[Physio Explained] Shockwave therapy for tendinopathy: what actually works?

In this episode with Cliff, we discuss the use of shockwave therapy for treatment of tendinopathies. We discuss:

• Different treatment modalities for tendinopathy
• Role of shockwave in treatment of tendinopathy and plantar fasciitis
• Achilles Insertional Tendinopathy vs Mid-portion Tendinopathy

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Cliff Eaton is a chartered Physiotherapist and a Clinical Specialist at Enovis. He specialises in the work of shockwave for all conditions and has extensive experience in this area. He is both a researcher and author and educates about electromodalities, including through his current role as a Clinical Specialist. 

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

SPEAKER_01 0:05

When you look at things like the Achilles tendinopathy, then there's debate. For mid-portion tendinopathies, the research clearly show that if you combine optimal loading, I'm not going to say eccentric, I'll say optimal loading with shockwave, you will get fantastic results.

SPEAKER_00 0:26

Welcome back to Physio Explained, the Physio Network podcast where we break down key treatments, ideas, and clinical approaches shaping modern physiotherapy practice. And in today's episode, we're diving into shockwave therapy and combined modalities, focusing on how clinicians can use them effectively in practice, particularly when managing tendinopathies. Joining me is Cliff Eaton, an eminent practitioner in sports medicine and electrotherapy, who has spent much of his career working in elite professional sports where outcomes matter and clinical decisions must stand up to scrutiny. Cliff is widely recognised internationally for his work on shockwave therapy, having published in leading sports medical journals, co-authored two books on the subject, contributing to a chapter in electrophysical agents, evidence-based practice, and lectured in more than 26 countries on shockwave therapy. In today's episode, we explore the foundations of radial and focus shockwave, what the treatment actually involves, and the evidence supporting its use. We also discuss how shockwave can be enhanced when integrated with other treatment modalities, combining manual therapy, exercise therapy, and electrotherapy to optimise outcomes for patients with tendinopathy and other musculoskeletal conditions. If you've ever wondered how Shockwave fits into modern physiotherapy toolkits or how to apply it more effectively alongside other modalities, this episode is packed with practical insights and clinical reasoning. I'm James Armstrong and this is Physio Explained. Cliff, welcome to the Physio Explained podcast. It's really great to have you on. I'm looking forward to this conversation.

SPEAKER_01 2:10

Yes, well, thank you so much, James, for the invitation. I was saying earlier to my wife actually that I'm very new to podcasts. I need to get caught up for the 21st century. So this is an excellent platform to make my debut.

SPEAKER_00 2:23

It is indeed. We thought we'd welcome you on to the best physio podcast, first of all, to cut your teeth. To do that, we're going to be talking about shockwave. And we were just talking off-air about how this is becoming a bigger, larger conversation and one that physios are really embracing in many areas of the UK and around the world. So let's just have a chat first, Cliff. What sort of best practice have we got currently now, Cliff, in terms of use of shockwave for tendonopathies, when we should be using them and how we should be using them, thinking ahead of our chat about combined modalities?

SPEAKER_01 3:02

That's a great question, James, for bringing that up because we've moved a long way with the evidence. There's a new piece of evidence being published every other day now on Shockwave, hence its interest. And certainly tendonopathy management is where a lot of the research has been done. I'll have a mantra when it comes to tendonopathy management. We have one tendon for every treatment, but we do not have one treatment for every tendon. And that's true of shockwave as well. So, for example, most of us use some form of optimal loading. We can go into the debate if you wish. We've got time about whether we use eccentrics, which is from Alpherson's work, but the research shows that we only get about 55% positive outcome with eccentrics. To me, that's a bit like flicking a coin. You can look at Jim Jill Cook's with a continuum model where we're talking about a reactive tendon or acute tendon, where she's talking about using isometric loading to help reduce pain. Then you get people like Professor Peter Maliaris in Australia, who talks about heavy, slow loads. So it's fair to say there's still debate on exercise prescription, and it has to be individualized with each patient. I mean, if you look at doing eccentrics, I'm sure, like me, that you've prescribed them over the years. I mean, it's twice daily, 15 repetitions done with progressive increases in load. So you're talking about 630 reps per week done on a daily basis. Okay, so you could have quite a compliant patient for that. If you're using these heavy, slow loads, then you're looking at doing that three times a week. So that's only 120 reps, if my math's correct. So a lot less input, but usually requires going to the gym or something because you've got to use over 70% of your maximum voluntary contraction for at least a 12-week period. So people then started turning to shockwave therapy because you've got systematic reviews, meta-analysis, one I think of Schlitzau 2015, looked at 365 different pathologies and found overall that after three one-weekly sessions of shockwave, one should expect an 89% positive outcome from intendonopathy management. So that's obviously sparked a lot of people's interest. So typically, as in a lot of things with physiotherapy, the pension really started to swing away from exercise towards just giving shockwave. And that's fine. And the research supports that. But what we're finding now, and this is something that I've been advocating for years, is that if we combine shockwave and exercise, we get far superior results. We've got people like Taklaritao was the first one to publish an article supporting this, and that was for planthofitis. But since then we've had a lot more. Best practice for your listeners. If you've got shockwave, don't stop prescribing your exercise prescription, but combine shockwave with it, and you'll get far superior results and using either one on its own.

SPEAKER_00 6:32

Brilliant. And that makes sense, doesn't it? With an awful lot of other things we see, that combination rather than standalone treatment is quite often the most effective. In terms of when we think about shockwave, should we be thinking about it immediately, as soon as the patient walks to the door and we've given the diagnosis? Or should we be looking at these for patients who are not responding to our normal, I say normal inverted commas there care?

SPEAKER_01 6:59

Certainly. Well, the early research was talking about utilizing shockwave once other conservative treatments, or indeed things like injection therapy hadn't worked. And then they were getting all these positive results. So we started to realize well, if you're getting the results when all those other things haven't worked, why don't we start with shockwave? That's the key. But it's all about presentation because most patients that we see tend to be referred to as with chronic conditions, especially in the UK where you're based, a very stoic nation. We put up with it until such time as our partner gets fed up of swinging about it and then packs us off to physio. This is where shockwave really comes into its own, because I need your listeners to consider shockwave as a pro-inflammatory modality. So we're actually going, what people like DiAgostina has shown us, is that we attract macrophages, genotype M1, pro-inflammatory macrophages to the area. And then as we continue with our treatment, we attract the genotype M2, the anti-inflammatory, along with stem cells. And stem cells are sort of blank cells, and the acoustic pressure waves created by shock waves cause those cells to differentiate into the type of cells that we need. So, for example, tenocytes with a tender. So early intervention in chronic conditions is really useful. But what I'm really excited about now is the recent research is that if we use very low energy values, they're being referred to as nanoenergy values, we can actually treat acute presentations for the same reason those very low energy values do not attract the genotype M1s, it only attracts the genotype M2 macrophages and the stem cells to the area. It's early days, but very exciting research.

SPEAKER_00 9:08

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today. So essentially what we're doing is we're trying to instigate that inflammatory cascade to promote a positive adaptation to the tendon and move forward.

SPEAKER_01 9:39

Yeah, if you've got if you've got a chronic if you've got a chronic situation, the normal healing cascade, of which inflammation is the most important part, has stalled, it's got stuck for some reason. Okay. So what we do we need to do is reboot it, restart it. We take it back into that inflammatory stage, and now we can manage that much better because obviously as physiotherapists, we've got those things. So hence why things that can act as inflammatory optimizers can also help. But equally, we must tell our patients not to take anti-inflammatory medication while they're on having a course of physiotherapy because it will negate the effects.

SPEAKER_00 10:25

I can imagine this situation occurring where we're working really hard to promote some pro-inflammatory and we're sort of popping the neproxin at the same time, which is going to be not conducive to the outcomes we're looking for.

SPEAKER_01 10:38

And guys, if so, James, if I could jump in, because this is a wonderful tool. Okay, my mine's pretty worn out now. But so for those people are doing things like transverse cross-frictions to set up hyperemia and inflammatory spark, that's okay. Okay, but bear in mind these things wear out, and the treatment you give at eight o'clock in the morning is not going to be the same as the one you give at seven o'clock at night. But studies that have compared the efficacy of shockwave to things like deep transverse frictions have clearly demonstrated shockwave is much better and less uncomfortable for the patients, so more accepted by the patients as well.

SPEAKER_00 11:20

And that's really quite key as well when we look at patients buy-in. And in terms of our tendinopathies, Cliff, do we find that certain tendinopathies at the moment are more receptive to shockwave than others?

SPEAKER_01 11:34

A lot of the early research was all on lower limb, and now we're getting more and more upper limb. Plantar fasciitis is a big one. Dylan Morrissey from the Queen's University in London did a fantastic review where he looked at nine different interventions for plantofasciitis and then looked at things like first step pain, ongoing pain, function on the short-term, medium term, and long term, and looked at all the evidence. And what became apparent was shockwave had the best outcomes over the three things, over those three time periods. When you look at things like the Achilles tendinopathy, then there's debate. For mid-portion tendinopathies, the research clearly showed that if you combine optimal loading, I'm not going to say eccentric, I'll say optimal loading with shockwave, you will get fantastic results. When it comes to insertional tendinopathies, there's been three very good studies, although to be fair, some of the methodology, and least one of them could be questioned, demonstrate if you do exercise and shock wave for an insertional Achilles tendinopathy, you're not going to get the results. But then you look at people like Romper's work 2009, Lee in 2020, they clearly demonstrated that using shockwave alone without exercise had fantastic results for insertional. So this is what people need to make themselves aware of. If they invest in shockwave, it's as I said right at the beginning, there is not one treatment for every tendon, and we have to treat them differently. As I'm I mentioned Devor's work on the patella tendon earlier, that was that showed no significant difference between focus and radial, but that included eccentric loading, and that's what we tend to do. We do single leg decline squats, don't we? That's fine. But when it comes to the upper limb, now that becomes a bit different. So it'd be fair to say for the rotator cuff, for example, I can find as many positive outcomes as I can negative. Rotator cuff tendinopathy without calcification. But if we have a rotator cuff with calcification, then shock wave really does have a place. When we look at it being a non-invasive intervention, as opposed to things like dry needling, which is minimal intervention, and orthoscope, which is a major intervention, it's a really good place to at least start with. And the other area that I've run courses on and people ask me a lot about is lateral hipochondylitis. Now, again, the research is good and supports the use of it, but the clinical outcomes that people are calling me or emailing me about, they struggle with it. And there's a reason for that, because it's quite a complex joint and we we do lots of different movements with it. So it's important not just to consider the tender, for example. You have to look at the capitulum itself and the joint capsule because they all blend with the tendon. Then you've got the orbicular ligament which crosses over the common extensor origin, and if that gets tight, then that creates friction. So all of these things play a part. What I'm trying to show is there is a difference, okay? So could because you've got shockwave guys and you've read the research that said it's great for tendinopathies, it doesn't mean to say that you're going to treat every patient the same way.

SPEAKER_00 15:15

Absolutely. And I think we just have to apply our evidence and clinical experience around exercise and to know that we've got to be treating everyone slightly differently, as we talked right at the beginning about optimal loading and leaving it as at that. Cliff, we've already run out of time. We we've covered an awful lot in a very short period of time, and it's been brilliant. I think really useful just to give people a real good overview of shockwave, what it is, what's it about, and how we can best approach the use of it with patients.

SPEAKER_01 15:44

It's been a wonderful experience. I've done able to share some of my knowledge with your listeners, and please keep up the great work that you're doing. Thank you.

SPEAKER_00 15:52

Thank you very much, Cliff.