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Shock-wave therapy in traumatology and orthopedics

The use of extracorporeal shocking therapy in traumatology and orthopedics

Yu.T. Shabchais, T.V. Dudina, O.Yu. Polyanskaya


Today, shocking therapy is an alternative to surgical interventions with a number of pathological conditions, including in injuries and diseases of the musculoskeletal system. The method of extracorporeal shocking therapy (ESWT) is based on the short-term effects of high-energy vibration in the application zone, which reduces pain syndrome, improves local blood circulation and breaks painful bone and fibrous foci with the subsequent resorption of their fragments. Bone fractures, degenerative changes and inflammatory processes in tendons are also a successful treatment with this method. With it, it is achieved to quickly relieve pain without the use of analgesics, which matters in the event of the development of allergic reactions. Since the method is recommended for non-invasive treatment of chronic pain in traumatology and diseases associated with the overvoltage of the musculoskeletal system, it is particularly relevant in sports medicine.

The effect of extracorporeal shock waves on biological fabrics is known since the Second World War, when, as a result of the detonation of water bombs, people in water at a considerable distance from them received deadly damage to the lungs without any visible external damage [1].

For the first time in medicine, shock waves were applied in 1980 for crushing kidney stones [2], and in 1985 - gallbladder stones [3]. Today, this method is successfully treated with diseases associated with the formation of stones not only in the kidneys and a bustard bubble, but also in salivary glands, pancreas. Since the studies of V. Valchannov [4], which described the healing of bone fractures under the influence of shock waves, the scope of ESWT in orthopedics significantly expanded and includes the treatment of pseudoarthrosis or false joint, epicondylitis, heel spur and other pathological conditions [3, 5-10].
Despite the fact that the use of ESWT in orthopedics, side effects are rarely observed, including remote, the theoretical possibility of their development requires not only the study of the mechanisms for the formation of shock waves and the physical principles of their action on tissue, but also the analysis of the clinical use of equipment that allows you to modify therapy parameters and technology propagation of the shock wave. The fact that today is known about the effects of shock waves used in urological practice, including the crushing of kidney stones, is not enough to determine the ESWT effect in orthopedics and does not explain the analgesic effect of shock waves and their influence provided at the cellular level [4, 7 , eleven]. Therefore, it is so important to understand the mechanisms of formation and the effect of extracorporeal shock waves, as well as their properties defined by physical parameters.
Physical principles of education and action of shock waves. The shock waves are customary to determine as vibrations of alternating pressure, which are distributed in three dimensions and lead to an increase in pressure for a short period of time. In most cases, such maximum pressure is achieved within several nanoseconds. In addition to the hoppy impulse of positive pressure, the shock waves are characterized by a tension phase with a negative pressure, which follows the phase of positive pressure. The main parameters of the shock waves: the maximum positive pressure (P +), which varies depending on the type of equipment of the device from 5 to 120 mR; Maximum negative pressure (R-); Pressure increase (TH) time and pressure pulse width (SW). The values ​​of P +, P-, TR and TW shock wave depend on the range of the shock wave source and the settings used [12]. Most modern devices transmits shock-wave energy through the water filled with water. It is believed that, since the muscles and fat fabric differ little in their acoustic properties, most likely, the acoustic resistance, measured in the NA / M3, is clinically insignificant in closely located border areas. To date, it is definitely not defined which of the parameters of the shock waves is the most essential value in biological effects and clinical results [13]. The relationship between the measured parameters of the shock wave and biological, in particular analgesic, effect is not clear.
There are various ways to generate shock waves, four of which are used in the clinic. All of them are aimed at creating a pressure pulse transmitted by tissues with minimal energy loss, for which various connecting media use [14]. In medicine, shock waves are most often generated by mechanical education based on the principles of ballistics. Compressed air gives acceleration projectile, which pushes the applicator placed on the skin, giving it greater kinetic energy. The use of a contact gel (ultrasonic gel or castor oil) contributes to the fact that the dynamic pulse, through the applicator transmitted by tissues as a shock wave, continues to spread in the body in the form of spherical or spherical waves, i.e. Radially, therefore, called the radial shock wave, and the method used - radial extracorporeal shocking therapy (RWST).
The main feature of the apparatus that uses such a principle is that an increase in the wave steepness occurs much slower than the devices focusing the shock wave, therefore focusing technologies are used in the treatment of deep layers of tissues (for example, for crushing stones in the kidneys, etc.). Radial technologies do not ensure the formation of secondary acoustic focus. With this type of drum wave generation, the surface of the applicator forms a geometric point of high pressure and high energy density, and as a result of radial propagation, the pressure and specific energy after the exit from the applicator gradually fade [12, 14]. In recent years, new modifications of applicators used in RAVTs are developed, allowing ballistic shock waves to focus on certain sections with a maximum concentration. Another method of formation of shock waves is the use of electromagnetic currents. In the thin copper foil under the influence of electromagnetic currents, explosive deformation occurs. At the same time, the column of bound water is shifted in proportion to pressure. The pressure generated in this way is associated and transmitted to another medium. Various additional devices, such as acoustic cutting lenses, are able to focus pressure waves at a given distance and transmit them to deeper parts of the body, and acoustic reflectors - to adjust the focus accuracy [15].
The electropneumatic principle is the oldest method of generating shock waves, according to which the wicked candle is located in the primary focus. High temperatures during the spark discharge make the surrounding fluid evaporate with the formation of plasma bubbles. Radial shock waves from primary focus thanks to an oval acoustic mirror are collected in secondary focus. The transmission of shock waves in the specified areas is provided with the help of appropriate binding environments. One of the disadvantages of this process is the instability of the shock wave, the need for frequent replacement of expensive electrodes [15, 16]. Piezoelectric principle. The effect of shock waves is based on the same principle as in other emission methods mentioned above. A small pressure impulse created by local electrical pulses of individual piezocrystals is emitted to the center of the spherical cup. Since the crystals are located in a longitudinal cutting tube, pressure waves are collected in one focus [17].
Principle of operation of a shock acoustic wave. In the equipment used in clinical practice, the shock waves are usually generated in water to facilitate their transmission of tissues with similar acoustic properties. Pressure pulses propagate in the tissues of the body is waveled, like through water, gas or solid. The speed of propagation of an acoustic wave is proportional to the density of the medium through which it passes. According to the authors of [18], the lagging segments of the shock waves of the sound pressure front are accelerated in a high density environment and, therefore, catch up with the early segments of the shock wave front. This phenomenon, depending on temperature, pressure and difference in the weakening of individual shock wave segments, entails its asymmetric deformation, an increase in pressure pulse and the formation of shock waves. Typical features of such a wave configuration - a cool rise of pressure curvature and a flattering pressure drop slot. These features are detected in acoustic focus. In the future, the wave front loses them, individual parts of the pressure pulse with variable frequency and intensity are dissipated, removing apart (defocus). At the border between two tissues or in the zone of calcium deposition in soft tissues, the shock wave is refracted, the pulse part is transmitted to the cloth, and the part is reflected. In such acoustic borders, sound energy, turning into mechanical, crushes calcium deposits. The amount of sound energy turning into mechanical depends on the difference in tissue resistance. Today, the mechanisms of extracorporeal shock-call impact on biological objects are generally clear. However, the relationship between the measured parameters of the shock wave and their biological, in particular an analgesic, effect is not studied. First of all, it is necessary to determine the relationship between the dose and the resulting effect, regardless of the equipment used, as well as optimize ESWT technique. Further clinical studies will help clarify the most acceptable characteristics of ESWT in orthopedics and traumatology.
Methods for measuring the magnitude of the shock wave. The solution of the tasks set above requires not only the improvement of equipment and the creation of new methods for generating shock waves, but also to continuously improve the technologies for measuring the magnitude of the shock wave. The magnitude of the shock wave can be measured by both electrical and non-electrical methods. Neelectric methods include optical methods and are determined by the crushing coefficient of "reference" stones [14, 19]. It is believed that only electrical sensors (so-called pressure seismic receivers - hydrophones) are acceptable to quantify the values ​​of the shock wave. These techniques were originally intended for low pressure areas and were based on the piezoelectric properties of a polyvinyl fluoride foil included in a thin steel tube. According to the authors of [19], the main disadvantage of such a hydrophone, except for a limited work period, is that the tensile part of the shock wave cannot be measured due to the local cavitation phenomenon. Therefore, in recent years, hydrophones in recent years are used, among which the most promising fibroids, registering acoustic waves as peaks and converting them in proportion to outlet voltage. Lack of hydrophones - high cost.
Biological and clinical effects induced by shock waves. Regardless of the source generating pressure pulses, the latter affect the tissue of the body as directly (mechanical effect) and indirectly in the form of chemical and thermal effects that cause various mediated biological reactions. Especially well studied and clinically proven mechanical effect of shock waves. This is primarily lithotripsy kidney stones, treatment of a calcining tendinite, etc. [20-23]. Indirect effects can also strengthen the biological and clinical result. Nevertheless, the mechanisms of analgesic and anti-inflammatory effects of shock waves are not entirely clear.
It is believed that the thermal impact is the result of high amplitudes of pressure and compression processes and decompression, which is ineffective in the clinical plan. A more significant is an indirect mechanism for the formation of cavitation (voids) [24]. Cavitation is defined as the formation of bubbles filled with gas with a negative pressure gradient. The voids of negative pressure occur if a liquid medium interacts, such as water, and if it is below the positive pressure forces. The prevailing negative pressure causes the evaporation of the liquid along the edge of the cavitation bubble, thus providing its growth. When the pressure shock wave passes through the tissue, the pressure returns to normal isobar and the bubble slams. Since absolutely symmetric bubble slam is extremely rare, in the process of its slamming, high-speed fluid flows are formed, called the reactive jet (focal effects), which has a powerful destructive effect [24]. In these cases, the frequency of the shock wave has a much greater influence, since the previous shock wave is overtaken by the next pulse wave. If the frequency shock wave reaches a certain level, bubbles that have not slammed, get the following shock wave. The cavitation bubble asymmetrically slams over a shorter period of time, and the reactive jet causes a significantly greater local destructive effect [19, 25]. Another indirect effect of shock waves is the formation of free radicals in the tissues of the body. Free radicals may also occur as a result of the effect of high temperatures, significant pressure gradients and release of mechanical energy, stressing reaction, but these mechanisms do not have a pronounced and clinically proven effect and have been reproduced only in laboratory conditions.
The question of a possible biological threshold dose when exposed to shock waves also remains unanswered. There is no evidence that "overdose" causes any structural and functional changes at the cellular level. Most likely, such effector bodies such as nerve endings and a vascular system cannot be destroyed by impact of shock waves. It is believed that the holding of low-energy ESWT does not require local anesthesia, since most of the promising placebo-controlled studies showed good results [26, 27]. Nevertheless, the use of local anesthesia with ESWT is one of the most discussed issues discussed in the literature. Roule in orthopedics: Swiss DolorClast® method. Initially shocking therapy used to treat urological diseases (lithotripsy), was carried out with the help of large installations focusing shock waves. Currently, more than 8,000 SWISS Lithus® devices are known - intracorporeal lithotripters operating on the principle of shock wave, with the help of which they remove stones in the kidneys, urinary bubble and ureters. Their manufacturer is EMS: Electro Medical System (Switzerland), which has repeatedly established the standards for the development and production of medical equipment. Since 1990, the company conducts research on the study of the effect of pneumatically educated shock waves on bone tissue. The use of shock waves in orthopedics in recent years using special devices for lithotripsy (Swiss Lithoclast®) has shown that they do not satisfy the requirements necessary for the treatment of the musculoskeletal system.
In 1999, the SWISS DolorClast® SWISS DolorClast® was introduced to the markets of many countries of the world, with the advent of which a new standard was installed in the RAVT. This compact apparatus, which is a modification of a lithotriptor, similar to those used for intracorporeal lithotripsy, produces shock waves with low and medium energy. In the context of studying the clinical effects of RSWT, it should be said about the activities of the International Medical Association, which is engaged in the use of ROVTs in the treatment of diseases of the bone-muscular system, - ATRAD (Association of Radial Pain Therapy), founded in 2003 in Switzerland [28].
The first and fairly convincing multicenter study of the RAVT performance using the SWISS DolorClast® apparatus was carried out in Switzerland in 2002 with ATRAD. To ensure proper level of reliability, the study was conducted separately among patients with three different diagnoses: the tendinopathy of the rotator cuff shoulder (pain in the shoulder joint), epipondylopathy ("elbow tennis player"), plantar fascia. In total, 249 patients were treated, which had 919 shocking therapy sessions using the SWISS DolorClast® apparatus. After the treatment is completed, good and very good results were observed in more than 80% of cases; After 10 weeks, good and very good results for the same patients were preserved. It is noted that the cost of this treatment is 3-4 times lower than when using large installations, which is based on other principles for generating shock waves [29]. It should be clarified that the action of the SWISS DolorClast® apparatus is based on a new principle of pain therapy in skeletal and muscle tissues. The shell in the tip of the apparatus is accelerated using dosage pulses of compressed air, and shock waves emitted from the tip of the applicator are accepted by radially inside the body. To minimize energy losses during a shock wave, a pin gel is used. The effectiveness of the method is clinically tested, and it is successfully applied to orthopedics in the treatment of the tendinopathy of the rotational cuff, the lateral and medial epicondylitis, the plantar fascia, the inflammation of the Achillos tendon, the contracture of Dupyutrena, the tend of the patella and pain caused by MojoLosa (trigger zones), other diseases [28 ].
To date, numerous promising controlled randomized studies in the field of orthopedics and traumatology, confirming the favorable results of treatment with extracorporeal shock waves [30-33]. Standard testimony for the treatment of therapy is the plantar fascia, epicondylitis and calcining shoulder tendinite [34]. Nevertheless, various treatment parameters (energy production, energy density, dosage, frequency of sessions) and differences between radial and focused impact of shock waves continue to cause discussions among specialists. In some studies, when comparing the effectiveness of treatment with focused and radial (non-cultivated) extracorporeal shock waves of the plantar fascination [35], the calcining tendinite [36] and other diseases [37-41], significant differences are not marked.
Recently, the SWISS DolorClast® apparatus uses a focusing handle transmitting generated pneumatically extracorporeal shock waves. Treatment with the use of such a focusing applicator conducted at the Institute of Sports Medicine (Frankfurt am Main) showed successful results in patients with a calcining shoulder tendinite and heel spur [28]. In assessing the quality of life in a long time after treatment, 87.5% of patients have satisfactory and excellent results. It should be emphasized that such characteristics of therapeutic devices as compactness and mobility are very important in pain. The energy source attached to the treatment area should have the ease of regulation and ease of use, the head (tip) of the device must be movable, for which it should be minimal size and weight. In this case, the patient will be able to settle on the couch and receive the therapeutic effects of the waves in a position convenient for it [42]. This conditions are fully answered by the EMS Swiss DolorClast® device. It consists of a control unit and tip. The applicator is installed on the far end of the tip and is attached to the cap nut. Pulse oscillations from the compressor lead the projectile inside the tip. It strikes the inner surface of the applicator sensor, the pulse causes a shock wave in the applicator, which moves to the distal surface of the sensor and is transferred to the treatment zone. In this case, the shock wave applies to the tissues from the contact point radially. The efficiency of the method is clinically proven. Contraindications are malignant tumors in the treatment area or near it, the presence of an infectious process in the field of treatment, blood coagulation disorders.
The most common example of the negative impact related to the use of the SWISS DolorClast® apparatus is pain and discomfort during treatment that during clinical studies were noted about 23% of patients. However, all patients withstood treatment without anesthesia. In most cases, the duration of pain did not exceed 10 minutes [42]. In general, it can be stated that the efficiency of the RSWT, including in comparison with other modes of shocking therapy, clinically proved, the Swiss DolorClast® method is 3-4 times more economical, the equipment used is significantly smaller in size, while treatment is well tolerated, local anesthetics are not Wanted, clinically significant side effects were not observed.
The main applications of the SWISS DolorClast® apparatus - traumatology, orthopedics and rheumatology: fresh fractures, hypertrophic false joints, slowing down the consolidation of bone fractures, degenerative changes and inflammatory processes in tendons and bundles, therapy of myofascial pain, post-mobilization contractures of joints, muscular contractures, damage to capsules The ligament apparatus of the muscles, as well as the plantar fasci, epicondylitis and calcining shoulder tendinite [34].
The effectiveness of the RSWT in the treatment of tendinopathies. RSWT is a new non-invasive method of tendinopathy therapy. The effectiveness of the short course of treatment and the possibility of continuing dosage and controlled physical activity are weighty arguments in favor of using this method, including in sports medicine. The efficiency of the method is due to a combination of mechanical, biochemical, analgesic and (or) local anti-inflammatory action. Shock waves also lead to fresh microtrams that contribute to the activation of reparation processes (this principle is used to treat certain types of pseudoarthrosis) [43]. 
Roules with a calcining tend little shoulder. Calcinating shoulder tendinite, called "Calcium deposits of hydroxyapatite deposits", is characterized by the ralocarbon formation of crystals of the basic calcium phosphate and occurs most often aged from 30 to 50 years. Different terms are used to designate this pathology: calcining perpetinitis, calcining periatritis, otolochertic calcification, Duplea disease. Women and representatives of the "seating" of professions are prone to developing the disease. However, the etiology of the calcining tendinite is still not completely defined. Some authors associate its origin with the age degenerative weakness of the muscles and repeated tendral injuries, leading to degeneration and necrosis of collagen fibers, followed by their calcification. In addition, in case of circulatory disorders and hypoxia, the tendons of the calcium crystals can penetrate the tendon or subacromial / subcado-shaped bag. The chronic phase of the calcining tendinite is characterized by a slow amplification of pain, irradiating to the area of ​​attaching the deltoid muscle or the distal shoulder. Patients complain about night pain, the intensity of which varies for a number of years. To date, the treatment of a chronic calcining shoulder tendinite is not standardized, the correlation between the intensity of pain and calcinate deposits is uniquely not defined, therefore various options for conservative therapy are used. In cases where the course of the disease acquires chronic character, pain - clinical significance, and conservative treatment methods do not succeed, the use of extracorporeal shocking therapy is recommended [44-46]. It is believed that high-energy shock waves have a direct mechanical destroying effect on the acoustic boundaries located around calcinates.
In 1993, M. Loew used highly and low-energy shock waves for the treatment of calcining tendinite [47]. In promising studies, he described success in 55% and 65% of patients who used one or two applications, respectively, according to 2000 pulses of medium energy (21 kV) compared to low energy (18 kV). Despite the relatively numerous experimental and clinical studies on the treatment of a calcining tendinite using ESWT, consensus regarding therapy parameters (energy flow density used by the number of pulses or the number of therapeutic procedures) was not achieved [48, 49]. In addition, the results of the ESWT influence the individual anatomical features of the patient, the method of application and variety of equipment used. Since 2000, pneumatically generated low-energy radial shock waves with an energy flow density in focus to 0.16 MJ / mm2 [50] are used to treat the calcination shoulder tendinite. When applying this regime, in 95% of cases, a general improvement in the state and disintegration of calcium deposits was noted. It is believed that the principle of the formation of shock waves does not play a significant role in the EUTO effect with the calcining shoulder tendencies, however, studies have been known to prove the superiority of the use of high-energy shock waves. In several clinical trials using high-energy shocking therapy of the calcining tendinite of the shoulder, a significant painful effect, an improvement in the function of the shoulder joint and the disintegration of calcium deposits [49, 51, 52] is marked [49, 51, 52]. 6 months after the PAVT, the decrease in pain or their complete disappearance was observed in 85.2% of patients [50].
In another perspective study conducted among 100 patients (the average duration of pain - 28 months (minimum 12 months), the size of calcium deposits is at least 10 mm), J. ROMPE ET AL. [53] also demonstrated successful remote results of RSWT. The authors used a single use of 1500 pulses of high-energy shock waves (EFD 0.28 MJ / mm2 with a frequency of 2 Hz). After three weeks, a significant improvement in constant points was observed, while 57% of patients decompose calcium deposits confirmed radiologically. Complete resorption is achieved in 19% of cases [53]. A significantly more pronounced full or partial decay of calcium deposits, confirmed x-geographically, was also noted in studies conducted after 6 months in the group of patients using high drum wave energy (64%) compared to low energy (32%) [54]. G. Dahmen et al. [55] was treated by a calcining shoulder tendinite with low-energy shock waves. All patients had a decrease in pain and improving the mobility of the shoulder joint, although there were no changes in calcium deposits on the radiograph. M. Maier et al. [56] showed that the size and morphology of calcium deposits do not significantly affect the result of low-energy shocking therapy. After four sessions of shocking therapy during chronic calcining, the shoulder tendeni (2000 pulses with a frequency of 2 Hz) in 78% of 65 patients after 18.2 months, the function has significantly improved.
Thus, in a number of randomized promising studies of the effects of shocking therapy of the calcining tendinite of the rotational cuff, the shoulder of various therapeutic protocols is noted the energy and dose-dependence of the results. It is important to emphasize that the comparative study of low-energy ESWT and therapy with shock waves of high energies did not reveal the clinically significant side effects, with the exception of small petechic hemorrhages or hematoma after high-energy ESWT [51]. One of the reasons explaining the best results of high-energy ESWT in the treatment of a calcining tendinite is that focused high-energy shock waves are characterized by a greater penetrating ability necessary for successful influence on calcifications [51].
The effectiveness of the RSWT in the treatment of epicondylitis. The radius epicondylitis of the shoulder bone, known today as the "elbow tennis player", was first described by Runge in 1873, called "writing spasm". The radial epicondylitis of the shoulder bone is caused by a large number of factors and is characterized by severe pain and restriction of mobility in the joint. The pain can be brought by the load or palpation of the supervision. In the pathogenesis of this disease, a certain role is played by periosal inflammation, which leads to microtrams of the muscle attachment zone of the brush extensors. Damage to the radiation sprinkler of the brush and the development of local inflammation of the nerves innervating lateral supermarkets have the greatest importance. As provoking factors, a microtrauma is considered or simply muscle failure. Visualizing diagnostic methods in lateral epicondylitis are used infrequently, as to establish an accurate diagnosis of a sufficient clinical examination. For differential diagnosis, MRI and X-ray examination are used. MRI and ultrasound research reveal local tissue edema. At the same time, the germination of blood vessels and the change in hyaline on histological sections of tissues in chronic epicondylitis indicates rather a degenerative, rather than the inflammatory nature of the disease.
It is known that neither corticosteroid hormones with their intra-articular administration nor non-steroidal anti-inflammatory drugs nor other methods of chronic epipidyl therapy do not significantly affect the long-term forecast of the disease. In addition, there are many surgical methods of treatment of lateral epicondylitis, clinically significant evidence of the effectiveness of which even less than conservative treatment. Nevertheless, the cases of spontaneous cure without additional interventions are not known [57]. For the first time the treatment of pain in the soft tissues surrounding the bone, G. Dahmen was used using extracorporeal shock waves, which used focused shock waves, used earlier for the treatment of urological diseases [55]. An alternative version of EUT-ROVT, which has been possible thanks to the instrument of SWISS DolorClast®, objectively demonstrated its advantages. G. Dahmen has proliste 512 patients with 30 different syndromes. Good results were achieved in 52% of patients, improvement - in 28%, in 3% of cases, surgery was subsequently performed [58].
J. Haist [59] reported on the results of successful treatment of 812 patients with enntsopathy, which was carried out on average 2.2 session of shocking therapy using the Siemens Lithostar suspended module. 525 patients from this group suffered from radiating epicondylitis, 87 - from elbow epicondylitis, 133 - from the shoulder-blade periantropathy. As a result of treatment, 76.1% of patients observed for 3 months were noted good or very good results. In the study of J. Rompe [40] similar results were obtained when 150 patients after unsuccessful conservative treatment of epicondylitis carried out shocking therapy (three sessions of shocking therapy with an energy density of 0.06 MJ / mm2 and interval 1 week). For a number of basic parameters (night pain, pain in rest and physical exertion) significant improvement is marked: 48% of patients managed to achieve very good, in 51% - good results. In 24 patients, the improvement has not been noted, 15 has surgical intervention.
In the studies of D. Richter [60], when evaluating the effectiveness of the treatment of epicondylitis using extracorporeal shock waves, higher energies have shown that success has been achieved in 8 out of 10 patients, although the average number of therapy sessions was smaller. R. Diesch has achieved similar results in 80 patients with epicondylitis (68%) [61]. Nevertheless, using similar equipment, after 6 months the author noted the unsatisfactory results of therapy. According to the recommendations of R. Schleberger, in the treatment of shoulder joint diseases, it is preferable to use the MPL 9000 apparatus with Uz-control, and with epipudilite, the MFL 5000 apparatus [63].
As for the treatment of epicondylitis with the help of focused low-energy shock waves, the convincing clinical prospective randomized placebo-controlled studies have not yet been carried out. M. Haake [13] and S. Speed ​​[62] did not find convincing advantages of the method, while other researchers provided evidence of greater EvoT's effectiveness [61, 64, 65]. For example, within the framework of prospective studies, J.-H. Ko et al. (56 patients), Deckler et al. (85 patients), L. gerdesmeyer et al. (64 patients) It was shown that the treatment of patients with chronic radiation epipidilite method of the RSWT causes a significant clinical improvement in more than 70% of cases [19, 64]. The studies carried out allow to adopt the reasonable assumption that RAVTs can be applied as a variant of conservative treatment to surgical intervention. In addition, all results indicate the effectiveness and safety of this method. It should be added that the frequency of successful results of the RSWT in most studies is comparable, although different sources of shock waves and their parameters were used.
RSWT in the treatment of heel spurs (plantar fasci). The primary symptom of the heel spur is pain associated with limited movements. Many conservative methods for the treatment of this disease are described, including injections of steroids and nonsteroidal anti-inflammatory funds, the impact of ultrasound, low-energy laser, ionophoresis and other physiotherapeutic methods that have not yet have a sufficient evidence base. Nevertheless, surgical treatment is recommended only for the ineffectiveness of conservative methods. For a long time, multicenter controlled studies were carried out, characterizing the conservative or operational treatment of the plantar fasci. Demonstrated in numerous tests osteogenic potential of shock waves (when healing wounds and bone fractures, in the therapy of pseudoarthritis, diseases of soft tissues) became the basis for the use of ESWT with a fitted fascia.
Several promising randomized placebo-controlled studies of the effects of focused ESWT in the treatment of chronic heel pain, in which there are some contradictions [66-70]. When comparing the effects of various types of ENUT, it is noted that the proportion of successful attempts to perform conventional extracorporeal shocking therapy with a complete absence of pain or its significant decrease is 50-70% [71-73]. RSWT showed comparable results, while clinically significant side effects were not detected, with the exception of minor pheetching bleeding, swelling, in some cases - transient pain observed in 4% of patients [74]. At the same time, the essential difference and advantage of the RAVT in comparison with the conventional focused shocking therapy are its easy handling that does not require visualization, and significantly lower cost; Practically no use of local anesthetics. Nevertheless, despite the obvious success of treatment with shock waves of the plantar fascination, for the final evaluation of the effectiveness of this method requires new clinical evidence.
RSWT with myofascial pain syndrome. The results of a number of prospective studies confirmed the possibility of applying the RSWT under the syndrome of myofascial trigger zones, i.e., in the treatment of patients with pain in the joints of the neck, shoulder and hands, lumbago and a sedanistic bursite. The concept of "trigger zones" is associated with a neuromuscular disease known as the Miofascial pain syndrome, in the initial phase, manifested only when exposed to excessive load. When chronizing the process, the pain is caused in conventional daily loads and even when the weather is changed. In the final phase, the disease is characterized by a constant pain, a minimum threshold of stability to loads, increasing social insulation and, accordingly, reactive depressive syndrome.
It is assumed that with this disease occurs excessive release of acetylcholine and the reduction of muscle sarcomers. The accumulation of such abbreviated sarcomers, known as the "Complex of the Trigger Zone", leads to the shortening of the entire muscle [75]. There is a hypothesis of the "energy muscular crisis", in accordance with which the vasoconstriction accompanying these processes determine the release of sensitizing substances acting on the nociceptizers, facilitating pain impulses [76, 77]. The development of the pathological local system of transmission of pain impulses can lead to the formation of a muscular trigger zone [78].
Clinically trigger zones are divided into active and latent. Active triggers shorten the muscle and contribute to the manifestation of the phenomenon of pain in other parts of the body. This pain is called reflected. Latent trigger zones, as well as active, determine the shortening of the muscle, but are not accompanied by reflected pain. After the diagnosis of the trigger zone in the muscles and subsequent treatment with the application of the RSWT on the SWISS DolorClast® apparatus in a number of studies, a clinically significant effect is shown in the form of an increase in mobility and reducing pain. Since the intensity of treatment was below the porterability threshold, local anesthetics were not required [79, 80]. In the same works, it was shown that the results of the treatment of the cervical spine and the shoulder joint were noticeably worse. According to the authors, the effectiveness of treatment can be increased by an increase in the number of pulses for one session of therapy and the improvement of the methodology for the diagnosis of myofascial pain syndrome in deep layers of muscles. However, these studies show the possibility of using RSWT with busty muscular diseases associated with the presence of trigger zones.
Thus, although many practical and theoretical issues of mechanisms and effects of RSWT require further research, you can define a list of major diseases that are successfully treated with this method. It is primarily a variety of tendinopathy, including a calcining shoulder tendinite, epicondylopathy ("elbow tennis player"), heel spur (plantar fascisate), antisopathy of the rotational cuff, achilodinia and antisopathy of the iliac and tibial bundle, myofascial pain syndrome, etc. To date, experimentally And it is clinically proven that the RSWT method based on the short-term effects of high-energy vibration in the application zone reduces pain syndrome, improves local blood circulation and breaks the painful bone growths, fibrous foci with the subsequent resorption of their fragments. With the introduction of the SWISS DolorClast® apparatus, which generates radial shock waves of compressed air, in the opinion of many specialists, has established a new ESWT standard. Nevertheless, the complete understanding of the mechanisms of action of this method of therapy is still on the hypothetical stage and requires further research.
This review of literature does not apply for a comprehensive coverage of numerous questions of the application of RAVT, however, from our point of view, the largest and most effective studies presented in it are convinced of the prospects for the use of the RSWT method in orthopedics and the appropriateness of further studying its clinical effect.


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Treatment of epicondylitis of shock-wave therapy