New Guidelines Developed to Inform Clinical Decision-Making for Shockwave Therapy in Sports Medicine

Sports Medicine experts from Mass General Brigham and collaborators around the world have established clinical guidelines to inform the use of a modern non-invasive treatment for musculoskeletal disorders known as extracorporeal shockwave therapy (ESWT). The guidelines clarify key concepts behind ESWT’s efficacy and cover indications, standardized terminology, treatment procedures for tendon injuries and bone diseases, pre- and post-treatment protocols, and potential side effects. The recommendations are published in the British Journal of Sports Medicine.

“In my eight years of performing and studying shockwave therapy, I have observed significant variability in its use across the medical community,” said senior author Adam S. Tenforde, MD, director of running medicine at Mass General Brigham and attending physician at Spaulding Rehabilitation. “Our goal in developing a consensus statement is to guide best clinical practices and optimize shockwave therapy outcomes for patients around the world.”

As of 2020, musculoskeletal injuries were the leading cause of non-fatal disability worldwide, affecting over 1.63 billion people. ESWT can treat such injuries with sound waves proposed to work through multiple mechanisms that include break up of scar tissue, promote blood flow, and modify inflammation to accelerate healing. ESWT has gained popularity in sports medicine, but experts remain divided on its optimal use, efficacy, and the types of injuries it can treat. To address these questions, sports medicine professionals collaborated to develop standardized clinical guidelines.

Tenforde and the lead author Hye Chang Rhim, MD, MPH, a medical resident in the Department of Physical Medicine and Rehabilitation at Spaulding, first performed a systematic literature review on ESWT for musculoskeletal and sports injuries to select panelists and develop a questionnaire. They then created a three-part survey, distributing it to 41 experts across 13 countries, all of whom completed all three rounds. Survey statements with expert consensus directly inform the guidelines put forth in this manuscript.

Authors hope that these recommendations can guide clinical decision-making for shockwave therapy and enhance patient outcomes in sports medicine.

Authorship: In addition to Rhim and Tenforde, Mass General Brigham authors include David M. Robinson, Johnny Jarnagin, Joseph Ruiz, and Joanne P. Borg-Stein. Additional authors include Mani Singh Nicola Maffulli, Amol Saxena, Leal Carlos, Ludger Gerdesmeyer, Kristina Quirolgico, John P. Furia, Johannes Zwerver, Chun-De Liao, Daniel Moya, Shih-Wei Huang, Kayle Noble-Taylor, Hazem M.I. Alkhawashki, Brice W. Blatz, Lauren Borowski, Jay E. Bowen, Michael J. Chin, Robert M. Conenello, Michael Fredericson, Brian W. Fullem, Karin Grävare Silbernagel, Karsten Hollander, Elena J. Jelsing, Paul Langer, Kenneth Mautner, Adele Meron, Robert Monaco, Rowan V. Paul, Sara N. Raiser, James W. Ratcliff, Steve Sampson, Wolfgang Schaden, Jay Spector, Wei Sun, Isaac P. Syrop, Kenji Takahashi, Benedict Tan, James F. Wyss, Dan Zin, and Jennifer Soo Hoo.

Disclosures: Tenforde serves as Senior editor for PM&R Journal. He gives professional talks, such as grand rounds and medical conference plenary lectures, and receives honoraria from conference organizers. He has participated in research funded by the Arnold P. Gold Foundation (physician and patient care disparities), the Football Player Health Study at Harvard (health in American-Style Football players), the American Medical Society for Sports Medicine (bone density research), the Uniform Health Service and Enovis (Achilles tendinopathy). He receives funding from the NFLPA and Department of Defense for studies evaluating shockwave for management of orthopedic injuries. He is a paid consultant for State Farm Insurance and Strava.

Funding: The authors did not receive a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Paper cited: Rhim, H et al. “Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified-Delphi study” British Journal of Sports Medicine DOI: 10.1136/bjsports-2024-109082