Shockwave Therapy for Pain Associated with Lower Extremity Orthopedic Disorders: A Review of the Clinical and Cost-Effectiveness [Internet]

Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Sep 16.


Orthopedic disorders encompass a variety of conditions including rotator cuff tendinopathy (shoulder disorder), epicondylitis (elbow disorder), patellar tendinosis (knee disorder) and plantar fasciitis (foot disorder) and are often associated with pain. Disorders such as these may be associated with decreased productivity or disability that may last several months resulting in a financial burden to society. Conventional therapies used in general practice to manage pain include rest, ice, nonsteroidal anti-inflammatory drugs, physical therapy, and subacromial corticosteroid injections. Patients unresponsive to such therapies may need to undergo surgical procedures. Shockwave therapy (SWT) may be an alternative to surgical procedures which can be expensive and associated with risk. Other therapeutic modalities include laser therapy, radiation therapy, and transcutaneous electric nerve stimulation (TENS).

SWT involves acoustic waves which carry energy to painful spots and musculoskeletal tissues with subacute, subchronic and chronic conditions. This energy assists in regeneration and repair of bones, tendons and other soft tissues. The exact mechanism of action is not clear. The interaction of shockwaves with tissue is thought to cause analgesia by over stimulation of the treated site resulting in reduced signal transmission to the brainstem, stimulation of tissue healing, breakdown of calcification, alteration of cell membrane permeability, and alteration of cell activity through cavitation. Devices used for SWT vary in design, depending on the way shockwaves are generated and the level of energy that they can produce. SWT includes focused shockwave therapy (FSWT) and radial shockwave therapy (RSWT). FSWT is based on shockwaves of single pressure pulses of a microsecond duration, which are focused on a specific target using ultrasound or radiography guidance. The methods to generate focused shockwaves include electrohydraulic, electromagnetic, or piezoelectric mechanisms. The focused shockwaves are generated in water (inside the applicator) and, as the acoustic impedance of water and biological tissue is comparable, this results in limited reflection and better transmission of the waves into the body. The radial shockwaves for RSWT are generated by acceleration of a projectile, using compressed air, through a tube at the end of which is the applicator. The applicator transmits the generated pressure waves into the body. SWT has been used for over two decades for the treatment soft tissue and bone related musculoskeletal disorders. There is however some debate regarding the effectiveness of SWT compared to placebo or other treatment modalities.

A previous CADTH report reviewed the clinical effectiveness and cost-effectiveness of shockwave therapy for pain associated with upper extremity orthopedic disorders. It reported that compared with placebo, high energy SWT was effective in reducing pain in calcific but not in non-calcific tendinitis of the shoulder. Findings on the effectiveness of SWT compared with placebo for treating epicondylitis were inconsistent and no relevant cost-effectiveness studies were identified. The purpose of this report is to review the clinical effectiveness and cost-effectiveness of shockwave therapy for pain associated with lower extremity orthopedic disorders.

Publication types

  • Review