Extracorporeal shockwave therapy (ESWT)
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History of extracorporeal shockwave therapy
Clinical use of ESWT was first introduced into practice in 1982 for urologic conditions . The success of this technology for the treatment of urinary stones quickly made it a first-line, noninvasive, and effective method. Subsequently, ESWT was studied in orthopedics where is was identified that ESWT could loosen the cement in total hip arthroplasty revisions. Further, animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface and also found an osteogenic response and improve fracture healing . While benefits in fracture healing have been shown with ESWT the majority of orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies, and soft tissue conditions.
Physiology of ESWT
Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration (10 ms). They have a single pulse, a wide frequency range (0-20 MHz) and a high pressure amplitude (0-120 MPa)
These characteristics produce a positive and negative phase of shockwave. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves.
In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave.
Mechanism of Action
The effects of ESWT treatment are unknown. The proposed mechanisms of action for ESWT include the following: promote neovascularization at the tendon-bone junction , stimulate proliferation of tenocytes  and osteoprogenitor differentiation , increase leukocyte infiltration , and amplify growth factor and protein synthesis to stimulate collagen synthesis and tissue remodeling    .
Extracorporeal shockwave therapy (ESWT) is primarily used in the treatment of common musculoskeletal conditions. These include both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, patellar tendinopathy, plantar fasciopathy.
There is no standardized ESWT protocol for the treatment of musculoskeletal conditions.
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