What is the evidence for extracorporeal shock-wave therapy on pain reduction in patients with various tendinopathies?
AMSTAR Rating
Summary
Patient Population:
45 randomized control trials (RCTs) were included in this meta-analysis, totaling 2853 participants (average age of 44.24 years). All patients in this meta-analysis were diagnosed with a type of tendinopathy. Specifically, 13 studies focused on the outcome of plantar fasciitis (PF), 3 studies examined the outcome of chronic Achilles tendinopathy (CAT), 22 studies investigated lateral epicondylitis (LE), 3 studies explored rotator cuff tendinopathy (RC tendinopathy), and 5 studies examined patellar tendinopathy (PT).
Intervention:
1420 participants received extracorporeal shock wave therapy (ESWT) as an intervention in the experimental groups. The type of ESWT in the studies included focused shock wave (FoSW) and radial shock wave (RaSW).
Comparison:
1433 participants were included in comparison groups which ranged in interventions excluding ESWT. These interventions included different pain-relieving methods such as corticosteroid injections (CSI), prolotherapy, ultrasound (US), conventional treatment, platelet-rich plasma (PRP) or autologous conditioned plasma (ACP), eccentric loading, exercise and placebo.
Outcome:
The main outcome measure was the visual analogue scale (VAS) score for pain assessed between one week and 80 weeks in various studies.
- Pooled results of mean VAS scores in patients with PF demonstrated a significant reduction in pain in ESWT groups compared to comparison groups with a standard mean difference (SMD) of –1.63 (95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). Specifically, RaSW reduced pain with a SMD of –0.26 (95% CI: -1.96, -0.01; I2: 99.60%; P heterogeneity: 0.001), and FoSW with a SMD of –1.98 (95% CI: -3.55, -0.42; I2: 94.16%; P heterogeneity: 0.001).
- Subgroup analysis demonstrated that ESWT significantly reduced mean pain in PF patients when their age exceeded 30 years (SMD age > 30: -2.02, 95% CI: -3.69, -0.35; I2: 87.49%; P heterogeneity: 0.0001) and when their BMI was higher than 25 (SMD BMI>25: -2.80, 95% CI: -6.64, -0.05; I2: 58.95%; P heterogeneity: 0.0001).
- Subgroup analysis revealed that ESWT has a significant effect on reducing PF patient pain when the frequency is less than 10 Hz (SMD HZ<10: -5.93, 95% CI: -8.65, -3.20; I2: 68.27%; P heterogeneity: 0.080) and the pulse is less than 2000 (SMD Plus<10: -2.77, 95% CI: -4.45, -1.08; I2: 77.01%; P heterogeneity: 0.001).
- Subgroup analysis indicated that the effect of ESWT on reducing pain was greater when the treatment consisted of five or more sessions in PF patients (SMD: -3.75, 95% CI: -7.21, -0.28; I2: 47.97%; P heterogeneity: 0.098).
- PF subgroup analysis revealed that ESWT significantly reduced mean pain at 5-10 weeks (SMD: –0.34; 95% CI: –2.07, –0.01; P: 0.001), 10-15 weeks (SMD: -4.33; 95% CI: -9.72, -1.06; P: 0.001), 15-20 weeks (SMD: -3.13; 95% CI: -6.99, -0.73; P: 0.001), and >20 (SMD: -0.91; 95% CI: -4.05, -0.23; P: 0.001)
- Pooled analysis of patients with LE demonstrated a significant reduction in pain with a SMD of –0.63 (95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003) in ESWT groups compared to comparison groups. Additionally, the effect of ESWT was strongest in patients with chronic LE compared to other patients (SMD: -1.02; 95% CI: -2.22, -0.18; I2: 89.72%; P heterogeneity: 0.0001).
- Subgroup analysis revealed that compared to US (SMD: -1.94; 95% CI: -4.24, -0.36; I2: 88.79%; P heterogeneity: 0.001) and CSI (SMD: -1.19; 95% CI: -3.55, -0.38; I2: 77.12%; P heterogeneity: 0.001), ESWT showed a greater effect in patients with LE.
- In LE patients, pain showed greatest reduction with frequency below 15 (SMD: -1.38; 95% CI: -2.06, 0.70; I2: 41.49%; P heterogeneity: 0.097) and pulse above 2000 (SMD: -3.54; 95% CI: -5.54, -1.55; I2: 79.59%; P heterogeneity: 0.79-0.59).
- Subgroup analysis indicated that the effect of ESWT on reducing pain was also greater when the treatment consisted of five or more sessions in LE patients (SMD: -1.12; 95% CI: -4.16, -0.02; I2: 86.99%; P heterogeneity: 0.0001).
- LE subgroup analysis revealed that ESWT significantly reduced mean pain at 5-10 weeks (SMD: –0.45; 95% CI: –1.58, –0.04; P: 0.001), 10-15 weeks (SMD: -1.60; 95% CI: -3.26, -0.05; P: 0.001), and >20 (SMD: -1.87; 95% CI: -3.61, -0.23; P: 0.001).
- In patients with CAT, ESWT group pain scores decreased by a SMD of –1.38 (95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001) compared to comparison groups.
- In patients with RC tendinopathy, ESWT group pain scores decreased by a SMD of -2.37 (95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001) compared to comparison groups.
- In patients with PT, ESWT group pain scores increased by a SMD of 1.36 (95% CI: 0.99, 1.73; I2: 97.73%; P heterogeneity: 0.0001) compared to comparison groups.
Guideline Recommendations
| Source | Recommendation |
|---|---|
| Journal of Orthopaedic & Sport Physical Therapy (2025) | Weak Evidence to NOT use for rotator cuff tendinopathy, BUT weak evidence to CONSIDER if calcific tendinopathy |
| BJSM Best Practice Guide (2021) | Strong to limited SUPPORT for Plantar Fasciitis |
| UBC Lateral Epicondyle Toolkit (LET) (2022) | Can CONSIDER use in chronic or acute LE |
| NICE guidelines (2016) | Inconsistent and Limited evidence for Achilles tendinopathy |
Outcomes Assessed
- Benefit
- Harm
- Inconclusive
Pain v. control
Plantar Fasciitis
Lateral Epicondylopathy
Rotator Cuff Tendinopathy
Chronic Achilles Tendinopathy
Patellar Tendinopathy
Relevant Clinical Info
Collins, E. D., Hildreth, D. H., & Jafarnia, K. K. (2011). A clinical study of extracorporeal shock waves (ESW) for treatment of chronic lateral epicondylitis. Current Orthopaedic Practice, 22(2), 185–192. https://doi.org/10.1097/BCO.0b013e31820d830e.
Collins, Hildreth, & Jafarnia (2011) was the largest RCT in this meta-analysis that examined the impact of ESWT on LE. A total of 183 patients (Male=87, Female=96, average age of 46 years) were split into two groups. All participants were diagnosed with chronic LE for at least six months and were previously unresponsive to other conservative treatments. The active treatment group received 1500 shocks delivered at a power setting of 18 k V from an OssaTron ESWT device performed with a local anesthetic or Bier block during a treatment time of 20.5 minutes. The placebo group received the same, except with a Styrofoam block placed against the coupling membrane of the shock head to absorb shockwaves. A fluid filled IV bag was also placed between the Styrofoam block and the patient’s elbow to mimic the feel of the coupling membrane. The “success” status for each participant was based on meeting three criteria: (1) a blinded investigator’s assessment of pain showing a minimum of 50% improvement from baseline and 10-cm VAS score of no more than 4.0; (2) participant’s self-assessment of pain with activity showing a minimum of 50% improvement from baseline with a VAS pain score of no more than 4.0; (3) participant not taking any analgesics for elbow pain at an 8-week follow-up visit. Researchers found that 40% of the active treatment participants met the success criteria at 8 weeks, compared to only 21% of placebo participants. The mean VAS score decreased from 7.73 to 3.64 at 8 weeks in the ESWT group (surpassing the minimum clinically important difference [MCID] of 3.0), compared to 7.81 to 5.17 at 8 weeks in the placebo group. At baseline 60.2% of active treatment participants and 62.2% of placebo participants routinely took medication for elbow pain. At 8 weeks, the ESWT group dropped to 29.1% and the placebo group dropped to 31.3%. Participant 36-item short form survey (SF-36) scores assessing function also increased from a mean of 30.7 to 33.0 at 4 weeks, 34.4 at 8 weeks, 38.1 at 12 weeks, 38.9 at 6 months, and 40.3 at 12 months in the ESWT group. In the placebo group, SF-36 scores increased from a mean of 28.2 to 32.4 at 4 weeks, 32.4 at 8 weeks, 37.9 at 6 months, and 41.0 at 12 months. A total of 98 minor complications related to the device and procedure (including localized swelling, bruising, petechia, and reaction to anesthetics) were reported in both groups.
Participant Information
The sample size was 2853
Mean age of 44.24 years.
There were 45 studies used.
