Extracorporeal shock wave therapy (ESWT) for musculoskeletal conditions

Policy context

Extracorporeal shock wave therapy (ESWT) is a noninvasive treatment based on ultrasound technology. ESWT is used for a variety of conditions including treatment of kidney stones. ESWT for soft tissue injuries is applied with the goal of promoting healing. ESWT may have multiple effects thought to impact healing including breaking calcium deposits and causing an inflammatory response that may stimulate tissue healing.

Status: Decision completed

Primary criteria ranking

  • Safety = High
  • Efficacy = High
  • Cost = Medium/High

Assessment timeline

  • Draft key question published: August 12, 2016
  • Public comment period: August 12 to 25, 2016
  • Final key questions published: September 20, 2016
  • Draft report published: December 29, 2016
  • Public comment period: December 30 to January 30, 2017
  • Final report published: February 16, 2017
  • HTCC public meeting: March 17, 2017


Originally developed to treat kidney stones and gallstones, extracorporeal shock wave therapy (ESWT) has been used for more than two decades to treat an increasing number of musculoskeletal conditions, such as tennis elbow, rotator cuff tendinitis, patellar tendinopathy, Achilles tendinopathy, plantar fasciitis, and bony nonunions. ESWT is a noninvasive procedure in which a series of high- or low-energy shockwaves are directed at the site of injury, and is commonly used in patients who have not responded to more conservative treatment modalities. Although the exact mechanism by which ESWT elicits a therapeutic effect is not fully understood, it is thought that ESWT induces tissue regeneration and neovascularization, induces pain relief via hyperstimulation analgesia, and in the case of tendinopathies, disintegrates calcified deposits.

ESWT devices have received FDA approval for lateral epicondylitis and plantar fasciitis. ESWT devices employ either focused shockwaves or radial pressure waves. Focused shockwaves are high energy acoustic waves that converge to achieve maximal energy at the target site — the energy of focused shockwaves is not diminished upon skin penetration. Focused shockwaves are generated in water via electrohydraulic, electromagnetic, or piezoelectric techniques. In contrast, radial shockwaves (or radial pressure waves) diverge as soon as they are discharged, the energy of radial pressure waves diminish upon skin penetration and result in low energy diffuse waves at the target site. Radial pressure waves are generated by pneumatic techniques. While radial ESWT is newer to the market, focused ESWT has been in use for many years and appears to be able to direct higher energy shockwaves at deeper tissue sites. The therapeutic impact of focused versus radial ESWT remains unclear, as the relationship between shockwave characteristics and mechanism of action has not been elucidated.

Although ESWT is increasingly being used to treat a variety of musculoskeletal conditions, the efficacy and safety of this procedure remain unclear. The objective of this report is to systematically review and critically appraise the evidence of the comparative efficacy, effectiveness, and safety of ESWT for the treatment of musculoskeletal conditions such as tendinopathies and plantar fasciitis. The differential effectiveness and safety of ESWT for subpopulations will be evaluated, as will the cost effectiveness.