Summary
Dr. Jake Wessels interviews Dr. Adam Tenforde about the growing use of extracorporeal shockwave therapy in musculoskeletal sports medicine. Dr. Tenforde, who has treated over 1,800 athletes in five years, explains the dual mechanisms of ESWT: stimulating tissue healing and remodeling, and reducing pain through hyperstimulation analgesia that overwhelms C-fiber pain signals. The conversation covers the evidence base for specific conditions including plantar fasciitis, Achilles tendinopathy, proximal hamstring tendinopathy, calcific shoulder tendinopathy, and lateral elbow pain. Dr. Tenforde discusses the practical aspects of delivering shockwave in clinical practice, including the typical protocol of three weekly sessions with full effects seen at 8-12 weeks, the importance of avoiding anesthetics during treatment, and the ceiling effect observed by six sessions.
Key Points
- ESWT works through two mechanisms: tissue healing/remodeling via inflammatory cascade and pain reduction via hyperstimulation analgesia
- Hyperstimulation analgesia overwhelms C-fiber pain signals, producing immediate pain relief after treatment
- Dr. Tenforde has treated over 1,800 athletes in five years using shockwave therapy
- Strong level 1 evidence supports ESWT for plantar fasciitis and mid-portion Achilles tendinopathy
- Typical protocol is three weekly sessions with full effects seen at 8-12 weeks and ceiling by six sessions
- Anesthetics reduce ESWT efficacy by disrupting clinical focusing and hyperstimulation analgesia
- Shockwave is not covered by most insurance, creating a barrier to wider adoption
Key Moments
Hyperstimulation analgesia explains immediate pain relief from ESWT
Dr. Tenforde explains how shockwave overwhelms C-fiber pain signals through hyperstimulation analgesia, producing immediate pain relief that then triggers secondary growth factor cascades promoting tissue healing and remodeling.
"this hyper-simulation analgesia is thought to be overwhelming the C fibers, which then leads to shutting off the pain signal to the injured tissue."
Top conditions responsive to shockwave therapy with level 1 evidence
Dr. Tenforde lists the conditions with strongest evidence for ESWT effectiveness, including plantar fasciitis, mid-portion Achilles tendinopathy, proximal hamstring tendinopathy, calcific shoulder tendinopathy, and lateral elbow pain.
"What would be some of the main go-to conditions? You brought up plantar fascia as a starting place. What are some of the other, you know, I'm looking to get into shockwave therapy or I'm just struggling with these conditions. What would be, what would you bring this to the top of your list as a, as someone who practices this a lot? Absolutely. So in the lower extremity, I really feel there is a number of good level one studies showing that shockwave is effective for plantar fasciitis."
Protocol of three weekly sessions with effects at 8-12 weeks
The standard ESWT protocol starts with three weekly sessions, with full effects seen at 8-12 weeks. A ceiling effect is typically reached by six sessions, and Dr. Tenforde charges a flat rate rather than per-session to optimize patient outcomes.
"We start with three weekly sessions. We know that the full effects of shockwave are seen eight to 12 weeks out."
