Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Effect of Extracorporeal Shock Waves on Calcaneal Bone Spurs Effects of extracorporal shock wave therapy on symptomatic heel spurs: a correlation between clinical outcome and radiologic changes Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled trial Magnetic Resonance Imaging and Clinical Outcomes of Laser Therapy, Ultrasound Therapy, and Extracorporeal Shock Wave Therapy for Treatment of Plantar Fasciitis: A Randomized Controlled Trial The application of shock-waves therapy in the treatment of resistant chronic painful shoulder. A clinical experience. High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. Shock waves in the treatment of post-traumatic myositis ossificans. Extracorporeal Shock Wave Therapy in the Treatment of Calcific Tendinitis of the Rotator Cuff Chronic plantar fasciitis: acute changes in the heel after extracorporeal high-energy shock wave therapy--observations at MR imaging. Ultrasound‐guided, high‐energy extracorporeal ­ shock‐wave treatment of symptomatic calcareous tendinopathy of the shoulder The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Extracorporeal Shockwave treatment is effective in calcific tendonitis of the shoulder. A randomized controlled trial Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: a randomized study Development of a prognostic naive bayesian classifier for successful treatment of nonunions. Extracorporal Shock Wave Therapy for Calcifying Tendinitis of the Shoulder Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis Comparative Effectiveness of Radial Extracorporeal Shockwave Therapy and Ultrasound-Guided Local Corticosteroid Injection Treatment for Plantar Fasciitis. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. Utility of Ultrasonography in Assessing the Effectiveness of Extracorporeal Shock Wave Therapy in Insertional Achilles Tendinopathy Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Extracorporeal shock wave therapy is not useful after arthroscopic rotator cuff repair Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study Effectiveness of extracorporeal shock wave therapy in bone marrow edema syndrome of the hip Extracorporeal shock wave therapy in runners with a symptomatic heel spur High-Energy Shock Wave Treatment of Femoral Head Necrosis in Adults Comparison of autologous conditioned plasma injection, extracorporeal shockwave therapy, and conventional treatment for plantar fasciitis: a randomized trial. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. The effects of shockwave on systemic concentrations of nitric oxide level, angiogenesis and osteogenesis factors in hip necrosis Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. Extracorporeal shock wave therapy in patients with plantar fasciitis. A randomized, placebo-controlled trial with ultrasonographic and subjective outcome assessments Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate Extracorporeal shockwaves versus ultrasound-guided percutaneous lavage for the treatment of rotator cuff calcific tendinopathy: a randomized controlled trial. Medium-energy shock wave therapy in the treatment of rotator cuff calcifying tendinitis Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Cocktail therapy for femoral head necrosis of the hip Treatment of Nonunions of Long Bone Fractures With Shock Waves Ultrasonographic evaluation at 6-month follow-up of plantar fasciitis after extracorporeal shock wave therapy Long-term effects of extracorporeal shockwave therapy in chronic calcific tendinitis of the shoulder. Dosage effects of extracorporeal shockwave therapy in early hip necrosis. Methodological index for non‐randomized studies (MINORS): development and validation of a new instrument Extracorporeal shock wave therapy in early osteonecrosis of the femoral head: prospective clinical study with long-term follow-up High-Energy Extracorporeal Shock Wave Treatment of Nonunions Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder Treatment of calcifying tendinitis of rotator cuff by extracorporeal shock waves: a preliminary report. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. Shockwave therapy under ultrasonographic guidance in rotator cuff calcific tendinitis. Effects of extracorporeal shock wave therapy on fracture nonunions. Shock Wave Therapy Versus Conventional Surgery in the Treatment of Calcifying Tendinitis of the Shoulder
We carried out a prospect i ve , r and omised controlled trial on two groups of 40 patients with painful calcific tendonitis and a mean age of 48.4 years ( 32.5 to 67.3 ) . All were to undergo arthroscopic removal of the calcific deposit within six months after r and omisation . The 40 patients in group I received ultrasound-guided needling followed by high-energy shock-wave therapy and the 40 in group II had shock-wave therapy alone . In both groups one treatment consisting of 2500 impulses of shock waves with an energy flux density of 0.36 mJ/mm(2 ) was applied . The clinical and radiological outcome was assessed using the 100-point Constant shoulder scoring system and st and ardised radiographs . The mean follow-up was 4.1 months and no patient was lost to follow-up . Both groups had significant improvement in their Constant shoulder score . Radiographs showed disappearance of the calcific deposit in 60.0 % of the shoulders in group I and in 32.5 % of group II ( p < 0.05 ) . Significantly better clinical and radiological results were obtained in group I than in group II . Arthroscopic removal of the deposit was avoided in 32 patients of group I and in 22 of group II . No severe side-effects were recorded . Ultrasound-guided needling in combination with high-energy shock-wave therapy is more effective than shock-wave therapy alone in patients with symptomatic calcific tendonitis , giving significantly higher rates of elimination of the calcium deposits , better clinical results and reduction in the need for surgery OBJECTIVES To evaluate the therapeutic effect of extracorporeal shock wave therapy ( ESWT ) in shoulders with chronic calcific tendinitis , to compare the functional outcomes of ESWT and transcutaneous electric nerve stimulation ( TENS ) therapy , and to investigate which types of calcium deposit effectively respond to ESWT . DESIGN R and omized controlled trial . SETTING Outpatient clinics of the departments of physical medicine and rehabilitation and of orthopedics and traumatology of a veterans hospital in Taiwan . PARTICIPANTS Sixty patients with continuous shoulder pain for 6 months or more and with radiographically and sonographically verified calcific tendinitis . Patients were r and omly allocated to receive ESWT ( 33 shoulders ) or TENS treatment ( 30 shoulders ) . INTERVENTIONS ESWT was performed with 2000 shock waves at 2Hz and energy level between.26 and .32mJ/mm(2 ) per session . Treatment was given in 2 sessions , 14 days apart . TENS therapy was given 3 times a week for 4 weeks . MAIN OUTCOME MEASURES Mean Constant score , visual analog scale ( VAS ) , manual muscle test , and changes of sonographic size and shape of calcium deposits were calculated for 4 time points : at baseline , 2 weeks , 4 weeks , 12 weeks posttherapy . RESULTS In both groups , Constant score and VAS improved significantly at 2- , 4- , and 12-week follow-ups ( P<.05 ) , and the size of calcium deposits decreased significantly at the 4- and 12-week follow-ups . Moreover , the arc-shaped calcific plaques of the rotator cuff were markedly meliorated with ESWT . CONCLUSIONS ESWT is more effective in the treatment of chronic calcific tendinitis of the shoulder than is TENS therapy , especially for arc-type calcific plaque In a prospect i ve study of 435 patients with chronic proximal plantar fasciitis , 283 ( 65 % ) had an inferior calcaneal bone spur of variable size evident prior to treatment with electrohydraulic high-energy extracorporeal shock waves ( ESW ) .  This included 308 patients who received extracorporeal shock wave treatments and 127 placebo ( sham control ) patients .  At both initial ( 3 months ) and final ( 12 months ) evaluations after receiving ESW , no patient who received shock wave applications had significant disappearance or change in the radiographic appearance of the heel spur . Clinical outcome after ESW was satisfactory in 168 patients ( 82 % ) with a radiographically demonstrable inferior heel spur and in 81 patients ( 79 % ) without such a heel spur . The results showed no correlation between the presence or absence of the heel spur and the eventual treatment outcome Plantar heel pain , a chronic and disabling foot alignment , occurs in the adult population . Extracorporal shock wave therapy ( ESWT ) offers a nonsurgical option in addition to stretching exercises , heel cups , NSAI , and corticosteroid injections . This study aim ed to investigate the effects of ESWT on calcaneal bone spurs and the correlation between clinical outcomes and radiologic changes . The study involved 108 patients with heel pain and radiologically diagnosed heel spurs . All patients underwent ESWT once a week for 5 weeks at the clinic . Each patient received 2,000 impulses of shock waves , starting with 0.05 mJ/mm2 ( 1.8 bar ) and increasing to 0.4 mJ/mm2 ( 4.0 bar ) . St and ard radiographies of the affected heels were obtained before and after the therapy . Clinical results demonstrated excellent ( no pain ) in 66.7 % of the cases , good ( 50 % of pain reduced ) in 15.7 % of the cases , and unsatisfactory ( no reduction in pain ) in 17.6 % . After five ESWT treatments , no patients who received shock wave applications had significant spur reductions , but 19 patients ( 17.6 % ) had a decrease in the angle of the spur , 23 patients ( 21.3 % ) had a decrease in the dimensions of the spur , and one patient had a broken spur . Therefore , results showed no correlation between clinical outcome and radiologic changes . The present study supports the finding that even with no radiologic change after ESWT therapy , the therapy produces significant effects in reducing patients ’ complaints about heel spurs Objectives : Extracorporeal shockwave therapy ( ESWT ) and corticosteroid injection ( CSI ) are treatment options for plantar fasciitis . Their clinical outcome comparison remains a debate . Also , the thickness changes of the plantar fascia on objective evaluation under the medium energy ESWT and CSI therapy are elusive . Methods : A total of 97 patients with chronic plantar fasciitis were enrolled in the r and omized prospect i ve trial . Forty-seven patients received extracorporeal shock wave therapy ( ESWT )  , and fifty patients received corticosteroid injection ( CSI ) . The thickness of the plantar fascia was evaluated respectively before ESWT and CSI , and at the 4th and 12th week after ESWT and CSI by ultrasonography .  Pain level and clinical outcomes were recorded using visual analogue scale ( VAS ) and 100-points scoring systems . Correlation analysis was performed between the thickness change and clinical outcome . Results : Under ultrasonography , we observed more increase of plantar fascia thickness of ESWT group than CSI group at 4th week ( p=0.048 ) . VAS of plantar fasciitis patients receiving ESWT was lower than those who received corticosteroid injection ( 0.001 and p<0.001 , at 4th and 12th week ) . On the assessment of 100-points scoring systems , the pain level of patients with ESWT was lower than those with CSI at the 12th week ( p<0.001 ) . On the other h and , the increase of plantar fascia thickness at 4th week was positively correlated with the decrease of VAS score at 12th week follow-up ( R=0.302 , P=0.039 ) . Conclusions : At 4th week after treatment , the thickness of plantar fascia increased . Then it decreased gradually , but not to the baseline at 12th week . On the pain level outcome at 12th week , extracorporeal shockwave therapy ( ESWT ) was more efficient than corticosteroid injection ( CSI ) on chronic plantar fasciitis . The more change of plantar fascia after ESWT , the more efficient on clinical outcome ABSTRACT We determined and compared the effectiveness of low‐level laser therapy ( LLLT ) , therapeutic ultrasound ( US ) therapy , and extracorporeal shock wave therapy ( ESWT ) using magnetic resonance imaging ( MRI ) . We performed a r and omized , prospect i ve , comparative clinical study . A total of 60 patients with a diagnosis of chronic plantar fasciitis were divided r and omly into 3 treatment groups : group 1 underwent 15 sessions of LLLT ( 8 J/cm2 ; 830 nm ) ; group 2 underwent 15 sessions of continuous US ( 1 mHz ; 2 W/cm2 ) ; and group 3 underwent 3 sessions of ESWT ( 2000 shocks ) . All patients were assessed using the visual analog scale ( VAS ) , heel tenderness index ( HTI ) , American Orthopaedic Foot and Ankle Society ( AOFAS ) ankle‐hindfoot scale , Roles – Maudsley score , and MRI before and 1 month after treatment . The primary efficacy success criterion was the percentage of decrease in heel pain of > 60 % from baseline at 1 month after treatment for ≥2 of the 3 heel pain ( VAS ) measurements . Significant improvement was measured using the mean VAS , AOFAS scale , and HTI scores for all 3 groups . The thickness of the plantar fascia had decreased significantly on MRI in all 3 groups . The treatment success rate was 70.6 % in the LLLT group , 65 % in the ESWT group , and 23.5 % in the US group . LLLT and ESWT proved significantly superior to US therapy using the primary efficacy criterion ( p = .006 and p = .012 , respectively ) , with no significant difference between the LLLT and ESWT groups ( p > .05 ) . The treatment of chronic plantar fasciitis with LLLT and ESWT result ed in similar outcomes and both were more successful than US therapy in pain improvement and functional outcomes . & NA ; Level of Clinical Evidence : BACKGROUND To evaluate the efficacy of extracorporeal shockwaves therapy ( ESWT ) in patients with chronic painful shoulder . METHODS EXPERIMENTAL DESIGN a prospect i ve design was used with a short term follow-up . SETTING data were collected at the Service of Physioterapy in Villa Stuart Clinic-Rome . PATIENTS 72 patients of both sexes with an average age of 38 years ( range 18 to 69 ) affected by chronic painful shoulder , whose symptoms lasted more than 6 months . INTERVENTIONS all patients received on average , 2,000 impulses of ESWT at level 5 energy ( 0.21 mJ/mm2 ) according to Dornier Epos equipment one session per week for 8 weeks . MEASURES all cases underwent an instrumental examination with X-ray conventional imaging and clinical assessment of pain ( visual analogue scale ) and functional limitation of the shoulder , two weeks before the treatment and at one month follow-up . RESULTS 53 % of patient scored excellent results , 14 % good , 13 % fair and 20 % poor . In the group of calcifying tendinitis we had a reduction in 37 % and no changes in 63 % . CONCLUSIONS Even with a limited number of cases our early results show the efficacy and safety of ESWT in the treatment of chronic painful shoulder resistant to other conservative approaches In a prospect i ve r and omised trial of calcifying tendinitis of the rotator cuff , we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy , via an electromagnetic generator under fluoroscopic guidance .  Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff , with calcification measuring 10 mm or more in maximum dimension . The primary outcome measure was the change in the Constant and Murley Score .  A total of 80 patients were enrolled ( 40 in each group ) , and were re-evaluated at a mean of 110 ( 41 to 255 ) days after treatment when the increase in Constant and Murley score was significantly greater ( t-test , p = 0.026 ) in the high-energy treatment group than in the low-energy group . The improvement from the baseline level was significant in the high-energy group , with a mean gain of 12.5 ( -20.7 to 47.5 ) points ( p < 0.0001 ) . The improvement was not significant in the low-energy group . Total or subtotal resorption of the calcification occurred in six patients ( 15 % ) in the high-energy group and in two patients ( 5 % ) in the low-energy group . High-energy shock-wave therapy significantly improves symptoms in refractory calcifying tendinitis of the shoulder after three months of follow-up , but the calcific deposit remains unchanged in size in the majority of patients Myositis ossificans ( MO ) is a fairly common evolution in sports activity and can be due to direct trauma or to repeated micro-injuries . The traditional therapeutic approach relies on a variety of treatments , such as physical therapy but evidence of their proven clinical efficacy is lacking . The latest therapeutic option is surgical removal but this is a demolitive procedure and is frequently associated with a significant loss of functional integrity . There are few articles in literature about the treatment of post-traumatic MO , and none on extracorporeal shock wave therapy ( ESWT ) . We illustrate a case series of 24 sportsmen treated with three sessions of electro-hydraulic shockwave therapy and an associated rehabilitation program .  Only a partial reduction of the ossification was observed in the X-ray images but all the patients showed signs of functional improvement immediately after therapy . Two months after the therapy , a normal range of motion and no signs of weakness were observed . Three months after treatment , 87.5 % of patients resumed regular sports activities Background Low-energy extracorporeal shock wave therapy is an alternative treatment , with limited evidence for effectiveness , for calcific tendinitis of the rotator cuff . Hypothesis Objective localization of the calcium deposit by 3-dimensional , computer-assisted navigation reveals superior clinical and radiographic outcomes compared to localization through patient-to-therapist feedback . Study Design R and omized controlled clinical trial ; Level of evidence , 1 . Methods A prospect i ve , r and omized , single-blind study was carried out on 50 patients . The population was divided into 2 groups of equal numbers ( navigation group and feedback group ) . In all patients , treatment-resistant pain was evident for longer than 6 months . A total of 3 therapy sessions of constant low-energy focused shock wave therapy was administered in weekly intervals in both groups . Local anesthesia was not applied . Radiographs and clinical assessment , including the Constant and Murley shoulder scoring system and the visual analog scale for pain , were performed both before therapy and after 12 weeks . In the navigation group , the calcium deposit was localized using a radiographically guided , 3-dimensional , computer-assisted device . The feedback group was treated after locating the point of maximum tenderness through palpation by the therapist with feedback from the patient . Results Both groups had significant improvements in the Constant and Murley score and the visual analog scale after 12 weeks . The results from the navigation group were statistically significantly superior to those of the feedback group . In the navigation group , 6 calcium deposits disappeared and 9 altered , compared to 1 disappearance and 12 alterations in the feedback group . No severe complications occurred . Conclusion Three-dimensional , computer-assisted navigation reveals significantly better results and is therefore recommended when extracorporeal shock wave therapy is used in the treatment of calcific tendinitis of the rotator cuff PURPOSE To prospect ively evaluate with magnetic resonance ( MR ) imaging the acute changes in the heel associated with extracorporeal shock wave therapy ( ESWT ) . MATERIAL S AND METHODS Institutional clinical study review board approved the study , and informed consent was obtained . MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients ( eight women and four men ; age range , 33 - 63 years ; average , 49.9 years ) with chronic plantar fasciitis .  ESWT was applied to the most painful point on the plantar surface of the heel , with a total of 1500 shocks at 18 kV. The MR imaging protocol consisted of sagittal and coronal T1- and T2-weighted images with and without fat saturation . The images were review ed to assess the post-ESWT changes in soft-tissue and bone marrow edema , the thickness of the proximal plantar fascia , and the presence of a heel spur . Paired t test was used for the statistical analysis . RESULTS Soft-tissue edema , which was present in 16 ( 89 % ) of 18 heels before ESWT , had increased in severity in 12 ( 75 % ) heels after ESWT .  Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT . After ESWT , the extant of bone marrow edema had increased in one heel and had newly developed in another heel . The heel spur seen in nine ( 50 % ) feet was not affected by ESWT . In 17 ( 94 % ) heels , the proximal plantar fascia was abnormally thick , with thickness not significantly changed with use of ESWT ( P > .05 ) . CONCLUSION Increase in soft-tissue edema is the most common acute response associated with ESWT Background : The objective of the present study was to test the effectiveness of ultrasound‐guided high‐energy extracorporeal shock‐wave treatment in symptomatic chronic calcareous tendinopathy of the shoulder rotator cuff , and to assess the morphology of the hydroxyapatite deposits before and after this treatment Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Summary Background Calcific tendonitis of the shoulder is often associated with chronic pain and impairment of function .  Extracorporeal Shockwave therapy ( ESWT ) is considered to be a treatment option . We compared the effects of two different ESWT regimens . Methods 43 patients ( 57 shoulders ) with symptomatic calcific tendonitis of the shoulder for more than six months were included in a double-blinded study . Thirty-one shoulders were treated at the area of maximum pain with application of 2 × 2000 impulses of 0.28mJ/mm2 at an interval of two weeks ( treatment group ) and 26 shoulders with 2 × 2000 impulses of < 0.07mJ/mm2 at an interval of two weeks ( control group ) , without pretreatment analgesia . Shoulder function ( Constant score ) and pain ( visual analogue scale , VAS ) were assessed before treatment and at one week , three months and seven months after treatment . Shoulder X-rays were performed at the 3- and 7-month follow-up visits . Results Improvement in Constant score was significantly higher in the treatment group at all follow-up visits ( p<0.05 ) . Seven months post-treatment , calcifications dissolved completely in 19 % of the treatment group and 8 % of the control group , and a > 50 % reduction was observed in 19 % and 8 % respectively . With regard to reduction of pain , there was significant improvement in the treatment group compared with the control group at the 1-week follow-up ( p<0.05 ) . However , at the 3-month and 7-month visits , no significant between-group difference in pain could be detected . Conclusion As applied , ESWT with an energy flux density of 0.28mJ/mm2 led to a significantly greater improvement in shoulder function and a slightly higher , nonsignificant , rate of > 50 % disintegration of calcific deposits compared with the control group . However , this did not result in reduction of pain Objective : To generate data on optimal shoulder position comparing two ultrasound-guided extracorporeal shock wave therapy techniques for the treatment of calcifying tendinitis of the shoulder . Design : R and om assignment to two groups of treatment with three months follow-up . Setting : The data were collected in out patients . Subjects : Thirty-five subjects affected by calcifying tendinitis of the shoulder were examined . Interventions : Each subject received three sessions of ultrasound-guided extracorporeal shock wave therapy ( performed weekly ) . Neutral position technique was used in group A ( n = 17 , mean age 53 ± 9.2 years ) and the hyperextended internal rotation technique was used in group B ( n = 18 , mean age 52.2 ± 10.8 years ) . Main outcome measures : The Constant and Murley method and radiographs were used to evaluate each subject before the treatment and at three months follow-up . Results : There were no significant differences between changes in Constant total score and pain , activity of daily living and range of motion subscales of the two groups . Only the pain subscale showed a significant difference in favour of group B. Significant differences in the radiographic outcome were observed between the two groups : the percentage of total or subtotal resorption of the calcified deposits was 35.3 % in group A ( neutral position technique ) versus 66.6 % in group B ( hyperextended internal rotation technique ) . The resorption of the calcific deposit positively influenced the clinical outcome . Conclusions : Positioning the shoulder in hyperextension and internal rotation during extracorporeal shock wave therapy seems to be a useful technique to achieve resorption of calcific deposits BACKGROUND predictive models permitting individualized prognostication for patients with fracture nonunion are lacking . The objective of this study was to train , test , and cross-vali date a Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy .  METHODS prospect ively collected data from 349 patients with delayed fracture union or a nonunion were utilized to develop a naïve Bayesian belief network model to estimate site-specific fracture-nonunion healing in patients treated with extracorporeal shock wave therapy .  Receiver operating characteristic curve analysis and tenfold cross-validation of the model were used to determine the clinical utility of the approach . RESULTS predictors of fracture-healing at six months following shock wave treatment were the time between the fracture and the first shock wave treatment , the time between the fracture and the surgery , intramedullary stabilization , the number of bone-grafting procedures , the number of extracorporeal shock wave therapy treatments , work-related injury , and the bone involved ( p < 0.05 for all comparisons ) . These variables were all included in the naïve Bayesian belief network model . CONCLUSIONS a clinical ly relevant Bayesian classifier was developed to predict the outcome after extracorporeal shock wave therapy for fracture nonunions . The time to treatment and the anatomic site of the fracture nonunion significantly impacted healing outcomes . Although this study population was restricted to patients treated with shock wave therapy  , Bayesian-derived predictive models may be developed for application to other fracture population s at risk for nonunion . LEVEL OF EVIDENCE prognostic Level II . See Instructions to Authors for a complete description of levels of evidence During the past 2 years , 40 patients referred to the authors ' hospital for persistent calcifying tendinitis of the shoulder were seen on prospect i ve followup after undergoing a single extracorporal shock wave therapy . During a single therapy session , all patients received 1500 impulses of the energy density 0.28 mj/mm2 in plexus anesthesia . Followup examinations were done at 6 and 24 weeks . In 62.5 % of the patients partial or complete disintegration of the deposit was observed . Statistical analysis showed significant improvement both of subjective and objective criteria . According to the Constant score , 60 % of the patients reached normal values , and 72.5 % of the patients had no or only occasional discomfort . Only 6 patients ( 15 % ) reported no improvement at the 24-week followup The aim of this study was to compare— clinical ly and ultrasonographically — the therapeutic effects of physical therapy modalities ( hot pack , ultrasound therapy , and friction massage ) , local corticosteroid injection , and extracorporeal shock wave treatment ( ESWT ) in lateral epicondylitis ( LE ) . Fifty-nine elbows of 59 patients with LE were r and omized into three treatment groups receiving either physical therapy , a single corticosteroid injection , or ESWT .  Visual analogue scale ( VAS ) was used to assess pain intensity , Jamar hydraulic dynamometer for grip strength , finger dynamometer for pinch strength ( before treatment , on the first , third , and sixth months of treatment ) . All subjects were also evaluated with ultrasonography before and 6 months after treatment . In all groups , VAS scores of the patients were found to decrease significantly on the first , third , and sixth months of treatment . With respect to grip strength evaluations , the increase after treatment was significant only on the first month in group II ; on the first and third months in group I ; and on the first , third , and sixth months of treatment in group III . Pinch strength and ultrasonographical findings did not change during follow-up in any group . We imply that physical therapy modalities , corticosteroid injection , and ESWT have favorable effects on pain and grip strength in the early period of LE treatment . The increase in grip strength lasts longer with ESWT . On the other h and , ultrasonographic findings do not change in the first six months of these treatment methods BACKGROUND We compared the long-term clinical and ultrasonographic effects of radial extracorporeal shockwave therapy ( rESWT ) versus ultrasound-guided corticosteroid injection treatment in patients with plantar fasciitis unresponsive to conservative therapy . METHODS Seventy-two patients with unilateral plantar fasciitis were r and omized to receive either rESWT ( three times once per week ) ( n = 36 ) or corticosteroid treatment ( a single 1-mL dose of betamethasone sodium plus 0.5 mL of prilocaine under ultrasound guidance by injection into the plantar fascia ) ( n = 36 ) . The primary outcome measures were visual analog scale ( VAS ) and Foot Function Index ( FFI ) scores . Secondary outcome measures included the heel tenderness index ( HTI ) score and plantar fascia thickness ( PFT ) as obtained by ultrasound examination . All of the assessment s were performed at baseline and 1 , 3 , and 6 months after treatment . RESULTS Significant improvements were observed in the rESWT group in VAS , HTI , and FFI scores and PFT at the end of treatment and were maintained during follow-up . Posttreatment improvements in VAS , HTI , and FFI scores and PFT were also seen in the corticosteroid group but were not maintained for VAS and FFI scores after the completion of therapy and were lost at 1 and 6 months , respectively . No serious treatment-related complications occurred . CONCLUSIONS Both rESWT and corticosteroid injection therapy are effective modalities for treatment of chronic plantar fasciitis . However , rESWT seems to be superior to corticosteroid injection therapy due to its longer duration of action We report a prospect i ve study of the effects of extracorporeal shock-wave therapy in 195 patients with chronic calcifying tendinitis . In part A 80 patients with chronic symptoms were r and omly assigned to a control and three subgroups which had different treatment by  low-energy and high-energy shock waves . In part B 115 patients had either one or two high-energy sessions .  We recorded subjective , functional and radiological findings at six months after treatment . The results showed energy-dependent success , with relief of pain ranging from 5 % in our control group up to 58 % after two high-energy sessions . The Constant scores and the radiological disintegration of calcification were also dose-dependent . Shockwave therapy should be considered for chronic pain due to calcific tendinitis which is resistant to conservative treatment Introduction . The aim of this study was to investigate the utility of ultrasonography ( US ) for predicting and assessing the effectiveness of extracorporeal shock wave therapy ( ESWT ) in insertional Achilles tendinopathy ( IAT ) . Methods . A total of 42 patients with an established diagnosis of chronic IAT were examined by US before ESWT and at 4 weeks and 12 weeks after ESWT . The thickness and cross-sectional area ( CSA ) of the Achilles tendon , size of calcific plaques , tendon structure score , and neovascularization score were measured at each time point . Results . After therapy , Victorian Institute of Sport Assessment -Achilles ( VISA-A ) scores increased significantly , and the size of calcific plaques decreased ( P < 0.05 ) . Neovascularization scores increased at the 4th week and then decreased at the 12th week ( P < 0.05 ) . The thickness , CSA , and structure of the Achilles tendon did not change . Variables observed by US at baseline were not associated with changes in VISA-A scores at follow-up . However , the changes in calcific plaque size and neovascularization scores were related to the improvement of VISA-A scores between pre- and posttherapy ( P < 0.01 ) . Conclusion . Ultrasonography can reveal some changes in the insertion of the Achilles tendon after ESWT , but the outcome of ESWT in IAT can not be predicted by the variables observed by US We prospect ively studied extracorporeal shock wave therapy ( ESWT ) for calcific tendinitis of the shoulder in 46 consecutive patients . All patients were r and omly divided into 2 groups : treatment and control . The 33 patients in the treatment group received 2 courses of ESWT at the energy density of 0.55 mJ/mm(2 ) ( 1000 impulses ) . The control group underwent sham treatment with a dummy electrode ( 13 patients ) . Evaluation included the Constant score , pain scale , and radiographs . The ESWT results were good to excellent in 87.9 % of shoulders ( 29/33 ) and fair in 12.1 % ( 4/33 ) , and the control results were fair in 69.2 % ( 9/13 ) and poor in 30.1 % ( 4/13 ) . Among ESWT patients , calcium deposits were completely eliminated in 7 cases ( 21.2 % ) , partially eliminated in 11 ( 36.3 % ) , and unchanged in 15 ( 45.4 % ) . In contrast , elimination was partial in 2 control patients ( 15.3 % ) and unchanged in 11 ( 84.7 % ) . There was no significant difference between Gärtner type I and type II groups in the Constant score ( P > .05 ) . ESWT shows promise for pain relief and functional restoration of calcific tendinitis with negligible complications Purpose Extracorporeal shock wave therapy ( ESWT ) is known to accelerate the healing of musculoskeletal tissue . The purpose of this study was to test the hypothesis that ESWT stimulates rotator cuff healing after arthroscopic repair . Methods Seventy-one consecutive patients with a small- to large-sized rotator cuff tear underwent arthroscopic rotator cuff repair .  The patients were r and omized into two groups : 35 patients underwent ESWT at 6 weeks after surgery ( ESWT group ) and 36 patients did not ( control group ) . Cuff integrity was evaluated with computed tomographic arthrography at 6 months after surgery . Constant and UCLA scores were measurable outcomes . Results All patients were available for a minimum one-year follow-up . The mean age of the ESWT and control groups was 59.4 ( SD : 7.7 ) and 58.6 years ( SD : 7.8 ) ( n.s . ) . There were no significant differences in tear size and repair method between the two groups ( n.s . ) . The mean Constant and UCLA scores , respectively , increased from 54.6 to 90.6 ( P < 0.001 ) and from 18.5 to 27.4 ( P < 0.001 ) in the ESWT group , and from 58.9 to 89.3 ( P < 0.001 ) and 18.5 to 27.4 in the control group . Computed tomographic arthrography was performed in 26 patients from the ESWT group and 24 from the control group , and cuff integrity was maintained in 46 out of 50 patients . Definite re-tear was observed in two patients of the ESWT group and four of the controls . There were no complications associated with ESWT . Conclusion This study failed to prove that ESWT stimulates rotator cuff healing after arthroscopic rotator cuff repair . Additional ESWT after rotator cuff repair could theoretically be advantageous , and it was proven to be safe in this study .Level of evidence II Objective : To evaluate the clinical and radiological response of chronic calcific tendinitis of the shoulder to extracorporeal shock wave therapy ( ESWT ) in a single blind study . Methods : 70 patients showing chronic , symptomatic , calcifying tendinitis of the shoulder were examined . A single blind r and omised study was performed with 35 patients undergoing a regular treatment ( group 1 ) and 35 a simulated one ( group 2 ) .  Pain and functional assessment was carried out according to Constant and Murley . Variations in the dimension of the calcification were evaluated by anteroposterior x ray films . Results : A significant decrease of pain and a significant increase in shoulder function was seen in group 1 . Examination by x ray showed partial resorption of the calcium deposits in 40 % of cases and complete resorption in 31 % of cases in group 1 . In the control group no significant decrease of pain and no significant increase in shoulder function was seen . No modifications were observed by x ray examination . Conclusion : Because of its good tolerance , safety , and clinical radiological response , ESWT can be considered as an alternative treatment for chronic calcific tendinitis of the shoulder There is no gold st and ard for treatment of  bone marrow edema syndrome of the hip ( BMESH ) . Usually , treatment is conservative , owing to the favorable and self-limiting prognosis . In musculoskeletal disorders , the effectiveness of extracorporeal shock wave therapy ( ESWT ) has been widely recognized and recent research supports its use in the treatment of the first stages of avascular osteonecrosis of the proximal femur and in other conditions where bone marrow edema is present . On this basis , we performed a prospect i ve study to evaluate the effectiveness of ESWT in normalizing the symptoms and imaging features of BMESH . Twenty consecutive symptomatic patients underwent two treatments  of high-energy ESWT and were followed-up at 2 , 3 and 6 months , with a final clinical follow-up at mean 15.52 ± 1.91 months . Patients underwent magnetic resonance imaging of the hip and were evaluated according to the Harris hip score . The mean improvement in HHS over the course of the study was of 58.5 ± 14.9 points ( p < 0.0001 ) , and the mean edema area reduced from 981.9 ± 453.2 mm2 pre-treatment to 107.8 ± 248.1 mm2 at 6 months . ESWT seems to be a powerful , non-pharmacological tool that produces rapid pain relief and functional improvement and aids the normalization of the vascular and metabolic impairments which characterize BMESH The aim of this paper is to assess the benefit to treat plantar fasciitis with low-dose energy extracorporeal shock wave therapy ( ESWT ) and the efficacy of such treatment to abate the painful symptoms allowing a rapid return to the running activity . Our study included 54 running athletes treated for plantar fasciitis associated with a heel spur who received four sessions ( once weekly ) of low-dose ESWT  , and followed prospect ively on average 45 days , 6 and 24 months after their last session . The clinical results were excellent in 59 % of cases , good in 12 % , satisfactory in 21 % and distinctly unsatisfactory in 8 % . No patient was observed a significant modification of the heel spur at the follow-up X-ray . The  ultrasound examination at 24 months showed a disappearance of the inflammation signs in 61 % of cases . A strong correlation between ultrasound improvement and clinical results were found . Low-energy ESWT seems to be a good mean to treat plantar fasciitis in runners with a 71 % of good or excellent results and a persistent improvement lasting 24 months . A r and omized multicentric study seems to be necessary to define the type of energy that should be used in the future to treat plantar fasciitis , in particular in the athletic patients , to allow a faster return to sports activities Adults with Stages I to III osteonecrosis of the femoral head present an overall therapeutic challenge . The objective of the current prospect i ve study was to show the effectiveness of high-energy shock wave therapy in treatment of patients with Association Research Circulation Osseous Stage I to Stage III necrosis of the femoral head by assessing clinical and magnetic resonance imaging results . The current study presents the results of 22 patients with femoral head necrosis 1 year after shock wave treatment .  The study population consisted of 10 women and 12 men with an average age of 54.9 years ( ± 12.3 ) . The scores achieved on the visual pain analog scale decreased from 8.5 before treatment to 1.2 after 1 year . Simultaneously , the Harris hip score increased from 43.3 to 92 points . Magnetic resonance imaging visualization of a distinct zone of sclerosis around the necrotic area remaining after treatment with extracorporeal shock wave therapy indicated therapeutic failure . The results obtained so far with high-energy shock wave therapy in these patients suggest that this method may offer an alternative to invasive treatment modalities for femoral head necrosis . A noninvasive and moderately priced method then would be available for the treatment of femoral head necrosis in the early stages of the disease process OBJECTIVES To evaluate the efficacy of autologous conditioned plasma ( ACP ) compared with extracorporeal shockwave ( ESWT ) and conventional treatments for plantar fasciitis . DESIGN R and omized trial . SETTING Sports medicine center in a tertiary care hospital . PATIENTS Fifty-four subjects ( age range , 29 - 71 years ) with unilateral chronic plantar fasciitis with more than 4 months of symptoms . METHODS Subjects r and omized to 3 groups : 19 to  ACP and conventional treatment ( ACP group ) , 19 to ESWT and conventional treatment ( ESWT group ) , and 16 to conventional treatment alone . Conventional treatment included stretching exercises and orthotics if indicated . MAIN OUTCOME MEASUREMENTS Outcomes were pain-Visual Analog Scale ( VAS ) , American Orthopaedic Foot and Ankle Society ( AOFAS ) ankle-hindfoot scale , and ultrasound plantar fascia thickness assessed at baseline before treatment and at 1 month , 3 months , and 6 months after treatment . RESULTS VAS , AOFAS ankle-hindfoot scale , and plantar fascia thickness improved in all groups . Significant VAS pain score improvements in the ACP group compared with conventional treatment at month 1 ( P = .037 ) and for the ESWT group compared with conventional treatment at months 1 , 3 , and 6 ( P = .017 , P = .022 , and P = .042 ) . The AOFAS ankle-hindfoot scale score improved in the ACP group at months 3 and 6 ( P = .004 and P = .013 ) and , for the ESWT group , at months 1 and 3 ( P = .011 and P = .003 ) compared with conventional treatment . Significant improvements in plantar fascia thickness were seen in the ACP group at months 1 and 3 compared with conventional treatments ( P = .015 and P = .014 ) and at months 3 and 6 compared with the ESWT group ( P = .019 and P = .027 ) . No adverse events reported . CONCLUSIONS Treatment of plantar fasciitis with ACP or ESWT plus conventional treatments result ed in improved pain and functional outcomes compared with conventional treatment alone . There was no significant difference between ACP and ESWT in terms of VAS and AOFAS ankle-hindfoot scale improvements , although the ACP group demonstrated greater reductions in plantar fascia thickness CONTEXT Extracorporeal shock wave therapy ( ESWT ) has been used to treat calcific tendonitis of the shoulder , but trials of ESWT for this purpose have had method ological deficiencies and thus there is limited evidence for its effectiveness . OBJECTIVE To determine whether fluoroscopy-guided ESWT improves function , reduces pain , and diminishes the size of calcific deposits in patients with chronic calcific tendonitis of the shoulder . DESIGN , SETTING , AND PARTICIPANTS Double-blind , r and omized , placebo-controlled trial conducted between February 1997 and March 2001 among 144 patients ( of 164 screened ) recruited from referring primary care physicians , orthopedic surgeons , and sports physicians in 7 orthopedic departments in Germany and Austria . INTERVENTIONS Either high-energy ESWT , low-energy ESWT , or placebo ( sham treatment ) . The 2 ESWT groups received the same cumulative energy dose . Patients in all 3 groups received 2 treatment sessions approximately 2 weeks apart , followed by physical therapy . MAIN OUTCOME MEASURES The primary end point was the change in the mean Constant and Murley Scale ( CMS ) score from baseline to 6 months after the intervention . Secondary end points were changes in the mean CMS scores at 3 and 12 months , as well as changes in self-rated pain and radiographic change in size of calcific deposits at 3 , 6 , and 12 months . RESULTS Of 144 patients enrolled , all completed treatment as r and omized and 134 completed the 6-month follow-up . Both high-energy and low-energy ESWT result ed in significant improvement in the 6-month mean ( 95 % confidence interval [ CI ] ) CMS score compared with sham treatment ( high-energy ESWT : 31.0 [ 26.7 - 35.3 ] points ; low-energy ESWT : 15.0 [ 10.2 - 19.8 ] points ; sham treatment : 6.6 [ 1.4 - 11.8 ] points ; P<.001 for both comparisons ) . Patients who received high-energy ESWT also had significant 6-month CMS improvements compared with those who received low-energy ESWT ( P<.001 ) . We found similar results for both the 3-month and 12-month CMS comparisons , as well as for self-rated pain and radiographic changes at 3 , 6 , and 12 months . CONCLUSIONS Both high-energy and low-energy ESWT appeared to provide a beneficial effect on shoulder function , as well as on self-rated pain and diminished size of calcifications , compared with placebo . Furthermore , high-energy ESWT appeared to be superior to low-energy ESWT This study investigated the effects of shockwave on systemic concentrations of nitric oxide ( NO ) level , angiogenic and osteogenic and anti-inflammatory factors in hips with osteonecrosis of the femoral head ( ONFH ) . Thirty-five patients ( 47 hips ) with ONFH were enrolled in this study . Each hip was treated with 6,000 impulses of shockwave at 28 kV in a single session . Ten milliliters of peripheral blood was obtained for the measurements of serum NO level , angiogenic factors ( VEGF , vWF , FGF basic and TGF-β1 ) ; osteogenic factors ( BMP-2 , osteocalcin , alkaline phosphatase , DKK-1 and IGF ) ; and anti-inflammation markers ( sICAM and sVCAM ) before treatment and at 1 , 3 , 6 and 12 months after treatment . The hips were evaluated with clinical assessment , serial radiograph and MRI . At 12 months , the overall results showed 83 % improved and 17 % un-improved . Total hip was performed in 4 cases ( 8.5 % ) . Serum NO3 level showed significant elevation at 1 month after treatment , but the changes at 3 , 6 and 12 months were not significant . For angiogenesis , significant elevations of VEGF , vWF and FGF basic and a decrease in TGF-β1 were observed at 1 month , but the changes at 3 , 6 and 12 months were non-significant . For osteogenesis , BMP-2 , osteocalcin , alkaline phosphatase and IGF were significantly elevated , while DKK-1 was decreased at 1 month , but the changes at 3 , 6 and 12 months were not significant . For anti-inflammation markers , significant decreases in sICAM and sVCAM were noted at 1 month after treatment , but the changes at 3 , 6 and 12 months were non-significant . Local ESWT application results in significant elevations of serum NO level , angiogenic and osteogenic and anti-inflammatory factors in ONFH BACKGROUND There is continuing controversy regarding the optimal treatment for patients with symptomatic early-stage osteonecrosis of the femoral head . We compared the results of noninvasive treatment with extracorporeal shock waves with those of core decompression and bone-grafting in similar groups of patients . METHODS Patients with stage-I , II , or III osteonecrosis were r and omly assigned to be treated either with shock waves or with core decompression and nonvascularized fibular grafting . The  shock-wave group consisted of twenty-three patients ( twenty-nine hips ) , and the surgical group consisted of twenty-five patients ( twenty-eight hips ) . The patients in the two groups had similar demographic characteristics , duration and stage of disease , and duration of follow-up . The patients in the shock-wave group received a single treatment with 6000 impulses of shock waves at 28 kV to the affected hip . The evaluation parameters included clinical assessment of pain with a visual analog pain scale , Harris hip scores , and an assessment of activities of daily living and work capacity . Radiographic assessment was performed with serial plain radiographs and magnetic resonance imaging . RESULTS Before treatment , the two groups had similar pain and Harris hip scores . At an average of twenty-five months after treatment , the pain and Harris hip scores in the shock-wave group were significantly improved compared with the pretreatment scores ( p < 0.001 ) . In this group , 79 % of the hips were improved , 10 % were unchanged , and 10 % were worse . Of the hips treated with a nonvascularized fibular graft , 29 % were improved , 36 % were unchanged , and 36 % were worse . In the shock-wave group , imaging studies showed regression of five of the thirteen lesions that had been design ated as stage I or II before treatment and no regression of a stage-III lesion . Two stage-II and two stage-III lesions progressed . In the surgical group , four lesions regressed and fifteen ( of the nineteen grade d as stage I or II ) progressed . The remaining nine lesions were unchanged . CONCLUSIONS Extracorporeal shock-wave treatment appeared to be more effective than core decompression and nonvascularized fibular grafting in patients with early-stage osteonecrosis of the femoral head . Long-term results are needed to determine whether the effect of this novel method of treatment for osteonecrosis of the femoral head endures Background and Aim : Results of previous studies have been conflicting on the efficacy of extracorporeal shock wave therapy ( ESWT ) in the treatment of plantar fasciitis . We evaluated the effects of ESWT on plantar fasciitis in terms of ultrasonographic and subjective evaluations . Material s and Methods : In this r and omized placebo-controlled trial , patients with plantar fasciitis were assigned to receive ESWT ( 4000 shock waves/session of 0.2 mJ/mm2 ) in 3 sessions at weekly intervals ) or sham therapy ( n = 20 in each group ) . Outcomes were documented by the ultrasonographic appearance of the aponeurosis and by patients ’ pain scores , performed at baseline and 12 weeks after completion of the therapy . Results : The two groups were similar in baseline characteristics . Over the study period , plantar fascia thickness significantly reduced in the ESWT group ( 4.1 ± 1.3 to 3.6 ± 1.2 mm , P < 0.001 ) , but slightly increased in the sham group ( 4.1 ± 0.8 to 4.5 ± 0.9 mm , P = 0.03 ) . Both groups showed significant pain improvement over the course of the study ( P < 0.001 ) , though pain scores were significantly more reduced in the ESWT than the sham group ( -4.2 ± 2.9 vs. -2.7 ± 1.8 , P = 0.049 ) . Conclusions : Extracorporeal shock wave therapy  contributes to healing and pain reduction in plantar fasciitis and ultrasound imaging is able to depict the morphologic changes related to plantar fasciitis as a result of this therapy Background and purpose Extracorporeal shockwave therapy ( ESWT ) and alendronate are reported effective in early osteonecrosis of the femoral head ( ONFH ) . We hypothesized that joint effects of ESWT and alendronate may produce superior results . This prospect i ve study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH . Patients and methods Forty-eight patients with 60 hips were r and omly divided into tow groups . There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics . All patients were treated with 6,000 impulses of ESWT at 28 KV ( equivalent to 0.62 mJ/mm² ) to the affected hip as a single session . Patients in group B also received alendronate 70 mg per week for 1 year , whereas patients in group A did not . The evaluations included clinical assessment , radiograph and MR image of the affected hip . Both groups were compared statistically using paired t , Mann – Whitney and Chi square tests with statistical significance at P < 0.05 . The primary end point is the need for total hip arthroplasty ( THA ) . The secondary end point is the improvement in pain and function of the hip . The third end point is the progression or regression of the lesion on image study . Results The overall clinical outcomes were improved in 83 % , unchanged in 7 % and worsened in 10 % for group A ; and improved in 77 % , unchanged in 13 % and worsened in 10 % for group B. THA was performed in 10 % of group A and 10 % of group B ( P = 1.000 ) . Significant improvements in pain and function of the hip were noted in both groups ( P < 0.001 ) , however , the differences between the two groups were not significant ( P = 0.400 , 0.313 ) . On MR images , the lesions showed progression in 10 % , regression in 47 % and unchanged in 43 % in group A , and progression in 7 % , regression in 53 % and unchanged in 40 % in group B ( P = 0.830 ) . Conclusion ESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH . It appears that ESWT is effective with or without the concurrent use of alendronate . The joint effects of alendronate over ESWT in early ONFH are not realized in short-term BACKGROUND Extracorporeal shockwave treatment ( ESWT ) and ultrasound-guided percutaneous lavage ( UGPL ) are two effective ways of treating rotator cuff calcific tendinopathy ( RCCT ) . AIM The aim of the present study was to compare the effectiveness of these techniques in the treatment of RCCT . DESIGN Prospect i ve , r and omized , controlled trial . SETTING Patients treated in our sports medicine and rehabilitation center ( Centro Médico Deyre , Madrid . Spain ) between January 2007 and December 2013 . METHODS This r and omized study compares the results achieved with these techniques over one year following their use to treat the above condition . Eighty patients received ESWT and 121 received UGPL .  A visual analogue scale was used to measure pain , and ultrasound to determine the extent of calcification , at 3 , 6 , and 12 months after treatment . RESULTS Pain and the amount of calcification were significantly reduced by both techniques at 3 , 6 and 12 months ( P<0.001 for each ) , but significantly more so by UGPL ( P<0.001 ) . CONCLUSIONS Both techniques are valid for the treatment of RCCT , although UGPL is associated with a greater reduction of calcification and greater reduction in pain . CLINICAL REHABILITATION IMPACT The results obtained applying UGPL , the low cost and the lack of complications should therefore make the treatment of choice in centers that are appropriately equipped and staffed To evaluate the results of the treatment with medium-energy extracorporeal shock wave therapy ( ESWT ) in rotator cuff calcifying tendinitis . Fifty-four non-consecutive patients , who were referred to our institute for rotator cuff calcifying tendinitis , were managed with a st and ardized protocol in four sessions of medium-energy ( 0.11 mJ/mm2 ) ESWT administered with an electromagnetic lithotriptor .  Pain was evaluated at the end of each session , functional state of shoulder was assessed at 1 and 6 months after the end of procedure . All patients underwent radiographs and sonography imaging . No systemic or local complications . Thirty-eight patients ( 70 % ) reported satisfactory functional results . Radiographs and sonographs showed a disappearance of calcium deposit in 29 patients ( 54 % ) and in 19 patients ( 35 % ) it appeared to be reduced more than a half . A correlation was found between residual calcium deposit and the clinical outcome , but some patients showed a reduced pain without modification of calcium deposit . These results were unmodified at 6 months follow-up . Our protocol of medium-energy ESWT provides good results overall about pain modulation BACKGROUND AND PURPOSE Radial shock-wave therapy ( RSWT ) is a pneumatically generated , low- to medium-energy type of shock-wave therapy . This single-blind , r and omized , " less active similar therapy"-controlled study was performed to evaluate the effectiveness of RSWT for the management of calcific tendinitis of the shoulder . SUBJECTS Ninety patients with radiographically verified calcific tendinitis of the shoulder were tested . METHODS Subjects were r and omly assigned to either a treatment group ( n=45 ) or a control group ( n=45 ) . Pain and functional level were evaluated before and after treatment and at a 6-month follow-up . Radiographic modifications in calcifications were evaluated before and after treatment . RESULTS The treatment group displayed improvement in all of the parameters analyzed after treatment and at the 6-month follow-up . Calcifications disappeared completely in 86.6 % of the subjects in the treatment group and partially in 13.4 % of subjects ; only 8.8 % of the subjects in the control group displayed partially reduced calcifications , and none displayed a total disappearance . DISCUSSION AND CONCLUSION The results suggest that the use of RSWT for the management of calcific tendinitis of the shoulder is safe and effective , leading to a significant reduction in pain and improvement of shoulder function after 4 weeks , without adverse effects Introduction Cocktail therapy consists of extracorporeal shock wave treatment ( ESWT ) , hyperbaric oxygen therapy ( HBO ) and alendronate . We hypothesized that this combined therapy may produce better results than ESWT alone when treating hip necrosis . Methods This prospect i ve , r and omized study evaluated the effectiveness of cocktail therapy in early hip necrosis , and then compared it to shock wave treatment alone . Sixty-three patients ( 98 hips ) were r and omly divided into two groups . Group A consisted of 28 patients ( 50 hips ) who received cocktail therapy  , and group B consisted of 35 patients ( 48 hips ) who received only ESWT .  Each affected hip was treated with 6,000 shocks of ESWT at 28 kV ( equivalent to 0.62 mJ/mm2 ) in a single session . Cocktail patients also received HBO therapy performed in a multi-place chamber daily for 20 treatments , and they were administered 70 mg of alendronate orally per week for 1 year . The evaluations included clinical assessment , radiograph and MRI . Results After a minimum of 2-years of follow-up , the overall results showed 74 % improved , 16 % unchanged and 10 % worsened in group A ; and 79.2 % improved , 10.4 % unchanged and 10.4 % worsened in group B ( P = 0.717 ) . Total hip replacement ( THR ) was performed for 10 % of group A and 10.4 % of group B ( P = 0.946 ) . MRI showed significant reduction in bone marrow edema and a trend of decrease in the size of the lesions in both groups , however , no difference was noted between the two groups . Cocktail therapy is effective for early hip necrosis , but the results are comparable to ESWT in short-term follow up . The joint effects of HBO and alendronate over EWST were not observed . Conclusion Long-term results are needed to determine whether or not the synergistic effects of ESWT , HBO and alendronate over ESWT alone exist in early hip necrosis A prospect i ve clinical study investigated the effectiveness of shock waves in the treatment of 72 patients with 72 nonunions of long bone fractures ( 41 femurs , 19 tibias , seven humeri , one radius , three ulnas and one metatarsal ) . The doses of shock waves were 6000 impulses at 28 kV for the femur and tibia , 3000 impulses at 28 kV for the humerus , 2000 impulses at 24 kV for the radius and ulna , and 1000 impulses at 20 kV for the metatarsal . The results of treatment were assessed clinical ly , and fracture healing was assessed with plain radiographs and tomography . The rate of bony union was 40 % at 3 months , 60.9 % at 6 months , and 80 % at 12 months followup . Shock wave treatment was most successful in hypertrophic nonunions and nonunions with a defect and was least effective in atrophic nonunions . There were no systemic complications or device-related problems . Local complications included petechiae and hematoma formation that resolved spontaneously . In the authors ’ experience , the results of shock wave treatment were similar to the results of surgical treatment for chronic nonunions with no surgical risks . Shock wave treatment is a safe and effective alternative method in the treatment of chronic nonunions of long bones Introduction The aim of this study was to investigate the effect of extracorporeal shock wave therapy ( ESWT ) on the ultrasonographic appearance of chronically painful , proximal plantar fasciitis . Material s and methods Twenty-two patients with a unilateral proximal plantar fasciitis were prospect ively enrolled after unsuccessful conservative treatment lasting 6 months . The contralateral plantar fascia was used as the control . ESWT ( 3 × 3000 shock waves/session of 0.2 mJ/mm2 ) was performed at weekly intervals . The thickness of the plantar fascia was measured ultrasonographically about 2 cm distal of the medial calcaneal tuberosity . Pain estimation on a visual analogue scale ( VAS ) and the comfortable walking time were recorded . No local anaesthesia was applied . Follow-up was done at 6 , 12 and 24 weeks . Results Before ESWT , the plantar fasciitis side was ultrasonographically significantly thicker than the control side ( p<0.05 ) , whereas 6 months after ESWT , the thickness of the fascia was no longer significantly different . The decrease in thickness of the plantar fasciitis side was significant ( p<0.05 ) . Pain during activities of daily living decreased by 79 % according to the VAS , and the comfortable walking time increased , both significantly ( p<0.01 ) . In patients with little pain ( VAS<30 ) , the thickness of the plantar fasciitis side was significantly less ( p<0.01 ) compared with patients who still suffered more pain ( VAS>30 ) . Conclusion After ESWT , the thickness of the plantar fascia in patients with plantar fasciitis decreased , pain and walking time improved ( all significantly ) Various short-term studies have demonstrated the effectiveness of extracorporeal shockwave therapy in the treatment of calcific tendinitis . To evaluate the long-term effects and any complications , the 4-year outcome was determined in a prospect i ve study of 115 patients . One session ( group A , n = 56 ) or two sessions ( group B , n = 59 ) of high-energy shockwave therapy were administered to each patient . The 6-month results showed that the level of success achieved in pain relief and the Constant score was energy-dependent and that there were significant differences in radiologic changes between the groups . By 4 years after shockwave therapy , 20 % of the entire patient population had undergone surgery on the involved shoulder . The effects of extracorporeal shockwave therapy not followed by any other therapy within the first 6 months were evaluated in 59 % ( n = 68 ) of the original 115 patients . Subjectively , 78 % of patients in group A and 87 % in group B thought the shockwave treatment had been successful . The Constant score increased from a mean of 45 before treatment to 88 in group A and 85 in group B after treatment . Radiologic changes were found in 93 % of patients in each group . In conclusion , the failure rate after ESWT is high , but for 70 % of the patients in this study , the treatment was successful and no long-term complications were seen BACKGROUND This study investigated the effects of different dosages of extracorporeal shockwave therapy ( ESWT ) in early osteonecrosis of the femoral head ( ONFH ) . MATERIAL S AND METHODS Thirty-three patients ( 42 hips ) were r and omly divided into three groups . Group A ( 10 patients with 16 hips ) received 2000 impulses of ESWT at 24 Kv to the affected hip . Group B ( 11 patients with 14 hips ) and Group C ( 12 patients with 12 hips ) received 4000 and 6000 impulses of ESWT respectively . The evaluations included clinical assessment , radiographs , dynamic contrast-enhanced MRI for microcirculation ( Ktrans ) and plasma volume ( Vp ) , and blood tests for biomarker analysis ( NO3 , VEGF , BMP-2 , osteocalcin , TNF-α , IL-6 , substance P , CGRP , DKK-1 and IGF ) . RESULTS Significant differences of pain and Harris hip scores were noticed between Group A and C in 6 months after ESWT ( all P < 0.05 ) . The pain score decreased , but not Harris hip score improved over the observation time period from 6 to 24 months . Total hip arthroplasty was performed in 3 patients ( 4 hips ) in Group A , but none in Groups B and C. Group C showed significant changes in serum biomarkers for angiogenesis , osteogenesis , anti-inflammation , pain threshold and tissue regeneration between one week and one month after treatment ( all P < 0.05 ) . However , no significant changes in the infa rct ion volume in image studies were noted in all groups ( all P > 0.05 ) . The post-treatment Ktrans and Vp in the peri-necrotic areas of Group B and C were significantly greater than pre-treatment data ( both P < 0.05 ) . CONCLUSIONS High dosage ESWT is more effective in early stage ONFH . The systemic beneficial effects of ESWT may ultimately enhance angiogenesis with improvement of microcirculation of the peri-necrotic areas , that in turn , can improve subchondral bone remodeling and prevent femoral head collapse Background : Because of specific method ological difficulties in conducting r and omized trials , surgical research remains dependent predominantly on observational or non‐r and omized studies . Few vali date d instruments are available to determine the method ological quality of such studies either from the reader 's perspective or for the purpose of meta‐ analysis . The aim of the present study was to develop and vali date such an instrument Introduction Extracorporeal shock wave therapy ( ESWT ) may exert beneficial effects in avascular necrosis of femoral head ( AVNFH ) . Patients The current study evaluated the effectiveness of ESWT in reducing pain and in slowing down the progression of bone damage in 36 patients with unilateral AVNFH of stage Association Research Circulation Osseous ( ARCO ) I , II and III . At the beginning of the study , 10 hips were classified as stage I , 11 as stage II and 15 as stage III . Each treatment cycle included four sessions , with 2,400 impulses each administered at 0.50 mJ/mm2 , at 48–72 h intervals . Follow-up examinations were scheduled at 3 , 6 , 12 and then 24 months . Method Clinical assessment s included assessment of pain scores , Harris Hip Scores and Roles and Maudsley score . Plain radiographs and magnetic resonances of the hip were used to evaluate the size of the lesion , the extent of collapse of subchondral bone , and degenerative changes of the hip joint . Results Patients from ARCO stage I group and stage II group achieved significantly better results than patients from ARCO stage III group at all follow-up time points ( p < 0.005 ) . During the follow-up period , 10 of the 15 stage III ARCO patients received an arthroplasty . ARCO stages I and II lesions were unchanged on radiographs and on magnetic resonance images . Conclusion ESWT in ARCO stages I and II may help to prevent progression of the area of avascular necrosis and manage pain Forty-three consecutive patients who did not have healing of tibial or femoral diaphyseal and metaphyseal fractures and osteotomies for at least 9 months after injury or surgery were examined prospect ively for use of high-energy extracorporeal shock waves . Former treatment modalities ( cast , external fixator , plate osteo synthesis , limitation of weightbearing ) remained unchanged . In all cases a 99mTechnetium dicarboxyphosphonate regional two-phase bone scintigraphy was performed before one treatment with 3000 impulses of an energy flux density of 0.6 mJ/mm2 . Radiologic and clinical followups were done at 4-week intervals starting 8 weeks after shock wave treatment . The success criterion was bridging of all four cortices in the anteroposterior and lateral radiographic views , in oblique views , or by conventional tomography . An independent observer described bony consolidation in 31 of 43 cases ( 72 % ) after an average of 4 months ( range , 2–7 months ) . Twenty-nine of 35 ( 82.9 % ) patients with a positive bone scan had healing of the pseudarthrosis compared with two of eight ( 25 % ) patients with a negative bone scan . Six of these eight patients with negative scans were heavy smokers . No complications were observed . High-energy shock wave therapy seemed to be an effective noninvasive tool for stimulation of bone healing in properly selected patients with a diaphyseal or metaphyseal nonunion of the femur or tibia . Additional controlled studies are m and atory Purpose Strategies for extracorporeal shockwave therapy in calcifying tendinitis of the rotator cuff vary concerning quantity of sessions and doses . The purpose of this prospect i ve pilot study was to determine the difference between the outcome of a single high-dosage extracorporeal shockwave therapy and two sessions of low-dosage extracorporeal shockwave therapy . Methods This study compared a single high-level middle-energetic extracorporeal shockwave therapy ( 0.3 mJ/mm2 ) with a low-level middle-energetic extracorporeal shockwave therapy applied twice in a weekly interval ( 0.2 mJ/mm2 ) . Thirty patients that suffered from calcifying tendinitis for at least 6 months received navigated , fluoroscopy-guided extracorporeal shockwave therapy . The gain of Constant Murley Score , Visual Analogue Scale during state of rest and weight-bearing situations ( “ stress ” ) and radiographic progress was documented 6 and 12 weeks after therapy . Results In both groups , a significant reduction in pain during stress and improvement of function was observed . In contrast , no significant reduction in pain during rest was observed . No significant difference between both groups concerning reduction in the calcific deposit after 6 weeks was detected . Group B showed minor advantages in radiographical improvement after 12 weeks . In 36 % of the patients , the calcific deposit completely dissoluted after 12 weeks . Conclusions This pilot study indicates that a single high-level extracorporeal shockwave therapy may be as effective as two applications of a lower-dosed extracorporeal shockwave therapy for calcifying tendinitis . An effective single-session strategy could reduce treatment time , material costs and healthcare expenses and ionizing radiation in case of fluoroscopy guidance . Level of evidence II This study examined the effects of high-energy shock wave treatment on the course of calcifying tendinitis of the shoulder . Twenty patients were included in the protocol .  Shock waves were applied to the calcifications with a lithotripter in two sessions of 2000 pulses each . The energy that produced the shock wave was 18 to 22 kV. Six and 12 weeks after treatment the subjective and functional state was assessed with the Constant score . All patients underwent radiographs and magnetic resonance imaging . At the 12-week follow-up evaluation 15 patients had a marked reduction of symptoms with an average of 30 % improvement in the Constant score . Radiographs showed a complete elimination of the calcifications in seven patients , and in five cases a partial disintegration was seen . The overall morbidity was low ; 14 patients had a transient subcutaneous hematoma . Magnetic resonance imaging did not show any lasting damage to bone or soft tissue HYPOTHESIS Ultrasound (US)-guided needling with subacromial corticosteroid injection is more effective than extracorporeal shock wave therapy ( ESWT ) for function restoration and pain relief in patients with calcific tendinitis of the shoulder . METHODS Fifty-four patients diagnosed with unilateral painful calcific tendinitis were r and omly allocated to a US needling or ESWT group . The US needling group underwent US-guided needling and received a subacromial corticosteroid injection . The ESWT group received ESWT 3 times a week . All patients were prospect ively evaluated ; American Shoulder and Elbow Surgeons , Simple Shoulder Test , and visual analog scale for pain scores were recorded before the procedure and at 6 weeks , 12 weeks , 6 months , 12 months , and the last follow-up . The size and morphology of the deposits were evaluated by radiography . RESULTS The average follow-up period was 23.0 months . At last follow-up , the mean size of the deposits was significantly different between the 2 groups ( P = .001 ) ; it decreased to 0.5 mm from 14.8 mm in the US needling group and to 5.6 mm from 11.0 mm in the ESWT group . There were also significant improvements in clinical outcomes in both groups after treatment ( P < .05 ) . At 1-year follow-up , the US needling group had significantly better scores than the ESWT group with regard to the American Shoulder and Elbow Surgeons assessment ( 90.3 and 74.6 , respectively ; P = .001 ) , Simple Shoulder Test ( 83.3 and 70.8 , respectively ; P = .015 ) , and visual analog scale for pain ( 1.4 and 3.3 , respectively ; P = .003).The initial calcium deposit sizes and clinical outcomes were weakly correlated in both groups ( P > .05 ) . CONCLUSION Both treatment modalities for calcific tendinitis improved clinical outcomes and eliminated calcium deposits . US-guided needling treatment , however , was more effective in function restoration and pain relief in the short term OBJECTIVES This is the first efficacy evaluation in patients with rotator cuff calcific tendinitis treated with shockwave therapy delivered using a dedicated extracorporeal lithotripter and ultrasonographic guidance . PATIENTS AND METHODS Thirty-two patients with rotator cuff calcific tendinitis received shockwave therapy delivered using a lithotripter specifically design ed for the musculoskeletal system ( DORNIER EPOS ULTRA ) , under ultrasonography guidance ( which is not part of the conventional procedure ) . The cumulative dose per patient was 1300 mJ/mm2 divided in two or three sessions . Three , six , 12 , and 24 weeks after treatment , the patients were evaluated using a visual analog scale for pain , the ASES self- question naire , Constant 's score , and plain radiographs . RESULTS Improvements in the pain and self- question naire scores were noted in 36.6 % of patients after 12 weeks and 55.1 % after 24 weeks . Plain radiographs were changed in 26.6 % of patients after 12 weeks ( with complete clearance of the calcific deposits in 6.6 % ) and in 24.1 % of patients after 24 weeks ( complete clearance in 17.2 % ) . CONCLUSION These results seem less favorable than those reported with dedicated lithotripters and computed tomography guidance The purpose of this study was to examine the effect of focused extracorporeal shock wave therapy ( ESWT ) on the treatment of nonunions . As part of a prospect i ve study , we included 143 patients ( average age , 41.4 years ) with a diagnosis of nonunion ( mean , 14.1 months ; range , 6 - 84 months ) .  High-energy shock wave treatment was applied using shock wave generator . The shock waves were applied in 3 - 5 sessions of 2500 to 3000 impulses each given at 0.25 - 0.84 mJ/mm(2 ) , at intervals of 48 - 72 hours between sessions . A maximum of 3 cycles of treatment was given , at 3-month intervals . The patients were followed during a 12-month period until fracture healing or , in case of failure , until another therapy was adopted . Complete healing was observed in 80 of 143 cases ( 55.9 % ) at an average time of 7.6 months ( range 2 - 24 months ) . Partial healing occurred in 41 cases ( 28.7 % ) and no healing was observed in 22 cases ( 15.4 % ) . Patients with trophic nonunions had a better success rate than patients with atrophic nonunions ( P<.05 ) . The results show extracorporeal shock wave therapy is a safe and effective treatment for nonunion . ESWT  is more effective for trophic nonunions than atrophic nonunions A prospect i ve quasir and omized study was performed to compare the effects of  surgical extirpation ( Group I , 29 patients ) with the outcome after high-energy extracorporeal shock wave therapy ( Group II , 50 patients ; 3000 impulses of an energy flux density of 0.6 mJ/mm2 ) in patients with a chronic calcifying tendinitis in the supraspinatus tendon . Symptoms and demographic data of the two groups were comparable . According to the University of California Los Angeles Rating System , the mean score in Group I was 30 points with 75 % good or excellent results after 12 months , and 32 points with 90 % good or excellent results after 24 months . Radiologically , there was no calcific deposit in 85 % of the patients after 1 year . In Group II , the mean score was 28 points with 60 % good or excellent results after 12 months , and 29 points with 64 % good or excellent results after 2 years . Radiologically , complete elimination of the deposit was observed in 47 % of the patients after 1 year . Clinical ly , according to the University of California Los Angeles score , there was no significant difference between both groups at 1 year . At 2 years , there was a significantly better result in Group II . Both groups then were subdivided into patients who had a homogenous deposit as seen on radiographs and patients who had an inhomogenous deposit before treatment . Surgery was superior compared with high-energy shock wave therapy for patients with homogenous deposits . For patients with inhomogenous deposits , high-energy extracorporeal shock wave therapy was equivalent to surgery and should be given priority because of its noninvasiveness
Shockwave therapy ( SWT ) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes .
However , the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear .
The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT .