Shockwave Therapy for Tendon Injuries

What is Shockwave therapy?

Shockwave therapy is a relatively new therapy to musculoskeletal medicine and is based around the first use of shockwaves (extracorporeal shockwave therapy) in a patient in the 1980s for kidney stones.  The therapy was used to reduce calcium stones, which formed within a patient’s kidney.  This system offered a good alternative to operations and more invasive means to remove the kidney stones.
One of the first conditions to be treated with shockwave therapy was a condition called calcific tendonitis.  In which small calcium deposits can be seen within the rotator cuff muscles.  The condition was reported in 1993.  Since then there have been more uses of shockwave therapy, which have lead to lots of research into this growing field of medicine.
Shockwave is still quite exclusive and few practices offer shockwave therapy as a course of treatment.
Extracorporeal shockwave therapy works by inducing a clear increase in pressure within few nanoseconds. There are very rapidly rising positive pressure impulses from 5 to 120 MPa in about 5 ns, followed by a decrease to negative pressure values of –20 MPa.  It is thought that the negative pressure spikes are the main therapeutic advantage of this treatment modality.
The proposed mechanisms of action are covered later in this article.

What is a tendon?

A tendon is a type of soft tissue, which is usually responsible for connecting muscle to bone.  It must therefore be good at withstanding tensile forces.  Although, new thoughts on tendon damage suggest that there are compressive and shear forces which also must be resisted by the tendon within normal physiological functioning in the human body.
Tendons are located all over the body and largely their function is related to the ideal positioning they have between the bone and muscle complex, allowing for a direct transmission along a line or force from the bone to the muscle and vice versa.
The main structure of the tendon is comprised of ground substance, collagen, elastin and cells called tenocytes.  This is important to understand when thinking about how degradation and repair in tendons can occur.  During recurrent overuse the tenocytes are responsible for the release of Matrix Metallo Pronteinases (MMP’s).  These MMP’s are responsible for the degradation of  the extracelluar matrix and subsequent remodelling in response to mechanical overload.  During the healing process there are other regulatory factors which are at play and interact to promote healing (insulin-like growth factor, basic fibroblast growth factor, transforming growth factor beta and vascular endothelial growth factor).

How do tendon injuries occur?

Generally there is a clear sequence of events, which occurs prior to the pathology being detected clinically.  Pain is often the first indicator, as with most conditions, of tendon reactivity.
Mechanical overload is often the precursor to changes within the cells.  As mentioned previously this stimulates the tenocytes to release MMP’s and increase in their activity levels.  Long term this will lead to ongoing degradation of the extracellular matrix.  Vascular changes often are thought to accompany degradation of the matrix.  Cook and Purdam 2009 (see below) proposed a schematic representation of progression to degenerative tendinopathy which clearly shows the states of disrepair and regeneration.

What other treatments are available for tendon injuries?

The most common treatments for tendon injuries currently include a combination of non-invasive therapy and more invasive therapies.  The evidence for each is generally good.  The management depends largely on a clear understanding of the factors resulting in the initial overload of the tendon.
The common types of management of tendon injuries involves the following;
  1. Eccentric musculotendinous training (Curwin, Curwin and Stanish 1984, Alfredson et al 2000)
  2. Corticosteroid injection (Smidt 2002, Fredburg 2004, Shrier 1996)
  3. Electrophysical agents – such as laser and ultrasound (Parvizi 1999, Giombini 2002)
  4. Night splints (Roos 2004)
  5. Surgery (Paavola 2002) 75% of patients having tenotomy had good to excellent results at 18 months post operative follow up
  6. Sclerosing injections (Alfredson 2005)
  7. Shockwave Therapy (Rompe 2009, Saxena 2012) 80% of patients having a good to excellent recovery after 18 months post intervention(Better than surgery)

How does shockwave therapy work for tendons?

Largely the study of exactly what happens during shockwave therapy is the topic of many research projects.  Some proposed mechanisms so far that has good evidence include;
  1. Direct stimulation of healing (increased TGF-b1, IGF-1, increased GAG’s)
  2. Neo-vascularisation
  3. Direct suppression effects on nociceptors
  4. Hyper-stimulation (blocking the gait control mechanism)
  5. Increased NO expression
  6. Increase PCNA (proliferating cell nuclear antigen), collagen type 1 and collagen type 3

What conditions does shockwave therapy work for?

Currently shockwave therapy in the UK has a great evidence base which is growing with the help of the ASSERT trial.  The trial includes data from the use of the Swiss Dolor Clast machines (the only machine that has an evidence base for it).  This means that with good reliability it is possible to understand patient outcomes at 3 and 6 months post intervention, which is useful clinically.
The areas of research where there is very strong evidence (level 1 evidence at RCT) include the following
  1. Patellar Tendonitis
  2. Proximal Hamstring Tendinopathy (Cacchio 2011)
  3. Achilles Tendinopathy (Rompe 2009)
  4. Plantar Fasciitis (Gerdesmeyer 2008)
  5. Greater Tronchanteric Pain Syndrome (Rompe 2009)
  6. Lateral Epicondylitis (Rompe 2009)
  7. Calcific Shoulder Tendonitis (Cacchio 2006)

Am I be suitable for shockwave therapy?

If you are looking to have shockwave therapy it is important you consider that you may respond to lesser forms of treatment if you have not already had these before.  Shockwave, although having few side effects, is an expensive form of treatment if your pain will resolve to more simple forms of therapy.  It is worth investigating these first.
If you have tried alternative forms of management already for any of the conditions above then you may be suitable to receive shockwave therapy.  Speaking to a clinician about your condition may be the best step to take before booking your session.

Where can I get shockwave therapy for my condition?

Shockwave therapy is not widely available and there are only a few specialist clinics in the UK that offer this form of treatment.  It is worth doing the research on the type of machine used.  The research published is using the swiss dolor clast machines which have a proven track record and are monitored for efficacy with the ASSERT study (mentioned above).
Should you require any further information on Shockwave therapy then please don’t hesitate to contact us for advice.
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