Shock the Monkey: Shock Wave Therapy and Musculoskeletal Disorders

Abstract & Commentary

Synopsis: An excellent review article of the current literature and a recent meta-analysis of shock-wave treatments in the management of musculoskeletal disorders is presented. Currently, there are 3 major commercial types of shock-wave devices, and accepted treatments include disorders of the plantar fascia and lateral epicondylitis. Many unanswered questions remain, especially with possible detrimental effects with the use of shock wave in tendon, muscle, and nerve.

Source: Ogden JA, et al. Shock wave therapy (orthotripsy) in musculoskeletal disorders. Clin Orthop. 2001;387:22-40.

This thorough review article describes the current knowledge base as well as less well-known but described applications of shock wave treatments to the musculoskeletal system. Introduction of therapeutic shock waves to noninvasively treat kidney stones (lithotripsy) has revolutionized the management of this urologic problem, and application of shock wave extracorporeal energy to the musculoskeletal system has had recent tremendous interest and study.

Three devices have been produced specifically for bone and contiguous soft tissues: Ossatron (High Medical Technologies, Lengwil, Switzerland), Epos (Dornier, Germering, Germany), and Sonocur (Siemens, Erlangen, Germany). The Ossatron produces shock waves electrohydraulically in contrast to Epos and Sonocur, which generate waves electromagnetically. Although multiple studies and articles have been proliferated on shock wave treatment, there is little consensus for efficacy of treatment except in the FDA-approved Ossatron treatment of plantar fasciitis.

Ogden and associates discuss (and in effect, translate) the thorough meta-analysis by Heller and Niethard who combed the literature and found the following reports in plantar fasciitis (1131 patients), lateral epicondylitis (1672 patients), nonunion of fractures (1737 patients), and calcific tendonitis of the shoulder (916 patients).1 From the meta-analysis, only the treatment of plantar fasciitis has credible science and efficacy. Currently approved FDA trials of shock wave applications to lateral epicondylitis are ongoing. Lastly, Ogden et al note the concern of detrimental effects to tendon, muscle, and nerve, but they present an extensive review of other investigator applications to osteochondroses and enthesopathies including medial epicondylitis, patellar tendonitis, trochanteric bursitis, Achilles tendonitis, and noncalcific shoulder problems. They conclude that current treatment recommendations for musculoskeletal soft-tissue disorders include that of plantar fasciitis and lateral epicondylitis (currently in FDA trial).

Comment by Robert C. Schenck, Jr., MD

The area of shock wave therapy to the musculoskeletal system has had recent interest and excitement. Application of low energy for bone healing with medium and higher energies for soft tissues has had recent practical applications to include tibial nonunions and FDA approved application of the Ossatron to plantar fasciitis. There is little agreement on energy levels (ie, what are considered low, medium, and high energy levels), the exact mechanism of shock wave therapy in healing, and degree of application. Although there are a plethora of applications, the clinician must be cautioned in taking a "shotgun" approach to musculoskeletal disorders with extracorporeal shock wave treatment. Nonetheless, the use of shock wave therapy to osteochondritic lesions may have great potential with the ability to affect osteochondral healing. There are many unanswered questions, but patients will ask.

Reference

1. Heller KD, Niethard FU. Der Einsatz der extrakorparalen stobwellen therapie in der orthopade: Eine metanalyse. Z Orthop. 1998;136:391-401.

Dr. Schenck, Associate Editor of Sports Medicine Reports, is Deputy Chairman, Department of Orthopaedics, University of Texas Health Science Center, San Antonio.