Systematic Review: Extracorporeal Shockwave Therapy for Athletes and Physically Active Individuals
Takeaways
- This is the first systematic review of extracorporeal shockwave therapy (ESWT) that focused on its results in athletes, physically active individuals with sports-type injuries, and people whose occupations require regular physical activity
- Based on the findings, ESWT may be considered an initial treatment option for patients with plantar fasciitis, lateral epicondylitis, proximal hamstring tendinopathy, distal biceps tendinopathy, or non-insertional Achilles tendinopathy
- ESWT may also be appropriate for patients with injuries such as medial tibial stress syndrome, osteitis pubis, or ischial apophysitis
- The procedure is well tolerated in young athletes as well as adults, with the most common adverse events being temporary erythema and pain at the application site
- Specific athletic populations that should be considered for ESWT are runners, soccer players, jumping athletes, and young athletes
Extracorporeal shockwave therapy (ESWT) is now considered a reasonable treatment option for athletes, especially because it often requires minimal or no time away from sport, and response can manifest as early as within one to three months. However, systematic reviews of ESWT have focused on pathologies (e.g., plantar fasciitis) rather than patient populations.
Hye Chang Rhim, MD, MPH, a PGY-4 resident in the Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation, Adam S. Tenforde, MD, a physician in the Department who specializes in non-surgical sports medicine, and colleagues recently completed the first systematic review of studies in which ESWT was administered to athletes, physically active individuals with sports-type injuries and people whose occupations require regular physical activity, such as military cadets.
In the British Journal of Sports Medicine, they conclude from limited high-level studies that ESWT, alone or as an adjunct to exercise treatment, facilitates return to sport or activity in many conditions and has an excellent safety profile.
Methods
The reviewers conducted separate searches of PubMed, Embase, CINAHL Complete (nursing and allied health research), and Web of Science on April 21, 2023. They selected randomized controlled trials (RCTs), cohort studies, case-control studies, case series, and case reports. Studies in which ESWT was used to treat hypertonia or spasticity were excluded.
The review included 56 studies (n=1,874 individuals). Only 18 studies (32%) provided level I evidence (from randomized controlled trials).
Results by Study Design
Most of the studies could be categorized into one of three groups:
ESWT versus no treatment or standard treatment—In plantar fasciitis and lateral epicondylitis, RCTs showed superior outcomes with ESWT over sham ESWT. In contrast, in patellar tendinopathy and medial tibial stress syndrome (MTSS), RCTs demonstrated no significant differences between ESWT and no treatment.
In proximal hamstring tendinopathy, one RCT showed more favorable results of ESWT over standard care. In distal biceps tendinopathy, one retrospective study found that ESWT resulted in more favorable outcomes compared with physical therapy.
ESWT + standard of care versus sham ESWT + standard of care—Three RCTs in patellar tendinopathy had mixed results when comparing ESWT plus exercise intervention with sham ESWT plus exercise intervention. In MTSS, on the other hand, ESWT was associated with more favorable outcomes when added to exercise programs in one RCT and two comparative studies.
In osteitis pubis and ischial apophysitis, one RCT and one observational study demonstrated that ESWT along with PT facilitated faster return to play in athletes compared with PT alone.
ESWT versus other treatments—In patellar tendinopathy, one RCT showed that ESWT resulted in more favorable outcomes than a combination of acupuncture, ultrasonic wave therapy and microwave therapy. In another RCT, platelet-rich plasma appeared to have more benefits in terms of pain and functional improvement. An observational study showed that pain and functional outcomes following ESWT at 24 weeks and two years were comparable to surgical outcomes at two years.
In plantar fasciitis, a prospective study showed that surgery resulted in better pain and function scores, but return to activity tended to be faster with ESWT.
In Achilles tendinopathy, ESWT appeared in RCTs to have similar efficacy as mesotherapy when combined with an exercise program. However, it allowed better activity-related pain relief than ultrasound therapy in non-insertional Achilles tendinopathy.
Efficacy in Young Athletes
The reviewers found cases in which ESWT had promising results in terms of improving pain and facilitating return to play in athletes under age 18 who had patellar tendinopathy, ischial apophysitis, osteochondritis dissecans, resistant stress fractures or delayed union of avulsion fracture. No high-level studies were available, though.
Safety
The safety profile of ESWT is one of its advantages. The procedure was well tolerated in young athletes as well as adults. The most common adverse events were temporary erythema and pain at the application site.
Patient Selection
The paper provides detailed findings according to type of pathology and type of sport. In summary:
- In plantar fasciitis, lateral epicondylitis, proximal hamstring tendinopathy, distal biceps tendinopathy and non-insertional Achilles tendinopathy, ESWT may be considered an initial treatment option
- ESWT can be considered for patients with injuries such as MTSS, osteitis pubis and ischial apophysitis, but it may be less effective as an added treatment for patellar tendinopathy
- Specific athletic populations that should be considered for ESWT are runners, soccer players, jumping athletes and young athletes