Scientific Evidence

Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions
by Angelo Cacchio, Lucio Giordano, Olivo Colafarina, Jan D. Rompe, Emanuela Tavernese, Francesco Ioppolo, Stefano Flamini, Giorgio Spacca and Valter Santilli

Abstract-Heel Pain Treatment Results using Extracorporeal Pulse Activation Therapy (EPAT) vs. Extracorporeal Shock Wave Therapy (ESWT).
by Angela Drury-Schimberg, D.P.M., F.A.C., F.A.S.

Shockwave Therapy for the Treatment of Chronic Proximal Hamstring Tendinopathy in Professional Athletes
Angelo Cacchio, Jan D. Rompe, John P. Furia, Piero Susi, Valter Santilli and Fosco De Paulis

The American Journal of Sports Medicine - Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinophathy of the Main Body of Tendo Achillis
Jan D. Rompe, M.D., Bernhard Nafe, M.D., John P. Furia, M.D. Ph.D., and Nicola Maffulli, M.D., Ph.D., F.R.C.S.(Orth)

The American Journal of Sports Medicine - High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Insertional Achilles Tendinopathy
by John Patrick Furia, M.D.

The American Journal of Sports Medicine - Extracorporeal Shockwave for Chronic Patellar Tendinopathy
Ching-Jen Wang M.D., Jih-Yang Ko M.D., Yi-Sheng Chan M.D., Lin-Hsiu Weng M.D. and Shan-Lin Hsu M.D.

Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Medial Tibial Stress Syndrome
Jan D. Rompe, Angelo Cacchio, John P. Furia and Nicola Maffulli

Radial Shockwave Therapy in Calcific Tendinitis of the Rotator Cuff
Dr. P. Magosch, ATOS Clinic Heidelberg (Germany)

Evaluation of Low-Energy Extracorporeal Shock-Wave Application for Treatment of Chronic Plantar Fasciitis
by Jan D. Rompe, MD, Carsten Schoellner, MD, And Bernhard Nafe, MD

The American Journal of Orthopedics - Safety and Efficacy of ESWT for Chronic Lateral Epicondylitis
by John P. Furia, M.D.

The American Journal of Sports Medicine - Shock Wave Therapy for Patients with Lateral Epiconylitis of the Elbow
by Ching-Jen Wang, M.S. & Han-Shiang Chen, M.D.

Radial Extracorporeal Shock Wave Therapy (rESWT) in Chronic Plantar Heel Pain - a RCT
L. Gerdesmeyer, L. Weil, B. Scrurran, J. Stienstra, C. Frey, K. Fedder, M. Maier, M. Henne, M. Russlies, H. Lohrer, J. Vester

Techniques in Foot and Ankle Surgery - Shock Wave Therapy for Treatment of Foot and Ankle Conditions
Alastair Younger, MB, ChB, FRCSC

Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial*
Gerdesmeyer L, Wagenpfeil S, Haake M, Maier M, Loew M, Wortler K, Lampe R, Seil R, Handle G, Gassel S, Rompe JD.

Context: Extracorporeal shock wave therapy (ESWT) has been used to treat calcific tendonitis of the shoulder, but trials of ESWT for this purpose have had methodological deficiencies and thus there is limited evidence for its effectiveness.

Objective: To determine whether fluoroscopy-guided ESWT improves function, reduces pain, and diminishes the size of calcific deposits in patients with chronic calcific tendonitis of the shoulder. DESIGN, SETTING, AND PARTICIPANTS: Double-blind, randomized, placebo-controlled trial conducted between February 1997 and March 2001 among 144 patients (of 164 screened) recruited from referring primary care physicians, orthopedic surgeons, and sports physicians in 7 orthopedic departments in Germany and Austria. INTERVENTIONS: Either high-energy ESWT, low-energy ESWT, or placebo (sham treatment). The 2 ESWT groups received the same cumulative energy dose. Patients in all 3 groups received 2 treatment sessions approximately 2 weeks apart, followed by physical therapy.

Main outcome measures: The primary end point was the change in the mean Constant and Murley Scale (CMS) score from baseline to 6 months after the intervention. Secondary end points were changes in the mean CMS scores at 3 and 12 months, as well as changes in self-rated pain and radiographic change in size of calcific deposits at 3, 6, and 12 months.

Results: Of 144 patients enrolled, all completed treatment as randomized and 134 completed the 6-month follow-up. Both high-energy and low-energy ESWT resulted in significant improvement in the 6-month mean (95% confidence interval [CI]) CMS score compared with sham treatment (high-energy ESWT: 31.0 [26.7-35.3] points; low-energy ESWT: 15.0 [10.2-19.8] points; sham treatment: 6.6 [1.4-11.8] points; P<.001 for both comparisons). Patients who received high-energy ESWT also had significant 6-month CMS improvements compared with those who received low-energy ESWT (P<.001). We found similar results for both the 3-month and 12-month CMS comparisons, as well as for self-rated pain and radiographic changes at 3, 6, and 12 months.

Conclusions: B Both high-energy and low-energy ESWT appeared to provide a beneficial effect on shoulder function, as well as on self-rated pain and diminished size of calcifications, compared with placebo. Furthermore, high-energy ESWT appeared to be superior to low-energy ESWT.

Antibacterial effects of extracorporeal shock waves*
Gerdesmeyer L, von Eiff C, Horn C, Henne M, Roessner M, Diehl P, Gollwitzer H.
Klinik und Poliklinik fur Orthopadie und Sportorthopadie der Technischen Universitat Munchen, Munchen, Germany.

Despite considerable knowledge about effects of extracorporeal shock-wave therapy (ESWT) on eukaryotic tissues, only little data are available concerning their effect on prokaryotic microorganisms. The objective of the present study was to determine the bactericidal activity as a function of energy flux density and shock-wave impulse number. Standardised suspensions of Staphylococcus aureus ATCC 25923 were exposed to different impulse numbers of shock waves with an energy flux density (ED) up to 0.96 mJ mm(-2) (2 Hz). Subsequently, viable bacteria were quantified by culture and compared with an untreated control. After applying 4000 impulses, a significant bactericidal effect was observed with a threshold ED of 0.59 mJ mm(-2) (p < 0.05). A threshold impulse number of more than 1000 impulses was necessary to reduce bacterial growth (p < 0.05). Further elevation of energy and impulse number exponentially increased bacterial killing. ESWT proved to exert significant antibacterial effect in an energy-dependent manner. Certain types of difficult-to-treat infections could offer new applications for ESWT.

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*
Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L.

Background: It remains unclear whether application of local anesthesia (LA) interferes with clinical efficacy of extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis.

Aims: To evaluate the effect of local anesthesia on the clinical outcome after repetitive low-energy ESWT for chronic plantar fasciitis.

Methods: Eighty-six patients with chronic plantar fasciitis were randomly assigned to receive either low-energy ESWT without LA, given weekly for three weeks (Group I, n=45; 3 x 2000 pulses, total energy flux density per shock 0.09 mJ/mm2) or identical ESWT with LA (Group II, n=41). Primary outcome measure was: Reduction of pain from baseline to month 3 post-treatment in a pain numeric rating scale [0-10 points] during first steps in the morning, evaluated by an independent blinded observer. Calculations were based on intention-to-treat.

Results: No difference was found between the groups at baseline. At 3 months, the average pain score was 2.2+/-2.0 points for patients of Group I, and 4.1+/-1.5 points for patients of Group II. The mean between-group difference was 1.9 points (95% CI: [1.1-2.7 points]; P<.001). Significantly more patients of Group I achieved 50% reduction of pain compared to Group II (67% vs 29%, P<.001).

Conclusions: ESWT as applied should be done without LA in patients suffering from chronic heel pain. LA applied prior treatment reduced the efficiency of low-energy ESWT.

Extracorporeal Shock Wave Therapy without Local Anesthesia for Chronic Lateral Epicondylitis
Frank A. Pettrone, MD1 and Brian R. McCall, MD2

Investigation performed at the Virginia Hospital Center, Arlington, Virginia, and the Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC

Background: The use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis is controversial. The purpose of this study was to evaluate the use of extracorporeal shock wave therapy without local anesthesia to treat chronic lateral epicondylitis.

Methods: One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that was unresponsive to conventional therapy were randomized into double-blind active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy without anesthetic or a sham treatment. Patients had a physical examination, including provocation testing and dynamometry, at one, four, eight, and twelve weeks and at six and twelve months after treatment. Radiographs, laboratory studies, and electrocardiograms were also evaluated prior to participation and at twelve weeks. A visual analog scale was used to evaluate pain, and an upper extremity functional scale was used to assess function. Crossover to active treatment was initiated for nonresponsive patients who had received the placebo and met the inclusion criteria after twelve weeks.

Results: A total of 108 of the 114 randomized patients completed all treatments and the twelve weeks of follow-up required by the protocol. Sixty-one patients completed one year of follow-up, whereas thirty-four patients crossed over to receive active treatment. A significant difference (p = 0.001) in pain reduction was observed at twelve weeks in the intent-to-treat cohort, with an improvement in the pain score of at least 50% seen in 61% (thirty-four) of the fifty-six patients in the active treatment group who were treated according to protocol compared with 29% (seventeen) of the fifty-eight subjects in the placebo group. This improvement persisted in those followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). Crossover patients also showed significant improvement after twelve weeks of active treatment, with 56% (nineteen of thirty-four) achieving an improvement in the pain score of at least 50% (p < 0.0001).

Conclusions: These results demonstrate that low-dose shock wave therapy without anesthetic is a safe and effective treatment for chronic lateral epicondylitis.