Is Shockwave Therapy a Good Treatment for Your Patient?

When patients come to see us with tendon problems, we often talk about a range of potential treatment options. The fact that we're talking about multiple options, and not a single gold standard treatment, illustrates some of the problems associated with treating tendon pathology. We simply don't have one single treatment that reliably helps all patients. While the mainstay of treating tendinopathy is a progressive strengthening program combined with careful control of training loads this does not always work. In this situation, there are a range of other treatments that can be effective. One of these treatments is called extracorporeal or radial shockwave therapy.

Radial shockwave therapy is a slightly strange treatment. Each treatment involves hitting the painful tendon repeatedly with a small jackhammer like device. This is often quite painful for the patient, especially where the tendons are near the surface. For most patients, a total of 2000 shocks are delivered over a period of 5-10 minutes. The speed and intensity of these shocks can be varied to make sure that it is not too uncomfortable. Most patients have a total of three sessions over three weeks.

The treatment has been around for a number of decades but over the past few years has become increasingly popular in New Zealand. Most patient who receive it notice that there is an immediate reduction in their pain following each treatment session. This analgesic (pain-relieving) effect occurs through what is known as 'hyperstimulation anaesthesia'. The treatment stimulates the nerves supplying the painful tendon, reducing their activity and decreasing or eliminating pain. Shockwave therapy also alters the release of the pain mediator and growth factor Substance P. Substance P is responsible for the slight discomfort during and after shock wave treatment. Over time the shock waves lead to the depletion of Substance P, less Substance P in the tissue results in reduced pain. Finally, radial shock waves can also produce a regenerative or tissue-repairing effect in musculoskeletal tissues. This appears to be by stimulating the release of growth factors and by improving the blood supply to the tendon. This in turn can lead to repair of the tendon. This final mechanism is most likely to be what leads to a longer-term improvement in symptoms. The best results are generally seen 12 weeks after the treatment is delivered.

Shockwave therapy can be useful for most tendon problems. The best evidence is for plantar fascia pain. Other clinical trials show that it is as effective as three months of eccentric strengthening for Achilles tendinopathy, is an effective treatment for proximal hamstring tendinopathy in professional athletes and that it is superior to eccentric strengthening and more 'traditional' rehabilitation techniques for insertional Achilles tendinopathy. There is also good evidence for other conditions including trochanteric pain and tennis/golfers elbow.

At Axis we use a Swiss Dolorclast system. This is the machine that much of the available clinical research has been conducted on. For this reason, we can be confident that we can replicate the results of these clinical trials. Many of the machines that are available in New Zealand do not have the same evidence base. The treatment is delivered by one of our practice nurses who is trained in the delivery of this procedure.