I decided to add this information about shockwave to my website as I regularly see new patients who did not experience benefit from shockwave. Most of these patients had been treated well beyond 6-8 visits. The majority of them had either not been cautioned about abstinence from oral or injected steroids or anti-inflammatory pills, or had not been made aware that shockwave initiates but does not instantly create healing, or had been treated with an untrained technique which didn’t follow the protocols for optimal efficacy.
What is Shockwave? Shockwave is a non-surgical modality which stimulates, accelerates, or reactivates the body’s natural healing processes, promoting regeneration of healthy tissue while purging degenerated tissue. Licensed professionals use a gel-tipped soft applicator which sends high-speed sound waves into depth-targeted injured tissues to stimulate essential factors of inflammation. This energizes what is commonly referred to as a “healing cascade”, stimulating much-needed microcirculation throughout the injured area. I set the depth target by measuring reliable images…MRI or sonogram.
Although shockwave is used successfully for all stages of healing, I believe it’s especially valuable with chronic injury, i.e., injury which has been present beyond the earliest stages, and shortly thereafter, when tissues bleed and circulation and stem cell production is active. After two weeks or so, the injury migrates from this acute state into a sub-acute state, and in time may continue to degrade, achieving chronic status, wherein circulation in the injured tissue is significantly diminished versus the surrounding healthy tissue.1
Diminished circulation prolongs healing time. Our primordial physiology still reserves precious energy for tissues requiring it instantly, fight or flight. Our minds have discovered ways to heal things. Shockwave helps return injured tissue to the acute/subacute threshold by reactivating circulation in the damaged tissue. It has therefore gained the reputation of speeding healing time by 50% or more. I have attended seminars which provide training in the use of shockwave, as is suggested by the manufacturer of the device, but not enforced.2 The correct technique is precise and unwavering, and requires constant feedback from the patient and monitoring on the part of the provider to optimize the value of the session. Provider monitoring, however, should not be limited to the time the applicator is in use.3 I employ either direct (aka focused or ESWT), or radial (aka EPAT) shockwave machines, or both, based upon the nature of the injury and targeted tissues.
Indications: Shockwave therapy has been used worldwide since the 1980’s for such conditions as muscle, tendon and ligament injury, plantar fasciitis, stress fractures, certain non-union fractures, avascular bone necrosis, ganglion cysts, osteoarthritis, reduction of excessive scar, etc. Shockwave is intended to restore healthy tissues, ultimately to eliminate or significantly reduce pain.
Please recognize that optimal effects and tissue healing are not instant with shockwave. I am emphasizing this, despite a common phenomenon associated with shockwave, i.e., you may experience higher pain tolerance for up to 2 days after the session. I believe this phenomenon may lure a patient to sign up for a string of shockwave treatments ad infinitum. The reduced pain does not mean the injury has yet healed. Thus don’t increase your activity above what you could do pre-treatment. Human physiology still prevails.
Drink plenty of water during the series. A shockwave series is usually comprised of six to eight 10 to 15-minute sessions. To avoid either redundance or a lag in efficacy, and to optimize your continuous 90-180-day healing cascade, the ideal timing of intersessions should be no less than every 3 days, and no more than every 7 days. Shockwave reinstitutes healing, often enabling optimal results between 3 to 6 months after a treatment series, depending upon degree of injury and an individual’s healing properties.
One should try to avoid anti-inflammatory medications (even baby aspirin) and ice therapy to avoid hindering the therapy. Withhold these counterproductive elements for 7-10 days prior to series initiation and for three months after series cessation to derive maximal benefit. If exceptions must be made please speak with me. You may take Tylenol if necessary for pain relief.
In addition to any e-mail or telephone communications I’ve requested, or which you initiate, I request 6–8-week interval return visits to check your status. I will review any physical therapy you likely may be having and assess the results, palpate or otherwise examine the injury and cohort sites, and likely either prescribe or perform imaging. This also gives you an in-person opportunity to ask questions, and for me your status with what I’d expected. It also gives me the opportunity to intercede and offer insights/treatment into other issues, e.g., a worsening knee or hip arthritis on the side opposite the injury we’ve been addressing. Often these types of opposite-side injuries slow down healing, requiring treatment to prevent a “Hatfields v McCoys” tête-à-tête between the two sides.
Patients who return to my office several months or years after the shockwave regime most frequently will have experienced complete remission of symptoms, demonstrating remarkably improved imaging (sonograms, MRIs) and return to normal daily activities. If thee injury is persistent or returning, I will check the ambient circumstances which may be responsible, and remind a patient they are welcome to contact me at any time to avoid recession of an injury back into chronicity.
Shockwave is either contraindicated or not recommended in the presence of active tumor or infection, blood clotting disorders, blood thinner meds, clots, or DVTs; during pregnancy or if you’re trying; directly atop growth plates; in temporal proximity of or during oral anti-inflammatory medication ingestion, or during oral steroid therapy or after steroid injection in the previous 6 weeks. Please inform me if you have any other concerns or uncertainties.
Side effects: A certain degree of discomfort is expected during a treatment session. I will monitor this, increasing the energy level from quite minimal per to your tolerance. It is well known that energy tolerance increases and discomfort decreases both during the session, and during the series!
Shockwave energy must reach a certain level to be therapeutic. If by the end of the second session you cannot tolerate a minimal therapeutic energy level, we will discuss the possibility of shockwave discontinuance.
Patients occasionally experience minimal skin bruising, reddening or swelling around the treatment area.
In cases where I cannot use shockwave, but wish to generate a healing cascade, I also have the option to treat a patient with Class IV laser therapy, or prolotherapy*, or prescribe PRP*, each of which has its advantages and indications.
(*Both of which are also rendered considerably less effective if anti-inflammatory meds are concurrently ingested.)
1 My ultrasound scanner, a 2024 GE Logiq Fortis, is equipped with the MVI option, which I employ to interrogate injured tissue, thus assess its degree of circulation. This helps us decide whether a patient should initiate a shockwave regime. This also helps us advise patients presenting for a second opinion regarding efficacy of shockwave they may be receiving from another provider. If MVI is less than expected, we review the provider’s technique and whether the prerequisite factors for both initiation of shockwave, and ambient conditions, case specific, during the healing period, are being met.
2 I purchased a radial shockwave machine in 2018, and used it in accord with manufacturer guidelines. To my knowledge, seminars were not offered in the USA at that time. Upon purchasing my direct shockwave machine in 2021, and when in-depth seminars became available, I availed myself of the opportunity and am very glad I did.
3 With the knowledge I have gained after 45 years’ experience treating professional dancers, athletes, and non-athletes, I have continuously honed my objective and subjective sensibility to dynamically monitoring tissue healing to keep the patient on the “healing tightrope”…which you can read about on my website.