Focused Shockwave Therapy 

Shin Splints: Medial Tibial Stress Syndrome (MTSS)

 

What it is / clinical goal
For MTSS (“shin-splints”), focused ESWT aims to reduce exercise-related pain, accelerate symptom resolution and shorten time to return to running/impact activities by modulating the local pain environment and promoting tissue recovery. It is used when rest, gait modification, and a graded loading/rehab programme have not produced adequate improvement.

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How it works
Shockwaves deliver focused acoustic pulses that produce mechanotransduction in bone-tendon interfaces and peri-periosteal tissues, this can reduce nociceptive signaling, influence local angiogenesis and tissue remodeling, and stimulate resolution of chronic micro-injury. The mechanical stimulus also appears to down-regulate pain mediators and may accelerate repair of stress reactions at the tibial cortex.

 

Who is suitable
Suitable patients are typically runners and athletes with clinically diagnosed MTSS or tibial stress reactions who have failed conservative management (activity modification, shoe/orthotic changes, physiotherapy) after several weeks to months. Exclude acute tibial fractures, metabolic bone disease not under control, or active infection at the treatment site. Imaging (plain X-ray or MRI) helps exclude a frank fracture and guide management.

 

What to expect: Procedure & Recovery

Treatment sessions are brief (5–15 minutes); We locate the painful tibial zone and deliver focused pulses across a targeted area, typically in 1–4 sessions spaced weekly. You may feel sharp, transient discomfort during impulses and soreness for 24–72 hours afterwards. A graded return to impact running is guided by pain and a supervised rehab plan. Many protocols combine ESWT with unloading strategies and progressive loading exercises.

 

Outcomes
Clinical studies are mixed but promising: several controlled and cohort studies report reduced pain and faster return to running after focused ESWT compared with sham or conservative care, with benefits often apparent within weeks and maintained for months in responders. Systematic reviews note heterogeneity in protocols and call for larger RCTs, but overall indicate ESWT can shorten recovery time and improve satisfaction in many patients. Some patients require adjunctive measures or longer rehabilitation for full return to sport.

 

Risks / cautions
Transient pain during treatment is common; Discuss altering training load and footwear and follow imaging advice if symptoms suggest stress fracture progression.

 

Bone healing: Stress fractures, delayed union and non-union

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What it is
High-energy focused ESWT is used to promote bone repair in stress fractures, delayed unions and non-unions by stimulating osteogenesis, reducing pain and promoting callus formation, offering a non-surgical alternative or adjunct to operative fixation in selected cases. The goal is to achieve radiological and clinical union while avoiding or delaying surgery.

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How it works
Shockwaves trigger mechanotransductive cascades in bone tissue: up-regulation of osteogenic growth factors, stimulation of osteoblast proliferation, modulation of osteoclast activity, enhanced angiogenesis and recruitment of progenitor cells, all of which can accelerate the phases of fracture healing and callus maturation. Mechanistic and animal data support these effects; clinical protocols typically use higher energy settings than for tendinopathy.

 

Who is suitable
Appropriate patients include those with: tibial/fibular metatarsal or other superficial bone delayed unions or atrophic non-unions where internal fixation is not immediately indicated, or athletes with stress fractures where surgery is undesirable. Suitability depends on fracture location (superficial bones respond better), absence of active infection, and clinician judgment; some large long-bone non-unions respond less predictably. Multidisciplinary assessment (orthopaedics, sports medicine, radiology) is recommended.

 

What to expect: Procedure & Recovery
Bone-healing focused ESWT sessions use higher energy flux densities and are performed in clinic. Protocols vary: single high-energy sessions or a small series spaced over weeks. After treatment, reduced weight-bearing or protected loading may be advised initially, then progressive mechanical loading as healing is seen on imaging. Clinical union times vary; many studies report radiological union within months.

 

Outcomes & Evidence
Systematic reviews show using ESWT for delayed unions/non-unions report good success rates in several series, pooled healing rates in many reviews range broadly but can be high (for delayed unions often >70–80%, for non-unions somewhat lower), particularly for superficial bones and early treated cases. High-energy ESWT has produced comparable healing rates to surgery in selected series, with low complication rates and shorter hospital stays; however study heterogeneity and selection bias exist.

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Risks / cautions
Higher energy treatments can produce more acute procedural pain and local tissue soreness; FESWT should not be used in infection at the fracture site, and care is needed in bones with poor soft-tissue coverage. Discuss imaging follow-up to confirm progressive union.