Shockwave Therapy
How Shockwave Therapy Works
"Shockwave therapy accelerates the healing process in the body by stimulating the metabolism and enhancing blood circulation to regenerate damaged tissue. Strong energy pulses are applied to the affected area. These pulses occur for short periods of time, creating micro-cavitation bubbles that expand and burst. The force created by these bubbles penetrates tissue and stimulates cells in the body that are responsible for bone and connective tissue healing. In many instances, shockwave therapy is most effective in cases where the human body has not been able to heal itself on its own." -shockwave canada inc.
Shockwave initializes your body's natural healing process by creating a controlled inflammatory response and vascularization (increased blood flow) to the treated area. Treatment typically consists of three sessions no more than 1 week apart, but some cases could require additional sessions. Shockwave is especially effective for people suffering from chronic pain conditions that won't heal on their own such as chronic back pain, whiplash,knee pain, shoulder pain, hip pain, elbow pain and TMJ pain. When conditions become chronic, your body's natural healing process may have been stalled for various reasons. Shockwave jump starts the healing process by triggering the repair sequence to begin again. The force emitted from the hand held devise penetrates tissue and stimulates osteoblast (bone cells) and fibroblast (connective tissue cells) which are responsible for healing. Shockwave is also highly effective and indicated for treatment of calcium deposits, such as calcific tendinitis of the achilles or rotator cuff tendons.
What are the Benefits of Shockwave Therapy?
Shockwave therapy has been used successfully by healthcare providers that treat musculoskeletal disorders such as Chiropractors, Athletic Therapist and Registered Massage Therapist. Compared to other treatment methods, the advantages are:
Shockwave initializes your body's natural healing process by creating a controlled inflammatory response and vascularization (increased blood flow) to the treated area. Treatment typically consists of three sessions no more than 1 week apart, but some cases could require additional sessions. Shockwave is especially effective for people suffering from chronic pain conditions that won't heal on their own such as chronic back pain, whiplash,knee pain, shoulder pain, hip pain, elbow pain and TMJ pain. When conditions become chronic, your body's natural healing process may have been stalled for various reasons. Shockwave jump starts the healing process by triggering the repair sequence to begin again. The force emitted from the hand held devise penetrates tissue and stimulates osteoblast (bone cells) and fibroblast (connective tissue cells) which are responsible for healing. Shockwave is also highly effective and indicated for treatment of calcium deposits, such as calcific tendinitis of the achilles or rotator cuff tendons.
What are the Benefits of Shockwave Therapy?
Shockwave therapy has been used successfully by healthcare providers that treat musculoskeletal disorders such as Chiropractors, Athletic Therapist and Registered Massage Therapist. Compared to other treatment methods, the advantages are:
- Quick pain relief
- Accelerates healing
- No side effects
- No risk of allergies
- Avoids surgery and anesthesia
- Effective for chronic conditions
- No medication is needed
- Cost effective
Treatable Conditions
- TREATMENT OF TENDINOPATHIES & TENDINITIS
- Tennis Elbow
- Bicep, Hamstring or Achilles Tendinitis
- Calcific Tendinitis of the Shoulder/Rotator Cuff
- HAMSTRINGS (Chronic tension, trigger points and restricted range of motion)
- MYOFASCIAL TRIGGER POINTS ( A very common cause of back pain, neck pain and headaches)
- BURSITIS
- HALLUX RIGIDUS (Arthritis if the big toe joint)
- SCAR TISSUE
- JUMPERS KNEE (patellar tendonitis is an overuse injury that results in pain at the front of the knee)
- SHOULDER PAIN (rotator cuff tendinitis, trigger points, calcific tendinitis)
- PLANTAR FASCIITIS/HEEL SPUR
- SHIN SPLINTS
- ENHANCEMENT OF BONE HEALING
Effectiveness based on clinical trials and treatment statistics
- Improvement for Calcific Tendinitis 91%
- Improvement for Calcific Tendinitis of the shoulder specifically 83%
- Improvement for Achilles Tendinopathy 76%
- Improvement for Plantar Fasciitis 90%
- Improvement for Patellar Tendinitis/Achillodynia 88%
- Improvement for Myofascial Trigger Points 80%
Conditions with High Therapeutic Success Rates
The information provided below is from Dr. M. Gleitz years of clinical practice and experience.
Achillodynia (achilles pain)
The dominant pain symptoms in achillodynia are caused by tendinitis, which is treated locally with focused shock waves. Achillodynia is frequently accompanied by calf muscle shortening. Shock wave therapy should be extended to treat these contractures as a reduction in the calf muscle tension by trigger point therapy will also relieve the Achilles tendon (similarly to raising the heel) and is reported by patients to provide rapid alleviation of pain. The experience gathered by the authors has shown that trigger point therapy ensures a lasting improvement in the frequently restricted active ankle joint extension from 16 degrees to 25 degrees after 4 to 5 sessions.
Adductor tendinopathies
Although adductor muscles can be easily reached with shock waves, they are still difficult to treat. This is due to the fact that, in addition to trigger points, there are insertional tendinopathies in the proximal and medial third of the muscles on the pelvic insertion.
Anterior tibial syndrome
Trigger point irritation of the anterior tibial muscle is encountered among runners and after mountain descents due to muscular overstrain. Shock waves are exclusively applied to the muscles.
Cervicalgia, cervical cephalalgia, cervicobrachialgia
These indications respond particularly well to trigger point shock wave therapy as the affected muscles (except for the trapezius muscle) are rather small and located close to the body surface. The local pain, which climbs up into the head, is primarily caused by the descending and horizontal parts of the trapezius muscle and by the semispinalis muscle, splenius muscle, levator scapulae muscle and sternocleidomastoideus muscle. Apart from the scaleni muscles, the muscles that are responsible for pseudoradicular brachialgia are all located in the shoulder girdle region (subscapularis muscle, infraspinatus muscle, teres muscles, serratus posterior superior muscle, pectoralis muscle). A reduction in pain is achieved after 6 to 8 therapy sessions, along with a lasting increase in mobility of about 20 degrees rotation, 17 degrees inclination/reclination and 17 degrees lateral inclination. If no improvement is achieved, examinations should be conducted to find out whether the patient suffers from temporomandibular dysfunctions or psychovegetative exhaustion.
Dorsalgia (Back Pain)
The primarily local pain is caused by trigger points in the multifidi and rotator muscles and, in the interscapular region, by trigger points in the rhomboidei muscles, serratus posterior superior muscle and in the ascending part of the trapezius muscle.
Lumbalgia, pseudoradicular lumbosciatica (Lower Back Pain with Pseudosciatica or Referral Pain in the Sciatic Nerve Distribution)
These indications can also be treated successfully, provided that the patient does not suffer from dominant radicular irritations (prolaps, foraminal stenosis with segmental deficiencies), arthrogenic irritations (activated facet syndrome, spondylolysis) or discogenic irritations (erosive discopathy). Local pain in the lumbar spine is caused by trigger points in the segmental muscles (multifidi and rotator muscles), in the dorsolumbar junction (iliocostalis lumborum and thoracis muscle) and in the iliopsoas muscle. Referred pseudoradicular pain is caused by trigger points in the gluteal muscles (gluteus minimus and medius muscles), in the external hip rotators and in the quadratus lumborum muscle. In these cases, referred pain (in the lower leg and foot) can be easily induced by applying focused shock waves.
Metatarsalgia
Pain in the forefoot is frequently caused by splay foot related overstrain of the longitudinal and transverse muscles. This pain can be reliably eliminated with radial shock waves in 4 to 5 sessions, provided that it is not accompanied by periosteal irritations of the metatarsals and that Morton's neuromas are excluded.
Periarticular shoulder pain and restricted mobility
The term "periarthritis", often reluctantly used, plays a major role in the description of these conditions as many types of shoulder pain originate in the periarticular muscles and cause restricted mobility (infraspinatus muscle with reduced internal rotation and anterior shoulder pain, subscapularis muscle with reduced external rotation and posterior shoulder pain). Referred pain in the lateral upper arm is caused by trigger points in the horizontal part of the trapezius muscle, in the supraspinatus muscle and in the deltoid muscle. Insertional inflammations of the supraspinatus tendon have to be treated separately with focused shock waves. Frozen shoulder, a condition characterized by painful shoulder stiffness and pain caused by capsular contracture, cannot be treated successfully with trigger point shock wave therapy.
Patellar chondropathy
This condition is often characterized by a shortened quadriceps and by trigger points in the medial and lateral vastus muscles near the knee joint. Quadriceps shortening can be reliably objectivated by measuring the heel-to-buttock distance in prone position. Successful results are achieved after only two to four therapy sessions. Moreover, parapatellar pain often manifests itself after total endoprosthetic surgery and can be well treated with trigger point shock wave therapy.
Patellar tendonitis
In addition to the symptomatic tendonitis, which can be treated locally with focused shock waves, this condition is often characterized by a shortened quadriceps muscle. Although trigger point shock wave therapy provides excellent quadriceps relaxation, the tendonitis often takes several months to cure completely.
Pelvic/hip pain
Pelvic/hip pain can be successfully treated with trigger point shock wave therapy. The frequently diagnosed trochanteric bursitis is often caused by trigger points in the gluteal muscles and the external hip rotators. Local trochanteric pain has to be treated with focused shock waves. These trigger points may have been caused by previous lumbar spine pain syndromes or by a developing coxarthrosis and residual conditions after total endoprosthetic surgery. Sciatic pain, which is caused by trigger points in the gluteus maximus muscle and in the ischiocrural muscles, responds well to trigger point shock wave therapy.
Plantar fasciitis of the heel (plantar calcaneal spur)
In most cases, sonographic diagnosis reveals that the frequent X-ray diagnosed calcaneal spur is a severe plantar fasciitis below the calcaneus, characterized by fascial swelling of 4.5 to over 12 mm (normal value < 4.0 mm). This means that on the one hand local therapy is required, applying focused shock waves to below the calcaneus. On the other hand, the therapy should also focus on eliminating muscle contractures of the calf muscles and plantar muscles, which form a functional chain.
Radial and ulnar epicondylopathy
In general, these indications are no promising candidates for trigger point therapy. Most disorders are caused by local insertional tendinopathy, and not by referred pain. However, early stages of these conditions, which are caused by muscular overstrain of the forearm flexor and extensor muscles, can be treated successfully. In the case of chronic pain syndromes, treatment of the muscle chains is a viable attempt. Radial epicondylopathy: scaleni muscles, horizontal part of trapezius muscle, supraspinatus muscle, lateral part of triceps brachii muscle, anconeus muscle, supinator muscle, brachioradialis muscle including forearm extensor muscles. Ulnar epicondylopathy: serratus posterior superior muscle, infraspinatus muscle, pectoralis muscle, medial part of triceps brachii muscle, pronator teres muscle and forearm flexor muscles. Local insertional tendinopathies have to be treated with focused shock waves.
Shin splint
Tendons and the periosteum are the dominant pathological features of shin splints and must be treated with focused shock waves. Accompanying radial shock wave therapy can be performed to eliminate indurations in the medial calf muscles and in the flexor hallucis longus muscle.
Shortening of thigh flexor and extensor muscles
The most frequent symptom of this condition is recurrent muscle sprain caused by increased muscle tension. It can be treated successfully with shock wave therapy, but requires a high number of shock waves due to the large size of the muscles involved.
Tensor fasciae latae syndrome
Overstrain of the tensor fasciae latae muscle is very common among runners and causes lateral hip and thigh pain. This condition is often accompanied by trigger points in the gluteal muscles and vastus lateralis muscle.
Wrist tendonitis
Wrist tendonitis is caused by overstrain of the forearm muscles involved in wrist movement. Accompanying trigger point shock wave therapy must be performed by applying shock waves to the affected forearm muscles.
Discussion
The many different types of disorders described above have shown that the combination therapy with focused and radial shock waves can be successfully used for a variety of indications in the treatment of myofascial pain syndromes. It has been pointed out that an accurate anamnesis, especially with respect to the patient's indication of pain, is of special importance. Extensive differential diagnostics is, of course, required, which means that extracorporeal shock wave therapy is and will continue to be a medical procedure to be performed by doctors. Even if radial shock wave therapy is delegated to a physiotherapist, the diagnosis must still be made by the physician. If no lasting improvement in the condition is achieved or in case of a poor therapy success, the physician will be required to re-examine the patient.
Palpation or pinch test diagnosis with provocation of the typical referred pain and local twitch response of the muscle, which is sometimes impossible to induce, continue to play a major role in clinical screening. Functional and stretching tests are performed to complement clinical examinations. The use of focused shock waves for the localization of muscular trigger points has proved its worth as a new diagnostic procedure. This method is more accurate than localization by dry needling. The characteristic referred pain can be reliably induced. Pain localization with focused shock waves is performed at a low frequency (3 Hz) to ensure successful feedback from the patient. Treatment is started after having successfully localized primary, satellite or secondary trigger points.
The precise mode of action of shock waves applied to muscular trigger points has not been defined to date. However, the shock wave mechanism can be explained on the basis of known theories (1).
The pain relief provided by shock waves is due to counter-irritation and pain modulation comparable to dry needling. Owing to the specific physical properties of shock waves, this therapy can be described as needle-free acupuncture which induces a down-regulation of nociceptive afferents through enkephalinergic interneurons in the dorsal horn of the spinal cord. The pain modulation achieved with radial shock waves through the activation of A-beta fibers in the muscle, which then provide pain inhibition through GABAergic interneurons in the dorsal horn, can be explained in a similar manner. This would confirm the findings of Travell and Rinzler (1952), who observed many years ago that pain is relieved and trigger points are eliminated after pressure and stretching. The vibration (15 Hz) of radial shock waves also seems to have a favorable effect on muscular structures. The physiological intrinsic oscillations of 15 to 30 Hz have been described by Nazarov (1988) as important for muscular blood circulation and lymphatic drainage.
On the basis of Simons' integrated hypothesis of trigger point formation (1996), according to which muscular end-plate dysfunction and an energy crisis caused by local ischemia are the central features of trigger point pathologies, the following additional shock wave mechanisms are discussed: mechanical resolution of permanent actin/myosin contractures through local transverse stretching of the sarcomeres by the application of shock waves perpendicular to the fiber orientation up to the destruction of abnormally contracted sarcomeres through the energy applied, reactive local tissue hyperperfusion and angioneogenesis (18), which would eliminate the ischemia responsible for the energy crisis, and eventually thinning of vasoneuroactive substances by the pressure exerted on the tissue by shock waves. All these mechanisms could explain the clinically observed reduction in muscle tension and muscular contracture.
Judging by the results of recently conducted animal tests, the effects of focused shock waves in the treatment of insertional tendinopathies, referred to as "attached trigger points" by Travell, are molecular, biochemical and cellular in nature (6, 10). Neurogenic messenger substances such as substance P or CGRP are considered to induce plasma extravasation, angiogenesis and neurogenic inflammation. Similarly to the chemical stimulus produced by capsaicin, shock waves used to induce a mechanical stimulus can cause immediate local tissue response, which would explain the regeneration of tendon tissue.
While the results of the aforementioned animal tests and pain therapy considerations may explain the effects of extracorporeal shock wave therapy in the treatment of trigger point syndromes associated with insertional tendinopathies, no clinical confirmatory studies have been conducted to date to verify the experience gathered in practical application. Further research is therefore required by university scientists and by the shock wave study group of the DGOOC (German Society for Orthopedics and Orthopedic Surgery).
Authors' contact address:
Dr. med. M. Gleitz
Orthopädische Praxis
[Orthopedic Surgery]
30, Grand Rue
L-1660 Luxembourg
E-mail: marklux@mail.anonymizer.com
Achillodynia (achilles pain)
The dominant pain symptoms in achillodynia are caused by tendinitis, which is treated locally with focused shock waves. Achillodynia is frequently accompanied by calf muscle shortening. Shock wave therapy should be extended to treat these contractures as a reduction in the calf muscle tension by trigger point therapy will also relieve the Achilles tendon (similarly to raising the heel) and is reported by patients to provide rapid alleviation of pain. The experience gathered by the authors has shown that trigger point therapy ensures a lasting improvement in the frequently restricted active ankle joint extension from 16 degrees to 25 degrees after 4 to 5 sessions.
Adductor tendinopathies
Although adductor muscles can be easily reached with shock waves, they are still difficult to treat. This is due to the fact that, in addition to trigger points, there are insertional tendinopathies in the proximal and medial third of the muscles on the pelvic insertion.
Anterior tibial syndrome
Trigger point irritation of the anterior tibial muscle is encountered among runners and after mountain descents due to muscular overstrain. Shock waves are exclusively applied to the muscles.
Cervicalgia, cervical cephalalgia, cervicobrachialgia
These indications respond particularly well to trigger point shock wave therapy as the affected muscles (except for the trapezius muscle) are rather small and located close to the body surface. The local pain, which climbs up into the head, is primarily caused by the descending and horizontal parts of the trapezius muscle and by the semispinalis muscle, splenius muscle, levator scapulae muscle and sternocleidomastoideus muscle. Apart from the scaleni muscles, the muscles that are responsible for pseudoradicular brachialgia are all located in the shoulder girdle region (subscapularis muscle, infraspinatus muscle, teres muscles, serratus posterior superior muscle, pectoralis muscle). A reduction in pain is achieved after 6 to 8 therapy sessions, along with a lasting increase in mobility of about 20 degrees rotation, 17 degrees inclination/reclination and 17 degrees lateral inclination. If no improvement is achieved, examinations should be conducted to find out whether the patient suffers from temporomandibular dysfunctions or psychovegetative exhaustion.
Dorsalgia (Back Pain)
The primarily local pain is caused by trigger points in the multifidi and rotator muscles and, in the interscapular region, by trigger points in the rhomboidei muscles, serratus posterior superior muscle and in the ascending part of the trapezius muscle.
Lumbalgia, pseudoradicular lumbosciatica (Lower Back Pain with Pseudosciatica or Referral Pain in the Sciatic Nerve Distribution)
These indications can also be treated successfully, provided that the patient does not suffer from dominant radicular irritations (prolaps, foraminal stenosis with segmental deficiencies), arthrogenic irritations (activated facet syndrome, spondylolysis) or discogenic irritations (erosive discopathy). Local pain in the lumbar spine is caused by trigger points in the segmental muscles (multifidi and rotator muscles), in the dorsolumbar junction (iliocostalis lumborum and thoracis muscle) and in the iliopsoas muscle. Referred pseudoradicular pain is caused by trigger points in the gluteal muscles (gluteus minimus and medius muscles), in the external hip rotators and in the quadratus lumborum muscle. In these cases, referred pain (in the lower leg and foot) can be easily induced by applying focused shock waves.
Metatarsalgia
Pain in the forefoot is frequently caused by splay foot related overstrain of the longitudinal and transverse muscles. This pain can be reliably eliminated with radial shock waves in 4 to 5 sessions, provided that it is not accompanied by periosteal irritations of the metatarsals and that Morton's neuromas are excluded.
Periarticular shoulder pain and restricted mobility
The term "periarthritis", often reluctantly used, plays a major role in the description of these conditions as many types of shoulder pain originate in the periarticular muscles and cause restricted mobility (infraspinatus muscle with reduced internal rotation and anterior shoulder pain, subscapularis muscle with reduced external rotation and posterior shoulder pain). Referred pain in the lateral upper arm is caused by trigger points in the horizontal part of the trapezius muscle, in the supraspinatus muscle and in the deltoid muscle. Insertional inflammations of the supraspinatus tendon have to be treated separately with focused shock waves. Frozen shoulder, a condition characterized by painful shoulder stiffness and pain caused by capsular contracture, cannot be treated successfully with trigger point shock wave therapy.
Patellar chondropathy
This condition is often characterized by a shortened quadriceps and by trigger points in the medial and lateral vastus muscles near the knee joint. Quadriceps shortening can be reliably objectivated by measuring the heel-to-buttock distance in prone position. Successful results are achieved after only two to four therapy sessions. Moreover, parapatellar pain often manifests itself after total endoprosthetic surgery and can be well treated with trigger point shock wave therapy.
Patellar tendonitis
In addition to the symptomatic tendonitis, which can be treated locally with focused shock waves, this condition is often characterized by a shortened quadriceps muscle. Although trigger point shock wave therapy provides excellent quadriceps relaxation, the tendonitis often takes several months to cure completely.
Pelvic/hip pain
Pelvic/hip pain can be successfully treated with trigger point shock wave therapy. The frequently diagnosed trochanteric bursitis is often caused by trigger points in the gluteal muscles and the external hip rotators. Local trochanteric pain has to be treated with focused shock waves. These trigger points may have been caused by previous lumbar spine pain syndromes or by a developing coxarthrosis and residual conditions after total endoprosthetic surgery. Sciatic pain, which is caused by trigger points in the gluteus maximus muscle and in the ischiocrural muscles, responds well to trigger point shock wave therapy.
Plantar fasciitis of the heel (plantar calcaneal spur)
In most cases, sonographic diagnosis reveals that the frequent X-ray diagnosed calcaneal spur is a severe plantar fasciitis below the calcaneus, characterized by fascial swelling of 4.5 to over 12 mm (normal value < 4.0 mm). This means that on the one hand local therapy is required, applying focused shock waves to below the calcaneus. On the other hand, the therapy should also focus on eliminating muscle contractures of the calf muscles and plantar muscles, which form a functional chain.
Radial and ulnar epicondylopathy
In general, these indications are no promising candidates for trigger point therapy. Most disorders are caused by local insertional tendinopathy, and not by referred pain. However, early stages of these conditions, which are caused by muscular overstrain of the forearm flexor and extensor muscles, can be treated successfully. In the case of chronic pain syndromes, treatment of the muscle chains is a viable attempt. Radial epicondylopathy: scaleni muscles, horizontal part of trapezius muscle, supraspinatus muscle, lateral part of triceps brachii muscle, anconeus muscle, supinator muscle, brachioradialis muscle including forearm extensor muscles. Ulnar epicondylopathy: serratus posterior superior muscle, infraspinatus muscle, pectoralis muscle, medial part of triceps brachii muscle, pronator teres muscle and forearm flexor muscles. Local insertional tendinopathies have to be treated with focused shock waves.
Shin splint
Tendons and the periosteum are the dominant pathological features of shin splints and must be treated with focused shock waves. Accompanying radial shock wave therapy can be performed to eliminate indurations in the medial calf muscles and in the flexor hallucis longus muscle.
Shortening of thigh flexor and extensor muscles
The most frequent symptom of this condition is recurrent muscle sprain caused by increased muscle tension. It can be treated successfully with shock wave therapy, but requires a high number of shock waves due to the large size of the muscles involved.
Tensor fasciae latae syndrome
Overstrain of the tensor fasciae latae muscle is very common among runners and causes lateral hip and thigh pain. This condition is often accompanied by trigger points in the gluteal muscles and vastus lateralis muscle.
Wrist tendonitis
Wrist tendonitis is caused by overstrain of the forearm muscles involved in wrist movement. Accompanying trigger point shock wave therapy must be performed by applying shock waves to the affected forearm muscles.
Discussion
The many different types of disorders described above have shown that the combination therapy with focused and radial shock waves can be successfully used for a variety of indications in the treatment of myofascial pain syndromes. It has been pointed out that an accurate anamnesis, especially with respect to the patient's indication of pain, is of special importance. Extensive differential diagnostics is, of course, required, which means that extracorporeal shock wave therapy is and will continue to be a medical procedure to be performed by doctors. Even if radial shock wave therapy is delegated to a physiotherapist, the diagnosis must still be made by the physician. If no lasting improvement in the condition is achieved or in case of a poor therapy success, the physician will be required to re-examine the patient.
Palpation or pinch test diagnosis with provocation of the typical referred pain and local twitch response of the muscle, which is sometimes impossible to induce, continue to play a major role in clinical screening. Functional and stretching tests are performed to complement clinical examinations. The use of focused shock waves for the localization of muscular trigger points has proved its worth as a new diagnostic procedure. This method is more accurate than localization by dry needling. The characteristic referred pain can be reliably induced. Pain localization with focused shock waves is performed at a low frequency (3 Hz) to ensure successful feedback from the patient. Treatment is started after having successfully localized primary, satellite or secondary trigger points.
The precise mode of action of shock waves applied to muscular trigger points has not been defined to date. However, the shock wave mechanism can be explained on the basis of known theories (1).
The pain relief provided by shock waves is due to counter-irritation and pain modulation comparable to dry needling. Owing to the specific physical properties of shock waves, this therapy can be described as needle-free acupuncture which induces a down-regulation of nociceptive afferents through enkephalinergic interneurons in the dorsal horn of the spinal cord. The pain modulation achieved with radial shock waves through the activation of A-beta fibers in the muscle, which then provide pain inhibition through GABAergic interneurons in the dorsal horn, can be explained in a similar manner. This would confirm the findings of Travell and Rinzler (1952), who observed many years ago that pain is relieved and trigger points are eliminated after pressure and stretching. The vibration (15 Hz) of radial shock waves also seems to have a favorable effect on muscular structures. The physiological intrinsic oscillations of 15 to 30 Hz have been described by Nazarov (1988) as important for muscular blood circulation and lymphatic drainage.
On the basis of Simons' integrated hypothesis of trigger point formation (1996), according to which muscular end-plate dysfunction and an energy crisis caused by local ischemia are the central features of trigger point pathologies, the following additional shock wave mechanisms are discussed: mechanical resolution of permanent actin/myosin contractures through local transverse stretching of the sarcomeres by the application of shock waves perpendicular to the fiber orientation up to the destruction of abnormally contracted sarcomeres through the energy applied, reactive local tissue hyperperfusion and angioneogenesis (18), which would eliminate the ischemia responsible for the energy crisis, and eventually thinning of vasoneuroactive substances by the pressure exerted on the tissue by shock waves. All these mechanisms could explain the clinically observed reduction in muscle tension and muscular contracture.
Judging by the results of recently conducted animal tests, the effects of focused shock waves in the treatment of insertional tendinopathies, referred to as "attached trigger points" by Travell, are molecular, biochemical and cellular in nature (6, 10). Neurogenic messenger substances such as substance P or CGRP are considered to induce plasma extravasation, angiogenesis and neurogenic inflammation. Similarly to the chemical stimulus produced by capsaicin, shock waves used to induce a mechanical stimulus can cause immediate local tissue response, which would explain the regeneration of tendon tissue.
While the results of the aforementioned animal tests and pain therapy considerations may explain the effects of extracorporeal shock wave therapy in the treatment of trigger point syndromes associated with insertional tendinopathies, no clinical confirmatory studies have been conducted to date to verify the experience gathered in practical application. Further research is therefore required by university scientists and by the shock wave study group of the DGOOC (German Society for Orthopedics and Orthopedic Surgery).
Authors' contact address:
Dr. med. M. Gleitz
Orthopädische Praxis
[Orthopedic Surgery]
30, Grand Rue
L-1660 Luxembourg
E-mail: marklux@mail.anonymizer.com
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