Tendinopathy is common and affects many sites around the body, including the Achilles, outside of elbow (tennis elbow) and outside of hip (gluteal) tendons.
People with these painful conditions often have difficulty with functions such as raising their arm, walking, running and going up and down stairs.
The only treatment that is supported by strong evidence is exercise, but there are many other treatments such as orthotics, acupuncture, massage that are also commonly used alongside exercise and therefore they are called ‘adjunct’ treatments.
Another adjunct that is very popular is shockwave therapy. Shockwave is a relatively new treatment so this short guide is designed to provide you with information about what it is, how it works and whether it is worthwhile for you.
What is shockwave?
Shockwave is applied to the body by an applicator that basically has a vibrating end, and this delivers energy into tissues in waves, and in doing so causes direct mechanical vibration of the tissue.
An important point is that there are two types of shockwave.
Focused shockwave penetrates deeper into the tissues (and has been used to break up calcium or bone deposits) whereas radial shockwave is more superficial and is commonly used to treat tendon pain.
How does it work?
Shockwave may work by changing biochemicals in the tendon that may be responsible for pain, but there is little evidence to support this. A more likely theory is that the body produces what we refer to as ‘inhibition’ of pain for some time after shockwave and this is because it is often painful to apply shockwave.
Short term pain inhibition after a painful input to the body is a well known mechanism.
The other potential mechanism is placebo. Placebo is related to expectation – if a patient has a positive expectation about a treatment than it probably will have some effect. We know a lot about placebo from pharmaceutical research where, for example, people derive benefit from ‘placebo pills’ if the patient believes it is medicine. A key point is that although it may be part of it, placebo is unlikely to explain all the benefit of shockwave therapy.
Is it effective?
I use shockwave everyday in clinical practice, and based on my experience, I would say it has a short term effect on pain and can be a very useful adjunct to exercise. If you look at the evidence, there are studies that show it is effective over and above placebo (a sham machine) and others that do not. The important thing to note is that these studies look at the effect over weeks and do not capture the potent short term effects on pain of shockwave.
Am I good candidate for shockwave?
If you have very high pain levels (e.g. pain that flares for days after walking or running, or is generally sore all the time) you may not be the best candidate for shockwave. The perfect candidate for shockwave therapy is the patient who has tendinopathy pain that they are stuck at a certain point with. It may have improved to certain extent but now it seems exercise and other treatments are having less effect on pain and you need a bit of a push along. Shockwave therapy alongside exercise in this scenario can be extremely helpful.
How many sessions would I need?
Generally, between 3-5 is the standard, but this depends on pain response.
Pain during activities that you find irritating such as hopping (Achilles tendon) or lifting your arm (shoulder tendon) should be assessed prior and after the shockwave. If pain on these tests is not immediately and dramatically reduced by shockwave, I would be less likely to offer a follow up session.
Can I continue to run and exercise when having shockwave?
Yes, you can. In contrast, in some shockwave studies people are told to refrain from activity, sometimes for weeks. But based on reading this blog you would have worked out that really shockwave is a powerful pain modulator, so harnessing the window of painfree period seems sensible. Many of our patients are running or playing sport during shockwave treatment.
The bottom line
- There is some evidence it is useful
- It is NOT a miracle cure
- It most likely works as a pain modulator to allow greater activity
- Shockwave is an adjunct to GOOD management – and this should include exercise