Extracorporeal Shockwave Therapy
Shockwave Therapy (SWT)
Referrer Information
Indications:
Patients who present with a chronic tendinopathy listed below which has failed to respond to standard physiotherapy :
o Plantar fasciopathy
o Achilles tendinopathy
o Medial tibial stress syndrome
o Patellar tendinopathy
o Gluteal tendinopathy
o Proximal hamstring tendinopathy
o Tennis elbow
o Golfer’s elbow
o Distal biceps tendinopathy
o Sub acromial pain:
▪ Rotator cuff tendinopathy
▪ Calcific tendinopathy
▪ Long bicipital tenosynovitis
When more invasive treatments including surgery are being considered.
No contraindications to SWT are present.
Precautions, contraindications and risk factors:
SWT is still an emerging treatment option. Further clarification is required regarding the use of SWT in the presence of certain pathologies and over certain areas of the body. When considering SWT as a treatment option for your patient, it is essential to employ thorough clinical reasoning and err on the side of caution, especially in the initial stages. The following is not a definitive list. It is based on the best currently available evidence and expert opinion.
• Application over lungs and other air filled tissues
Air filled tissue can be damaged by SWT (strict contraindication).
• Application over bowels
Commonly listed as a contraindication however definitive reasoning as to why is not well documented. Presumably this is because of the potential for tissue damage (air filled tissue can be damaged by SWT).
• Application over active epiphyseal regions in those who have not reached skeletal maturity
The effects of SWT on epiphyseal regions are unclear at present. Until there is greater clarity it should be avoided.
• Application over major blood vessels
Application over major blood vessels should be avoided due to the risk of causing an embolism.
• Over major nerves
Commonly listed as a contraindication however definitive reasoning as to why is not well documented. Presumably this is because of the potential for significant discomfort and possible nerve damage.
• Pregnancy
This is a strict contraindication to SWT.
• Tumours
Due to a lack of clarity on the effects of SWT on tumours, treatment over such areas should be avoided at present.
• Cardiac implants
SWT should not be carried out on those with a pacemaker. The effect of SWT over cardiac implants such as stents or valves has not been evaluated and should be avoided.
• Blood clotting disorders, antiplatelet or anticoagulant medications (such as aspirin, clopidogrel, apixaban, warfarin or rivaroxaban)
SWT can induce visible tissue damage as a result of microvascular disruption. This can lead to erythyma, skin petechiae or haematoma.
• Areas of reduced sensation or ischaemic tissues
SWT should not be utilized over areas of reduced sensation or ischaemic tissues.
• Joint replacements
SWT may have a prosthetic loosening effect and thus should be avoided over joint replacements.
• Steroid injection in the last 12 weeks
Due to the risk of tendon rupture, SWT should not be carried out until at least 12 weeks post steroid injection.
• A history of tendon rupture
In light of the risk of tendon rupture, careful clinical reasoning should be employed before committing to SWT with such patients.
• Post surgical and open wounds
Application over post surgical and open wounds is contraindicated.
• Local infection
The effect of SWT over an area of infection is unknown at present and should be avoided.
• Area of inflammation
In light of the pro inflammatory effect of SWT, application over actively inflamed tissues should be avoided.
• Area of irritated skin
Application over delicate or damaged skin should be avoided.
• Allergies
Certain coupling agents may contain latex. For patients with a latex allergy, the coupling agent (gel) to be utilized should be checked prior to considering SWT.
• Non Steroidal Anti-Inflammatory Drugs (NSAIDS)
It is believed that SWT enhances tissue repair via stimulation of an inflammatory response therefore NSAIDS should be stopped at least 2 weeks prior to starting SWT and where possible they should not be taken during the course of treatment.
Treatment Dose and application:
The shockwave machine currently used in our service is the EMS Swiss Dolorclast Master. Please see for further information regarding suggested treatment settings. Bar and frequency settings can be altered in order to adjust for patient comfort (high frequency, low bar, tolerated best). Current evidence from Tim Watson’s website regarding treatment dose suggests:
• Low - medium energy (up to 0.28mJ/mm2) as appropriate / tolerated.
• 1000 - 2000 shocks per session.
• 3-5 treatment sessions (up to 7 for more recalcitrant lesions).
Unlike ultrasound therapy, the applicator head does not need to be in constant motion during treatment, however it is advisable to regularly adjust head position for optimal treatment and patient comfort. Treatment may be uncomfortable, NPRS < 7/10. Please see for videos demonstrating application.
Please see for further clarity regarding any of the information provided above.
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Date published: April 2018
NHS GG&C
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