Beyond Physiotherapy: Shockwave Therapy in Upper Limb Tendinopathies
DOI:
https://doi.org/10.25759/spmfr.508Keywords:
Extracorporeal Shockwave Therapy, Shoulder Tendinopathy, Epicondylitis, Upper Limb TendinopathiesAbstract
Introduction and objectives: Shoulder Tendinopathy (ST) and Epicondylitis (EL) result in pain and functional disability. Although most cases improve with the use of conservative treatments, the risk of recurrence is high. In this context, Extracorporeal Shock Wave Therapy (ESWT) seems to be a safe, effective and non-invasive treatment. Objective: to gather the most recent knowledge about ESWT in upper limb tendinopathies.
Material and Methods: This article consists in a Evidence- Based Review. Systematic Reviews (RS), Meta-analyses (MA), Randomized Clinical Studies (RCT) and Guidelines were included, in English, Portuguese and Spanish, published between January 2017 and June 2023. Exclusion criteria were articles published in non-peer-reviewed journals, ongoing studies or with an additional cost. Pubmed, Cochrane Library, ClinicalTrials.gov and webpages from international societies were consulted. For levels of evidence, the Strength of Recommendation Taxonomy (SORT) was used.
Results: Of 118 articles, 35 were selected. Regarding Calcific ST, ESWT is considered by international guidelines as a first-line treatment. Four RS, three MA and five RCTs included corroborate this indication. Two of the RS found no differences comparing ESWT with other therapies. Regarding Lateral EL, ESWT is considered by the Guidelines as a treatment when it is refractory to treatment. The evidence included supports this recommendation, with three RS, three MA and thirteen RCT reporting improvements in elbow pain and functionality. However, two RS found no differences when compared with other methods. Adverse effects were transient and infrequent.
Conclusions: Most articles were classified as NE 1, however, the protocols used by the articles in applying ESWT were heterogeneous. We attributed a Strength of Recommendation B to the use of ESWT in these two pathologies - a safe and effective technique, with infrequent adverse effects, but more studies with standardized protocols are needed.
Downloads
References
Burton I. Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: a narrative review. Sports Med Health Sci. 2022;4(1):8–17.
Testa G, Vescio A, Perez S, Consoli A, Costarella L, Sessa G, et al. Extracorporeal shockwave therapy treatment in upper limb diseases: a systematic review. J Clin Med. 2020;9(2):453.
Pereira Dias R. Approach to shoulder pain in primary health care: a literature review. Gaz Médica [Internet]. 2021 [cited 2023 Jul 16]. Available from: https://gazetamedica.pt/index.php/gazeta/article/view/518
Hawk C, Minkalis AL, Khorsan R, Daniels CJ, Homack D, Gliedt JA, et al. Systematic review of nondrug, nonsurgical treatment of shoulder conditions. J Manipulative Physiol Ther. 2017;40(5):293–319.
Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, et al. An update of systematic reviews examining the effectiveness of conservative physiotherapy interventions for subacromial shoulder pain.
Vaz R, Silva Á, Cordeiro A. Musculoskeletal pathology for family physicians. 3rd ed. [Place of publication]: [Publisher]; [Year].
Fatima A, Darian H, Gilani SA, Ahmad A, Hanif A, Kazmi S. Role of extracorporeal shockwave therapy in patients with rotator cuff tendinopathy: a synthesis of the last two decades. J Pak Med Assoc. 2021;1–16.
Yao G, Chen J, Duan Y, Chen X. Efficacy of extracorporeal shock wave therapy for lateral epicondylitis: a systematic review and meta-analysis. Biomed Res Int. 2020;2020:1–8.
Zheng C, Zeng D, Chen J, Liu S, Li J, Ruan Z, et al. Effectiveness of
Buckle P, Devereux J. Work-related neck and upper limb musculoskeletal disorders. Luxembourg: Office for Official Publications of the European Communities; 1999.
Menta R, Randhawa K, Cote P, Wong JJ, Yu H, Sutton D, et al. The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review. J Manipulative Physiol Ther. 2015;38(7):507-20.
Authority for Working Conditions. Activity report 2019 [Internet]. 2019 [cited 2023 Jun]. Available from: https://portal.act.gov.pt/Pages/dnptst_relations_oit.aspx
Auersperg V, Trieb K. Extracorporeal shock wave therapy: an update. EFORT Open Rev. 2020;5(10):584-92.
International Society for Medical Shockwave Therapy. ISMST guidelines [Internet]. [cited 2023 May]. Available from: https://shockwave therapy.org/ismst-guidelines/
Surace SJ, Deitch J, Johnston RV, Buchbinder R. Shock wave therapy for rotator cuff disease with or without calcification. Cochrane Database Syst Rev. 2020;(3):CD008962.
Castro BKC, Correa FG, Maia LB, Oliveira VC. Effectiveness of conservative therapy in tendinopathy-related shoulder pain: a systematic review of randomized controlled trials. Phys Ther Sport. 2021;49:15-20.
Wu YC, Tsai WC, Tu YK, Yu TY. Comparative effectiveness of nonoperative treatments for chronic calcific tendinitis of the shoulder: a systematic review and network meta-analysis. Arch Phys Med Rehabil. 2017;98(8):1678-1692. e6.
Simpson M, Pizzari T, Cook T, Wildman S, Lewis J. Effectiveness of nonsurgical interventions for rotator cuff calcific tendinopathy: a systematic review. J Rehabil Med. 2020.
Arirachakaran A, Boonard M, Yamapahi S, Prommahachai A, Kesprayura S, Kongthavornsukul J. Extracorporeal shock wave therapy, ultrasound- guided percutaneous lavage, corticosteroid injection and combined treatment for rotator cuff calcific tendinopathy: a network meta-analysis of RCTs. Eur J Orthop Surg Traumatol. 2017;27(3):381-90.
Zhang T, Duan Y, Chen J, Chen X. Efficacy of ultrasound- guided percutaneous lavage for rotator cuff calcific tendinopathy: a systematic review and meta-analysis. Medicine (Baltimore). 2019;98(21):e15552.
Louwrens JKG, Siervelt IN, Kramer ET, Boonstra R, van den Bekerom MPJ, van Royen BJ, et al. Comparing ultrasound- guided needling combined with subacromial corticosteroid injection versus high- energy extracorporeal shockwave therapy for calcific tendinitis of the rotator cuff: a randomized controlled trial. Arthroscopy. 2020;36(7):1823-1833. e1.
Abo Al- Khair MA, El Khouly RM, Khodair SA, Elsergany MAS, Hussein MI, Mowafy ME. Focused, radial and combined shock wave therapy in the treatment of calcific shoulder tendinopathy. Phys Sportsmed. 2021;49(4):480-7.
Fatima A, Ahmad A, Gilani SA, Darian H, Kazmi S, Hanif K. Effects of high- energy extracorporeal shockwave therapy on pain, functional disability, quality of life, and ultrasonographic changes in patients with calcified rotator cuff tendinopathy. Biomed Res Int. 2022;2022:1-9.
Li C, Li Z, Shi L, Wang P, Gao F, Sun W. Effectiveness of focused shockwave therapy versus radial shockwave therapy for noncalcific rotator cuff tendinopathies: a randomized clinical trial. Biomed Res Int. 2021;2021:1-9.
Frizziero A, Vittadini F, Barazzuol M, Gasparre G, Finotti P, Meneghini A, et al. Extracorporeal shockwave therapy versus hyaluronic acid injection for painful non- calcific rotator cuff tendinopathies: preliminary results. J Sports Med Phys Fitness. 2017;57(9).
Yoon SY, Kim YW, Shin IS, Moon HI, Lee SC. Does the type of extracorporeal shockwave therapy influence treatment effectiveness in lateral epicondylitis? A systematic review and meta- analysis. Clin Orthop Relat Res. 2020;478(10):2324-39.
Cheema AS, Doyon J, Lapner P. Transcutaneous electrical nerve stimulation (TENS) and extracorporeal shockwave therapy in lateral epicondylitis: a systematic review and meta-analysis. JSEs Int. 2023;7(2):351-6.
Liu WC, Chen CT, Lu CC, Tsai YC, Liu YC, Hsu CW, et al. Extracorporeal shock wave therapy shows superiority over injections for pain relief and grip strength recovery in lateral epicondylitis: a systematic review and network meta-analysis. Arthroscopy. 2022;38(6):2018-2034.e12.
Xiong Y, Xue H, Zhou W, Sun Y, Liu Y, Wu Q, et al. Shockwave therapy versus corticosteroid injection for lateral epicondylitis: a meta-analysis of randomized controlled trials. Phys Sportsmed. 2019;47(3):284-9.
Yan C, Xiong Y, Chen L, Endo Y, Hu L, Liu M, et al. Comparative efficacy of ultrasound and extracorporeal shock wave therapy in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019;14(1):248.
Yalvaç B, Mesci N, Geler Külcü D, Yurdakul OV. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc. 2018;52(5):357-62.
Celik D, Anaforoglu Kulunkoglu B. Photobiomodulation therapy versus extracorporeal shock wave therapy in the treatment of lateral epicondylitis. Photobiomodul Photomed Laser Surg. 2019;37(5):269-75.
Atalay SG, Gezginaslan Ö. Effect of neural therapy versus extracorporeal shock wave therapy for lateral epicondylitis: a randomized controlled trial. Eur J Integr Med. 2020;39:101210.
Çorum M, Başoğlu C, Yavuz H, Aksoy C. Comparison of radial extracorporeal shock wave therapy and supervised exercises with neuromuscular inhibition technique in lateral epicondylitis: a randomized controlled trial. Turk J Phys Med Rehabil. 2021;67(4):439-48.
Şahbaz T, Medin Ceylan C, Karacay BC, Korkmaz MD, Diracoğlu D. Comparison of platelet-rich plasma and extracorporeal shock wave therapy in patients with chronic lateral epicondylitis: a prospective randomized controlled study. Turk J Phys Med Rehabil. 2021;67(4):490-501.
Guler T, Yildirim P. Comparison of the efficacy of kinesiotaping and extracorporeal shock wave therapy in patients with newly diagnosed lateral epicondylitis.
Özmen T, Koparal SS, Karataş Ö, Eser F, Özkurt B, Gafuroğlu Ü. Comparison of clinical and sonographic effects of ultrasound therapy, extracorporeal shock wave therapy, and kinesio taping in lateral epicondylitis. Turk J Med Sci. 2021;51(1):76-83.
Altun RD, Incel NA, Cimen OB, Sahin G. Efficacy of extracorporeal shock wave therapy for lateral epicondylitis treatment: comparison with physical therapy modalities. J Musculoskelet Res. 2018;21(1):1850001.
Abadi T, Esmaeili Jamkarani M, Raissi GR, Mansoori K, Emami Razavi SZ, Sajadi S. Prolotherapy versus radial extracorporeal shock wave therapy in the short-term treatment of lateral epicondylosis: a randomized clinical trial. Pain Med. 2019;20(9):1745-9.
Aldajah S, Alashram AR, Amino G, Romagnoli C, Padua E. Analgesic effect of extracorporeal shock wave therapy in individuals with lateral epicondylitis: a randomized controlled trial. J Funct Morphol Kinesiol. 2022;7(1):29.
Nambi G, Alghadier M, Ebrahim EE, Verma A, Aldhafian OR, Mohamed SHP, et al. MRI and ultrasound analysis of corticosteroid injection combined with extracorporeal shockwave therapy in lateral epicondylitis: a randomized double-blind placebo-controlled trial. J Pers Med. 2022;12(11):1892.
Kaplan S, Sah V, Ozkan S, Adanas C, Delen V. Comparative effects of focused and radial extracorporeal shock wave therapies on lateral epicondylitis: a randomized sham-controlled trial. 2023.
Defoort S, De Smet L, Brys P, Peers K, Degeef I. Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy. Hand Surg Rehabil. 2021;40(3):263-7.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Revista da Sociedade Portuguesa de Medicina Física e de Reabilitação
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Copyright statement
Authors must also submit a copyright statement (as seen below) on article submission.
To the Editor-in-chief of the SPMFR Journal:
The below signed author(s) hereby state that the article
________________________________________ (ref. MFR_________) is
an original unpublished work and all facts stated are a product of the author(s) investigation. This article does not violate any copyright laws or privacy statements. The author(s) also hereby confirm that there is no conflict of interest's issues in this article.
By submitting this article the author(s) agree that after publication all copyrights belong to the SPMFR Journal.
Signed by all authors
Date:
Names (capital letters):
Signatures:
The SPMFR Journal’s contents are follow a Creative Commons licence. After publication the authors can hand out the articles as long as the SPMFR Journal is credited.
