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.

Reading time approx. 15 minutes Published: November 1, 2021 Publication type:

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.

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

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).
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.
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.
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.
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
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.

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

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CINAHL via EBSCO 3 March 2021

AB = Abstract; AU = Author; DE = Term from the thesaurus; MH = Exact Subject Heading from CINAHL Subject Headings; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; N = Near Operator (N) finds the words if they are a maximum of x words apart from one another, regardless of the order in which they appear.; W = Within Operator (W) finds the words if they are within x words of one another, in the order in which you entered them.
Search terms		Items found
Population:
1.	TI ( tendon# OR tendinopathy OR tendinosis OR tendonitis OR tendinitis OR epicondylitis OR "tennis elbow" OR "golfer's elbow" OR "shoulder impingement" OR “subacromial impingement” OR "rotator cuff#" OR "jumper's knee" ) OR AB ( tendon# OR tendinopathy OR tendinosis OR tendonitis OR tendinitis OR epicondylitis OR "tennis elbow" OR "golfer's elbow" OR "shoulder impingement" OR “subacromial impingement” OR "rotator cuff#" OR "jumper's knee" ) OR SU ( tendon# OR tendinopathy OR tendinosis OR tendonitis OR tendinitis OR epicondylitis OR "tennis elbow" OR "golfer's elbow" OR "shoulder impingement" OR “subacromial impingement” OR "rotator cuff#" OR "jumper's knee" )	30 076
Intervention:
2.	TI ( shockwave# OR "shock wave#" ) OR AB ( shockwave# OR "shock wave#" ) OR SU ( shockwave# OR "shock wave#" )	1 934
Study types:
3.	TI ( (systematic* N2 (review OR overview)) OR metaanalysis OR "meta analysis" ) OR AB ( (systematic* N2 (review OR overview)) OR metaanalysis OR "meta analysis" ) OR SU ( (systematic* N2 (review OR overview)) OR metaanalysis OR "meta analysis" )	179 333
Combined sets:
4.	1 AND 2 AND 3	74
Final result
		74

Embase via Elsevier 3 March 2021

/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ' ' = Citation Marks; searches for an exact phrase; NEAR/n = Requests terms that are within 'n' words of each other in either direction; NEXT/n = Requests terms that are within 'n' words of each other in the order specified
Search terms		Items found
Population:
1.	‘tendinitis’/de OR ‘epicondylitis’/exp OR ‘shoulder impingement syndrome’/de OR ’patellar tendinopathy’/de	16 691
2.	tendinitis:ti,ab,kw OR tendinopathy:ti,ab,kw OR tendinosis:ti,ab,kw OR tendonitis:ti,ab,kw OR tendon$:ti,ab,kw OR epicondylitis:ti,ab,kw OR 'tennis elbow':ti,ab,kw OR 'golfer´s elbow':ti,ab,kw OR 'rotator cuff$':ti,ab,kw OR 'shoulder impingement':ti,ab,kw OR 'subacromial impingement':ti,ab,kw OR 'jumper´s knee':ti,ab,kw	99 997
3.	1 OR 2	104 903
Intervention:
4.	'shock wave therapy'/de	1 700
5.	shockwave$:ti,ab,kw OR 'shock wave$’:ti,ab,kw	15 726
6.	4 OR 5	16 036
Study types:
7.	'systematic review'/exp OR 'meta analysis'/exp	387 711
8.	((systematic* NEAR/3 review):ti,ab,kw) OR metaanalysis:ti,ab,kw OR 'meta analysis':ti,ab,kw	368 337
9.	7 OR 8	479 504
Combined sets
10.	3 AND 6 AND 9	111
Final result
		111

Medline via OvidSP 3 March 2021

Search terms		Items found
.ab. = Abstract; .ab,ti. = Abstract or title; .af. = All fields; Exp = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; .sh. = Term from the Medline controlled vocabulary; .ti. = Title; / = Term from the Medline controlled vocabulary, but does not include terms found below this term in the MeSH hierarchy; * = Focus (if found in front of a MeSH-term); * or $ = Truncation (if found at the end of a free text term); .mp = Text, heading word, subject area node, title; “ “ = Citation Marks; searches for an exact phrase; ADJn = Positional operator that lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
Population:
1.	exp Tendinopathy/ or Shoulder Impingement Syndrome/ or Rotator Cuff Injuries/	19 658
2.	(tendinitis or tendinopathy or tedinosis or tendonitis or tendon? or epicondylitis or tennis elbow or golfer’s elbow or rotator cuff? or shoulder impingement or subacromial impingement or jumper’s knee).ab,kw,ti	81 195
3.	1 or 2	87 064
Intervention:
4.	High-Energy Shock Waves/ or Extracorporeal Shockwave Therapy/	2 281
5.	(shockwave? or shock wave?).ab,kw,ti.	12 080
6.	4 or 5	12 982<
Study types:
7.	meta-analysis/ or “systematic review”/	212 329
8.	((systematic* adj3 (review or overview)) or meta analysis or metaanalysis).ab,kw,ti.	287 493
9.	7 or 8	315 954
Combined sets
10.	3 and 6 and 9	92
Final result
		92

Scopus via Elsevier 3 March 2021

TITLE-ABS-KEY = Title or abstract or keywords; ALL = All fields; PRE/n = "precedes by". The first term in the search must precede the second by a specified number of terms (n).; W/n = "Within". The terms in the search must be within a specified number of terms (n) in any order.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; LIMIT-TO (SRCTYPE, "j" = Limit to source type journal; LIMIT-TO (DOCTYPE, "ar" = Limit to document type article; LIMIT-TO (DOCTYPE, "re" = Limit to document type review
Search terms		Items found
Population:
1.	TITLE-ABS-KEY ( ( tendon OR tendinopathy OR tendinosis OR tendonitis OR tendinitis OR epicondylitis OR "tennis elbow" OR "golfer's elbow" OR "shoulder impingement" OR “subacromial impingement” OR "rotator cuff" OR "jumper's knee" ) )	137 252
Intervention:
2.	TITLE-ABS-KEY ( ( shockwave OR "shock wave" ) )	83 315
Study types:
3.	TITLE-ABS-KEY ( ( systematic* W/2 review ) OR metaanalysis OR "meta analysis" )	487 274
Combined sets
4.	1 AND 2 AND 3	124
Final result
		124

Page published November 1, 2021