The effect of shockwave therapy in treating tendonitis of the shoulder, elbow, or knee

Straining the shoulder, elbow or knee can cause tendon injuries and swollen, inflamed tendons (tendinitis), that can be both painful and decrease the function of the joint. The aim of extracorporeal shockwave therapy is to decrease pain and increase both function and mobility.

Question

What systematic reviews are there on shockwave therapy in treating tendonitis of the shoulder, elbow or knee?

Identified literature

Table 1. Systematic reviews with low/medium risk of bias
CS = Corticosteroid injections; DASH = Disabilities of the Arm, Shoulder and Hand; eECRB = Enthesopathy of the extensor carpi radialis brevis/lateral epicondylitis/”tennis elbow”; ESWT = Extracorporeal shock wave therapy; GTPS = Greater trochanteric pain syndrome; LLLT = Low-level laser therapy; MD = Mean difference; NRS = Numerical rating scale; n/a = not applicable; PRP = Platelet-rich plasma; RA = Rheumatoid arthritis; SMD = Standard mean difference; SWT = Shockwave therapy; UEFS = Upper Extremity Function Scale; VAS = Visual analogue scale; VISA-P = The Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy
Included studies Population/Intervention Outcome
Elbow
Yoon et al (2020)
Does the Type of Extracorporeal Shock Therapy Influence Treatment Effectiveness in Lateral Epicondylitis? A Systematic Review and Meta-analysis. [1]
12 randomised placebo-controlled studies Population:
n=1104
Patients with lateral epicondylitis (“tennis elbow”)

Intervention:
ESWT (focused or radial) compared to sham stimulation or no additional treatment
Pain intensity (VAS-score) after ESWT (12 trials)
No clinically important difference relative to comparison
MD: –0.68
(95% CI, –1.17 to –0.19)
The duration of follow-up varied from 1 week to 12 months, the VAS-score at the longest follow-up period was included for each study

Patients with symptoms <6 months (5 trials):
No clinically important improvement in VAS-score relative to comparison
MD: –0.95
(95% CI, –1.75 to –0.15)

Patients with symptoms <3 months (5 trials):
No differences in VAS-score between the groups
MD: –0.49
(95% CI, –1.35 to 0.37)

Grip strength after ESWT (6 trials)
No clinically important difference relative to comparison
MD: 3.33
(95% CI, 0.93 to 5.73)

Subgroup analysis: type of ESWT (radial/focused
Radial ESWT:
No clinically important difference in VAS-score
MD: –1.13
(95% CI, –1.84 till –0.42)

Focused ESWT:
No improvement in pain (VAS-score)
MD: –0.67
(95% CI, –1.41 till 0.07)

Adverse effects
Although no statistical comparisons were made between the groups, there seemed to be more adverse events with ESWT compared to sham.

All adverse events were resolved at final follow-up evaluation. No severe adverse events, or reports of safety issues during the intervention in all studies.
Authors' conclusion:
“ESWT did not show clinically important improvement in pain reduction and grip strength.”
Buchbinder et al (2005)
Shock wave therapy for lateral elbow pain [2]
9 randomised placebo-controlled studies

1 study on ESWT vs steroid injection
Population:
n=1099 (total)
n=1006 for ESWT vs placebo
n=93 for ESWT vs injection

Adults (>16 years) with lateral elbow pain (defined as elbow pain, which is maximal over the lateral epicondyle, and increased by pressure on the lateral epicondyle and resisted dorsiflexion of the wrist and/or middle finger).
Exclusion: history of significant trauma or systemic inflammatory conditions, such as RA.

Intervention:
ESWT versus placebo, or another modality, or of varying types and dosages of shock wave therapy.
ESWT vs placebo (9 studies)
The 9 placebo-controlled trials included in this updated review reported conflicting results.

Outcomes measured:
Overall pain, pain at rest and with activities and resisted movements, function/disability (Disabilities of the Arm, Shoulder and Hand (DASH) and the Upper Extremity Function Scale (UEFS), quality of life (EQ-5D thermometer), Roles and Maudsley score, grip strength, satisfaction with abilities to perform full activities and sport, composite endpoints of 'success' of treatment as defined in the various trials, and adverse effects.

Note: This a very short summary. Please see the review [2], p 30–43 for a complete list of results and analyses.

Adverse effects
4 studies:
No significant adverse effects in either treatment groups

1 study:
Significantly more side effects in the ESWT group
(OR 4.3, 95% CI, 2.9 to 6.3).
There were however no treatment discontinuations or dosage adjustments related to adverse effects. The most frequently reported side effects in the ESWT group were transitory reddening of the skin (21.1%), pain (4.8%) and small haematomas (3.0%).
Authors' conclusion:
“This systematic review does not support the use of ESWT for lateral elbow pain in clinical practice.”
Shoulder
Al-Abbad et al (2020)
The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: A systematic review and meta-analysis with meta-regression. [5]
23 studies, including 8 RCTs on ESWT for rotator cuff calcific tendinitis

(Total 63 studies including 30 RCTs)
Population:
n=1110, n=1141 shoulders
Patients with image identified symptomatic type I or II calcification of the rotator cuff (Gartner and Simons radiographic classification)

Intervention:
Extracorporeal shockwave therapy, focused (21 studies) and radial (2 studies).
Mean SWT shocks, ± SD (range):
2104, ± 990.57 (1000–6000)
Mean energy flux density, ± SD (range):
0.26, ± 15, (0.02–0.6) ml/mm²
Mean SWT sessions, ± SD (range):
2.66, ± 1.91 (1–8)
Reduction in calcium deposit size, mm (5 studies)
MD: 8.44
(95% CI, 4.30 to 12.57)

Subgroup analysis
SWT vs placebo (2 studies)
MD: –11.26
(95% CI, –24.68 to 2.17)

SWT vs ultrasound-guided needling (2 studies)
MD: 4.25
(95% CI, 2.27 to 6.24)

Total calcification resorption (8 studies)
SWT vs placebo (6 studies)
OR: 0.16
(95% CI, 0.03 to 0.75)

SWT vs ultrasound-guided needling (2 studies)
OR: 3.67
(95% CI, 1.56 to 8.61)
Authors' conclusion:
“The reduction in calcium deposit size favoured SWT compared to placebo but did not reach statistical significance. However, the effect of SWT on calcium deposit size was less compared to ultrasound-guided needling. Total calcium resorption was greater in the SWT group compared to placebo, but not compared to ultrasound guided-needling.”
Surace et al (2020)
Shock wave therapy for rotator cuff disease with or without calcification. [4]
32 RCTs Population:
n=2281
Participants with rotator cuff disease with (25 studies) or without (5 studies) calcific deposits, or mixed populations (2 studies).

Intervention:
Extracorporeal (focused or radial) shock wave therapy, all varying types and dosage.
Placebo vs Shock wave therapy at 3 months
Pain (VAS 1–10), 9 studies, n=608:
SMD: –0.49
(95% CI, –0.88 to –0.11) (favouring ESWT, 0.78 (0.17 to 1.4) points less pain)
⊕⊕⊕⊝

Function (Constant 1–100), 9 studies, n=612:
SMD: 0.62
(95% CI, 0.13 to 1.11)
(favouring ESWT, 7.9 (1.6 to 14) points better function).
⊕⊕⊕⊝

Number of participants experiencing any adverse event at 12 months, placebo vs Shock wave therapy (5 studies, 295 patients)
RR 3.61 (95% CI, 2.00 to 6.53)
19% (range: 7% to 40%) more events in ESWT compared with placebo.

Note: Please see the review [4], p 141–177 for a complete list of results and analyses.
Authors' conclusion:
“We are uncertain if shock wave therapy has any benefits over ultrasound-guided needling, TENS, supervised exercises, no treatment, percutaneous lavage or multiple versus single treatments, as there was only low- to very low certainty evidence from single or few small studies.”
Huisstede et al (2011)
Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis - A systematic review. [3]
17 RCTs Population:
Patients with shoulder impingement syndrome (SIS), both calcific tendinosis (11 studies) and non-calcific tendinosis (6 studies).

Intervention: Extracorporeal shockwave therapy, low-, medium- and high-energy (16 studies), and radial shockwave therapy (1 study)
High-ESWT vs placebo
Significant effect in favour of treatment on pain, function and calcific deposit size. (2 studies)

High-ESWT vs low-ESWT
Significant effect in favour of high-ESWT on pain, conflicting results on function (2 studies)

Note: Please see the review [3] for a complete list of results and analyses.
Authors' conclusion:
“In conclusion, high-ESWT is effective to treat calcific RC-tendinosis in the short, mid and long-term. Focus on the calcific deposit is more effective than focus on the tuberculum majus. Also RSWT seems to be a promising modality to treat this disorder.

[…] Further, no evidence in favour of low, mid or high-ESWT compared to placebo, each other, or other treatment was found for non-calcific RC-tendinosis.”
Knee
Korakakis et al (2018)
The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. [6]
31 studies included in qualitative synthesis, of which 13 included in quantitative synthesis

11 of 31 included studies relevant to PICO
Population:
Adult patients with patellar tendinopathy (11 studies), achilles tendinopathy (15 studies), medial tibial stress syndrome (3 studies), greater trochanteric pain syndrome (2 studies), or proximal hamstring tendinopathy (1 study)

Intervention:
Extracorporeal shock wave therapy, radial or focused, high or low energy, as monotherapy or as additive intervention.
ESWT vs placebo in patellar tendinopathy (2 studies, n=114)
VISA-P scores, 3 months:
MD –3.79 (95% CI, –10.84 to 3.26)
Not statistically significant

VISA-P scores, 5–6 months:
MD –4.72
(95% CI, –11.26 to 1.82)
Not statistically significant

VAS/NRS pain score, 3 months:
MD –0.75
(95% CI, –1.62 to 0.11)
Not statistically significant

VAS/NRS pain score, 5–6 months:
MD –0.40
(95% CI, –1.29 to 0.49)

Not statistically significant
Authors' conclusion:
“[…] shockwave therapy is no better than placebo shockwave in patellar tendinopathy. This needs to be further investigated as preliminary evidence exists for a non-linear dose-responses relationship for extracorporeal shockwave therapy with both the lowest and highest levels of total energy flux.”

References

  1. Yoon SY, Kim YW, Shin I-S, Moon HI, Lee SC. Does the Type of Extracorporeal Shock Therapy Influence Treatment Effectiveness in Lateral Epicondylitis? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2020;478(10).
  2. Buchbinder R, Green S, Youd J, Assendelft W, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005(4):CD003524. Available from: https://doi.org/10.1002/14651858.CD003524.pub2.
  3. Huisstede BM, Gebremariam L, van der Sande R, Hay EM, Koes BW. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis--a systematic review. Man Ther. 2011;16(5):419-33. Available from: https://doi.org/10.1016/j.math.2011.02.005.
  4. 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(3):CD008962. Available from: https://doi.org/10.1002/14651858.CD008962.pub2.
  5. Al-Abbad H, Allen S, Morris S, Reznik J, Biros E, Paulik B, et al. The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression. BMC Musculoskelet Disord. 2020;21(1):275. Available from: https://doi.org/10.1186/s12891-020-03270-w
  6. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018;52(6):387-407. Available from: https://doi.org/10.1136/bjsports-2016-097347.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 11/1/2021
Report no: ut202123
Registration no: SBU 2020/894