Shockwave for Musculoskeletal Conditions

Anatomy: plantar fascia, calcaneal enthesis. ISMST approved standard indication — highest evidence tier. Radial protocol: 1,500-2,100 impulses, 4 Hz, 3-5 weekly sessions. Focused protocol: 2,000 impulses, 0.20 mJ/mm², 3 sessions. Key finding: radial ranked 91% probability of best treatment. Evidence: multiple Level I RCTs, 60-80% improvement. Dornier Epos Ultra FDA-approved specifically for this. Runner-specific protocol: 2,100 impulses low-energy (RCT data).

Rotator cuff anatomy. Uhthoff classification of calcific deposits. THE prime focused shockwave indication. Protocol: 2,000 pulses, 0.20-0.32 mJ/mm², 2-5 Hz, 3 weekly sessions. US-guided targeting strongly recommended (RCT: superior to landmark-based). High-energy (0.32+ mJ/mm²) significantly better for calcification resorption. ISMST approved standard indication. Equally effective in athletes and non-athletes.

Common extensor tendon anatomy. Protocol: 1,500-2,000 shocks, 3-4 weekly sessions. ESWT superior to corticosteroid injection for long-term outcomes. Combining with eccentric exercises improves results. High energy >0.12 mJ/mm² and low energy both show benefit. ISMST approved standard indication. Systematic review and meta-analysis confirmed pain relief and grip strength improvement.

CRITICAL distinction: insertional vs mid-portion — different pathologies, different approaches. Mid-portion: 2,000 impulses, 2.0-3.0 bar radial, 3-5 sessions. ESWT + eccentric loading > eccentric alone for non-insertional. Insertional: different approach, eccentric loading less effective, focused may be preferred. ISMST approved standard indication.

Prevalence up to 50% in volleyball players. Radial: minimum 3,000 shocks, 15 Hz, 1.8-4.5 bar. Focused: minimum 1,000 shocks, 0.07-0.22 mJ/mm². Both reduced pain and improved function over 3 sessions. 90% satisfactory outcome vs 50% conservative care. Only 13% recurrence in ESWT group vs 50% conservative. ISMST approved standard indication.

Gluteus medius/minimus tendinopathy and trochanteric bursitis. Protocol: 2,000-3,000 impulses, 2.0-3.0 bar, 10-15 Hz, 3-5 sessions. Clinical differentiation tests. Combine with hip abductor strengthening program. ISMST approved standard indication.

Ischial tuberosity enthesopathy. 2,000-3,000 pulses/session, 3-4 weekly sessions. In professional athletes: 80% returned to pre-injury sport at mean 9 weeks. RCT of 40 pro athletes: 85% achieved ≥50% pain reduction vs only 10% conservative. Prone positioning, focused preferred for depth. Differentiation from sciatic nerve irritation.

Treatment along posteromedial tibial border with radial shockwave. Single focused ESWT session + exercise program (military cadet RCT: faster recovery). ISMST empirical indication. Important: differentiate from stress fractures — ESWT contraindicated in acute stress fractures.

ESWT is both diagnostic AND therapeutic for myofascial trigger points. Focused ESWT diagnostic accuracy: QL 96%, glut med 95%, glut min 92% referral rate. Treatment mapping for common referral patterns. ESWT more effective than other MPS treatments. ESWT + dry needling more effective than either alone for tendinopathy. Vibration applicator techniques.

IT band syndrome: radial shockwave to lateral thigh/knee. Adductor tendinopathy in soccer/football. Osteitis pubis: benefits within 10 weeks of ESWT. Snapping hip syndrome. General hip/pelvis tendinopathy protocols.

FOCUSED ONLY — radial insufficient for bone (depth limitation). Protocol: 4,000 pulses, 0.22-1.10 mJ/mm² — must be HIGH energy. Success rate: 85% bone union across 204 cases. By bone: clavicle/metatarsus 100%, ulna 96%, femur/scaphoid 80%, humerus/tibia 78%. Results at 8-10 weeks. Post-treatment immobilization unless stable osteosynthesis. ISMST approved standard indication.

AVN femoral head: better outcomes than core decompression. Effective in ARCO stages I-II. Cocktail therapy: HBO + ESWT + alendronate. OCD: ISMST considers ESWT effective and safe in early stages. Case reports: complete healing with hyaline cartilage at 14 months. Both require focused high-energy devices.