Shock wave therapy (ESWT)

ESWT is a treatment method for kidney and ureter stones. It also brings relief from painful tendon and muscle diseases

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Extracorporeal shock wave therapy - briefly explained

a non-operative procedure

Highly energetic sound waves generated outside the body (extracorporeal) penetrate the body, where they develop various effects

It is used for stones and calcified tendons, promotes relaxation and loosening of muscles and increased blood flow to tissues

Urology and orthopedics are the most common areas of application

A distinction is made between focused shock waves (bundled, with greater penetration depth) and radial shock waves (effect on the surface)

Shock waves propagate through the layers of the skin to the tendon

© Shutterstock / Rumruay

How does the ESWT work?

The ESWT (extracorporeal shock wave therapy) works with pressure pulses, the so-called shock waves. They are generated, for example, by devices with piezoelectric elements. There certain quartz crystals cause mechanical vibrations when exposed to electricity. These shock waves propagate particularly well in a watery environment. This also includes the human body. If the shock waves hit a solid body with significantly less water and a higher density than the body tissue, for example a stone in the ureter, they are reflected. The stone absorbs energy - tensile and compressive forces are created. The solid material eventually breaks into smaller pieces.

The focused ESWT

With focused ESWT, several shock waves are bundled onto the target area. So they are able to shatter the solid, for example to shatter a kidney stone. The stone fragments are then usually small enough to get out of the body through the urinary tract. In orthopedics, the shock wave primarily affects the fiber-forming cells. Even if the shock wave is used in the heel spur, the effect is primarily aimed at the changes in the plantar fascia, the inflamed fibers in the sole of the foot. The spur on the X-ray usually does not go away during treatment, but it is no longer painful.

The radial ESWT

The radial ESWT sends pressure waves over the body near the body surface. This makes it work in a similar way to a massage. It is often used to treat muscular tension.

In erectile dysfunction one makes use of the vasodilating properties of the waves. The penis with the cavernous bodies that are important for an erection is better supplied with blood and an erection can arise again and also lasts.

In any case, the device that generates the sound waves needs direct skin contact. This is made with the help of ultrasound gel, which is applied without air bubbles if possible.

Stones less than two centimeters in size can be treated with the ESWT.

© Thinkstock / iStockphoto

ESWT for kidney stones and erectile dysfunction

Kidney and ureter stones

The ESWT has long been established in this area. It can shatter kidney and ureter stones and thus prevent and possibly even eliminate congestion of the urinary tract. If a urinary stone has already caused a congestion of the urinary tract, a urinary diversion via a stent (inner splint from the urinary bladder into the kidney) must usually be ensured before the ESWT.

So-called calcium oxalate dihydrate stones and ammonium phosphate stones are primarily suitable for ESWT. While the former can form, for example, through low fluid intake and certain eating habits, the latter more often arise in connection with a urinary tract infection. The ESWT helps with stones that are no more than two centimeters in size. EWST is also used in children with kidney stones. Only a shock wave focused on the stone with a high energy density is used to crush stones.

Erectile dysfunction

The EWST is a very new application for erectile dysfunction. For erectile dysfunction, i.e. the lack of limb stiffness during sexual intercourse, it has been an additional treatment option since 2010. Often the disorder is caused by insufficient blood flow to the erectile tissue of the penis. Around half of men between 40 and 70 years of age suffer from it to varying degrees. Since 2015, the European Association of Urology has listed ESWT as the therapy of first choice for erectile dysfunction alongside medication.

The treatment of plantar fasciitis with shock waves is now paid for by the health insurers

© Shutterstock / Aksanaku

ESWT for muscle and tendon diseases

The ESWT as a cash benefit

ESWT has also been used in orthopedics for a long time, but has not been covered by health insurance for a long time. Plantar fasciitis is a painful inflammation of the tendon plate of the sole of the foot that often occurs with heel spurs. Here, three shock wave therapy for the affected foot is paid for by the statutory health insurance. However, some conditions must be met:

  • the pain persists for more than six months and significantly restricts everyday mobility
  • Pain medication does not help permanently
  • Insoles and stretches have been used and are not sufficient either

The treatment is carried out by specialist practices for orthopedics and trauma surgery or for physical and rehabilitative medicine.

Calcifications of tendons

Shock wave therapy is also used for other painful diseases of the musculoskeletal system, but in these cases you must continue to pay for it yourself. In the group of tendon diseases, these include:

  • the famous tennis elbow
  • Achillodynia, a painful disease of the Achilles tendon
  • the calcareous shoulder

Muscle disorders

Another area of ​​application can be pain and dysfunction of the muscles, including:

  • Tension
  • Indurations
  • Foreshortenings
  • Strains

In all these cases, the following applies: ESWT is mainly used when other non-surgical therapies such as painkillers or physiotherapy are not sufficiently successful.

The procedure is also used for delayed healing of a broken bone: the shock waves are supposed to promote new bone formation.

Use of ESWT on the heel

© Mauritius / Photopat / Alamy

Course of an ESWT treatment

For those affected with kidney and ureter stones, the exact location of the stone is documented in advance. X-rays and ultrasound images help here. The drainage conditions of the urinary tract are shown, for example, by a computed tomography or an excretory urography. There must be no bottleneck in the urinary system below the stone. Those who are taking anticoagulant medication must interrupt them in good time - depending on the doctor's instructions - several days before the ESWT. How the procedure works in each individual case is discussed in an informative discussion. The pain to be expected during the treatment is also an issue here. Anesthesia is generally not used during ESWT, but pain killers are usually given. Not only so that the treatment causes as little pain as possible, but also because you shouldn't move during the examination. That’s easier without pain. In this way, the stones can be broken up precisely. It starts with a lower frequency and lower energy level of the sound waves, both of which are then slowly increased. After treatment, a new imaging exam will usually check whether the ESWT was successful and the stone has disappeared. Often after the ESWT you get medication that makes the stone fragments go off more easily, thus promoting the excretion. This means that fewer pain relievers are needed after the treatment and a higher percentage of the stones have safely disappeared. Antibiotics are only used in special cases. For example, with stones that have formed due to an infection, or when catheters or other foreign bodies are lodged in the urinary system.

If the ESWL is used for muscle, tendon and bone diseases, on the other hand, there is usually no need for any special preliminary or follow-up examinations. The most sensible place to use it is felt: once the most painful region has been identified, therapy is started here. The treating doctors decide on a case-by-case basis whether the treatment can be carried out with the use of anticoagulants. After treatment, pain relievers will help. Local anesthesia before the ESWT is useless: it leads to a reduced effect of the shock wave.

Are there any side effects?

ESWT is a procedure with relatively few side effects or complications to fear.

If ESWT is used to treat a urinary stone, colic of the urinary tract can occur after the treatment. This is the case when fragments of the stone are excreted. In addition, the fragments of large stones can again interfere with the flow of urine, in which case a ureteral splint (an inner splint from the urinary bladder into the kidney, also called a double J catheter) would be inserted before the procedure. Bleeding in or around the kidney is rare and occurs in less than one percent of cases.

In all of the above-mentioned areas of application of the ESWT, there may be slight pain during the treatment and tiny skin hemorrhages (petechiae), occasionally bruises (hematomas) can also be found. As a rule, these do not require any further therapy.

In the case of muscle and tendon diseases, ESWT usually works in combination with other therapies. The side effects and the effort for the treated are usually lower there compared to the urological area. What you have to reckon with here, too, is that the treatment itself is a bit painful. A certain rest pain can also occur afterwards; depending on the sensitivity, this can be similar to sore muscles. Those affected should seek advice on possible advantages and disadvantages and the costs in advance.

When is ESWT not advisable?

In the event of a blood coagulation disorder, the benefits and risks of shock wave treatment must be weighed up individually with a doctor. This applies to both congenital coagulation disorders and therapies with anticoagulant drugs. The treatment is not carried out in pregnant women. Before ESWT of the kidneys and urinary tract, urinary tract infections should be treated first. Excessive weight over 130 kg often leads to technical problems. Doctors make decisions here on a case-by-case basis. In the case of particularly hard kidney stones, the therapy can fail and is therefore not used. It is also refrained from special features such as vascular bulges (aneurysms) in the therapy area or deformations of the bones. In addition, an acute inflammation of the skin or a tumor in the treatment area speaks against the use of EWST. Direct application to growth plates in the child or to the articular cartilage should also be avoided.

Urinary stones: are there alternatives to ESWT?

Especially with ureter stones or kidney stones up to one centimeter in diameter, the so-called ureteroscopic removal of the stone or the atomization of the stone by laser (lithotripsy) is now usually the better alternative to ESWT due to the further development of the smallest instruments. An endoscope, which is inserted through the ureter, helps to remove the stone. This method is also well suited for stones that are already relatively deep in the ureter, halfway to the urinary bladder or just before it.

Kidney stones over two centimeters in diameter are removed using percutaneous nephrolithotomy (PCNL), in which the kidney is punctured through the skin with an endoscope. This procedure is performed under general anesthesia. On the one hand, it is suitable for stones that, due to their composition, cannot be broken up with an ESWT. But PCNL is often better than shock wave therapy even with stones in places where the fragments could cause problems during ESWT: It immediately sucks the remains of the stone through the endoscope - this is the case, for example, at the lower kidney pole. The remains of the stone would get stuck here again after being smashed.

Prof. Christian Stief

© W & B / private

Advisory experts:

Professor Dr. med. Christian Stief is a specialist in urology. He completed his habilitation in 1991 at the Hannover Medical School. Since 2004 he has been Director of the Urological Clinic at the University of Munich Clinic. He is the editor of several German and English-language academic books and was co-editor of the journal from 2006 to 2012 European Urology.

Prof. Markus Walther

© Schön Kliniken Munich Harlaching

Professor Dr. med. Markus Walther has been chief physician at the Center for Foot and Ankle Surgery at the Schön Klinik Munich-Harlaching since 2005. In 2012 he became medical director of the Schön Klinik München Harlaching. He was president of the Society for Foot and Ankle Surgery and is a member of several orthopedic-surgical associations.

Swell:

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  • C. Türk (Chair), A. Skolarikos (Vice-chair), A. Neisius et al: EAU Guidelines on Urolithiasis 2018, Online: https://uroweb.org/wp-content/uploads/EAU-Guidelines-on- Urolithiasis-2018-large-text.pdf (accessed on May 9, 2019)
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  • Dreisilker U: Enthesiopathies, 1st edition, Bamberg Buchverlag Daniela 2010
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Important NOTE:
This article contains general information only and should not be used for self-diagnosis or self-treatment. It cannot replace medical advice. Please understand that we do not answer individual questions.

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