However, the longer-term effectiveness of ESWT was less clear (due to a lack of follow-up period beyond one year in the studies), and there was little insight into the appropriate doses of ESWT required to produce an optimum response. “ESWT is a potential alternative to surgery with good mid-term effectiveness and minimal side effects”. “there was consistent evidence of midterm effectiveness of ESWT in reducing pain and improving shoulder function”, All studies had follow-up periods of at least six months, and the researchers concluded that
For example, a 2011 systematic review study pooled data from nine previous studies that examined the effectiveness of extracorporeal shockwave therapy (ESWT) in reducing pain and improving shoulder function (2). Much of the early research around ESWT focussed on using ESWT for the treatment of calcific shoulder tendinitis (a related pathology to AC). The pressure wave becomes more concentrated as tissue depth increases. Focussed ESWT (below) uses much higher-amplitude pressure waves of much shorter duration. The pressure wave generated dissipates as tissue depth increases. In radial ESWT (above), the shockwave is of low amplitude but long duration. In reality, the therapeutic action of ESWT likely arises from a combination of these actions. The high-energy shock waves break up fibrous/calcified deposits, thereby loosening structures and promoting the resorption of calcium, which decreases pain and improves function.The direct and indirect impact of the shock waves cause damage to the cell membranes and reduce the ability of nociceptors to generate sufficient potential to transmit pain signals.ESWT disrupts fibrous tissue allowing for the subsequent promotion of revascularization and healing.The hypotheses for its effects include (1): The exact mechanism by which ESWT exerts its actions within the tissue is not well understood. The shockwave application may be radial (affecting a more diffuse volume of tissue nearer the surface) or focussed (affecting a smaller volume of deeper tissue) – see figure 1. The key question, of course, is how do outcomes compare between the use of modalities and conventional treatment? Extracorporeal shock wave therapyĮxtracorporeal shock wave therapy (ESWT – also referred to as extracorporeal shock wave lithotripsy) is a noninvasive treatment that uses the mechanical force of a powerful acoustic shock wave within injured tissues to reduce pain and speed healing of the affected area. This treatment mode is noninvasive, rapidly administered and not dependent upon patient compliance outside of the clinic. In recent years, the use of extracorporeal shock wave therapy has become an increasingly popular alternative mode of treatment for AC. When a diagnosis of AC is made in an athlete therefore, clinicians may wish to explore less conventional treatment approaches in order to speed up recovery. This is especially true at higher levels of sport, where the loss of fitness and ability to practice skills can profoundly impact an athlete’s future.
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A technological approachĪ rapid return to full shoulder functionality is a priority for all athletes. The literature better supports other approaches such as steroid/anti-inflammatory injection and certain stretching modalities however, even with these treatments, the evidence is somewhat limited and far from overwhelming.
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To summarise from the previous article, the evidence supporting the benefits of conventional treatments such as traditional physiotherapy and manual therapy under anesthesia is far from conclusive. However, when it does occur, the very long timescales required for resolution can make it particularly disruptive.
In part two, Andrew examines the evidence for the benefits or otherwise of newer, more technological therapies for this condition including pulsed radiofrequency therapy and guided ultrasound.Īs we saw in part one of this article, frozen shoulder, more technically known as adhesive capsulitis (AC), is comparatively rare in athletes. In the first of this 2-part article, Andrew Hamilton discussed the etiology of ‘frozen shoulder’ and the efficacy of conservative treatment options.