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Shock-wave therapy in traumatology and sports medicine

Ya. Shel, Head of the Branch of Shock-Wave Therapy, Doctor of Medical Sciences; G. Lorera, Director of the Institute, Doctor of Medical Sciences, Professor; Institute of Sports Medicine of the city of Frankfurt am Main (Germany)


Shock-wave therapy took a reliable place in sports traumatology and became an integral means in the treatment of injuries and diseases of the musculoskeletal system. The advantage of this method consists in the possibility of treatment in the depths of the patient's body of arranged pathological foci without damage to the skin and soft tissues. The treatment session lasts no more than ten minutes, the decrease in pain occurs after the first sessions. The course of treatment consists of three, the maximum of five sessions carried out on the weekly interval. With proper use of shock-wave therapy, there are practically no complications and side effects. It can treat various diseases of the musculoskeletal system, ranging from degenerative muscle inflammation and tendons to the incompletent bone fractures. When applying shock-wave therapy, you can avoid surgery. And yet we must not forget that the shock waves are physical energy, which, with improper use, can cause substantial damage.

Waves not only destroy! Waves are restored

Extracorporeal shock-wave therapy (ESWT) began to be used in medicine since 1980, when the first successful crushing of the renal stone in the patient was held at the University Hospital of Munich. The advantage of this treatment method was that the destruction of the renal stone was carried out without disrupting the integrity of the patient's body tissues with minimal side effects. Initial concerns that shock waves can damage the fabrics through which they pass, were not confirmed. Shock waves, despite the high amplitude, pass through soft tissues, without damaging them. They show their shock force when entering solid materials or on the border of two media with different density. In addition, it is possible to focus the shock waves and, thus, to spatially limit the wave propagation zone, which allows you to send shock waves on a certain organ or patient body. Therefore, the shock waves of steel will be applied not only for crushing kidney stones, but also the stones of the gallbladder, bile ducts, pancreas and ducts of the salivary glands. Shock waves have not only destructive power, but also able to stimulate a number of biological processes. The first drew attention to the therapeutic action of the drum waves of Valkhanov, published in 1991 together with his colleague Mikhailov the results of the successful treatment of incompletent fractures of the bones of the brush and forearm (Valchanov, Michailov, 1991).

Further studies have shown the effectiveness of shock waves in the deposits of calcium salts, with inflammation of the tendons and points of attaching tendons to the bones, during muscle spastic and a number of other diseases. Along with the focused shock waves, steel since 1999 is applied in traumatology and orthopedics Ophpoxy shock waves, in other words, radial shock-wave therapy (ESWT). The effectiveness of this method is explained by the fact that the focus of inflammation in orthopedic diseases is mainly superficially and in such cases to focus the waves there is no need. Treatment of diseases with common foci of inflammation, for example, with inflammation of tendons at a high length or in muscle spastic, was particularly successful. Significant technical changes have undergone equipment. For the treatment of diseases of the musculoskeletal system, devices with a low degree of risk and easy to maintain were designed.

How to "refresh" edges of fractures

The action of extracorporeal shock waves (SW) should be considered as a mechanical stress capable of causing biochemical changes in cells and tissues of living organisms. It is noteworthy that when conducting a session of ESWT, there is a decrease in the level of pain until it has completely disappeared by the end of the session. The next effect is the visible redness of the skin in the zone of the uv. Hyperemia indicates the expansion of blood vessels with an appropriate improvement in blood circulation and metabolism. This happens in all soft tissues after the impact of SW. Based on this, ESWT began to be used to treat long non-healing wounds and degenerative diseases of the musculoskeletal system (HAUPT et al., 1990). One of the important properties of HC is the ability to destroy the sediments of calcium salts in soft tissues up to their complete disappearance (Loew et al., 1995). The mechanism of action in this case differs from that in urology.

If in urology, the target is the destruction of the stone, followed by the removal of fragmented particles through the ureters, then in the treatment of the musculoskeletal system, the main goal is to improve blood circulation. This is in turn to increase phagocytosis and resorption, which ultimately provides saline deposits. With the help of ESWT, you can also achieve a healing of long-grazing bone fractures. For this, high-energy waves are needed, which, when they are refreed to "refresh" the edges of the fracture and stimulate the growth of bone cells (Schleberger, 1995). In the study of tissues after ESWT, the rotation of new blood vessels was detected in the treatment zone, which allowed this method to apply in cardiovascular diseases. The first experiments in Cardiology gave a positive result (Schaden, 2005). SW ability to relax muscles led to their widespread use in the treatment of spashed muscles (triggerpunctions), as well as for children's spastic paralysis.

Euuts helped Olympians

With a number of diseases of the musculoskeletal system arising from high sports loads, a treatment method that does not have side effects and not giving complications was required. For these diseases, we became at the Institute of Sports Medicine Frankfurt am Main since 1996 to apply ESWT. They were treated mainly by the sprat of the heel bone, calcifiable tendinitis of the shoulder joint and epicondylitis of the shoulder bone (elbow tennis player), which are currently a standard indication for the use of SW. Similar treatment of diseases caused by sports loads, in particular, the inflammation of the Achilles tendon, the tibia periostele, the tops of the patella, etc., brought good results. Data analysis has shown that ESWT in the early stages of the diseases turned out to be more efficient.

In patients with disease duration less than 6 months, a complete recovery was 62%, and in patients with a duration of the process over six months - only 40%. For successful treatment, it is necessary during treatment to reduce sports loads. In 1996, before the Olympic Games in Atlanta, we treated members of the German national team who were in the preparatory period to competitions. With a large expectation load, the results of treatment were unsatisfactory. But Euuts turned out to be highly effective in those patients who reduced the volume of physical exertion until complete cessation of training. In the treatment of calcifying diseases in the field of shoulder joint, calcium deposits are completely dissolved. But the dissolution of calcium occurs slowly. So, according to research work (Magosch et al., 2003), the complete disappearance of calcium salts 4 weeks after the completion of treatment occurred only in 17.6% of cases, after 3 months in 44.8% of cases, after 6 months 65.3% of cases, 12 months in 75% of cases. In the spur of the heel bone and the calcification trend, the pain disappear in 80-85% of patients, as a rule, in the first 2-3 weeks. Pain syndrome with these diseases is mainly connected with the inflammatory process in the soft tissues of the shoulder. Removing the inflammatory process leads to a decrease in pain and improved mobility.

Triggerpunks, they are Moogelosis

In 1997, we began to study therapeutic effects of SWT. The results of the treatment of patients with elbow epicodile and spur of the heel bone treated with a radial wave were comparable to the results of the classical SWT. In connection with the development of this species, new therapeutic capabilities of the treatment of diseases of the musculoskeletal system appeared. Improved the results of disease treatment with a large area of ​​lesion, for example, the inflammation of the Achilles tendon, the tibiance and jersey chain and tendopathy (Sch Ll et al., 2004). Especially successfully RSWT is used in the treatment of trigger points in the muscles (Bauermeister, 2004). This pathological process is known in European literature called Moogelosis. American colleagues introduced the term triggerpunctions for this disease (TriggerPoints).

The disease is caused by excessive physical or mental loads, as well as injuries of the musculoskeletal system. At the same time, the equilibrium of the neuromuscular system is disturbed. In places of contact of the nerve endings with muscle fibers, there is a long-term muscle fiber spasm, which causes a painful cutting of the part or the entire muscle. Most often affected muscles and backs, but the process can develop in any muscle of the body. Traditional methods of treatment, like massage, physiotherapy, acupuncture, etc., rather laborious and often ineffective. With the help of ESWT, the muscle spasms and the treatment session requires little time. Dr. Everka (Konstanz, Germany) for the first time began to apply radial WC instead of a needle for acupuncture. At the same time, it uses the small diameter applicator and activates acupuncture items, applying from five to ten shots to each point (Everke, 2006). The success of therapy is comparable to classical needlerapy, but it is better to be transferred to children and patients with fear of needles.

Healing comes through pain

In all until the present, published scientific works, ESWT is recognized as a method of treatment with minor side effects and complications. The complications described occurred mainly in the initial period of the use of HC to treat the musculoskeletal system. During this period urological devices were used - lithotriprators that generated high energy waves. The technique of a treatment session was not sufficiently developed, waves were used inappropriate energy or their number exceeded the required number. The ESWT procedure itself may be painful. The level of pain is proportional to the magnitude of the energy used, that is, the higher the power of the SW, the painful procedure. By the end of the session, the pain decreases, only in isolated cases there was an increase in pain lasting to one week. During therapy, hemorrhages may occur (from pointing to the size of the maiden nail) in the shock wave applixation zone. The hematomas of large sizes, as well as damage to large vessels and nerves, were not observed. The literature describes single cases of swelling of soft tissues in the shock wave zone. In most cases, the occurring skin irritation with its redide should be considered as a positive side effect, as this indicates an improvement in blood circulation. Of the reactions of the body of a general nature, a single case of lifting hell up to 200 mm Hg were described. Art. Tetania associated with the hyperventilation of the lungs. But with the development of special equipment for the treatment of the musculoskeletal system, the use of low-energy waves was possible and the complications described above in the treatment of SW became a rarity.