Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study

Hye Chang Rhim¹, Mani Singh², Nicola Maffulli³, Amol Saxena⁴, Carlos Leal⁵, Ludger Gerdesmeyer⁶, Kristina Quirolgico⁷, John P Furia⁸, Johannes Zwerver⁹, Chun-De Liao¹⁰, Daniel Moya¹¹, Shih-Wei Huang¹², David M Robinson¹³, Johnny Jarnagin¹³, Joseph Ruiz¹³, Kayle E Noble-Taylor¹⁴, Hazem Alkhawashki¹⁵, Brice W Blatz¹⁶, Joanne Borg-Stein¹³, Lauren Borowski¹⁷, Jay Bowen¹⁸, Michael Chin¹⁹, Robert M Conenello²⁰, Michael Fredericson²¹, Brian W Fullem²², Karin Gravare Silbernagel²³, Karsten Hollander²⁴, Elena J Jelsing²⁵, Paul Langer²⁶, Kenneth Mautner²⁷, Adele Meron²⁸, Robert Monaco²⁹, Rowan V Paul³⁰, Sara Raiser³¹, James W Ratcliff³², Steven Sampson³³, Wolfgang Schaden³⁴, Jay Spector³⁵, Wei Sun³⁶, Isaac P Syrop³⁷, Kenji Takahashi³⁸, Benedict Tan³⁹, James F Wyss⁴⁰, Dan Zin⁴¹, Jennifer Soo Hoo⁴², Adam S Tenforde¹³

Affiliations

¹ Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA hrhim@mgh.harvard.edu.
² Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
³ Department of Trauma and Orthopaedic Surgery, Sapienza University of Rome, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Rome, Italy.
⁴ Bay Area Surgical Specialists, Palo Alto, California, USA.
⁵ Bosque University Medical School, Bogota, Colombia.
⁶ Technical University Munich, Munchen, Germany.
⁷ Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic/University of Tennessee College of Medicine, Memphis, Tennessee, USA.
⁸ WellSpan Orthopedics, Lewisburg PA, Pennsylvania, USA.
⁹ Gelderse Vallei Hospital and Center for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands.
¹⁰ College of Nursing, Taipei Medical University, Taipei, Taiwan.
¹¹ Department of Orthopedics, Buenos Aires British Hospital, Buenos Aires, Argentina.
¹² Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
¹³ Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.
¹⁴ Department of Orthopedics, Corewell Health, Grand Rapids, Michigan, USA.
¹⁵ Advanced Medical Centre, Riyadh, Saudi Arabia.
¹⁶ Stanford University School of Medicine, Stanford, California, USA.
¹⁷ NYU Langone Health, New York, New York, USA.
¹⁸ New Jersey Regenerative Institute, Parsippany, New Jersey, USA.
¹⁹ The Running Institute, Chicago, Illinois, USA.
²⁰ Orangetown Podiatry, Orangeburg, New York, USA.
²¹ Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA.
²² Elite Sports Podiatry, Clearwater, Florida, USA.
²³ Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
²⁴ Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany.
²⁵ Department of Physical Medicine and Rehabilitation, Mayo Clinic, Minneapolis, Minnesota, USA.
²⁶ Twin Cities Orthopedics, Minneapolis, Minnesota, USA.
²⁷ Emory Orthopedics and Spine Center, Atlanta, Georgia, USA.
²⁸ Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA.
²⁹ Atlantic Health System, Morristown, New Jersey, USA.
³⁰ Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.
³¹ University of Virginia, Charlottesville, Virginia, USA.
³² Menlo Medical Clinic, Menlo Park, California, USA.
³³ The Orthohealing Center, Los Angeles, California, USA.
³⁴ Ludwig Boltzmann Institute for Traumatology, Vienna, Austria.
³⁵ Atlanta Sports Podiatry, Atlanta, Georgia, USA.
³⁶ Department of Orthopedic Surgery, Beijing United Family Hospital, Beijing, Beijing, China.
³⁷ Department of Physical Medicine and Rehabilitation, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
³⁸ Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Japan.
³⁹ Singapore Sport and Exercise Medicine Centre, Singapore.
⁴⁰ Hospital for Special Surgery, New York, New York, USA.
⁴¹ Israel Shockwave Center, Petach Tikva, Israel.
⁴² Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York, USA.

PMID: 40032293
DOI: 10.1136/bjsports-2024-109082

Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study

Hye Chang Rhim et al. Br J Sports Med. 2025.

. 2025 Sep 2;59(18):1287-1301.

doi: 10.1136/bjsports-2024-109082.

Authors

Affiliations

¹ Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA hrhim@mgh.harvard.edu.
² Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
³ Department of Trauma and Orthopaedic Surgery, Sapienza University of Rome, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Rome, Italy.
⁴ Bay Area Surgical Specialists, Palo Alto, California, USA.
⁵ Bosque University Medical School, Bogota, Colombia.
⁶ Technical University Munich, Munchen, Germany.
⁷ Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic/University of Tennessee College of Medicine, Memphis, Tennessee, USA.
⁸ WellSpan Orthopedics, Lewisburg PA, Pennsylvania, USA.
⁹ Gelderse Vallei Hospital and Center for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands.
¹⁰ College of Nursing, Taipei Medical University, Taipei, Taiwan.
¹¹ Department of Orthopedics, Buenos Aires British Hospital, Buenos Aires, Argentina.
¹² Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
¹³ Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.
¹⁴ Department of Orthopedics, Corewell Health, Grand Rapids, Michigan, USA.
¹⁵ Advanced Medical Centre, Riyadh, Saudi Arabia.
¹⁶ Stanford University School of Medicine, Stanford, California, USA.
¹⁷ NYU Langone Health, New York, New York, USA.
¹⁸ New Jersey Regenerative Institute, Parsippany, New Jersey, USA.
¹⁹ The Running Institute, Chicago, Illinois, USA.
²⁰ Orangetown Podiatry, Orangeburg, New York, USA.
²¹ Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA.
²² Elite Sports Podiatry, Clearwater, Florida, USA.
²³ Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
²⁴ Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany.
²⁵ Department of Physical Medicine and Rehabilitation, Mayo Clinic, Minneapolis, Minnesota, USA.
²⁶ Twin Cities Orthopedics, Minneapolis, Minnesota, USA.
²⁷ Emory Orthopedics and Spine Center, Atlanta, Georgia, USA.
²⁸ Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA.
²⁹ Atlantic Health System, Morristown, New Jersey, USA.
³⁰ Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.
³¹ University of Virginia, Charlottesville, Virginia, USA.
³² Menlo Medical Clinic, Menlo Park, California, USA.
³³ The Orthohealing Center, Los Angeles, California, USA.
³⁴ Ludwig Boltzmann Institute for Traumatology, Vienna, Austria.
³⁵ Atlanta Sports Podiatry, Atlanta, Georgia, USA.
³⁶ Department of Orthopedic Surgery, Beijing United Family Hospital, Beijing, Beijing, China.
³⁷ Department of Physical Medicine and Rehabilitation, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
³⁸ Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Japan.
³⁹ Singapore Sport and Exercise Medicine Centre, Singapore.
⁴⁰ Hospital for Special Surgery, New York, New York, USA.
⁴¹ Israel Shockwave Center, Petach Tikva, Israel.
⁴² Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York, USA.

PMID: 40032293
DOI: 10.1136/bjsports-2024-109082

Abstract

Objectives: While extracorporeal shockwave therapy (ESWT) may be an efficacious adjunctive treatment option for musculoskeletal injuries, current research is limited by significant heterogeneity within treatment protocols. This study aims to establish international expert consensus recommendations on ESWT terminology, parameters, procedural considerations, contraindications and side effects in the application of ESWT to sports injuries.

Methods: A systematic literature search was performed on the use of ESWT for musculoskeletal and sports medicine injuries to identify potential panellists, followed by the development of a steering committee-led questionnaire. A three-stage, modified Delphi questionnaire was provided to a panel of 41 international clinical and research experts across 13 countries. Panellists had the opportunity to suggest edits to existing statements or recommend additional statements in Round 1. Consensus was defined as≥75% agreement.

Results: All 41 panellists completed Rounds 1, 2 and 3. Consensus was reached on 69/118 statements (58.5%), including recommendations on terminology and fundamental concepts, indications for use, procedural aspects for tendinopathy and bone pathologies, treatment correlations with imaging, periprocedural and postprocedural considerations, absolute and relative contraindications and potential side effects. Of the 49 statements that did not reach consensus, 17/49 (34.7%) were related to procedural aspects of bone pathology.

Conclusion: This international panel presents recommendations on ESWT terminology, indications and treatment considerations to guide ESWT use and decision-making by sports medicine clinicians. While our panel supported the use of ESWT in the treatment of bone pathologies, certain procedural aspects of ESWT specific to these injuries did not reach consensus and require further investigation.

Keywords: Consensus; Sports medicine; Tendinopathy.

PubMed Disclaimer

Conflict of interest statement

Competing interests: BWB is the Medical Director and receives compensation from CuraMedix LLC. MC is a consultant for CuraMedix/Storz and BioTissue. RMC is a consultant for CuraMedix/Storz, Swift/Emblation, OOFOS and Vimazi shoes. MF has received grant funding through the Department of Defense for the investigation of ‘ESWT for high grade bone stress injuries’. KGS has received research support (in-kind support of equipment) from Enovis. NM serves as the Editor in Chief for the Journal of Orthopaedic Surgery. NM also serves as the Editor in Chief for the British Medical Bulletin. KM serves as a consultant for Lipogems and is the MAB and co-founder of TendoNova. SR receives research funding from Bauerfeind USA for the ankle brace study. AS serves as a Section editor for the Journal of Orthopedic Surgery and Research. Speaker for CuraMedix, LLC. WSc is a share holder and International Medical Director of SoftWave Tissue Regeneration Technologies, Georgia, USA. AST serves as Senior editor for PM&R Journal. He gives professional talks, such as grand rounds and medical conference plenary lectures and receives honoraria from conference organisers. He has participated in research funded by the Arnold P Gold Foundation (physician and patient care disparities), the Football Player Health Study at Harvard (health in American-Style Football players), the American Medical Society for Sports Medicine (bone density research), the Uniform Health Service and Enovis (Achilles tendinopathy). He receives funding from the NFLPA and Department of Defense for studies evaluating shockwave for management of orthopaedic injuries. He is a paid consultant for State Farm Insurance and Strava. JFW receives textbook royalties from Springer publishing. JZ receives e-book royalties from UpToDate (Wolter Kluwers publishing).

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

LinkOut - more resources

Full Text Sources
- HighWire
Medical
- MedlinePlus Health Information

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study

Affiliations

Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study

Authors

Affiliations

Abstract

Conflict of interest statement

MeSH terms

LinkOut - more resources

Full Text Sources

Medical