fracture in the area ≤12 months ago Eccentric loading (25 subjects): 2×/day ×7 days/week, ×12 weeks, not allowed to perform other physical therapy or use innersoles. ESWT (25 subjects): R-SWT (Swiss DolorClast) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.12 mJ/mm2. Both groups to avoid pain-provoking activities during treatment period, light jogging on flat ground allowed after 4–6 weeks 4, 12 months At 4 months, greater improvement in VISA-A score, pain rating, pain threshold, and tenderness. Per Likert scale, 64% ESWT group reported complete resolution or much improvement at 4 months compared to 28% in eccentric loading group Furia et al. 2008 Retrospective case control 68 subjects (22 M, 46 F), 50% recreational athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, cycling, and golf) Noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 forms of nonoperative treatment ≥6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding disorders, tumors, <18 years old, severe endocrine disease, advanced peripheral vascular disease, pain and tenderness at retrocalcaneal bursa, calcifications and/or spurs near retrocalcaneal bursa, Achilles tendon calcifications/spurs/tenderness within <2 cm proximal from insertion, Achilles tendon surgery Control (34 subjects): conservative management ≥6 months. ESWT (34 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, EFD 604 mJ/mm2, anesthesia was patient-dependent (ankle block for 32 subjects, ankle blocks with sedation for two patients). Posttreatment: decrease activity for 24 hours, permitted early range of motion and immediate weight-bearing, return to sport and heavy-labor occupations made on individual basis 1, 3, 12 months At 1, 3, 12 months, mean VAS score significantly decreased and R&M scores significantly increased for SWT, but not for the control group. 78% of the athletes in ESWT group returned to sport compared to 63% of athletes in the control group Furia et al. 2006 Retrospective case–control 68 subjects (24 M, 44 F), 62% athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, golf) Insertional Achilles tendinopathy ≥6 months, refractory to ≥3 types of conservative treatment for ≥ 6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding, tumors, < 18 years old, severe endocrine disease, pain and tenderness at retrocalcaneal bursa, calcifications of Achilles tendon, spurs near retrocalcaneal bursa, advanced peripheral vascular disease, prior Achilles tendon surgery Control (33 subjects): conservative treatment. ESWT (35 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, 604 mJ/mm2, 12 patients received local anesthesia block and 23 patients received a regional block. Posttreatment: immobilization period (walking boot) varied in duration per provider, individualized return to activity 1, 3, 12 months At 1, 3, 12 months, VAS scores improved for ESWT group compared to control. At 12 months, using the R&M score, 82.9% in the ESWT group reported excellent or good results compared to 39.4% in the control group. At 1, 3, 12 months, there was significantly less improvement in VAS for the local anesthetic group versus regional block. No difference in R&M scores between local and nonlocal anesthetic groups Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE II. Detailed Summary of Key Literature Related to the Use of ESWT in Achilles Tendinopathy Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Achilles tendinopathy Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment VISA-A scores improved from 53.5 pretreatment to 79 at final follow-up for insertional Achilles tendinopathy and from 56.8 pretreatment to 81.4 at final follow-up for noninsertional Achilles tendinopathy Zhang et al. 2020 Retrospective cohort 33 subjects (31 M, 2 F), stratified based on activity level, sports-active group of self-reported joggers with Tegner activity level >3 versus nonsports-active group with Tegner activity level ≤3 Insertional Achilles tendinopathy >3 months, no history of NSAID use or physiotherapy Haglund deformity, Achilles tendon rupture, noninsertional Achilles tendinopathy, ankle deformities or osteoarthritis, peripheral neuropathies, systemic neurological conditions, seronegative diseases ESWT (33 subjects): R-SWT (EMS Swiss Dolor-Clast) ×1 session/week ×5, 2,000 pulses, EVD 0.06–0.1 mJ/mm2, anesthesia unspecified. Posttreatment: restricted NSAID for a few days after each treatment Immediately posttreatment, 5 years VISA-A scores and VAS scores improved in both groups. At 5 years, active group had lower VAS scores (0.3 ± 0.8 versus 1.6 ± 1.3) and higher mean VISA-A scores (90 ± 4 versus 78 ± 7) compared to less-active group. No difference in calcification or neovascularization of Achilles tendinopathy on ultrasound Erroi et al. 2017 Retrospective 45 subjects (30 M, 15 F), required to do physical activity or sport Insertional Achilles tendinopathy ≥6 months, refractory to conservative treatment, washout period of 12 weeks from conservative treatments, age 20–70 years old, could have retrocalcaneal bursitis Bilateral Achilles tendinopathy, coexisting foot injuries, noninsertional AT, Haglund deformity, deformities of knee or ankle, foot surgery or corticosteroid injection ≤3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infection, immunosuppressed, tumor, platelets <150 K, pregnancy PRP (21 subjects): mean platelet concentration of 0.89–1.1 ×109 cc, 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Postinjection: rest for 15 minutes, moderate compressive bandage for remainder of day, permitted full weight-bearing and ADLs, tylenol PRN, restricted NSAID usage ESWT (24 subjects): F-SWT (Modulith SLK) with ultrasound guidance ×1 session/week ×3, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Post-PRP and F-SWT treatment: identical daily home exercise program explained by clinician and executed without physical therapy ×8 weeks until 1st follow-up and 2×/week for 4 following weeks. 4 weeks after treatment, gradual return to previous activity level 2, 4, 6 months VISA-A, VAS, and R&M scores improved for both groups at 2, 4, and 6 months, with no difference between two groups except for greater improvement in VISA-A in F-SWT group at 4 months Vulpiani et al. 2009 Prospective cohort 105 subjects (89 M, 16 F), athletes (9.5% professionals, 60% amateurs, 30.5% practicing sports ≥1×/week) Insertional or noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 months conservative treatment Conservative treatment ≤4 weeks before study, polyneuropathies, Achilles tendon surgery ESWT (105 subjects): F-SWT (STORZ medical AG) × average 4 sessions (minimum 3, maximum 5) with 2 to 7 days rest, 1,500–2,500 pulses, EFD 0.08–0.33 mJ/mm2, no local anesthesia. Posttreatment: did not return to sports for ≥3 weeks, no adjuvant medical treatments 2, 6–12 months, 12–24 months At all follow-up time points, mean VAS score decreased significantly and subjective clinical evaluation improved. Overall, satisfactory results were reported in 47.2% subjects at 2 months, 73.2% at 6–12 months, and 76% at 12–24 months. When stratified into noninsertional Achilles tendinopathy, satisfactory results were reported in 60.5% at 2 months, 77.7% at 6–12 months, 75% at 12–24 months. For insertional, satisfactory results were reported in 43.7% at 2 months, 42.3% at 6–12 months, and 37.4% at 12–24 months. Bone spurs remained unchanged Rompe et al. 2008 RCT 50 subjects (20 M, 30 F), 58% athletes (undefined level) Insertional Achilles tendinopathy > 6 months, refractory to conservative treatment, ages 18–70 years old Peritendinous injections ≤4 weeks, other posterior ankle pain pathology, ankle or knee deformities, prior ankle or Achilles tendon surgery, prior Achilles tendon rupture, dislocation or fracture in the area ≤12 months ago Eccentric loading (25 subjects): 2×/day ×7 days/week, ×12 weeks, not allowed to perform other physical therapy or use innersoles. ESWT (25 subjects): R-SWT (Swiss DolorClast) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.12 mJ/mm2. Both groups to avoid pain-provoking activities during treatment period, light jogging on flat ground allowed after 4–6 weeks 4, 12 months At 4 months, greater improvement in VISA-A score, pain rating, pain threshold, and tenderness. Per Likert scale, 64% ESWT group reported complete resolution or much improvement at 4 months compared to 28% in eccentric loading group Furia et al. 2008 Retrospective case control 68 subjects (22 M, 46 F), 50% recreational athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, cycling, and golf) Noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 forms of nonoperative treatment ≥6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding disorders, tumors, <18 years old, severe endocrine disease, advanced peripheral vascular disease, pain and tenderness at retrocalcaneal bursa, calcifications and/or spurs near retrocalcaneal bursa, Achilles tendon calcifications/spurs/tenderness within <2 cm proximal from insertion, Achilles tendon surgery Control (34 subjects): conservative management ≥6 months. ESWT (34 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, EFD 604 mJ/mm2, anesthesia was patient-dependent (ankle block for 32 subjects, ankle blocks with sedation for two patients). Posttreatment: decrease activity for 24 hours, permitted early range of motion and immediate weight-bearing, return to sport and heavy-labor occupations made on individual basis 1, 3, 12 months At 1, 3, 12 months, mean VAS score significantly decreased and R&M scores significantly increased for SWT, but not for the control group. 78% of the athletes in ESWT group returned to sport compared to 63% of athletes in the control group Furia et al. 2006 Retrospective case–control 68 subjects (24 M, 44 F), 62% athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, golf) Insertional Achilles tendinopathy ≥6 months, refractory to ≥3 types of conservative treatment for ≥ 6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding, tumors, < 18 years old, severe endocrine disease, pain and tenderness at retrocalcaneal bursa, calcifications of Achilles tendon, spurs near retrocalcaneal bursa, advanced peripheral vascular disease, prior Achilles tendon surgery Control (33 subjects): conservative treatment. ESWT (35 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, 604 mJ/mm2, 12 patients received local anesthesia block and 23 patients received a regional block. Posttreatment: immobilization period (walking boot) varied in duration per provider, individualized return to activity 1, 3, 12 months At 1, 3, 12 months, VAS scores improved for ESWT group compared to control. At 12 months, using the R&M score, 82.9% in the ESWT group reported excellent or good results compared to 39.4% in the control group. At 1, 3, 12 months, there was significantly less improvement in VAS for the local anesthetic group versus regional block. No difference in R&M scores between local and nonlocal anesthetic groups Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Achilles tendinopathy Mitchkash et al. 2020 Prospective cohort 17 subjects (6 M, 11 F) with plantar fasciitis out of 94 total subjects, all runners Primary diagnosis of running-related injury that impaired normal training and ability to compete for >7 days, completed baseline and functional outcome measures Receiving treatment for multiple lower extremity conditions simultaneously, presence of other conditions including joint disease, surgery ≤6 months ago ESWT (27 subjects): R-SWT (Storz extracorporeal pulse activation technology device) for minimum 3-weekly sessions with additional sessions PRN for maximal clinical response, 12–15 Hz, 2–5 bar, treatment targeted to sites with pain, no anesthetic. All recommended to complete PT or home exercise program. Posttreatment: avoid NSAIDs, icing during treatment through final follow-up, able to run as tolerated 6–8 weeks post-initial treatment VISA-A scores improved from 53.5 pretreatment to 79 at final follow-up for insertional Achilles tendinopathy and from 56.8 pretreatment to 81.4 at final follow-up for noninsertional Achilles tendinopathy Zhang et al. 2020 Retrospective cohort 33 subjects (31 M, 2 F), stratified based on activity level, sports-active group of self-reported joggers with Tegner activity level >3 versus nonsports-active group with Tegner activity level ≤3 Insertional Achilles tendinopathy >3 months, no history of NSAID use or physiotherapy Haglund deformity, Achilles tendon rupture, noninsertional Achilles tendinopathy, ankle deformities or osteoarthritis, peripheral neuropathies, systemic neurological conditions, seronegative diseases ESWT (33 subjects): R-SWT (EMS Swiss Dolor-Clast) ×1 session/week ×5, 2,000 pulses, EVD 0.06–0.1 mJ/mm2, anesthesia unspecified. Posttreatment: restricted NSAID for a few days after each treatment Immediately posttreatment, 5 years VISA-A scores and VAS scores improved in both groups. At 5 years, active group had lower VAS scores (0.3 ± 0.8 versus 1.6 ± 1.3) and higher mean VISA-A scores (90 ± 4 versus 78 ± 7) compared to less-active group. No difference in calcification or neovascularization of Achilles tendinopathy on ultrasound Erroi et al. 2017 Retrospective 45 subjects (30 M, 15 F), required to do physical activity or sport Insertional Achilles tendinopathy ≥6 months, refractory to conservative treatment, washout period of 12 weeks from conservative treatments, age 20–70 years old, could have retrocalcaneal bursitis Bilateral Achilles tendinopathy, coexisting foot injuries, noninsertional AT, Haglund deformity, deformities of knee or ankle, foot surgery or corticosteroid injection ≤3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infection, immunosuppressed, tumor, platelets <150 K, pregnancy PRP (21 subjects): mean platelet concentration of 0.89–1.1 ×109 cc, 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Postinjection: rest for 15 minutes, moderate compressive bandage for remainder of day, permitted full weight-bearing and ADLs, tylenol PRN, restricted NSAID usage ESWT (24 subjects): F-SWT (Modulith SLK) with ultrasound guidance ×1 session/week ×3, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Post-PRP and F-SWT treatment: identical daily home exercise program explained by clinician and executed without physical therapy ×8 weeks until 1st follow-up and 2×/week for 4 following weeks. 4 weeks after treatment, gradual return to previous activity level 2, 4, 6 months VISA-A, VAS, and R&M scores improved for both groups at 2, 4, and 6 months, with no difference between two groups except for greater improvement in VISA-A in F-SWT group at 4 months Vulpiani et al. 2009 Prospective cohort 105 subjects (89 M, 16 F), athletes (9.5% professionals, 60% amateurs, 30.5% practicing sports ≥1×/week) Insertional or noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 months conservative treatment Conservative treatment ≤4 weeks before study, polyneuropathies, Achilles tendon surgery ESWT (105 subjects): F-SWT (STORZ medical AG) × average 4 sessions (minimum 3, maximum 5) with 2 to 7 days rest, 1,500–2,500 pulses, EFD 0.08–0.33 mJ/mm2, no local anesthesia. Posttreatment: did not return to sports for ≥3 weeks, no adjuvant medical treatments 2, 6–12 months, 12–24 months At all follow-up time points, mean VAS score decreased significantly and subjective clinical evaluation improved. Overall, satisfactory results were reported in 47.2% subjects at 2 months, 73.2% at 6–12 months, and 76% at 12–24 months. When stratified into noninsertional Achilles tendinopathy, satisfactory results were reported in 60.5% at 2 months, 77.7% at 6–12 months, 75% at 12–24 months. For insertional, satisfactory results were reported in 43.7% at 2 months, 42.3% at 6–12 months, and 37.4% at 12–24 months. Bone spurs remained unchanged Rompe et al. 2008 RCT 50 subjects (20 M, 30 F), 58% athletes (undefined level) Insertional Achilles tendinopathy > 6 months, refractory to conservative treatment, ages 18–70 years old Peritendinous injections ≤4 weeks, other posterior ankle pain pathology, ankle or knee deformities, prior ankle or Achilles tendon surgery, prior Achilles tendon rupture, dislocation or fracture in the area ≤12 months ago Eccentric loading (25 subjects): 2×/day ×7 days/week, ×12 weeks, not allowed to perform other physical therapy or use innersoles. ESWT (25 subjects): R-SWT (Swiss DolorClast) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.12 mJ/mm2. Both groups to avoid pain-provoking activities during treatment period, light jogging on flat ground allowed after 4–6 weeks 4, 12 months At 4 months, greater improvement in VISA-A score, pain rating, pain threshold, and tenderness. Per Likert scale, 64% ESWT group reported complete resolution or much improvement at 4 months compared to 28% in eccentric loading group Furia et al. 2008 Retrospective case control 68 subjects (22 M, 46 F), 50% recreational athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, cycling, and golf) Noninsertional Achilles tendinopathy ≥6 months, refractory to ≥3 forms of nonoperative treatment ≥6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding disorders, tumors, <18 years old, severe endocrine disease, advanced peripheral vascular disease, pain and tenderness at retrocalcaneal bursa, calcifications and/or spurs near retrocalcaneal bursa, Achilles tendon calcifications/spurs/tenderness within <2 cm proximal from insertion, Achilles tendon surgery Control (34 subjects): conservative management ≥6 months. ESWT (34 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, EFD 604 mJ/mm2, anesthesia was patient-dependent (ankle block for 32 subjects, ankle blocks with sedation for two patients). Posttreatment: decrease activity for 24 hours, permitted early range of motion and immediate weight-bearing, return to sport and heavy-labor occupations made on individual basis 1, 3, 12 months At 1, 3, 12 months, mean VAS score significantly decreased and R&M scores significantly increased for SWT, but not for the control group. 78% of the athletes in ESWT group returned to sport compared to 63% of athletes in the control group Furia et al. 2006 Retrospective case–control 68 subjects (24 M, 44 F), 62% athletes (basketball, jogging, running, volleyball, racquetball, tennis, soccer, golf) Insertional Achilles tendinopathy ≥6 months, refractory to ≥3 types of conservative treatment for ≥ 6 months Rheumatoid arthritis, generalized polyarthritis, Reiter syndrome, infection, pregnancy, bleeding, tumors, < 18 years old, severe endocrine disease, pain and tenderness at retrocalcaneal bursa, calcifications of Achilles tendon, spurs near retrocalcaneal bursa, advanced peripheral vascular disease, prior Achilles tendon surgery Control (33 subjects): conservative treatment. ESWT (35 subjects): F-SWT (Dornier Epos lithotripter) ×1 session, 3,000 pulses, 604 mJ/mm2, 12 patients received local anesthesia block and 23 patients received a regional block. Posttreatment: immobilization period (walking boot) varied in duration per provider, individualized return to activity 1, 3, 12 months At 1, 3, 12 months, VAS scores improved for ESWT group compared to control. At 12 months, using the R&M score, 82.9% in the ESWT group reported excellent or good results compared to 39.4% in the control group. At 1, 3, 12 months, there was significantly less improvement in VAS for the local anesthetic group versus regional block. No difference in R&M scores between local and nonlocal anesthetic groups Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE III. Detailed Summary of Key Literature Related to the Use of ESWT in Medial Tibial Stress Syndrome Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Medial Tibial Stress Syndrome (MTSS) Newman et al. 2018 RCT 28 subjects (10 M, 18 F), runners with average 9-year running history Pain at distal half posteromedial tibia associated with running lasting for hours-days post-run for ≥21 days, no paresthesias Prior ESWT treatment, another lower extremity injury Sham group (14 subjects): ×5 sessions, 1,000 pulses EFD 0.01 mJ/mm2 week 1, 1,500 impulses ×4 weeks 2, 3, 5, 9. ESWT (14 subjects): F-SWT (Duolith SD1) ×5 sessions, 1,000 pulses EFD 0.1 mJ/mm2 week 1, 1,500 pulses with EVD 0.15 mJ/mm2 week 2, 1,500 pulses with EVD 0.2 mJ/mm2 week 3, 1,500 pulses with EVD 0.25 mJ/mm2 week 5, 1,500 pulses with EVD 0.3 mJ/mm2 week 9. 1 week post-final ESWT treatment (week 10) Sham group with less pain on NRS during bone pressure versus ESWT group. No difference in pain during muscle pressure or running. No difference in pain-limited running distance or self-perception of change per GROC. Sham dose may have had clinical effect Gomez et al. 2017 RCT 42 subjects (33 M, 9 F), military cadets >18 years old, MTSS per Yates and White criteria, pain ≥3 weeks, pain with exercise, unilateral MTSS, X-ray to rule out fracture Current or history of stress fracture, infection, cancer, compartment syndrome, surgery on injured leg, prior ESWT for MTSS, rheumatic disease, coagulopathy, pregnancy Exercise only (29 subjects): 40 minutes exercise 5 days/week ×4 weeks under physiotherapist guidance, cryotherapy post-exercise ×10 minutes. ESWT + exercise (23 subjects): R-SWT (Duolith SD1) ×1 session, 1,500 pulses, EFD 0.20 mJ/mm2, without anesthesia, same exercise regimen as exercise only group with exception of no cryotherapy. Posttreatment: rest, analgesics PRN for 24–48 hours 4 weeks ESWT group with greater improvement in VAS scores compared to control. ESWT group able to run longer than control. Lower VAS scores post-running in ESWT group. Per R&M score, 82.6% ESWT with excellent or good results compared to 36.8% in control Moen et al. 2012 Prospective observational controlled control 42 subjects (23 M, 19 F), athletes (recreational running, soccer, field hockey, tennis, basketball, dancing) Pain along posteromedial border of tibia over ≥5 cm area, symptoms ≥21 days, pain exacerbated by exercise, no history of paresthesias History of tibial fracture, prior ESWT treatment Running program (20 subjects): graded running program ×3/week and could not run on consecutive days. ESWT + running program (22 subjects): F-SWT (Duolith SD1) ×5 sessions over 9 weeks, 1,000–1,500 pulses, EFD 0.1–0.3 mJ/mm2, without local anesthesia. Posttreatment: no restrictions, running program started same week as ESWT No follow-up Time to full recovery (able to run 18 minutes consecutively without pain) was 59.7 days in ESWT/running program group versus 91.6 days in running only group Rompe et al. 2010 Retrospective case control 94 subjects (40 M, 50 F), running athletes (runners, soccer, track athletes) Unilateral chronic MTSS ≥6 months, failed 3 forms of traditional conservative treatment for ≥3 months, corticosteroid or local anesthetic injection Compartment syndrome, rheumatoid arthritis, polyarthritis, infection, pregnancy tumors, <18 years old, end-stage ipsilateral knee osteoarthritis, bleeding disorders, knee or ankle surgery Control group (47 subjects): relative rest, ice, home training program ×2/day × 12 weeks. ESWT + exercise (47 subjects): R-SWT (Swiss DolorClast) ×3 sessions at weeks 2, 3, 4 after initiation of 12-week home exercise program, 2,000 pulses, EFD 0.1 mJ/mm2, without local anesthesia. Posttreatment: immediate weight-bearing, unrestricted range of motion, no adjuvant therapy for 4 months, pain meds available upon request, ≥6 weeks before initiation of gradual return to sport, stationary cycling immediately, easy running at >1 week 1, 4, 15 months Based on Likert scale, neither group had worsening symptoms at 1, 4, 15 months. Greater percentage of ESWT patients with Likert scale ratings of 1 or 2 compared to control. At 1, 4, 15 months, greater decrease in NRS in ESWT group. At 15 months, 85% ESWT subjects and 49% control subjects returned to level of sport pre-injury Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Medial Tibial Stress Syndrome (MTSS) Newman et al. 2018 RCT 28 subjects (10 M, 18 F), runners with average 9-year running history Pain at distal half posteromedial tibia associated with running lasting for hours-days post-run for ≥21 days, no paresthesias Prior ESWT treatment, another lower extremity injury Sham group (14 subjects): ×5 sessions, 1,000 pulses EFD 0.01 mJ/mm2 week 1, 1,500 impulses ×4 weeks 2, 3, 5, 9. ESWT (14 subjects): F-SWT (Duolith SD1) ×5 sessions, 1,000 pulses EFD 0.1 mJ/mm2 week 1, 1,500 pulses with EVD 0.15 mJ/mm2 week 2, 1,500 pulses with EVD 0.2 mJ/mm2 week 3, 1,500 pulses with EVD 0.25 mJ/mm2 week 5, 1,500 pulses with EVD 0.3 mJ/mm2 week 9. 1 week post-final ESWT treatment (week 10) Sham group with less pain on NRS during bone pressure versus ESWT group. No difference in pain during muscle pressure or running. No difference in pain-limited running distance or self-perception of change per GROC. Sham dose may have had clinical effect Gomez et al. 2017 RCT 42 subjects (33 M, 9 F), military cadets >18 years old, MTSS per Yates and White criteria, pain ≥3 weeks, pain with exercise, unilateral MTSS, X-ray to rule out fracture Current or history of stress fracture, infection, cancer, compartment syndrome, surgery on injured leg, prior ESWT for MTSS, rheumatic disease, coagulopathy, pregnancy Exercise only (29 subjects): 40 minutes exercise 5 days/week ×4 weeks under physiotherapist guidance, cryotherapy post-exercise ×10 minutes. ESWT + exercise (23 subjects): R-SWT (Duolith SD1) ×1 session, 1,500 pulses, EFD 0.20 mJ/mm2, without anesthesia, same exercise regimen as exercise only group with exception of no cryotherapy. Posttreatment: rest, analgesics PRN for 24–48 hours 4 weeks ESWT group with greater improvement in VAS scores compared to control. ESWT group able to run longer than control. Lower VAS scores post-running in ESWT group. Per R&M score, 82.6% ESWT with excellent or good results compared to 36.8% in control Moen et al. 2012 Prospective observational controlled control 42 subjects (23 M, 19 F), athletes (recreational running, soccer, field hockey, tennis, basketball, dancing) Pain along posteromedial border of tibia over ≥5 cm area, symptoms ≥21 days, pain exacerbated by exercise, no history of paresthesias History of tibial fracture, prior ESWT treatment Running program (20 subjects): graded running program ×3/week and could not run on consecutive days. ESWT + running program (22 subjects): F-SWT (Duolith SD1) ×5 sessions over 9 weeks, 1,000–1,500 pulses, EFD 0.1–0.3 mJ/mm2, without local anesthesia. Posttreatment: no restrictions, running program started same week as ESWT No follow-up Time to full recovery (able to run 18 minutes consecutively without pain) was 59.7 days in ESWT/running program group versus 91.6 days in running only group Rompe et al. 2010 Retrospective case control 94 subjects (40 M, 50 F), running athletes (runners, soccer, track athletes) Unilateral chronic MTSS ≥6 months, failed 3 forms of traditional conservative treatment for ≥3 months, corticosteroid or local anesthetic injection Compartment syndrome, rheumatoid arthritis, polyarthritis, infection, pregnancy tumors, <18 years old, end-stage ipsilateral knee osteoarthritis, bleeding disorders, knee or ankle surgery Control group (47 subjects): relative rest, ice, home training program ×2/day × 12 weeks. ESWT + exercise (47 subjects): R-SWT (Swiss DolorClast) ×3 sessions at weeks 2, 3, 4 after initiation of 12-week home exercise program, 2,000 pulses, EFD 0.1 mJ/mm2, without local anesthesia. Posttreatment: immediate weight-bearing, unrestricted range of motion, no adjuvant therapy for 4 months, pain meds available upon request, ≥6 weeks before initiation of gradual return to sport, stationary cycling immediately, easy running at >1 week 1, 4, 15 months Based on Likert scale, neither group had worsening symptoms at 1, 4, 15 months. Greater percentage of ESWT patients with Likert scale ratings of 1 or 2 compared to control. At 1, 4, 15 months, greater decrease in NRS in ESWT group. At 15 months, 85% ESWT subjects and 49% control subjects returned to level of sport pre-injury Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE III. Detailed Summary of Key Literature Related to the Use of ESWT in Medial Tibial Stress Syndrome Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Medial Tibial Stress Syndrome (MTSS) Newman et al. 2018 RCT 28 subjects (10 M, 18 F), runners with average 9-year running history Pain at distal half posteromedial tibia associated with running lasting for hours-days post-run for ≥21 days, no paresthesias Prior ESWT treatment, another lower extremity injury Sham group (14 subjects): ×5 sessions, 1,000 pulses EFD 0.01 mJ/mm2 week 1, 1,500 impulses ×4 weeks 2, 3, 5, 9. ESWT (14 subjects): F-SWT (Duolith SD1) ×5 sessions, 1,000 pulses EFD 0.1 mJ/mm2 week 1, 1,500 pulses with EVD 0.15 mJ/mm2 week 2, 1,500 pulses with EVD 0.2 mJ/mm2 week 3, 1,500 pulses with EVD 0.25 mJ/mm2 week 5, 1,500 pulses with EVD 0.3 mJ/mm2 week 9. 1 week post-final ESWT treatment (week 10) Sham group with less pain on NRS during bone pressure versus ESWT group. No difference in pain during muscle pressure or running. No difference in pain-limited running distance or self-perception of change per GROC. Sham dose may have had clinical effect Gomez et al. 2017 RCT 42 subjects (33 M, 9 F), military cadets >18 years old, MTSS per Yates and White criteria, pain ≥3 weeks, pain with exercise, unilateral MTSS, X-ray to rule out fracture Current or history of stress fracture, infection, cancer, compartment syndrome, surgery on injured leg, prior ESWT for MTSS, rheumatic disease, coagulopathy, pregnancy Exercise only (29 subjects): 40 minutes exercise 5 days/week ×4 weeks under physiotherapist guidance, cryotherapy post-exercise ×10 minutes. ESWT + exercise (23 subjects): R-SWT (Duolith SD1) ×1 session, 1,500 pulses, EFD 0.20 mJ/mm2, without anesthesia, same exercise regimen as exercise only group with exception of no cryotherapy. Posttreatment: rest, analgesics PRN for 24–48 hours 4 weeks ESWT group with greater improvement in VAS scores compared to control. ESWT group able to run longer than control. Lower VAS scores post-running in ESWT group. Per R&M score, 82.6% ESWT with excellent or good results compared to 36.8% in control Moen et al. 2012 Prospective observational controlled control 42 subjects (23 M, 19 F), athletes (recreational running, soccer, field hockey, tennis, basketball, dancing) Pain along posteromedial border of tibia over ≥5 cm area, symptoms ≥21 days, pain exacerbated by exercise, no history of paresthesias History of tibial fracture, prior ESWT treatment Running program (20 subjects): graded running program ×3/week and could not run on consecutive days. ESWT + running program (22 subjects): F-SWT (Duolith SD1) ×5 sessions over 9 weeks, 1,000–1,500 pulses, EFD 0.1–0.3 mJ/mm2, without local anesthesia. Posttreatment: no restrictions, running program started same week as ESWT No follow-up Time to full recovery (able to run 18 minutes consecutively without pain) was 59.7 days in ESWT/running program group versus 91.6 days in running only group Rompe et al. 2010 Retrospective case control 94 subjects (40 M, 50 F), running athletes (runners, soccer, track athletes) Unilateral chronic MTSS ≥6 months, failed 3 forms of traditional conservative treatment for ≥3 months, corticosteroid or local anesthetic injection Compartment syndrome, rheumatoid arthritis, polyarthritis, infection, pregnancy tumors, <18 years old, end-stage ipsilateral knee osteoarthritis, bleeding disorders, knee or ankle surgery Control group (47 subjects): relative rest, ice, home training program ×2/day × 12 weeks. ESWT + exercise (47 subjects): R-SWT (Swiss DolorClast) ×3 sessions at weeks 2, 3, 4 after initiation of 12-week home exercise program, 2,000 pulses, EFD 0.1 mJ/mm2, without local anesthesia. Posttreatment: immediate weight-bearing, unrestricted range of motion, no adjuvant therapy for 4 months, pain meds available upon request, ≥6 weeks before initiation of gradual return to sport, stationary cycling immediately, easy running at >1 week 1, 4, 15 months Based on Likert scale, neither group had worsening symptoms at 1, 4, 15 months. Greater percentage of ESWT patients with Likert scale ratings of 1 or 2 compared to control. At 1, 4, 15 months, greater decrease in NRS in ESWT group. At 15 months, 85% ESWT subjects and 49% control subjects returned to level of sport pre-injury Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Medial Tibial Stress Syndrome (MTSS) Newman et al. 2018 RCT 28 subjects (10 M, 18 F), runners with average 9-year running history Pain at distal half posteromedial tibia associated with running lasting for hours-days post-run for ≥21 days, no paresthesias Prior ESWT treatment, another lower extremity injury Sham group (14 subjects): ×5 sessions, 1,000 pulses EFD 0.01 mJ/mm2 week 1, 1,500 impulses ×4 weeks 2, 3, 5, 9. ESWT (14 subjects): F-SWT (Duolith SD1) ×5 sessions, 1,000 pulses EFD 0.1 mJ/mm2 week 1, 1,500 pulses with EVD 0.15 mJ/mm2 week 2, 1,500 pulses with EVD 0.2 mJ/mm2 week 3, 1,500 pulses with EVD 0.25 mJ/mm2 week 5, 1,500 pulses with EVD 0.3 mJ/mm2 week 9. 1 week post-final ESWT treatment (week 10) Sham group with less pain on NRS during bone pressure versus ESWT group. No difference in pain during muscle pressure or running. No difference in pain-limited running distance or self-perception of change per GROC. Sham dose may have had clinical effect Gomez et al. 2017 RCT 42 subjects (33 M, 9 F), military cadets >18 years old, MTSS per Yates and White criteria, pain ≥3 weeks, pain with exercise, unilateral MTSS, X-ray to rule out fracture Current or history of stress fracture, infection, cancer, compartment syndrome, surgery on injured leg, prior ESWT for MTSS, rheumatic disease, coagulopathy, pregnancy Exercise only (29 subjects): 40 minutes exercise 5 days/week ×4 weeks under physiotherapist guidance, cryotherapy post-exercise ×10 minutes. ESWT + exercise (23 subjects): R-SWT (Duolith SD1) ×1 session, 1,500 pulses, EFD 0.20 mJ/mm2, without anesthesia, same exercise regimen as exercise only group with exception of no cryotherapy. Posttreatment: rest, analgesics PRN for 24–48 hours 4 weeks ESWT group with greater improvement in VAS scores compared to control. ESWT group able to run longer than control. Lower VAS scores post-running in ESWT group. Per R&M score, 82.6% ESWT with excellent or good results compared to 36.8% in control Moen et al. 2012 Prospective observational controlled control 42 subjects (23 M, 19 F), athletes (recreational running, soccer, field hockey, tennis, basketball, dancing) Pain along posteromedial border of tibia over ≥5 cm area, symptoms ≥21 days, pain exacerbated by exercise, no history of paresthesias History of tibial fracture, prior ESWT treatment Running program (20 subjects): graded running program ×3/week and could not run on consecutive days. ESWT + running program (22 subjects): F-SWT (Duolith SD1) ×5 sessions over 9 weeks, 1,000–1,500 pulses, EFD 0.1–0.3 mJ/mm2, without local anesthesia. Posttreatment: no restrictions, running program started same week as ESWT No follow-up Time to full recovery (able to run 18 minutes consecutively without pain) was 59.7 days in ESWT/running program group versus 91.6 days in running only group Rompe et al. 2010 Retrospective case control 94 subjects (40 M, 50 F), running athletes (runners, soccer, track athletes) Unilateral chronic MTSS ≥6 months, failed 3 forms of traditional conservative treatment for ≥3 months, corticosteroid or local anesthetic injection Compartment syndrome, rheumatoid arthritis, polyarthritis, infection, pregnancy tumors, <18 years old, end-stage ipsilateral knee osteoarthritis, bleeding disorders, knee or ankle surgery Control group (47 subjects): relative rest, ice, home training program ×2/day × 12 weeks. ESWT + exercise (47 subjects): R-SWT (Swiss DolorClast) ×3 sessions at weeks 2, 3, 4 after initiation of 12-week home exercise program, 2,000 pulses, EFD 0.1 mJ/mm2, without local anesthesia. Posttreatment: immediate weight-bearing, unrestricted range of motion, no adjuvant therapy for 4 months, pain meds available upon request, ≥6 weeks before initiation of gradual return to sport, stationary cycling immediately, easy running at >1 week 1, 4, 15 months Based on Likert scale, neither group had worsening symptoms at 1, 4, 15 months. Greater percentage of ESWT patients with Likert scale ratings of 1 or 2 compared to control. At 1, 4, 15 months, greater decrease in NRS in ESWT group. At 15 months, 85% ESWT subjects and 49% control subjects returned to level of sport pre-injury Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE IV. Detailed Summary of Key Literature Related to the Use of ESWT in Patellar Tendinopathy Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Patellar tendinopathy Cheng et al. 2019 RCT 51 subjects (25 M, 26 F), unknown activity level Peritendinous pain at patellar tendon, pain with knee extension against resistance, negative patella grind test, could not participate in competitions Other knee or muscular injuires, history of knee surgery Physical treatments including acupuncture, ultrasound, or microwave therapy (25 subjects): ×1 session/week × 16 weeks. ESWT (26 subjects): R-SWT (DolorClast) ×1 session/week ×16 weeks, 2,000 pulses, EFD not specified. Posttreatment: ice ×10 minutes Upon completion of treatment Reduction in VAS scores in 69.4% ESWT group, 16.9% control. Knee joint peak torques at 60 degrees/s and 240 degrees/s increased by 17.2% in ESWT group compared to 7.2% in control Thijs et al. 2017 RCT 52 subjects (38 M, 14 F), active (sports at least 1×/week) Knee pain at patellar tendon or insertion point, most painful knee included in cases with bilateral pathology, symptoms >8 weeks, baseline VISA-P score <80, 18–40 years old Acute knee or patellar injury, Rheumatoid arthritis, co-existing knee pathology, immunosuppressed, oral corticosteroids ≤6 months or corticosteroid injection ≤1 month, ACL or patellar tendon reconstructive surgery, pregnancy, tumor, coagulopathy, prior ESWT ESWT + eccentric training (22 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.2 mJ/mm2. Sham ESWT + eccentric training (30 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.03 mJ/mm2, no gel between applicator and focusing pad to reduce transmission 6, 12, 24 weeks No significant differences in VISA-P, NRS, and Likert scores between the two groups Vetrano et al. 2013 RCT 46 subjects (37 M, 9 F), elite and nonelite athletes Unilateral proximal patellar tendon confirmed by ultrasound, symptoms ≥6 months, failure of conservative management, washout period of 12 weeks, ages 18–50 years old Bilateral tendinopathy, co-existing knee injuries, knee surgery or corticosteroid injection ≤ 3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infections, cardiovascular disease, immunosuppressed, cancer, platelets <150 K, pregnancy PRP injections (23 subjects): Average platelet concentration 0.89–1.1 × 109 cc. 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Posttreatment: rest for 15 minutes, moderate compression bandage that could be removed <24 hours, permitted to perform full-weight-bearing immediately, tylenol, restricted NSAIDs. ESWT (23 subjects): F-SWT (Modulith SLK, STORZ Medical) under ultrasound guidance ×3 sessions at 48- to 72-hour intervals, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Posttreatment for both groups: after 1 week, standard stretching and muscle strengthening protocol ×2 weeks followed by return to water activities pending pain, gradual return to play at 4 weeks 2, 6, 12 months VISA-P and VAS scores improved at 2, 6, 12 months in both groups, with greater improvement in PRP group at 6 and 12 months. 91.3% endorsed satisfactory with PRP compared to 60.8% with ESWT Zwerver et al. 2011 RCT 62 subjects (41 M, 21 F), elite and non-elite athletes (volleyball, handball, basketball) Pain at patellar tendon or patellar insertion, symptoms for 3–12 months, 18–35 years old, VISA-P score <80 Acute knee injuries, coexisting knee pathology, long-term NSAIDs, fluroquinolones, knee surgery, history of corticosteroid injection <3 months ago, pregnancy, tumor, coagulopathy, anticoagulation Sham ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, EFD <0.03 mJ/mm2, no transmission gel between applicator and focusing pad. ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.1–0.58 mJ/mm2. Posttreatment for both groups: no local anesthesia for either group, no restrictions in terms of return to sport or adjuvant medical treatment, tylenol allowed 1, 12, 22 weeks No significant difference between VISA-P and VAS scores at 1, 12, 22 weeks. At 1 week, significantly more subjects in ESWT reported subjective improvement Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Patellar tendinopathy Cheng et al. 2019 RCT 51 subjects (25 M, 26 F), unknown activity level Peritendinous pain at patellar tendon, pain with knee extension against resistance, negative patella grind test, could not participate in competitions Other knee or muscular injuires, history of knee surgery Physical treatments including acupuncture, ultrasound, or microwave therapy (25 subjects): ×1 session/week × 16 weeks. ESWT (26 subjects): R-SWT (DolorClast) ×1 session/week ×16 weeks, 2,000 pulses, EFD not specified. Posttreatment: ice ×10 minutes Upon completion of treatment Reduction in VAS scores in 69.4% ESWT group, 16.9% control. Knee joint peak torques at 60 degrees/s and 240 degrees/s increased by 17.2% in ESWT group compared to 7.2% in control Thijs et al. 2017 RCT 52 subjects (38 M, 14 F), active (sports at least 1×/week) Knee pain at patellar tendon or insertion point, most painful knee included in cases with bilateral pathology, symptoms >8 weeks, baseline VISA-P score <80, 18–40 years old Acute knee or patellar injury, Rheumatoid arthritis, co-existing knee pathology, immunosuppressed, oral corticosteroids ≤6 months or corticosteroid injection ≤1 month, ACL or patellar tendon reconstructive surgery, pregnancy, tumor, coagulopathy, prior ESWT ESWT + eccentric training (22 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.2 mJ/mm2. Sham ESWT + eccentric training (30 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.03 mJ/mm2, no gel between applicator and focusing pad to reduce transmission 6, 12, 24 weeks No significant differences in VISA-P, NRS, and Likert scores between the two groups Vetrano et al. 2013 RCT 46 subjects (37 M, 9 F), elite and nonelite athletes Unilateral proximal patellar tendon confirmed by ultrasound, symptoms ≥6 months, failure of conservative management, washout period of 12 weeks, ages 18–50 years old Bilateral tendinopathy, co-existing knee injuries, knee surgery or corticosteroid injection ≤ 3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infections, cardiovascular disease, immunosuppressed, cancer, platelets <150 K, pregnancy PRP injections (23 subjects): Average platelet concentration 0.89–1.1 × 109 cc. 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Posttreatment: rest for 15 minutes, moderate compression bandage that could be removed <24 hours, permitted to perform full-weight-bearing immediately, tylenol, restricted NSAIDs. ESWT (23 subjects): F-SWT (Modulith SLK, STORZ Medical) under ultrasound guidance ×3 sessions at 48- to 72-hour intervals, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Posttreatment for both groups: after 1 week, standard stretching and muscle strengthening protocol ×2 weeks followed by return to water activities pending pain, gradual return to play at 4 weeks 2, 6, 12 months VISA-P and VAS scores improved at 2, 6, 12 months in both groups, with greater improvement in PRP group at 6 and 12 months. 91.3% endorsed satisfactory with PRP compared to 60.8% with ESWT Zwerver et al. 2011 RCT 62 subjects (41 M, 21 F), elite and non-elite athletes (volleyball, handball, basketball) Pain at patellar tendon or patellar insertion, symptoms for 3–12 months, 18–35 years old, VISA-P score <80 Acute knee injuries, coexisting knee pathology, long-term NSAIDs, fluroquinolones, knee surgery, history of corticosteroid injection <3 months ago, pregnancy, tumor, coagulopathy, anticoagulation Sham ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, EFD <0.03 mJ/mm2, no transmission gel between applicator and focusing pad. ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.1–0.58 mJ/mm2. Posttreatment for both groups: no local anesthesia for either group, no restrictions in terms of return to sport or adjuvant medical treatment, tylenol allowed 1, 12, 22 weeks No significant difference between VISA-P and VAS scores at 1, 12, 22 weeks. At 1 week, significantly more subjects in ESWT reported subjective improvement Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab TABLE IV. Detailed Summary of Key Literature Related to the Use of ESWT in Patellar Tendinopathy Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Patellar tendinopathy Cheng et al. 2019 RCT 51 subjects (25 M, 26 F), unknown activity level Peritendinous pain at patellar tendon, pain with knee extension against resistance, negative patella grind test, could not participate in competitions Other knee or muscular injuires, history of knee surgery Physical treatments including acupuncture, ultrasound, or microwave therapy (25 subjects): ×1 session/week × 16 weeks. ESWT (26 subjects): R-SWT (DolorClast) ×1 session/week ×16 weeks, 2,000 pulses, EFD not specified. Posttreatment: ice ×10 minutes Upon completion of treatment Reduction in VAS scores in 69.4% ESWT group, 16.9% control. Knee joint peak torques at 60 degrees/s and 240 degrees/s increased by 17.2% in ESWT group compared to 7.2% in control Thijs et al. 2017 RCT 52 subjects (38 M, 14 F), active (sports at least 1×/week) Knee pain at patellar tendon or insertion point, most painful knee included in cases with bilateral pathology, symptoms >8 weeks, baseline VISA-P score <80, 18–40 years old Acute knee or patellar injury, Rheumatoid arthritis, co-existing knee pathology, immunosuppressed, oral corticosteroids ≤6 months or corticosteroid injection ≤1 month, ACL or patellar tendon reconstructive surgery, pregnancy, tumor, coagulopathy, prior ESWT ESWT + eccentric training (22 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.2 mJ/mm2. Sham ESWT + eccentric training (30 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.03 mJ/mm2, no gel between applicator and focusing pad to reduce transmission 6, 12, 24 weeks No significant differences in VISA-P, NRS, and Likert scores between the two groups Vetrano et al. 2013 RCT 46 subjects (37 M, 9 F), elite and nonelite athletes Unilateral proximal patellar tendon confirmed by ultrasound, symptoms ≥6 months, failure of conservative management, washout period of 12 weeks, ages 18–50 years old Bilateral tendinopathy, co-existing knee injuries, knee surgery or corticosteroid injection ≤ 3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infections, cardiovascular disease, immunosuppressed, cancer, platelets <150 K, pregnancy PRP injections (23 subjects): Average platelet concentration 0.89–1.1 × 109 cc. 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Posttreatment: rest for 15 minutes, moderate compression bandage that could be removed <24 hours, permitted to perform full-weight-bearing immediately, tylenol, restricted NSAIDs. ESWT (23 subjects): F-SWT (Modulith SLK, STORZ Medical) under ultrasound guidance ×3 sessions at 48- to 72-hour intervals, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Posttreatment for both groups: after 1 week, standard stretching and muscle strengthening protocol ×2 weeks followed by return to water activities pending pain, gradual return to play at 4 weeks 2, 6, 12 months VISA-P and VAS scores improved at 2, 6, 12 months in both groups, with greater improvement in PRP group at 6 and 12 months. 91.3% endorsed satisfactory with PRP compared to 60.8% with ESWT Zwerver et al. 2011 RCT 62 subjects (41 M, 21 F), elite and non-elite athletes (volleyball, handball, basketball) Pain at patellar tendon or patellar insertion, symptoms for 3–12 months, 18–35 years old, VISA-P score <80 Acute knee injuries, coexisting knee pathology, long-term NSAIDs, fluroquinolones, knee surgery, history of corticosteroid injection <3 months ago, pregnancy, tumor, coagulopathy, anticoagulation Sham ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, EFD <0.03 mJ/mm2, no transmission gel between applicator and focusing pad. ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.1–0.58 mJ/mm2. Posttreatment for both groups: no local anesthesia for either group, no restrictions in terms of return to sport or adjuvant medical treatment, tylenol allowed 1, 12, 22 weeks No significant difference between VISA-P and VAS scores at 1, 12, 22 weeks. At 1 week, significantly more subjects in ESWT reported subjective improvement Diagnosis . Author . Year . Study design . Subject population . Inclusion criteria . Exclusion criteria . Treatment . Follow-up . Results . Patellar tendinopathy Cheng et al. 2019 RCT 51 subjects (25 M, 26 F), unknown activity level Peritendinous pain at patellar tendon, pain with knee extension against resistance, negative patella grind test, could not participate in competitions Other knee or muscular injuires, history of knee surgery Physical treatments including acupuncture, ultrasound, or microwave therapy (25 subjects): ×1 session/week × 16 weeks. ESWT (26 subjects): R-SWT (DolorClast) ×1 session/week ×16 weeks, 2,000 pulses, EFD not specified. Posttreatment: ice ×10 minutes Upon completion of treatment Reduction in VAS scores in 69.4% ESWT group, 16.9% control. Knee joint peak torques at 60 degrees/s and 240 degrees/s increased by 17.2% in ESWT group compared to 7.2% in control Thijs et al. 2017 RCT 52 subjects (38 M, 14 F), active (sports at least 1×/week) Knee pain at patellar tendon or insertion point, most painful knee included in cases with bilateral pathology, symptoms >8 weeks, baseline VISA-P score <80, 18–40 years old Acute knee or patellar injury, Rheumatoid arthritis, co-existing knee pathology, immunosuppressed, oral corticosteroids ≤6 months or corticosteroid injection ≤1 month, ACL or patellar tendon reconstructive surgery, pregnancy, tumor, coagulopathy, prior ESWT ESWT + eccentric training (22 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.2 mJ/mm2. Sham ESWT + eccentric training (30 subjects): F-SWT (Swiss PiezoClast) ×1 session/week ×3 weeks, 1,000 pulses, EFD 0.03 mJ/mm2, no gel between applicator and focusing pad to reduce transmission 6, 12, 24 weeks No significant differences in VISA-P, NRS, and Likert scores between the two groups Vetrano et al. 2013 RCT 46 subjects (37 M, 9 F), elite and nonelite athletes Unilateral proximal patellar tendon confirmed by ultrasound, symptoms ≥6 months, failure of conservative management, washout period of 12 weeks, ages 18–50 years old Bilateral tendinopathy, co-existing knee injuries, knee surgery or corticosteroid injection ≤ 3 months ago, diabetes, rheumatoid arthritis, coagulopathies, infections, cardiovascular disease, immunosuppressed, cancer, platelets <150 K, pregnancy PRP injections (23 subjects): Average platelet concentration 0.89–1.1 × 109 cc. 1 injection/week ×2 under ultrasound guidance by the same clinician without local anesthesia. Posttreatment: rest for 15 minutes, moderate compression bandage that could be removed <24 hours, permitted to perform full-weight-bearing immediately, tylenol, restricted NSAIDs. ESWT (23 subjects): F-SWT (Modulith SLK, STORZ Medical) under ultrasound guidance ×3 sessions at 48- to 72-hour intervals, 2,400 pulses, EFD 0.17–0.25 mJ/mm2, without local anesthesia. Posttreatment for both groups: after 1 week, standard stretching and muscle strengthening protocol ×2 weeks followed by return to water activities pending pain, gradual return to play at 4 weeks 2, 6, 12 months VISA-P and VAS scores improved at 2, 6, 12 months in both groups, with greater improvement in PRP group at 6 and 12 months. 91.3% endorsed satisfactory with PRP compared to 60.8% with ESWT Zwerver et al. 2011 RCT 62 subjects (41 M, 21 F), elite and non-elite athletes (volleyball, handball, basketball) Pain at patellar tendon or patellar insertion, symptoms for 3–12 months, 18–35 years old, VISA-P score <80 Acute knee injuries, coexisting knee pathology, long-term NSAIDs, fluroquinolones, knee surgery, history of corticosteroid injection <3 months ago, pregnancy, tumor, coagulopathy, anticoagulation Sham ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, EFD <0.03 mJ/mm2, no transmission gel between applicator and focusing pad. ESWT (31 subjects): F-SWT (Piezowave) ×1 session/week ×3 weeks, 2,000 pulses, EFD 0.1–0.58 mJ/mm2. Posttreatment for both groups: no local anesthesia for either group, no restrictions in terms of return to sport or adjuvant medical treatment, tylenol allowed 1, 12, 22 weeks No significant difference between VISA-P and VAS scores at 1, 12, 22 weeks. At 1 week, significantly more subjects in ESWT reported subjective improvement Abbreviations: EFD: energy flux density, ESWT: extracorporeal shockwave therapy, F: female, F-SWT: focused shockwave therapy, GROC: global rating of change, HHS: Harris Hip Score, M: male, LPS: Laitinen Pain Scale, NRS: Numerical Rating Scale, OST: Original Schober Test, PPT: pressure pain threshold, RMBB: radiofrequency medial branch block, R&M: Roles and Maudsley Score, QBS: Quebec Back Pain Disability Scale Scores, RMQ: Roland–Morris Questionnaire, R-SWT: radial shockwave therapy, SF-36: Short Form-36, VISA-A: Victorian Institute of Sports Assessment-Achilles, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. FAAM: Foot and Ankle Ability Measure, EPF: endoscopic plantar fasciotomy, PRP: platelet-rich plasma, RCT: randomized clinical trial, MTSS: medial tibial stress syndrome Open in new tab Plantar Fasciitis One retrospective study evaluated the use of ESWT for PF in a military population. Four primary articles were identified in athletes, including one RCT and three prospective studies. Purcell et al. performed a retrospective, unblinded study evaluating 56 active duty military patients and 20 non-active duty patients with chronic PF.48 A majority of patients received one session of ESWT with conscious sedation, and one patient required two sessions. The patients were restricted from strenuous exercise for 4 weeks posttreatment and counseled against using ice or non-steroidal anti-inflammatory drugs (NSAIDs) for 6 weeks. Patients reported on average 68% reduction in pain on the numeric rating scale (NRS), and 74% of the cohort reported outcomes of “good” or “excellent” on the Roles and Maudsley scale (R&M). When groups were stratified based on active status, non-active duty achieved significantly greater mean improvement in pain compared to active duty. Seventy-six percent of patients returned to running, although 18% of patients left the military because of ongoing foot pain. Notably, the study was limited because of loss of follow-up and lack of a true control. Moretti et al. conducted a prospective cohort study evaluating the effects of 4-weekly F-SWT sessions in runners with insertional PF and radiographically evident heel spur.49 Visual Analog Scale (VAS) scores significantly improved, and 61% of patients showed complete disappearance of inflammatory signs under ultrasound at 2 years of follow-up. Visual Analog Scale reduction correlated with inflammatory resolution and reduced tissue thickness on ultrasound (r = 0.30). Saxena et al. reported on treatment of PF in 28 patients comparing treatment in early (symptoms <3 months) and chronic (>6 months) case. Each patient received 3-weekly R-SWT sessions.50 Visual Analog Scale and R&M scores at 3 and 12 months were significantly improved for both groups. At 1 year, all participants in the early group returned to desired activity, whereas 36% of the control group did not, suggesting potential benefit of earlier intervention with ESWT in management of PF. Saxena et al. prospectively compared shockwave to endoscopic surgery for treatment of chronic PF (>6 months) in athletes. Treatment groups consisted of elected surgical endoscopic plantar fasciotomy (EPF) (n = 12) or choice of nonoperative treatment including randomization to F-SWT (n = 11) or sham F-SWT (n = 14).51 Participants in the F-SWT group received 3-weekly sessions, and sham ESWT was provided using shockwave-blocking head. Endoscopic plantar fasciotomy demonstrated greatest improvement of VAS pain scores and R&M scores than sham and F-SWT. Both sham and F-SWT improved function over time without significant group differences. Notably, the shockwave participants continued sports participation during treatment, while the EPF group did not return to sport for nearly 3 months. Mitchkash et al. evaluated responses to R-SWT across runners including 17 with PF.52 Within runners with PF, 71% and 65% met clinical improvement in sports subscale and activities of daily living using the Foot and Ankle Activity Measure (FAAM) receiving on average 4-weekly treatments. Such studies show the potential role for F-SWT and R-SWT in PF in the military as demonstrated by improvement in the various functional outcomes. Achilles Tendinopathy We did not identify any studies that evaluated ESWT for AT in the military. A total of seven studies evaluated physically active groups, one RCT, two prospective cohorts, and four retrospective cohorts. Erroi et al. retrospectively compared effects of F-SWT to PRP in physically active patients at 2, 4, and 6 months posttreatment.53 Participants in the F-SWT group (n = 24) received 3-weekly sessions, and those in the PRP group (n = 21) underwent 2-weekly injections under color Doppler guidance without local anesthesia. Visual Analog Scale, Victoria Institute of Sports Assessment-Achilles (VISA-A), and R&M scores were improved at every time point in both groups, and there was no difference between groups, except at 4-month follow-up. The F-SWT group demonstrated superior VISA-A results. Both groups demonstrated significant improvement in pain and patient satisfaction. Both study arms were given the same posttreatment eccentric exercises and at 4 weeks posttreatment could gradually return to training. Vulpiani et al. reported prospective cohort study results that evaluated the effect of F-SWT in 105 athletes with insertional or noninsertional AT.54 Focused SWT was performed three to five treatments separated by 2- to 7-day intervals. Visual Analog Scale scores significantly improved from baseline of 7.49 to 4.75 at short term (2 months), 2.88 at medium term (6–12 months), and 2.6 at long term (13–24 months). Results were better in noninsertional cases; however, energy flux density (EFD) also differed based on location of tendinopathy making interpretation difficult. The case series by Mitchkash et al. included 27 runners who received R-SWT. Most runners (10 of 11 insertional and 13 of 16 noninsertional) met clinical improvement measures using VISA-A.52 Other studies using mix of athletes and non-athlete populations revealed favorable outcomes of ESWT for management of AT. Zhang et al. reported on long-term outcomes at 5 years post R-SWT,55 within a retrospective cohort using VAS and VISA-A scores in both sports-active group of joggers (n = 16) and nonsports-active group (n = 17). All participants received 5-weekly sessions of R-SWT. Sports-active participants reported a superior response in VAS and VISA-A scores than nonsports-active participants at the conclusion of the study. Ultrasonographic evaluation of calcifications pre- and post-intervention did not significantly change in either group. Earlier, Rompe et al. published an RCT evaluating the effects of 3-weekly sessions of R-SWT combined with eccentric loading exercises compared to eccentric loading exercises as monotherapy.56 Combined treatment group had significantly better VISA-A scores at 4-month follow-up. Further, 82% in the combined group compared to 56% of patients in control group reported being completely recovered or much improved. Although eccentric loading alone can augment the tissue healing response,57,58 superior results in the combination group may reflect additional regenerative effects induced by ESWT. Furia et al. conducted two retrospective case–control studies in 200659 and 200860 evaluating a single session of F-SWT for chronic insertional and noninsertional AT compared to control groups, respectively. In the 2006 study, mean VAS scores demonstrated a significant reduction in the F-SWT group, improving across time points, whereas the control group was unchanged from baseline. Notably, a subset of patients in the F-SWT group received local anesthesia and achieved less pain reduction than those without anesthesia. In noninsertional AT, F-SWT was superior to control group for mean VAS scores and R&M scores of excellent or good were reported in 85% of F-SWT group and 27% of control group. The abovementioned studies demonstrate the benefit of ESWT on functional outcomes in management of AT in the active population. Medial Tibial Stress Syndrome One report was identified in the military that evaluated ESWT for treatment of MTSS. Gomez et al. conducted an RCT11 in a military population with symptoms >3 weeks evaluating a single session of F-SWT combined with an exercise program compared to exercise program alone. Participants in the F-SWT group reported superior pain reduction and satisfaction with treatment. At 4 weeks, pain-free running time was longer in the F-SWT group (17 minutes compared to <5 minutes). Three studies in athlete populations were identified including one RCT, one prospective cohort, and one retrospective case–control study. Newman et al. evaluated treatment of MTSS in 28 runners randomized to equal groups of five sessions of F-SWT or sham ESWT. No differences were observed in NRS pain scores, global rating of change questionnaire, and functional limitation during running. Focused SWT treatment consisted of a progressively increasing EFD over 9 weeks. Notably, sham F-SWT EFD was non-zero (70 mJ/mm2), which cannot completely exclude physiological effects contributing to improvement from this low energy. Moen et al. prospectively compared an exercise running program to F-SWT plus exercise program.61 Participants in the F-SWT group received five treatment sessions over 9 weeks, with graded increase of total EFD. Time to recovery was significantly faster in the F-SWT group. Rompe et al. found significantly better Likert scale and NRS pain scores at 4- and 15-month follow-up in participants who received R-SWT plus a standardized home training program compared to home training alone.62 In addition, 85% of R-SWT participants returned to sport at preinjury level compared to 47% of participants in exercise alone. Participants in the R-SWT group underwent 3-weekly sessions. Of note, participants in the shockwave group paid out of pocket for treatment, which may have been a factor influencing outcome given the selection bias and financial incentive.63 The abovementioned studies demonstrated functional improvement after application of ESWT, with utilization of F-SWT except for one study that applied R-SWT. Patellar Tendinopathy No studies were identified that evaluate ESWT effects on PT in military personnel. Four articles were identified evaluating outcomes in athletes. Cheng et al.64 reported results from a 2019 RCT that identified athletes who received R-SWT had significantly improved VAS scores, extension peak torque, and extensor endurance compared to controls. The R-SWT group received once-weekly treatments for 16 weeks, while the control group underwent the same frequency of acupuncture, ultrasonic wave therapy, and microwave therapy. Mean VAS scores were superior in the R-SWT group compared to control at 16 weeks. Muscle strength, represented by knee joint 60°/s and 240°/s extension peak torque values, significantly improved in the R-SWT group over control by 17.2% and 7.3%, respectively. Extensor endurance increased by 17.4% in R-SWT without change in flexion peak torque values between groups. Thijs et al. performed an RCT65 that compared results from 3-weekly sessions of F-SWT combined with eccentric exercises compared to sham F-SWT and eccentric exercises. Focused SWT sessions and sham demonstrated improvement in Victorian Institute of Sport Assessment-Patella (VISA-P) scores over time with no between-group differences. NRS scores and Likert scores also improved and were not significantly different between groups. This study was limited by non-zero EFD in sham condition, which could have physiological effects. Further, loss to follow-up (31.8% of F-SWT participants and 13.3% of sham group) may have confounded results. Vetrano et al. compared 3-weekly F-SWT sessions to 2-weekly autologous PRP injections.66 At 2-month follow-up, VISA-P, VAS, and modified Blazine scale scores demonstrated no difference between groups. At mid and long-term follow-up, PRP showed superior results compared to F-SWT group in VISA-P and VAS. At 12 months, 91.3% of PRP group reported satisfactory results compared to 60.8% of F-SWT group. Zwerver et al.’s RCT reported no significant difference in VISA-P or VAS pain scores between F-SWT versus sham ESWT groups.67 Focused SWT group received 3-weekly sessions of F-SWT. Sham ESWT participants received the same treatment without transmission gel and EFD did not exceed 0.03 mJ/mm2. Neither group were given sport participation restrictions. The EFD in this study varied within the F-SWT group, and some athletes received up to 0.58 mJ/mm2. Animal studies have shown that high-energy shockwave (exceeding 0.28 mJ/mm2) may result in detrimental histologic changes.68,69 The high-energy levels may have contributed to less therapeutic results. The results of ESWT show mixed results in management of PT. However, study protocols modifying load and incorporating eccentric exercises appear to have a more robust response. The limited studies comparing ESWT to PRP suggest comparable effects of both treatments in the shorter-term outcomes but potential higher gain from PRP seen in longer-term outcomes. Knee Osteoarthritis and Bone Marrow Edema Specific studies in the military and athlete population were not identified in the literature evaluating ESWT in management of bone marrow edema or knee osteoarthritis. Kang et al. performed a retrospective evaluation in two cohorts of patients with mild-to-moderate knee osteoarthritis and associated bone marrow lesions seen on MRI. One cohort received F-SWT (n = 82), and a second cohort received alendronate (n = 44).70 Patients in the F-SWT group received 2-weekly treatments (3,000–4,000 pulses/session, EFD of >0.44 mJ/mm2), while patients in the alendronate group received 70 mg weekly. Both groups received intravenous alprostadil daily for 2 weeks. The F-SWT cohort had a rapid, greater improvement in VAS and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores. At 6 months, 95.1% and 79.5% of patients had measured improvement in MRI bone marrow lesions in the F-SWT and alendronate cohorts, respectively. One patient in the F-SWT group developed recurrence of pain and was found to have bone marrow edema in a different region, resolved at final follow-up. Gao et al.91 conducted an RCT (2015) that examined outcomes of F-SWT (n = 20) versus IV prostacyclin and alendronate weekly (n = 20) for the treatment of bone marrow edema. The F-SWT group received 2-weekly sessions. All participants were placed on partial weight-bearing and walking aids. Although both groups demonstrated significant improvement in VAS, WOMAC, and Short Form-36, the F-SWT group progressed more rapidly and dramatically. MRI results at 6-month follow-up revealed complete regression in 65% of the F-SWT participants and 25% of the pharmacological participants. At 1 year, both groups showed complete regression on MRI in almost all patients. Two recent systematic reviews and meta-analyses71,72 for the treatment of bone marrow edema demonstrated that ESWT significantly reduced pain and improved WOMAC scores for at least 12 months compared to control groups.70,73–84 Both studies evaluating management of bone marrow lesions suggest the potential advantage that F-SWT may have over alendronate with or without prostacyclin on functional outcomes and disease regression detected on imaging. Adverse Effects of ESWT Side effects of ESWT in management of musculoskeletal conditions are typically minor and self-limited. One patient experienced a plantar fascia rupture following treatment while running upstairs; the injury appeared to be self-limited as she returned to running after 6 weeks.50 Achilles tendon rupture was reported in a study that did not meet our search criteria: two women aged 63 and 65 years suffered rupture within 2 weeks of using F-SWT.85 Most commonly, adverse effects were limited to minor bruising, temporary pain, transient erythema, and soft tissue swelling. A recent systematic review evaluating the safety of F-SWT and R-SWT in management of musculoskeletal conditions concluded that treatment is safe with minimal serious adverse events.86 DISCUSSION The purpose of this narrative review is to evaluate the efficacy of ESWT in the treatment of lower extremity musculoskeletal injuries in the military. Our review identified two studies11,48 specific to treatment of military personnel in management of PF and MTSS. Both studies reported favorable results. The review was expanded to active populations of athletes and revealed that a majority of conditions demonstrated favorable responses to ESWT including pain reduction and improved functional outcomes with minimal side effects. In contrast to PRP, ESWT may require less posttreatment activity limitation, making it particularly useful for the military by accelerating return to duty. Extracorporeal shockwave therapy in the U.S. Military40 evaluated from November 2008 to March 2015 revealed heterogeneity in application protocols with 4,766 patients treated at 22 sites. U.S. military facilities identified OssaTron as its sole device in 2008, which may have limited use of ESWT because of the cumbersome size and the procedural requirement for conscious sedation.40 Most newer machines are smaller and portable, and anesthesia is not routinely used because of the effects of ESWT acting on pain pathways.87,88 Advances in technology suggest the feasibility of future use of ESWT in the military. Limited studies directly compared ESWT to PRP. Comparable outcomes were observed for management of insertional AT at short-term and mid-term follow-up. For PT, results were comparable in the short-term follow-up although PRP showed superior results at mid-term and long-term follow-up. Platelet-rich plasma typically requires greater activity modification than ESWT. Extracorporeal shockwave therapy is typically less expensive than other regenerative techniques and noninvasive. Additional studies comparing efficacy of ESWT to PRP are needed and should measures objective outcomes of tissue healing (such as imaging), validated outcomes measures, and time to return to military duty. Our narrative review demonstrates heterogeneity in ESWT protocol that may limit comparison of study findings across conditions. A recent meta-analysis89 sought to distinguish clinical efficacy of shockwave types and dosage (total energy dose, TED) for lower extremity tendinopathy. Better outcomes were reported using F-SWT with high TED, defined as >240 mJ/mm2, over low TED. There was no difference in treatment efficacy between high energy versus low energy in the radial device. Another study90 that compared effectiveness of different shockwave types and intensity levels for PF reported higher success rates with medium- and high-intensity F-SWT when using a traditional meta-analysis. Applying a network meta-analysis suggested that success was higher with R-SWT over F-SWT. The authors concluded that if using F-SWT, the highest tolerable EFD without anesthesia may be preferable, but R-SWT may yield superior clinical efficacy.90 The senior authors of our review advise considering a ceiling on EFD dosage as a study using animal model tendon observed high dosages (values exceeding 0.28 mJ/mm2) resulted in detrimental histopathologic changes including necrosis, fibrotic deposition, and persistent inflammatory cells.68 Higher EFD may be desirable targeting bone, whereas lower EFD may be appropriate for treatment of tendon and fascia. Although number of treatments vary across protocols, authors of our review recommend a minimum of three to five sessions once weekly. However, one session may still be of benefit for active duty personnel requiring quick return to duty or change in location.11,48,59,60 Although our review identified limited studies comparing ESWT to PRP, there is biological plausibility to suggest overlap in mechanism to promote healing. Extracorporeal shockwave therapy produces interstitial and extracellular responses including release of cytokines and growth factors leading to angiogenesis, cell proliferation, and repair.27–32 A recent review92 also suggested that ESWT may represent a regenerative medicine technique. The proposed regenerative properties of PRP also include accelerating the healing process by producing growth factors and cytokines.93 Two network meta-analyses94,95 reported that ESWT had either similar or superior outcomes to autologous blood-derived products at 6 months. However, another network meta-analysis96 comparing nonsurgical treatments for PT pain found that PRP had superior outcomes. Using network meta-analysis to evaluate shorter- and longer-term outcomes for mid-portion AT,97 favorable outcomes were observed with combined eccentric exercise and ESWT; these gains exceeded eccentric exercise alone and suggest synergistic effects of mixed treatment protocols. Similarly, a recent report98 emphasizes the importance of a concomitant rehabilitation protocol to improve the efficacy of regenerative procedures. The study describes a post-procedure rehabilitation protocol divided into three phases that complement the three stages of tissue healing (inflammatory, proliferative, and remodeling), including progression from isometric to eccentric strengthening and increased loading. Extracorporeal shockwave therapy may be more appropriate during active duty, given prescribed relative rest following PRP. In contrast, a more significant tendon defect may favor PRP with appropriate time to protect the tissue and provide more predictable return to activity. There may also be benefits in staged procedures such as the use of ESWT combined with PRP or other types of therapy. One in vitro study99 noted that the increase in the expression of growth factors was greater in PRP exposed to ESWT than PRP alone. More studies are needed to evaluate the combined effects of various treatment strategies. LIMITATIONS Although this is the first known review to evaluate the application of ESWT in the military, there are limitations. Limited studies in the military prompted our search to include non-military individuals receiving ESWT and study design, including retrospective and unblinded investigation. Few studies used RCT design, blinding, and placebo. Furthermore, studies demonstrate variable diagnostic investigations and criteria for various conditions. Heterogeneity in ESWT protocols was observed. This review may serve as a background to identify strategies to use best practice in providing ESWT within the military and guide future translational research. CONCLUSIONS We identified the potential use of ESWT in the management of lower extremity conditions in the military. The overall favorable responses, few side effects, and the ability to maintain activity during treatment suggest value in future use within the military. Our review and practical experiences support looking at ESWT, PRP, and physical therapy protocols as having the capacity to have additive effects on individualized treatment protocols. We do not propose a one-fit model that argues superiority of one class of treatment. Future studies in the active military would help explore treatment success in different treatment settings, including basic training and deployment. Future investigations within military personnel are needed to understand and optimize the use of ESWT and PRP for musculoskeletal care. ACKNOWLEDGMENTS None declared. SUPPLEMENTARY MATERIAL Supplementary material is available at Military Medicine online. FUNDING None declared. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Khan SR , Pearle MS, Robertson WG, et al. : Kidney stones . Nat Rev Dis Prim 2016 ; 2 : 16008. doi: doi: 10.1038/nrdp.2016.8. Google Scholar OpenURL Placeholder Text WorldCat Crossref 2. Park SH , Park JB, Weinstein JN, Loening S: Application of extracorporeal shock wave lithotripter (ECSWL) in orthopedics. I. Foundations and overview . J Appl Biomater 1991 ; 2 ( 2 ): 115 – 26 . doi: doi: 10.1002/jab.770020207. Google Scholar Crossref Search ADS PubMed WorldCat 3. Haupt G , Haupt A, Ekkernkamp A, Gerety B, Chvapil M: Influence of shock waves on fracture healing . Urology 1992 ; 39 ( 6 ): 529 – 32 . doi: doi: 10.1016/0090-4295(92)90009-l. Google Scholar Crossref Search ADS PubMed WorldCat 4. Maffulli G , Iuliano E, Padulo J, Furia J, Rompe J, Maffulli N: Extracorporeal shock wave therapy in the treatment of midsubstance plantar fasciitis: the ASSERT database . Vol 8 . 2018 . Available at www.assert.org.uk; accessed March 23, 2020. 5. Maffulli G , Padulo J, Iuliano E, Saxena A, Rompe J, Maffulli N: Extracorporeal shock wave therapy in the treatment of insertional Achilles tendinopathy: the ASSERT database . Available at www.assert.org.uk; accessed March 23, 2020. 6. Maffulli G , Padulo J, Iuliano E, Saxena A, Rompe J, Maffulli N: Extracorporeal shock wave therapy in the treatment of midsubstance Achilles tendinopathy: the ASSERT database . Vol 8 . 2018 . Available at www.assert.org.uk; accessed March 23, 2020. 7. Rasmussen S , Christensen M, Mathiesen I, Simonson O: Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy . Acta Orthop 2008 ; 79 ( 2 ): 249 – 56 . doi: doi: 10.1080/17453670710015058. Google Scholar Crossref Search ADS PubMed WorldCat 8. Rompe JD , Furia J, Maffulli N: Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomized, controlled trial . J Bone Jt Surg - Ser A 2008 ; 90 ( 1 ): 52 – 61 . doi: doi: 10.2106/JBJS.F.01494. Google Scholar Crossref Search ADS WorldCat 9. Vahdatpour B , Forouzan H, Momeni F, Ahmadi M, Taheri P: Effectiveness of extracorporeal shockwave therapy for chronic Achilles tendinopathy: a randomized clinical trial . J Res Med Sci 2018 ; 23 ( 4 ): 37 – 37 . doi: doi: 10.4103/jrms.JRMS_413_16. Google Scholar PubMed OpenURL Placeholder Text WorldCat 10. Maffulli G , Padulo J, Iuliano E, Furia J, Rompe J, Maffulli N: Extracorporeal shock wave therapy in the treatment of patellar tendinopathy: the ASSERT database . Vol 8 . 2018 . Available at www.assert.org.uk; accessed March 23, 2020. 11. Gomez Garcia S , Rona SR, Claudia Gomez Tinoco M, et al. : Shockwave treatment for medial tibial stress syndrome in military cadets: a single-blind randomized controlled trial . Int J Surg 2017 ; 46 : 102 – 109 . doi: doi: 10.1016/j.ijsu.2017.08.584. Google Scholar Crossref Search ADS PubMed WorldCat 12. Smith L , Westrick R, Sauers S, et al. : Underreporting of musculoskeletal injuries in the US Army: findings from an infantry brigade combat team survey study . Sports Health 2016 ; 8 ( 6 ): 507 – 13 . doi: doi: 10.1177/1941738116670873. Google Scholar Crossref Search ADS PubMed WorldCat 13. Belmont PJ , Owens BD, Schoenfeld AJ: Musculoskeletal injuries in Iraq and Afghanistan: epidemiology and outcomes following a decade of war . J Am Acad Orthop Surg 2016 ; 24 ( 6 ): 341 – 8 . doi: doi: 10.5435/JAAOS-D-15-00123. Google Scholar Crossref Search ADS PubMed WorldCat 14. Scher DL , Belmont PJ, Bear R, Mountcastle SB, Orr JD, Owens BD: The incidence of plantar fasciitis in the United States military . J Bone Jt Surg - Ser A 2009 ; 91 ( 12 ): 2867 – 72 . doi: doi: 10.2106/JBJS.I.00257. Google Scholar Crossref Search ADS WorldCat 15. Brian Waterman MR , Usa M, Baris Gun C, Bader JO, Justin Orr LD, Philip Belmont CJ Jr: Epidemiology of lower extremity stress fractures in the United States Military . Mil Med 2016 ; 181 ( 10 ): 1308 – 1313 . doi: doi: 10.7205/MILMED-D-15-00571. Google Scholar Crossref Search ADS PubMed WorldCat 16. Knapik JJ , Graham B, Cobbs J, Thompson D, Steelman R, Jones BH: A prospective investigation of injury incidence and risk factors among army recruits in combat engineer training. J Occup Med Toxicol 2013 ; 8 ( 1 ): 5 doi: doi: 10.1186/1745-6673-8-5. Google Scholar OpenURL Placeholder Text WorldCat Crossref 17. Knapik J , Montain SJ, McGraw S, Grier T, Ely M, Jones BH: Stress fracture risk factors in basic combat training . Int J Sports Med 2012 ; 33 ( 11 ): 940 – 6 . doi: doi: 10.1055/s-0032-1311583. Google Scholar PubMed OpenURL Placeholder Text WorldCat 18. Owens BD , Wolf JM, Seelig AD, et al. : Risk factors for lower extremity tendinopathies in military personnel . Orthop J Sports Med 2013 ; 1 ( 1 ): 2325967113492707 doi: doi: 10.1177/2325967113492707. Google Scholar OpenURL Placeholder Text WorldCat Crossref 19. Cameron KL , Owens BD: The burden and management of sports-related musculoskeletal injuries and conditions within the US Military . Clin Sports Med 2014 ; 33 ( 4 ): 573 – 89 . doi: doi: 10.1016/j.csm.2014.06.004. Google Scholar Crossref Search ADS PubMed WorldCat 20. Cohen SP , Brown C, Kurihara C, Plunkett A, Nguyen C, Strassels SA: Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study. Lancet 2010 ; 375 ( 9711 ): 301 – 309 . doi: doi: 10.1016/S0140-6736(09)61797-9. Google Scholar Crossref Search ADS PubMed WorldCat 21. Cross JD , Ficke JR, Hsu JR, Masini BD, Wenke JC: Battlefield orthopaedic injuries cause the majority of long-term disabilities . J Am Acad Orthop Surg 2011 ; 19 ( Suppl 1 ): S1 – S7 . doi: doi: 10.5435/00124635-201102001-00002. Google Scholar PubMed OpenURL Placeholder Text WorldCat 22. Patzkowski JC , Rivera JC, Ficke JR, Wenke JC: The changing face of disability in the US Army . J Am Acad Orthop Surg 2012 ; 20 ( 8 ): S23 – 30 . doi: doi: 10.5435/JAAOS-20-08-S23. Google Scholar PubMed OpenURL Placeholder Text WorldCat 23. Kelsall HL , McKenzie DP, Forbes AB, Roberts MH, Urquhart DM, Sim MR: Pain-related musculoskeletal disorders, psychological comorbidity, and the relationship with physical and mental well-being in Gulf War veterans . Pain 2014 ; 155 ( 4 ): 685 – 92 . doi: doi: 10.1016/j.pain.2013.12.025. Google Scholar Crossref Search ADS PubMed WorldCat 24. López-Martínez AE , Reyes-Pérez Á, Rocío Serrano-Ibáñez E, Esteve R, Ramírez-Maestre C: Chronic pain, posttraumatic stress disorder, and opioid intake: a systematic review. Conflict-of-interest statement, PRISMA 2009 checklist statement. World J Clin Cases 2019 ; 7 ( 24 ): 4254 – 69 . doi: doi: 10.12998/wjcc.v7.i24.4254. Crossref Search ADS PubMed 25. Hinojosa R , Hinojosa MS, Clark DJ: Activity-limiting musculoskeletal conditions in US veterans compared to non-veterans: results from the 2013 National Health Interview Survey . PLoS One 2016 ; 11 ( 12 ): e0167143. doi: doi: 10.1371/JOURNAL.PONE.0167143. Google Scholar OpenURL Placeholder Text WorldCat Crossref 26. Arthritis among veterans—United States, 2011–2013 . Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6344a4.htm; accessed April 10 , 2020 . 27. Chen Y , Wang C, Yang KD, et al. : Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-β1 and IGF-I expression . J Orthop Res 2004 ; 22 ( 4 ): 854 – 61 . doi: doi: 10.1016/J.ORTHRES.2003.10.013. Google Scholar Crossref Search ADS PubMed WorldCat 28. Waugh C , Morrissey D, Jones E, Riley G, Langberg H, Screen H: In vivo biological response to extracorporeal shockwave therapy in human tendinopathy . Eur Cells Mater 2015 ; 29 : 268 – 80 .doi: 10.22203/eCM.v029a20 . Google Scholar Crossref Search ADS WorldCat 29. Wang F-S , Wang C-J, Chen Y-J, et al. : Ras induction of superoxide activates ERK-dependent angiogenic transcription factor HIF-1α and VEGF-A expression in shock wave-stimulated osteoblasts . J Biol Chem 2004 ; 279 ( 11 ): 10331 – 7 . doi: doi: 10.1074/JBC.M308013200. Google Scholar Crossref Search ADS PubMed WorldCat 30. Wang C-J , Huang H-Y, Pai C-H: Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs . J Foot Ankle Surg 2002 ; 41 ( 1 ): 16 – 22 . doi: doi: 10.1016/S1067-2516(02)80005-9. Google Scholar Crossref Search ADS PubMed WorldCat 31. Wang F , Yang K, Chen R, Wang C, Sheen-Chen S: Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-β1 . J Bone Joint Surg Br 2002 ; 84 ( 3 ): 457 – 61 . doi: doi: 10.1302/0301-620X.84B3.0840457. Google Scholar Crossref Search ADS PubMed WorldCat 32. Bosch G , Lin YL, van Schie HTM, van de Lest CHA, Barneveld A, van Weeren PR: Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponies . Equine Vet J 2007 ; 39 ( 3 ): 226 – 31 . doi: doi: 10.2746/042516407X180408. Google Scholar Crossref Search ADS PubMed WorldCat 33. Zhao Z , Ji H, Jing R, et al. : Extracorporeal shock-wave therapy reduces progression of knee osteoarthritis in rabbits by reducing nitric oxide level and chondrocyte apoptosis . Arch Orthop Trauma Surg 2012 ; 132 ( 11 ): 1547 – 53 . doi: doi: 10.1007/S00402-012-1586-4. Google Scholar Crossref Search ADS PubMed WorldCat 34. Saggini R , Stefano A, Saggini A, Bellomo R: Clinical application of shock wave therapy in musculoskeletal disorders: part I . J Biol Regul Homeost Agents 2015 ; 29 ( 3 ): 533 – 45 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 35. Maier M , Averbeck B, Milz S, Refior HJ, Schmitz C: Substance P and prostaglandin E2 release after shock wave application to the rabbit femur . Clin Orthop Relat Res 2003 ; 406 ( 1 ): 237 – 45 .doi: 10.1097/00003086-200301000-00034 . Google Scholar OpenURL Placeholder Text WorldCat Crossref 36. Hausdorf J , Lemmens MAM, Kaplan S, et al. : Extracorporeal shockwave application to the distal femur of rabbits diminishes the number of neurons immunoreactive for substance P in dorsal root ganglia L5 . Brain Res 2008 ; 1207 : 96 – 101 . doi: doi: 10.1016/J.BRAINRES.2008.02.013. Google Scholar Crossref Search ADS PubMed WorldCat 37. Hausdorf J , Lemmens MAM, Heck KDW, et al. : Selective loss of unmyelinated nerve fibers after extracorporeal shockwave application to the musculoskeletal system . Neuroscience 2008 ; 155 ( 1 ): 138 – 44 . doi: doi: 10.1016/J.NEUROSCIENCE.2008.03.062. Google Scholar Crossref Search ADS PubMed WorldCat 38. Lyras DN , Kazakos K, Agrogiannis G, et al. : Experimental study of tendon healing early phase: is IGF-1 expression influenced by platelet rich plasma gel? Orthop Traumatol Surg Res 2010 ; 96 ( 4 ): 381 – 7 . doi: doi: 10.1016/J.OTSR.2010.03.010. Google Scholar Crossref Search ADS PubMed WorldCat 39. Christgau M , Moder D, Hiller K-A, Dada A, Schmitz G, Schmalz G: Growth factors and cytokines in autologous platelet concentrate and their correlation to periodontal regeneration outcomes . J Clin Periodontol 2006 ; 33 ( 11 ): 837 – 45 . doi: doi: 10.1111/J.1600-051X.2006.00991.X. Google Scholar Crossref Search ADS PubMed WorldCat 40. Corey S , Mueller T, Bojescul J, Cameron C: Application of high energy extracorporeal shockwave therapy on musculoskeletal conditions in US Military medical facilities . US Army Med Dep J ( 2–18 ): 76 – 83 . Available at http://www.ncbi.nlm.nih.gov/pubmed/30623403; accessed March 18, 2020. OpenURL Placeholder Text WorldCat 41. Sharma J , Greeves JP, Byers M, Bennett AN, Spears IR: Musculoskeletal injuries in British Army recruits: a prospective study of diagnosis-specific incidence and rehabilitation times epidemiology of musculoskeletal disorders . BMC Musculoskelet Disord 2015 ; 16 ( 1 ): 106. doi: doi: 10.1186/s12891-015-0558-6. Google Scholar OpenURL Placeholder Text WorldCat Crossref 42. Lovalekar MT , Abt JP, Sell TC, et al. : Descriptive epidemiology of musculoskeletal injuries in the Army 101st Airborne (Air Assault) Division . Mil Med 2016 ; 181 ( 8 ): 900 – 6 . doi: doi: 10.7205/milmed-d-15-00262. Google Scholar Crossref Search ADS PubMed WorldCat 43. Lovalekar M , Johnson CD, Eagle S, et al. : Epidemiology of musculoskeletal injuries among US Air Force special tactics operators: an economic cost perspective . BMJ Open Sport Exercise Med 2018 ; 4 ( 1 ): e000471. doi: doi: 10.1136/bmjsem-2018-000471. Google Scholar OpenURL Placeholder Text WorldCat Crossref 44. Almeida SA , Williams KM, Shaffer RA, Brodine SK: Epidemiological patterns of musculoskeletal injuries and physical training . Medicine & Science in Sports & Exercise. Available at https://journals.lww.com/acsm-msse/Fulltext/1999/08000/Epidemiological_patterns_of_musculoskeletal.15.aspx, published 1999 ; accessed March 23, 2020 . 45. Moya D , Ramón S, Schaden W, Wang C-J, Guiloff L, Cheng J-H: The role of extracorporeal shockwave treatment in musculoskeletal disorders . J Bone Jt Surg 2018 ; 100 ( 3 ): 251 – 63 . doi: doi: 10.2106/JBJS.17.00661. Google Scholar Crossref Search ADS WorldCat 46. Császár NBM , Angstman NB, Milz S, et al. : Radial shock wave devices generate cavitation . PLoS One 2015 ; 10 ( 10 ): e0140541. doi: doi: 10.1371/JOURNAL.PONE.0140541. Google Scholar OpenURL Placeholder Text WorldCat Crossref 47. Tailly GG : Extracorporeal shock wave lithotripsy today . Indian J Urol 2013 ; 29 ( 3 ): 200. doi: doi: 10.4103/0970-1591.117283. Google Scholar OpenURL Placeholder Text WorldCat Crossref 48. Purcell RL , Schroeder IG, Keeling LE, Formby PM, Eckel TT, Shawen SB: Clinical outcomes after extracorporeal shock wave therapy for chronic plantar fasciitis in a predominantly active duty population . J Foot Ankle Surg 2018 ; 57 ( 4 ): 654 – 7 . doi: doi: 10.1053/j.jfas.2017.11.030. Google Scholar Crossref Search ADS PubMed WorldCat 49. Moretti B , Garofalo R, Patella V, Sisti GL, Corrado M, Mouhsine E: Extracorporeal shock wave therapy in runners with a symptomatic heel spur . Knee Surg Sports Traumatol Arthroscopy 2005 ; 14 ( 10 ): 1029 – 32 . doi: doi: 10.1007/S00167-005-0025-2. Google Scholar Crossref Search ADS WorldCat 50. Saxena A , Hong BK, Yun AS, Maffulli N, Gerdesmeyer L: Treatment of plantar fasciitis with radial soundwave “early” is better than after 6 months: a pilot study . J Foot Ankle Surg 2017 ; 56 ( 5 ): 950 – 3 . doi: doi: 10.1053/J.JFAS.2017.06.020. Google Scholar Crossref Search ADS PubMed WorldCat 51. Saxena A , Fournier M, Gerdesmeyer L, Gollwitzer H: Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete . Muscles Ligaments Tendons J 2012 ; 2 ( 4 ): 312. Google Scholar OpenURL Placeholder Text WorldCat 52. Mitchkash M , Robinson D, Tenforde A: Efficacy of extracorporeal pulse-activated therapy in the management of lower-extremity running-related injuries: findings from a large case cohort . J Foot Ankle Surg 2020 ; 59 ( 4 ): 795 – 800 . doi: doi: 10.1053/j.jfas.2020.02.008. Google Scholar Crossref Search ADS PubMed WorldCat 53. Erroi D , et al. : Conservative treatment for insertional Achilles tendinopathy: platelet-rich plasma and focused shock waves. A retrospective study . Muscles Ligaments Tendons J 2017 ; 7 ( 1 ): 98. doi: doi: 10.11138/MLTJ/2017.7.1.098. Google Scholar OpenURL Placeholder Text WorldCat Crossref 54. Vulpiani MC , Trischitta D, Trovato P, Vetrano M, Ferretti A: Extracorporeal shockwave therapy (ESWT) in Achilles tendinopathy. A long-term follow-up observational study . J Sports Med Phys Fitness 2009 ; 49 ( 2 ): 171 – 6 . Available at https://www.minervamedica.it/en/journals/sports-med-physical-fitness/article.php?cod=R40Y2009N02A0171; accessed April 26, 2020. Google Scholar PubMed OpenURL Placeholder Text WorldCat 55. Zhang S , Li H, Yao W, Hua Y, Li Y: Therapeutic response of extracorporeal shock wave therapy for insertional Achilles tendinopathy between sports-active and nonsports-active patients with 5-year follow-up . 2020 ; 8 ( 1 ): 2325967119898118. doi: doi: 10.1177/2325967119898118. OpenURL Placeholder Text WorldCat Crossref 56. Rompe J , Furia J, Maffulli N: Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy. A randomized, controlled trial . J Bone Jt Surg 2008 ; 90 ( 1 ): 52 – 61 .doi: 10.2106/JBJS.F.01494 . Google Scholar Crossref Search ADS WorldCat 57. Valero MC , Huntsman HD, Liu J, Zou K, Boppart MD, Phillips SM: Eccentric exercise facilitates mesenchymal stem cell appearance in skeletal muscle . PLoS One 2012 ; 7 ( 1 ): 29760. doi: doi: 10.1371/journal.pone.0029760. Google Scholar OpenURL Placeholder Text WorldCat Crossref 58. Hyldahl RD , Olson T, Welling T, Groscost L, Parcell AC: Satellite cell activity is differentially affected by contraction mode in human muscle following a work-matched bout of exercise . Front Physiol 2014 ; 5 : 485 – 485 . doi: doi: 10.3389/FPHYS.2014.00485. Google Scholar Crossref Search ADS PubMed WorldCat 59. Furia JP : High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy . Am J Sports Med 2006 ; 34 ( 5 ): 733 – 740 . doi: doi: 10.1177/0363546505281810. Google Scholar Crossref Search ADS PubMed WorldCat 60. Furia JP : High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy . Am J Sports Med 2008 ; 36 ( 3 ): 502 – 508 . doi: doi: 10.1177/0363546507309674. Google Scholar Crossref Search ADS PubMed WorldCat 61. Moen MH , Rayer S, Schipper M, et al. : Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study . Br J Sports Med 2012 ; 46 ( 4 ): 253 – 7 . doi: doi: 10.1136/BJSM.2010.081992. Google Scholar Crossref Search ADS PubMed WorldCat 62. Rompe JD , Cacchio A, Furia JP, Maffulli N: Low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome . Am J Sports Med 2010 ; 38 ( 1 ): 125 – 132 . doi: doi: 10.1177/0363546509343804. Google Scholar Crossref Search ADS PubMed WorldCat 63. Espay AJ , Norris MM, Eliassen JC, et al. : Placebo effect of medication cost in Parkinson disease. A randomized double-blind study. Neurology 2015 ; 84 ( 8 ): 794 – 802 . Available at www.pstnet.com; accessed April 26, 2020 . Google Scholar Crossref Search ADS PubMed WorldCat 64. Cheng L , Chang S, Qian L, Wang Y, Yang M: Extracorporeal shock wave therapy for isokinetic muscle strength around the knee joint in athletes with patellar tendinopathy . J Sports Med Phys Fitness 2019 ; 59 ( 5 ): 822 – 827 . Available at https://www.minervamedica.it/en/journals/sports-med-physical-fitness/article.php?cod=R40Y2019N05A0822&acquista=1, published 2019 ; accessed April 7, 2020 . Google Scholar Crossref Search ADS PubMed WorldCat 65. Thijs KM , Zwerver J, Backx FJG, et al. : Effectiveness of shockwave treatment combined with eccentric training for patellar tendinopathy: a double-blinded randomized study . Clin J Sport Med 2017 ; 27 ( 2 ): 89 – 96 . doi: doi: 10.1097/JSM.0000000000000332. Google Scholar Crossref Search ADS PubMed WorldCat 66. Vetrano M , Castorina A, Chiara Vulpiani M, Baldini R, Pavan A, Ferretti A: Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes . Am J Sports Med 2013 ; 41 ( 4 ): 795 – 803 . doi: doi: 10.1177/0363546513475345. Google Scholar Crossref Search ADS PubMed WorldCat 67. Zwerver J , Hartgens F, Verhagen E, van der Worp H, van den Akker-scheek I, Diercks RL: No effect of extracorporeal shockwave therapy on patellar tendinopathy in jumping athletes during the competitive season: a randomized clinical trial . Am J Sports Med 2011 ; 39 ( 6 ): 1191 – 1199 . doi: doi: 10.1177/0363546510395492. Google Scholar Crossref Search ADS PubMed WorldCat 68. Rompe JD , Kirkpatrick CJ, Küllmer K, Schwitalle M, Krischek O: Dose-related effects of shock waves on rabbit tendo Achillis . J Bone Joint Surg Br 1998 ; 80 ( 3 ): 546 – 552 . doi: doi: 10.1302/0301-620X.80B3.0800546. Google Scholar Crossref Search ADS PubMed WorldCat 69. Maier M , Tischer T, Milz S, et al. : Dose-related effects of extracorporeal shock waves on rabbit quadriceps tendon integrity . Arch Orthop Trauma Surg 2002 ; 122 ( 8 ): 436 – 41 . doi: doi: 10.1007/S00402-002-0420-9. Google Scholar Crossref Search ADS PubMed WorldCat 70. Kang S , Gao F, Han J, et al. : Extracorporeal shock wave treatment can normalize painful bone marrow edema in knee osteoarthritis: a comparative historical cohort study . Medicine (Baltimore) 2018 ; 97 ( 5 ): e9796. doi: doi: 10.1097/MD.0000000000009796. Google Scholar OpenURL Placeholder Text WorldCat Crossref 71. Ma HZ , Zhang W, Shi J, Zhou D, Wang J: The efficacy and safety of extracorporeal shockwave therapy in knee osteoarthritis: a systematic review and meta-analysis . Int J Surg 2020 ; 21 ( 4 ): 822 – 835 . doi: doi: 10.1016/J.IJSU.2020.01.017. Google Scholar OpenURL Placeholder Text WorldCat Crossref 72. Wang Y-C , Huang H-T, Huang P-J, Liu Z-M, Shih C-L: Efficacy and safety of extracorporeal shockwave therapy for treatment of knee osteoarthritis: a systematic review and meta-analysis . Pain Med 2020 ; 21 ( 4 ): 822 – 35 . doi: doi: 10.1093/pm/pnz262. Google Scholar Crossref Search ADS PubMed WorldCat 73. Lizis P , Kobza W, Manko G: Extracorporeal shockwave therapy vs. kinesiotherapy for osteoarthritis of the knee: a pilot randomized controlled trial . J Back Musculoskelet Rehabil 2017 ; 30 ( 5 ): 1121 – 8 . doi: doi: 10.3233/BMR-169781. Google Scholar Crossref Search ADS PubMed WorldCat 74. Zhong Z , Liu B, Liu G, et al. : A randomized controlled trial on the effects of low-dose extracorporeal shockwave therapy in patients with knee osteoarthritis . Arch Phys Med Rehabil 2019 ; 100 ( 9 ): 1695 – 702 . doi: doi: 10.1016/J.APMR.2019.04.020. Google Scholar Crossref Search ADS PubMed WorldCat 75. Imamura M , Alamino S, Hsing W, Alfieri F, Schmitz C, Battistella L: Radial extracorporeal shock wave therapy for disabling pain due to severe primary knee osteoarthritis . J Rehabil Med 2017 ; 49 ( 1 ): 54 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 76. Li W , Pan Y, Yang Q, Guo Z, Yue Q, Meng Q-G: Extracorporeal shockwave therapy for the treatment of knee osteoarthritis: a retrospective study . Medicine (Baltimore) 2018 ; 97 ( 27 ): e11418. doi: doi: 10.1097/MD.0000000000011418. Google Scholar OpenURL Placeholder Text WorldCat Crossref 77. Kim J-H , Kim J-Y, Choi C-M, et al. : The dose-related effects of extracorporeal shock wave therapy for knee osteoarthritis . Ann Rehabil Med 2015 ; 39 ( 4 ): 616. doi: doi: 10.5535/ARM.2015.39.4.616. Google Scholar OpenURL Placeholder Text WorldCat Crossref 78. Ediz L , Ozgokce M: Effectiveness of extracorporeal shock wave therapy to treat primary medial knee osteoarthritis with and without bone marrow edema in elderly patients . Turk J Geriatr 2018 ; 21 ( 3 ): 394 – 401 . Available at https://www.researchgate.net/publication/329571830_Effectiveness_of_extracorporeal_shock_wave_therapy_to_treat_primary_medial_knee_osteoarthritis_with_and_without_bone_marrow_edema_in_elderly_patients; accessed April 26, 2020. Google Scholar OpenURL Placeholder Text WorldCat 79. Lee J-K , Lee B-Y, Shin W-Y, An M-J, Jung K-I, Yoon S-R: Effect of extracorporeal shockwave therapy versus intra-articular injections of hyaluronic acid for the treatment of knee osteoarthritis . Ann Rehabil Med 2017 ; 41 ( 5 ): 828. doi: doi: 10.5535/ARM.2017.41.5.828. Google Scholar OpenURL Placeholder Text WorldCat Crossref 80. Lee J-H , Lee S, Choi S, Choi Y-H, Lee K: The effects of extracorporeal shock wave therapy on the pain and function of patients with degenerative knee arthritis . J Phys Ther Sci 2017 ; 29 ( 3 ): 536 – 8 . doi: doi: 10.1589/jpts.29.536. Google Scholar Crossref Search ADS PubMed WorldCat 81. Cho SJ , Yang JR, Yang HS, Yang H-E: Effects of extracorporeal shockwave therapy in chronic stroke patients with knee osteoarthritis: a pilot study . Ann Rehabil Med 2016 ; 40 ( 5 ): 862. doi: doi: 10.5535/ARM.2016.40.5.862. Google Scholar OpenURL Placeholder Text WorldCat Crossref 82. Elerian AE , Ewidea TMA, Ali N: Effect of shock wave therapy versus corticosteroid injection in management of knee osteoarthritis . Int J Physiother 2016 ; 3 ( 2 ): 246 – 51 .doi: 10.15621/ijphy/2016/v3i2/94906 . Google Scholar Crossref Search ADS WorldCat 83. Chen T-W , Lin C-W, Lee C-L, et al. : The efficacy of shock wave therapy in patients with knee osteoarthritis and popliteal cyamella . Kaohsiung J Med Sci 2014 ; 30 ( 7 ): 362 – 70 . doi: doi: 10.1016/J.KJMS.2014.03.006. Google Scholar Crossref Search ADS PubMed WorldCat 84. Zhao Z , Jing R, Shi Z, Zhao B, Ai Q, Xing G: Efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a randomized controlled trial . J Surg Res 2013 ; 185 ( 2 ): 661 – 6 . doi: doi: 10.1016/J.JSS.2013.07.004. Google Scholar Crossref Search ADS PubMed WorldCat 85. Costa ML , Shepstone L, Donell ST, Thomas TL: Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial . Clin Orthop Relat Res 2005 ; 440 : 199 – 204 . doi: doi: 10.1097/01.blo.0000180451.03425.48. Google Scholar Crossref Search ADS PubMed WorldCat 86. Schmitz C , Császár NBM, Milz S, et al. : Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database . Br Med Bull 2015 ; 116 ( 1 ): 115 – 38 . doi: doi: 10.1093/bmb/ldv047. Google Scholar PubMed OpenURL Placeholder Text WorldCat 87. Rompe JD , Meurer A, Nafe B, Hofmann A, Gerdesmeyer L: Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis . J Orthop Res 2005 ; 23 ( 4 ): 931 – 41 . doi: doi: 10.1016/j.orthres.2005.09.003. Google Scholar Crossref Search ADS PubMed WorldCat 88. Furia JP , Rompe JD: Extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis and Achilles tendinopathy . Curr Opin Orthop 2007 ; 18 ( 2 ): 102 – 11 . doi: doi: 10.1097/BCO.0b013e328013e594. Google Scholar Crossref Search ADS WorldCat 89. Liao C-D , Tsauo J-Y, Chen H-C, Liou T-H: Efficacy of extracorporeal shock wave therapy for lower-limb tendinopathy: a meta-analysis of randomized controlled trials . Am J Phys Med Rehabil 2018 ; 97 ( 9 ): 605 – 19 . doi: doi: 10.1097/PHM.0000000000000925. Google Scholar Crossref Search ADS PubMed WorldCat 90. Chang K-V , Chen S-Y, Chen W-S, Tu Y-K, Chien K-L: Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis . Arch Phys Med Rehabil 2012 ; 93 ( 7 ): 1259 – 68 . doi: doi: 10.1016/j.apmr.2012.02.023. Google Scholar Crossref Search ADS PubMed WorldCat 91. Gao F , Sun W, Li Z, et al. : Extracorporeal shock wave therapy in the treatment of primary bone marrow edema syndrome of the knee: a prospective randomised controlled study . BMC Musculoskelet Disord 2015 ; 16 : 379. doi: doi: 10.1186/s12891-015-0837-2. Google Scholar OpenURL Placeholder Text WorldCat Crossref 92. Simplicio CL , Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD: Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine . J Clin Orthop Trauma 2020 ; 11 : S309 – 18 . doi: doi: 10.1016/j.jcot.2020.02.004. Google Scholar Crossref Search ADS PubMed WorldCat 93. Wu PI-K , Diaz R, Borg-Stein J: Platelet-rich plasma . Phys Med Rehabil Clin N Am 2016 ; 27 ( 4 ): 825 – 53 . doi: doi: 10.1016/j.pmr.2016.06.002. Google Scholar Crossref Search ADS PubMed WorldCat 94. Hsiao M-Y , Hung C-Y, Chang K-V, Chien K-L, Tu Y-K, Wang T-G: Comparative effectiveness of autologous blood-derived products, shock-wave therapy and corticosteroids for treatment of plantar fasciitis: a network meta-analysis . Rheumatology (Oxford) 2015 ; 54 ( 9 ): 1735 – 43 . doi: doi: 10.1093/rheumatology/kev010. Google Scholar Crossref Search ADS PubMed WorldCat 95. Li H , Lv H, Lin T: Comparison of efficacy of eight treatments for plantar fasciitis: a network meta-analysis . J Cell Physiol 2018 ; 234 ( 1 ): 860 – 70 . doi: doi: 10.1002/jcp.26907. Google Scholar Crossref Search ADS PubMed WorldCat 96. Chen P-C , Wu K-T, Chou W-Y, et al. : Comparative effectiveness of different nonsurgical treatments for patellar tendinopathy: a systematic review and network meta-analysis . Arthroscopy J Arthroscopic Related Surg 2019 ; 35 ( 11 ): 3117 – 31.e2 . doi: doi: 10.1016/j.arthro.2019.06.017. Google Scholar Crossref Search ADS WorldCat 97. Rhim HC , Kim MS, Choi S, Tenforde AS: Comparative efficacy and tolerability of nonsurgical therapies for the treatment of midportion Achilles tendinopathy: a systematic review with network meta-analysis . Orthop J Sport Med 2020 ; 8 ( 7 ): 2325967120930567. doi: doi: 10.1177/2325967120930567. Google Scholar OpenURL Placeholder Text WorldCat Crossref 98. Sussman WI , Mautner K, Malanga G: The role of rehabilitation after regenerative and orthobiologic procedures for the treatment of tendinopathy: a systematic review . Regen Med 2018 ; 13 ( 2 ): 249 – 63 . doi: doi: 10.2217/rme-2017-0110. Google Scholar Crossref Search ADS PubMed WorldCat 99. Seabaugh KA , Thoresen M, Giguère S: Extracorporeal shockwave therapy increases growth factor release from equine platelet-rich plasma in vitro . Front Vet Sci 2017 ; 4 : 205. doi: doi: 10.3389/fvets.2017.00205. Google Scholar OpenURL Placeholder Text WorldCat Crossref Author notes This work has not been presented elsewhere in any form. © The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - A Narrative Review Evaluating Extracorporeal Shockwave Therapy as a Potential Regenerative Treatment for Musculoskeletal Conditions in Military Personnel
JF - Military Medicine
DO - 10.1093/milmed/usab106
DA - 2021-03-26
UR - https://www.deepdyve.com/lp/oxford-university-press/a-narrative-review-evaluating-extracorporeal-shockwave-therapy-as-a-1RMuJG9HfP
SP - 1
EP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -