Extracorporeal shockwave therapy in musculoskeletal conditions: a narrative review

Extracorporeal shockwave therapy (ESWT) has evolved from its initial application in urologic lithotripsy into an increasingly utilized noninvasive treatment modality for musculoskeletal disorders. This narrative review summarizes the physical principles, mechanisms of action, treatment protocols, contraindications, and clinical applications of ESWT across a range of orthopedic and sports medicine conditions. Two primary forms of ESWT are discussed: focused shockwave therapy (FSWT) and radial shockwave therapy (RSWT), which differ in wave generation, tissue penetration, and energy delivery. Proposed therapeutic mechanisms include neovascularization, stimulation of collagen synthesis, modulation of inflammatory mediators, osteogenic signaling, and alteration of pain neurotransmission pathways.Current evidence demonstrates the strongest support for ESWT in chronic plantar fasciitis, calcific rotator cuff tendinopathy, greater trochanteric pain syndrome, mid-portion Achilles tendinopathy, and selected cases of fracture nonunion. In contrast, evidence for lateral epicondylitis, patellar tendinopathy, and non-calcific rotator cuff tendinopathy remains inconsistent due to significant heterogeneity in study protocols and outcome measures. ESWT is generally well tolerated, with most adverse effects being mild and transient, though rare, serious complications have been reported. Overall, ESWT represents a promising conservative and adjunctive treatment option, though further high-quality studies are needed to standardize protocols and optimize patient selection.