suggests that extracorporeal shockwave treatment (ESWT) is safe and effective for treating several musculoskeletal disorders. ä Two types of technical principles are usually included in ESWT: focused ESWT (F-ESWT) and radial pressure waves (RPW). These 2 technologies differ with respect to their generation devices, physical characteristics, and mechanism of action but share several indications. ä Strong evidence supports the use of ESWT in calcifying tendinopathy of the shoulder and plantar fasciitis. ä The best evidence for the use of ESWT was obtained with low to medium energy levels for tendon disorders as well as with a high energy level for tendon calcification and bone pathologies in a comprehensive rehabilitation framework.

Shoulder pain is one of the most common musculoskeletal pathologies. Treatment by ESWT (extracorporeal shockwave therapy) has emerged as an alternative when conservative treatment fails in rotator cuff calcific tendinopathy, prior to invasive procedures. The clinical efficacy of ESWT in non-calcific tendinopathy remains controversial. The good results in the treatment of rotator cuff calcifications, have led to indications of ESWT being expanded to other shoulder pathologies. We review the current state of indications and evidence based practice.

Background High energy diaphyseal fractures constitute a complicated matter for trauma units and urgent medical and surgical decisions to prompt stabilization of these patients, might leave some skeletal distortions that affect bone union. The objective is to evaluate the safety and efficacy of extracorporeal shockwave therapy (ESWT), as a treatment for patients with atrophic or pseudoatrophic nonunion. Patients and Methods Case series which included 50 patients with nonseptic and stable nonunion diaphyseal fracture of femur and tibia. They received a defined protocol of up to three high-energy ESWT (10.000 shocks per session). Each patient was evaluated with x-rays or CT between 4 and 6 weeks, to determine the necessity to continue the protocol and obtain data about initial periosteal-endosteal responses and its evolution. We analyzed, semi-quantitatively, the volume of the fracture zone from initial CT using a mathematical method to calculate the volume in cylinders, and confronting this data with Winquist Classification. Results 17/25 (68%) tibia and 13/25 (52%) femur nonunion were treated successfully. There were no complications during or after treatment. Conclusions ESWT induced bone healing in an average 60% of cases, which is consistent with current reported literature. CT studies gave some clues to patients’ real condition of fracture anatomy before treatment, allowing a better decision in the orientation of ESWT application for each case. Volumetric Fracture Analysis for Winquist Classification shown that ESWT was able to induce significant bone regeneration in fractures with high volume. This kind of therapy was well accepted in reluctant patients to invasive methods. Highlights

Background Application of extracorporeal shockwave therapy (ESWT) induces an improvement in tissue healing associated with augmented tissue perfusion. The present study aimed to investigate the responses of human rotator cuff tissue to the application of ESWT. Methods Thirty‐one consecutive patients with symptomatic rotator cuff tendinopathy with complete tears were approached and enrolled in the present study. Before surgical resolution, a single treatment of focused ESWT was offered to all patients. Ten patients accepted such treatment and 21 refused ESWT. Tendon tissue biopsies were collected for evaluation using haematoxylin and eosin and characterized according to the Riley Classification. Vascular volume area (VVA) was determined semi‐quantitatively and immunohistochemical (IHC) analysis included CD14, CD34, PCNA, Tenascin‐C and D2‐40 markers. Results Distribution of grade according to the Riley Classification with respect to study group was: Group A: Grade III (n = 9), Grade IV (n = 1); Group B: Grade III (n = 13), Grade IV (n = 8). Mean group‐specific VVA analysis was 18.47% and 7.03% for Group A and Group B, respectively. IHC Grade III protein staining was significantly more prevalent in Group A compared to Group B for CD34, PCNA, Tenascin‐C and D2‐40 (p < 0.05 for all comparisons). Conclusions ESWT is associated with increased neovascularization and neolymphangiogenesis in rotator cuff tendinopathy. IHC analysis suggests an improvement in healing response in the ESWT‐treated tendon.

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