Shock wave therapy (ESWT)

What is Shock Wave Therapy (ESWT)?

With ESWT, short, high-energy pressure waves are directed from the outside into the tissue. The impulses spread through the tissue, hit transitions of different densities (e.g. tendon-bone) and release mechanical stimuli there. These stimuli can stimulate blood flow, influence cell activity and activate pain-modulating mechanisms. The goal is not “anesthesia”, but rather the stimulation of healing processes – without surgery and without a scar.

• Outpatient, without anesthesia – usually well tolerated
• Sessions usually last 10-20 minutes
• Typically serial treatment (e.g. 3-5 sessions)
• Can be combined with active physiotherapy and exercise programs

Types of ESWT: focused vs. radial

There are two main forms used in orthopedics, which differ in penetration depth and energy distribution. Which method makes sense depends on the symptoms, tissue depth and treatment goal.

• Focused ESWT (fESWT): Focuses the energy in a defined deep focus. Suitable for deeper structures (e.g. calcium deposits in the shoulder, tendon attachments).
• Radial shock wave (rESWT): The energy has a more superficial and extensive effect. Often used for myofascial trigger points and superficial tendon attachments.
• Supplementary technologies: Modern practices combine ESWT with other non-invasive procedures (e.g. EMTT, laser) if necessary - depending on the indication and objective.

Typical areas of application

ESWT is used in particular for chronic, stress-dependent pain from tendon attachments (tendinopathies) and for calcific changes. It is crucial to carefully determine the indication after clinical examination and, if necessary, imaging.

• Calcific shoulder (rotator cuff calcareous tendinitis)
• Heel pain due to plantar fasciitis (with/without heel spurs)
• Tennis and golfer’s elbow (lateral/medial epicondylopathy)
• Achilles tendon problems (midportion or insertional)
• Patella tendinopathy (jumper's knee)
• Trochanteric pain syndrome (gluteal tendinopathy)
• Myofascial trigger points and muscular tension
• Selected bony indications (e.g. delayed bone healing) – only after strict testing

When does ESWT make sense – and when not?

ESWT is usually useful when symptoms persist for weeks to months despite consistent basic therapy and when typical clinical and sonographic findings are present. Not every form of pain is suitable; in some situations other measures are more superior.

• Good candidates: Chronic tendinopathy with pain typical of exertion; palpable or sonographically visible findings at the tendon insertion; therapy-resistant calcium deposits on the shoulder.
• Less suitable: Acute tears, unstable conditions, primary inflammatory systemic diseases without local triggers, pain without correlatable findings.

Contraindications and caution:

• Pregnancy (safety reasons)
• Coagulation disorders or anticoagulation: individual risk assessment
• Acute infections/inflammations or open wounds in the target area
• Tumors, loosening of prostheses or nerve courses in the focal area
• Avoid lung tissue in the beam path (e.g. on the ribs).
• Recent cortisone injection in the target area: time interval if necessary

Diagnostics and conservative basic therapy first

As a conservative practice, we always check the underlying disease before ESWT. This includes medical history, physical examination, and often ultrasound imaging. In many cases, significant improvement can be achieved with targeted activity control, eccentric training, technique/ergonomics adjustment, physiotherapy, taping/orthotics and temporary medication.

Only when the basic measures have been consistently implemented and are not yet sufficiently effective is ESWT integrated into the treatment plan - always with realistic goals and accompanying active rehabilitation.

Process of the treatment in our practice in Hamburg

• Duration: approx. 10-20 minutes per session
• Series: often 3-5 sessions spaced 1-2 weeks apart
• Aftercare: 24-48 hours no high stress; ongoing exercise program

Principles of action: mechanical stimuli and pain modulation

The therapeutic effect of ESWT is based on mechanotransductive effects: cells react to the pressure and shear forces by releasing messenger substances, blood flow can increase locally, and degeneratively modified tissue is given a “stimulus to remodel”. In addition, pain-processing processes in the skin, muscles and tendons are modulated. For calcific shoulder, focused ESWT can help to mechanically fragment calcium deposits so that the body can gradually break them down.

Important: The effects often develop over weeks. Particularly with chronic tendon problems, patience is required and consistent combination with active therapy is crucial.

Evidence: Where is ESWT well documented?

The data on ESWT is solid for some indications and heterogeneous for others. Overall, numerous studies show a benefit compared to placebo or standard therapy - especially in combination with structured exercise programs. However, not every person responds equally well; individual consideration remains important.

• Plantar fasciitis/heel spurs: good evidence for reducing pain and improving function, especially in chronic cases.
• Calcific shoulder: focused ESWT can promote the resorption of calcium deposits and relieve pain.
• Tennis elbow: positive effects possible, partly moderate; Accompanying training increases the chances of success.
• Achilles tendon, trochanter pain, patella tip: Evidence of benefit, results vary; Indication and technique are crucial.

We follow current recommendations and adapt the parameters to the respective structure and tissue depth. If the expected effectiveness is low, we transparently recommend alternatives.

Risks and side effects

The ESWT is considered safe. Side effects are usually mild and temporary. A slight irritation can even be part of the desired stimulus. Serious complications are rare but cannot be ruled out.

• Temporary pressure pain during/after the session
• Redness, swelling or small hematomas
• Short-term increase in pain (“irritation reaction”) over 1–3 days
• Rare: nerve irritation, abnormal sensations
• Very rare: tendon injury - therefore careful dosage, especially on previously damaged tendons

We discuss the benefits and risks individually, adjust the energy gradually and avoid sensitive structures in the beam path.

Combinations and alternatives

ESWT has the best effect when it is embedded in a conservative overall concept. Depending on the findings, a combination may make sense - without prematurely resorting to invasive steps.

• Active therapy: Eccentric/load-controlled training, coordination and technique training
• Physiotherapy: Manual techniques, myofascial therapy, progressive load control
• Aids: taping, temporary relief, insoles for plantar pain
• Short-term medication: Anti-inflammatory measures after medical consideration
• Regenerative processes: e.g. B. PRP injection in selected cases (after informed consent) or additional physical procedures such as EMTT or laser – always indication-related
• Surgical options: only after conservative measures have been exhausted and a clear risk-benefit assessment has been made

Preparation and aftercare

• Preparation: Please inform us about coagulation medications, previous illnesses, previous injections and image findings.
• On the day of treatment: Comfortable clothing that allows easy access to the target area.
• Aftercare: No intense peaks of stress for 24-48 hours; Cooling if necessary.
• Continuation: Continue individually tailored exercises and, if necessary, physiotherapy.
• Control: follow-up check after the series; Adjustment of the training plan.

Duration, number of sessions and costs

In many cases we schedule 3-5 sessions 1-2 weeks apart. Some patients notice the first changes early on, but in chronic tendinopathies the effect is often delayed. A realistic goal is a gradual, everyday improvement over weeks.

About the cost coverage: Private insurance companies will partially or fully reimburse the ESWT depending on the tariff and indication. For those with statutory health insurance, this is often a self-pay service (IGeL); Exceptions are possible. We prepare a transparent cost estimate in advance and advise on reimbursement issues.

Who is the ESWT in Hamburg suitable for?

For active people with long-term tendon or insertion pain, for working people with stress-related complaints or for athletes who are not making sufficient progress despite training therapy. In our practice in Hamburg-Winterhude, we check whether the ESWT suits your situation and which conservative components make additional sense.