A Closer Look at Extracorporeal Shock Wave Therapy For Ulcer Treatment

Extracorporeal shock wave treatment (ESWT) was used in the 1980s as extracorporeal shock wave lithotripsy (ESWL) to disintegrate kidney stones. Most podiatric physicians know ESWT has been around for over 20 years for treating orthopedic concerns. The essential principle behind ESWT revolves around the action of shockwaves, which are rapid but short-duration acoustic waves that carry energy and can propagate through tissues.¹ The difference between ESWT and ESWL is that ESWT uses the application of shockwaves in orthopedics to cause interstitial and extracellular responses, leading to tissue regeneration. I have used this modality for conditions such as plantar fasciitis, tendonitis, and other orthopedic conditions that cause pain.
 
Recently I was reintroduced to ESWT in the context of wound healing. In 2018 and 2020, ESWT technology became US Food and Drug Administration (FDA)-approved for diabetic foot ulcers (DFUs) and burns. Compared to the ESWT modality used in the early 2000s, in these updated iterations, you do not need to anesthetize the patient. Although the mechanism of action of ESWT in wound care is not clearly understood, several studies show that ESWT reduced apoptosis and acute inflammatory reactions in wounds.² Shock waves cause a release of vascular endothelial growth factor, which disrupts endothelial adhesions and enables migration of endothelial cells to form capillary structures. Also, shock waves can cause the release of nitrous oxide, which also induces angiogenesis. Extracorporeal shock wave therapy can additionally suppress the early proinflammatory immune response in severe cutaneous burn injuries.²
 
An article published by Huang and colleagues in 2019 summarized several randomized controlled trials (RCTs) evaluating ESWT and wound healing.³ Although 21 RCT trials were screened, eight trials fulfilled the PRISMA guidelines (a guideline for systematic reviews). Huang's review of RCTs revealed that extracorporeal shock wave therapy (ESWT) can effectively shorten the healing period of DFUs and reduce the ineffectiveness of wound treatments for diabetic foot ulcer treatment 4.8-fold.³ Moreover, they found ESWT superior to standard wound care and significantly better than hyperbaric oxygen therapy and other adjunct wound care therapy. The results of one study suggested that ESWT can effectively promote DFU complete closure and shorten healing time. The literature review revealed there are few potential side effects, including slight pain, mild redness, and small hematomas. The low reporting of side effects supports that ESWT is a safe adjunct therapy.³
 
Chronic DFUs are challenging for most practitioners. Although I am just implementing ESWT in my practice for wound healing, I am excited to experience how ESWT can positively change my DFUs on a cellular level. Hopefully, this "not so new" technology can significantly reduce healing times for chronic DFUs.

Dr. Robinson is the Chair of and an Assistant Professor in the Department of Medicine at the Temple University School of Podiatric Medicine. She is a Diplomate of the American Board of Podiatric Medicine.

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References
1. Cheng JH, Wang CJ. Biological mechanism of shockwave in bone. Int J Surg. 2015;24(Pt B):143-6. PeHUB 2015 Jun 25. PMID: 26118613.
2. Davis TA, Stojadinovic A, Anam K, et al. Extracorporeal shock wave therapy suppresses the early proinflammatory immune response to a severe cutaneous burn injury. Int Wound J. 2009;6(1):11
3. Huang Q, Yan P, Xiong H, et ao. Extracorporeal Shock Wave Therapy for Treating Foot Ulcers in Adults With Type 1 and Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Can J Diabetes. 2020;44(2):196-204.e3. doi: 10.1016/j.jcjd.2019.05.006. Epub 2019 May 23. PMID: 31515158.