A 59-year-old woman with calcific tendinitis in her right shoulder underwent extracorporeal shock-wave lithotripsy. Three years and four months later she presented with osteonecrosis of the head of the right humerus. It is known that shock waves in patients with urological disorders can damage blood vessels. A possible reason for the development of osteonecrosis in this patient may have been damage to the blood supply of the head of the humerus

The aim of this study was to evaluate the analgesic effect of extracorporeal shock wave lithotripsy (ESWL) in patients with refractory tennis elbow, golfer’s elbow and plantar fasciitis. Patients with tennis elbow (34), golfer’s elbow (11) and plantar fasciitis lesions (14) who had not responded to a minimum of six months’ conservative treatment were included in this three-year study of ESWL. Patients who were pregnant or had neurological problems, coagulation disorder and tumour in the area of treatment were excluded. Patients received 2 000 shock waves of 0.04 to 0.12 mj/mnf three times at monthly intervals. Patients were followed up for a minimum of six months and maximum of 36 months. The effectiveness of ESWL was assessed in terms of improvement in duration and severity of pain, functional disability, complication of treatment and recurrence. Good or excellent results were achieved in 67.65% of patients with tennis elbow, 45.45% with golfer’s elbow and 71.42% with plantar fasciitis. ESWL seems a useful treatment option, as effective administered monthly as weekly. Its effectiveness in cases of golfer’s elbow in questionable

The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm², 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively).

It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.

Cite this article: Bone Joint J 2013;95-B:1521–6.

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers. Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment. The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect. Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective

Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients. Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy. Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist. The cases included:. 4 Humeral fractures: 1 Case in HIV +ve 19 years old. 5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta. 4 Tibial non-union: 1 Recurent Fracture in 65 years old man. 2 Osteochondritis of the Talus. 2 Osteochondritis of the knee. 4 Scaphoid fractures: 1 case had been fixed and grafted. Medial Epicondyle fracture non union. 5. th. Metacarpal Fracture. Trochanteric Bursitis. Tennis Elbow. 4 Planter fasciitis. – The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec. – Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal. – Size of focal zone 9X 50 mm or 6X 28 mm. – Total shock wave applied per session 2000 to 3000 shock. – large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval. – in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions. Results: There was complete resolution of symptoms in the 4 cases of soft tissues. – Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid. – 50% pain relief in Psedo arthrosis. – Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation. – None of the patient’s have so far required subsequent operative interventions, several had residual symptoms. Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT

Biofilm-associated infections in wounds or on implants are difficult to treat. Eradication of the bacteria is nearly always impossible, despite the use of specific antibiotics. The bactericidal effects of high-energy extracorporeal shock waves on Staphylococcus aureus have been reported, but the effect of low-energy shock waves on staphylococci and staphylococcal biofilms has not been investigated. In this study, biofilms grown on stainless steel washers were examined by electron microscopy. We tested ten experimental groups with Staph. aureus-coated washers and eight groups with Staph. epidermidis.

The biofilm-cultured washers were exposed to low-energy shock waves at 0.16 mJ/mm² for 500 impulses. The washers were then treated with cefuroxime, rifampicin and fosfomycin, both alone and in combination. All tests were carried out in triplicate. Viable cells were counted to determine the bactericidal effect.

The control groups of Staph. aureus and Staph. epidermidis revealed a cell count of 6 × 10⁸ colony-forming units/ml. Complete eradication was achieved using the combination of antibiotic therapy (single antibiotic in Staph. aureus, a combination in Staph. epidermidis) and shock wave application (p < 0.01).

We conclude that shock waves combined with antibiotics could be tested in an in vitro model of infection.