UCHealth Today

Pain from an injury may bother you for weeks or even years later. You may have tried everything the doctor recommended, but you are still having trouble getting back on the playing field or court or even returning to everyday activities.

A noninvasive treatment called extracorporeal shockwave therapy (ESWT), one that multiple professional athletes have turned to, could help take the nagging out of an injury. The treatment is now available at UCHealth Primary Care and Sports Medicine Clinic – Lake Plaza.

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Dr. Nicholas Piantanida, a sports medicine doctor and West Point graduate who spent two decades serving soldiers and their families in the Army, believes the therapy can kick-start the natural healing process.

“We are finding ways to treat our patients, especially those who have not responded to conventional therapeutic remedies, and shockwave therapy is a nice option because it is non-invasive. Patients don’t have to endure injections or other forms of needle therapy,’’ Piantanida said.

Shockwave therapy delivers high-energy acoustic waves to injured parts of the body that need healing. The shockwave is a physical sound wave, ‘shock,’ not an electric one. To help you learn more about shockwave therapy and who may benefit from the treatment, we asked Piantanida to explain more about it.

What is shockwave therapy?

Shockwave therapy is a non-invasive alternative treatment for active patients who are struggling with pain and not responding to conventional treatment after an injury. There is an immediate post-procedure reduction in pain and improved range of motion.

How does shockwave therapy work?

Shockwave therapy devices deliver acoustic energy shockwaves in a phase of either nanoseconds or microseconds to stimulate healing in injured soft tissue, ligaments and tendons.

Shockwave treatment has been shown to have physiologic benefits by:

• Increasing cell permeability to create a localized inflammatory response. The energy coming into and out of the tissue increases blood flow, much the same as, but to a greater extent than, a deep tissue massage or percussive hand pressure device known as a TheraGun.
• Causing degradation of the nerve bundle (nociception inhibition), which allows for pain modulation via the peripheral nervous system.
• Upgrading the physiologic process of healing by stimulating hormones and cells that are associated with a reparative process of healing.

What sports injuries are treated?

• Feet: Plantar fasciitis, Morton’s neuroma, nerve impingement or ligament injury
• Ankle: Chronic ankle pain, whether from osteoarthritis or ligamentous instability; a ligamentous defect in the ankle; gastrocnemius muscle strain or injury
• Lower leg: Achilles tendonitis; gastrocnemius muscle strain or injury; retrocalcaneal bursitis (heel pain)
• Knee: IT band; insertional pain; strain to the medial or lateral collateral (ligaments that form either side of the knee); jumper’s knee; patella tendinopathy
• Upper leg: quad injury or hamstring strain or injury
• Hand: strains and injuries
• Elbow: Little leaguer’s elbow; tennis elbow; tricep or bicep elbow injuries
• Hip: Gluteal muscle strain; bursitis; iliopsoas bursitis; hip flexor tendinosis
• Shoulder: Calcinosis of the rotator cuff; partial tear of the rotator cuff; bicep injuries

What does shockwave therapy feel like? Is it painful?

Patients will experience a number of fast pulses and some warmth.

“I tell patients that I would like for them to have less than 5 out of 10 discomfort. I call it discomfort; I don’t call it pain,’’ Piantanida said. “More discomfort is sometimes felt when we are doing the acoustic shockwave closer to a bone.’’

A little swelling and redness may also occur.

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“As we treat tissue with energy, blood flow increases, so there may be some bruising with tissue. We are able to control the machine, so if we are told that the discomfort is 5 out of 10 when we start the machine, we’ll turn it down so it is more comfortable.’’

Why don’t bodies always respond to conventional therapy to heal injuries?

During an injury healing process, the body responds in two ways: either in a healthy way to repair the injury or it goes down a degenerative path, where the healing process stalls and inflammation sets in. People in this state experience pain, including degenerative chronic pain. Shockwave therapy, in essence, wakes the body so it can get on the right path and begin a healing, reparative process.

Does insurance cover shockwave therapy?

Shockwave therapy is generally not covered by insurance plans. Shockwave therapy is a package treatment — up to six segments that are 15 minutes in duration. The cost of the package is $550. Funds in a Health Savings Account or Flexible Spending Account can cover the cost.

How effective is it?

“The results of treatment are based on completion of the treatment. A lot of our patients, in my experience, even after the first treatment, are feeling significantly better and resuming some normal activity within 24 to 48 hours of the treatment.

“The nice thing about shockwave is you’re going to get results very quickly. Though we have six weeks set aside, I anticipate that many of these patients are going to be at their treatment goal within three to four weeks,’’ Piantanida said.

What kind of shockwave therapy devices are used?

UCHealth Sports Medicine Clinic has purchased two devices, thanks to donors who contributed to the UCHealth Memorial Hospital Foundation. The Focus shockwave uses a 10-nanosecond burst and allows the provider to send pulses deeper into the body, as much as 13 or 14 centimeters. The Radial shockwave sends pulses in 5 to 10 microseconds and reaches a depth of 3 to 6 centimeters. Radial shockwave is used for most patients.

Can shockwave therapy help patients who have other ailments?

“I have patients who have neurologic conditions — maybe they had a stroke, maybe they have ALS, or maybe they have a neurologic deficit where they deal with chronic spasticity. For neurologic spasticity, there are some indications to use shockwave.

“These are not your average athletes; these are patients with chronic medical conditions that are neuro-muscular in nature, and they, potentially, could benefit from shockwave therapy.’’

What does a patient need to do to get shockwave therapy?

A patient should talk to their primary care provider and inquire about shockwave therapy. If the treatment is right for the patient, a provider will refer the patient to Dr. Piantanida in sports medicine. Any provider can send a referral to a sports medicine doctor.

“We will review the referral and evaluate the patient to make sure there is a good indication for shockwave and to make sure we have optimized all of the other treatments.’’

How should a patient prepare for shockwave therapy?

It’s easy. A patient can drive to their own appointment for treatment and back home since they will not be receiving medication, anesthetic or sedation. In the clinic, a technician would expose the body part that is injured and use the hand-held ESWT device to deliver shockwave therapy. The treatment is designed to last 15 minutes, and then the patient would leave the office.

Is this technique used now with professional athletes?

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“It is,’’ Piantanida said. “There are professional teams that have a team physician who carries the shockwave device on the plane when the team travels. They do this mainly because it works so quickly. They have all of these away games, and the team physician wants to do treatments on the road.

“If you’re on a plane, they’re making use of the time that they have. They’re isolated; they can’t move anywhere. So the provider can go seat to seat and do treatments throughout the plane ride,’’ said Kevin Roberts, an athletic trainer for UCHealth who works with athletes from the University of Colorado Colorado Springs and Academy School District 20.

Who is a candidate for shockwave therapy?

Patients who have lingering injuries and who have not responded to time-honored methods of treatment and therapy are likely candidates.

“We are not willing to push shockwave ahead of all the other therapies (physical therapy). Having said that, there are a large number of patients who we see that deal with chronic or unrelenting pain from a sports or muscular-skeletal injury that may be 4 to 6 weeks in duration or it may be four months or six years in duration.

“Shockwave can handle all of that in terms of the therapeutic indication, but it is costly, so we want to make sure that we are using our health care dollars in a way that our patients are getting the best impact. There will be a variety of acute conditions where it may be relevant, but for the most part, these are patients who are at least four to six weeks out from the injury, and their response to therapy has yet to be realized in terms of the benefit.

Who is not a candidate for shockwave therapy?

Patients who have the following contraindications:

• Coagulation disorders, thrombosis or occlusive vascular disease
• Use of anticoagulants: Warfarin, Eliquis, Xarelto, etc.)
• Tumor disease: carcinoma, cancer patients under treatment
• Pregnancy
• Polyneuropathy, in the case of diabetes mellitus
• Acute inflammation associated with an infection
• Children with open-growth plates

How was shockwave therapy discovered?

“It’s been in the medical treatment arm for years,’’ Piantanida said. “You’ve heard of lithotripsy? That the procedure that uses focused shockwave to break up and deliver renal stones. It’s been used in that capacity, and the urology team is starting to use it for erectile dysfunction – again, it improves blood flow,’’ Piantanida said.

How long has it been used to stimulate healing in injuries?

“It’s been in the conversation, along the periphery, for a number of years. As regenerative medicine has become more of the mainstay, I would say it has been 20 years now that it’s been in our conversations, especially in connection with plantar fasciitis and tennis elbow — there’s always been a description of how this could be applied. But now, with this upgraded technology and how it is easily deployed at the bedside, it is becoming more available.’’

Does a medical doctor have to deliver shockwave treatment?

“No. When the FDA approved this device, they put it in a category that allows us to use ‘extenders’ to use the machine under the supervision of a physician. The FDA was wise to note that its extremely high safety profile allows supervising physicians to hand off care to a trained ‘extender.’’’

“We have protocols that are associated with specific diagnoses — plantar fasciitis or tennis elbow, for example. In sports medicine, we have a team approach, so this is another example where you can have an athletic trainer and a sports medicine physician working with a patient.’’

Roberts, the athletic trainer, will spend time twice a week in the clinic to deliver shockwaves under the supervision of Piantanida.

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