Extracorporeal shockwave therapy
Encyclopedia
Extracorporeal Shockwave Therapy or ESWT is a method of treatment for multiple tendonopathies.
Presently this technology is only approved in the US by the Food and Drug Administration
(FDA) for treatment of plantar fasciitis
and tennis elbow
. In the future possible approvals may be given to treat patella tendinitis, shoulder
tendinitis, achilles
tendinitis, pseudoarthrosis, stress fracture
s and shoulder calcification. There is also an FDA study to treat recalcitrant diabetic wound
s.
There are several theories as to how ESWT may or may not help promote better healing. The most accepted one is that the microtrauma
of the repeated shock wave
to the affected area creates neo-vascularization (new blood
flow) into the area. It is this new blood flow that promotes tissue healing. The second theory is that in chronic pain, the brain has "forgotten" about the pain and is doing nothing to heal the area. By having shockwave therapy a new inflammatory process is created and the brain can react to it by sending the necessary body nutrient
s to the area to promote healing
.
For treatment of heel
pain the FDA study criteria are quite specific. A person has to have experienced heel pain for at least six months and had at least three other types of treatments (cortisone
injection
s, oral anti-inflammatory medication, orthotics, physical therapy
, etc.) without relief.
Contraindication
s for this procedure include: neurological and vascular
disease
of the foot
, history of rupture of the plantar fascial ligament
, open bone growth plates, pregnancy
, implanted metal in the area (bone screws and pins) and people on medication
that interferes with blood clotting such as coumadin
and prophylactic aspirin
.
The procedure used to be performed in an out-patient setting, under local anesthesia
, taking up to 30 minutes. Now with newer technology it can be done without anesthesia in the physician's office in less than 10 minutes. Research indicates that there is significant reduction in intensity of application pain with the use of castor oil
rather than ultrasound jelly. The positive effect of castor oil
can be explained by its cavitation
-free quality. The patient is afterwards able to walk out, the major complaint being of a thumping feeling on the heel.
Because re-inflammation is being introduced, the patient cannot take anti-inflammatory medication afterward, nor should they ice the area. Acetaminophen with codeine
may be utilized.
However the use of ESWT continues to expand across medical disciplines, such as cardiology, urology (erectile dysfunction), and wound applications.
Presently this technology is only approved in the US by the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
(FDA) for treatment of plantar fasciitis
Plantar fasciitis
Plantar fasciitis is a painful inflammatory process of the plantar fascia, the connective tissue on the sole of the foot.Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. The suffix...
and tennis elbow
Tennis elbow
Lateral epicondylitis or lateral epicondylalgia, also known as tennis elbow, shooter's elbow and archer's elbow, is a condition where the outer part of the elbow becomes sore and tender...
. In the future possible approvals may be given to treat patella tendinitis, shoulder
Shoulder
The human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...
tendinitis, achilles
Achilles tendon
The Achilles tendon , also known as the calcaneal tendon or the tendo calcaneus, is a tendon of the posterior leg. It serves to attach the plantaris, gastrocnemius and soleus muscles to the calcaneus bone.- Anatomy :The Achilles is the tendonous extension of 3 muscles in the lower leg:...
tendinitis, pseudoarthrosis, stress fracture
Stress fracture
A stress fracture is one type of incomplete fracture in bones. It is caused by "unusual or repeated stress" and also heavy continuous weight on the ankle or leg...
s and shoulder calcification. There is also an FDA study to treat recalcitrant diabetic wound
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...
s.
There are several theories as to how ESWT may or may not help promote better healing. The most accepted one is that the microtrauma
Microtrauma
Microtrauma is the general term given to small injuries to the body.Microtrauma can include the microtearing of muscle fibres, the sheath around the muscle and the connective tissue. It can also include stress to the tendons, and to the bones . It is unknown whether or not the ligaments adapt like...
of the repeated shock wave
Shock wave
A shock wave is a type of propagating disturbance. Like an ordinary wave, it carries energy and can propagate through a medium or in some cases in the absence of a material medium, through a field such as the electromagnetic field...
to the affected area creates neo-vascularization (new blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
flow) into the area. It is this new blood flow that promotes tissue healing. The second theory is that in chronic pain, the brain has "forgotten" about the pain and is doing nothing to heal the area. By having shockwave therapy a new inflammatory process is created and the brain can react to it by sending the necessary body nutrient
Nutrient
A nutrient is a chemical that an organism needs to live and grow or a substance used in an organism's metabolism which must be taken in from its environment. They are used to build and repair tissues, regulate body processes and are converted to and used as energy...
s to the area to promote healing
Healing
Physiological healing is the restoration of damaged living tissue, organs and biological system to normal function. It is the process by which the cells in the body regenerate and repair to reduce the size of a damaged or necrotic area....
.
For treatment of heel
Heel
In human anatomy, the heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, the calcaneus or heel bone, behind the articulation of the bones of the lower leg.- Human anatomy :...
pain the FDA study criteria are quite specific. A person has to have experienced heel pain for at least six months and had at least three other types of treatments (cortisone
Cortisone
Cortisone is a steroid hormone. It is one of the main hormones released by the adrenal gland in response to stress. In chemical structure, it is a corticosteroid closely related to corticosterone. It is used to treat a variety of ailments and can be administered intravenously, orally,...
injection
Injection (medicine)
An injection is an infusion method of putting fluid into the body, usually with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body...
s, oral anti-inflammatory medication, orthotics, physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
, etc.) without relief.
Contraindication
Contraindication
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment.Some contraindications are absolute, meaning that there are no reasonable circumstances for undertaking a course of action...
s for this procedure include: neurological and vascular
Blood vessel
The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
of the foot
Foot
The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws...
, history of rupture of the plantar fascial ligament
Plantar fascia
The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones .The often painful condition plantar fasciitis is an inflammatory condition of the plantar...
, open bone growth plates, pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
, implanted metal in the area (bone screws and pins) and people on medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
that interferes with blood clotting such as coumadin
Coumadin
*For the rodenticide class of anticoagulant poisons sometimes loosely referred to as coumadins or coumarins, see 4-hydroxycoumarins.*For the pharmaceutical with the trade name Coumadin, see warfarin....
and prophylactic aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
.
The procedure used to be performed in an out-patient setting, under local anesthesia
Local anesthesia
Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...
, taking up to 30 minutes. Now with newer technology it can be done without anesthesia in the physician's office in less than 10 minutes. Research indicates that there is significant reduction in intensity of application pain with the use of castor oil
Castor oil
Castor oil is a vegetable oil obtained from the castor bean . Castor oil is a colorless to very pale yellow liquid with mild or no odor or taste. Its boiling point is and its density is 961 kg/m3...
rather than ultrasound jelly. The positive effect of castor oil
Castor oil
Castor oil is a vegetable oil obtained from the castor bean . Castor oil is a colorless to very pale yellow liquid with mild or no odor or taste. Its boiling point is and its density is 961 kg/m3...
can be explained by its cavitation
Cavitation
Cavitation is the formation and then immediate implosion of cavities in a liquidi.e. small liquid-free zones that are the consequence of forces acting upon the liquid...
-free quality. The patient is afterwards able to walk out, the major complaint being of a thumping feeling on the heel.
Because re-inflammation is being introduced, the patient cannot take anti-inflammatory medication afterward, nor should they ice the area. Acetaminophen with codeine
Codeine
Codeine or 3-methylmorphine is an opiate used for its analgesic, antitussive, and antidiarrheal properties...
may be utilized.
Efficacy
The medical value of extracorporeal shockwave therapy is disputed. A number of both favorable and unfavorable studies exist, some utilizing deficient research practices.However the use of ESWT continues to expand across medical disciplines, such as cardiology, urology (erectile dysfunction), and wound applications.
External links
- ISMST International Society for Medical Shockwave Treatment
- General Information About Extracorporal Shock Wave Therapy commercial advocacy website promoting this treatment
- The Journal of Bone and Joint Surgery-Rompe et al. March 2002 pp. 335-341