International Journal of Surgery 24 (2015) 201e206

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International Journal of Surgery

journal homepage: www.journal-surgery.net

Review

Update on the efficacy of extracorporeal shockwave treatment for

myofascial pain syndrome and fibromyalgia
Silvia Ramon a, *, Markus Gleitz b, Leonor Hernandez c, Luis David Romero c
a
Hospital Quiron Barcelona, School of Medicine and Health Sciences, Universitat Internacional de Catalunya. Garcia Cugat Foundation, CEU e UCH Chair of
Medicine and Regenerative Surgery, Spain
b
Orthopaedic Practice, Luxembourg
c
Physical Medicine and Rehabilitation Department, Hospital Quiron Barcelona, Spain

h i g h l i g h t s

We present the current knowledge on shockwave treatments for myofascial pain syndrome.

ESWT is an efficient tool for the treatment of myofascial pain síndrome.

The clinical efficacy of ESWT in fibromyalgia is controversial.

Promising results have been reported on myofascial pain syndrome.

a r t i c l e i n f o a b s t r a c t

Article history: Chronic muscle pain syndrome is one of the main causes of musculoskeletal pathologies requiring
Received 13 June 2015 treatment. Many terms have been used in the past to describe painful muscular syndromes in the
Received in revised form absence of evident local nociception such as myogelosis, muscle hardening, myalgia, muscular rheu-
31 July 2015
matism, fibrositis or myofascial trigger point with or without referred pain. If it persists over six months
Accepted 6 August 2015
Available online 10 September 2015
or more, it often becomes therapy resistant and frequently results in chronic generalized pain, charac-
terized by a high degree of subjective suffering.
Myofascial pain syndrome (MPS) is defined as a series of sensory, motor, and autonomic symptoms
Keywords:
Myofascial pain
caused by a stiffness of the muscle, caused by hyperirritable nodules in musculoskeletal fibers, known as
Trigger point myofascial trigger points (MTP), and fascial constrictions.
Tender point Fibromyalgia (FM) is a chronic condition that involves both central and peripheral sensitization and
Fibromyalgia for which no curative treatment is available at the present time. Fibromyalgia shares some of the features
Shockwave of MPS, such as hyperirritability.
Efficacy Many treatments options have been described for muscle pain syndrome, with differing evidence of
efficacy. Extracorporeal Shockwave Treatment (ESWT) offers a new and promising treatment for
muscular disorders.
We will review the existing bibliography on the evidence of the efficacy of ESWT for MPS, paying
particular attention to MTP (Myofascial Trigger Point) and Fibromyalgia (FM).
© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

1. Extracorporeal shockwave treatment and myofascial pain as myofascial trigger points (MTP) [1e6]. (Fig. 1). MTP produce pain
syndrome with any activating stimulus (direct or indirect trauma), causing
local and referred pain, tenderness, motor dysfunction, autonomic
Myofascial Pain Syndrome (MPS) is a musculoskeletal disorder phenomena and hyperexcitability of the central nervous system
with local pain and stiffness, characterized by the presence of hy- [7e9]. Recent research argues that MPS offers a simplistic explan-
perirritable palpable nodules in the skeletal muscle fibers, known atory model, which posits a local (muscular) origin of nociception
within the trigger points (TP) and advocates local treatment.
MPS is a common disorder (12% in general population) [10].
* Corresponding author. Some studies observed an incidence of 30% MTPs in internal
E-mail address: [email protected] (S. Ramon).

http://dx.doi.org/10.1016/j.ijsu.2015.08.083
1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
202 S. Ramon et al. / International Journal of Surgery 24 (2015) 201e206

Fig. 1. Myofascial Trigger Point complex: Muscle knot (central trigger point) with taut band and attachment TP [1,2].

medicine practice [11], with a prevalence of 54% in women and 45% hypothesis” reflects this vicious circle. This hypothesis has evolved
in men [2,5,12], although some publications do not report signifi- into the “integrated TP hypothesis” [14], which postulates that
cant differences between the two genders [2,7]. The most common abnormal depolarization of the post-junctional membrane of the
age bracket at onset is 27e50 [8,9]. motor endplates causes a localized hypoxic energy crisis, associated
The mechanism of action that best explains it is Simons' Inte- with sensory and autonomic reflex arcs that are sustained by
grated Hypothesis of TP Formation (or Energy Crisis Integrated complex sensitization mechanisms.
Hypothesis) [1,2]. Fig. 2. Muscular injury causes a dysfunction of the neuromuscular
Muscle trauma, strain, repetitive low-intensity muscle overload, endplate, which in turn increases the release of Acetylcholine (ACh)
or intense muscle contractions may give raise to a vicious circle in the synaptic gap. This triggers high-frequency miniature end-
which ends up damaging the sarcoplasmic reticulum, and leading plate potentials, causing permanent depolarization. These end-
to an increase of the calcium concentration, a shortening of the plate potentials can be experimentally revealed as spontaneous
actin and myosin filaments, a shortage of adenosine triphosphate electrical activity (SEA) by needle electromyography [2]. The
and an impaired calcium pump [2,13]. The “energy crisis release of ACh in turn increases the release of calcium at the

Fig. 2. Integrated myofascial trigger point (MTP) hypothesis [1,2].

 S. Ramon et al. / International Journal of Surgery 24 (2015) 201e206 203

sarcoplasmic reticulum, which produces sustained myofascial trigger point palpation: flat palpation, pincer palpation, and deep
contraction and forms a knot. The contraction knot thus com- palpation.
presses vascular capillaries causing itself a local ischemia and then The approach to the treatment of myofascial pain should be
local hypoxia. A local energy crisis will ensue due to the loss of conservative and multidisciplinary, and should include education,
energy caused by the ischemia and the increased energy require- pharmacological treatment (analgesics, myorelaxants such as bac-
ment of calcium-pump activation [1,2]. The ischemia sensitizes the lofen or tizanidine, nonsteroidal anti-inflammatory drugs); phys-
nociceptors through the release of known inflammation mediators ical therapy (hot packs or ice, massage therapy using myofascial
(such as bradykinin, prostaglandin, serotonin and histamine) and release techniques consisting in gentle fascia manipulation, which
causes local sensitivity to pressure on the MTPs. In addition, may be effective in short-term pain relief; and gentle stretching and
ischemia will further damage the already dysfunctional endplate exercise, useful for maintaining or recovering a full range of motion
and activate acetylcholinesterase, leading to the release of ACh as and overcoming motor imbalance; stretch and spray, biofeedback,
part of the aforementioned vicious circle. Recent research in human transcutaneous electrical nerve stimulation eTENS-, ultrasound,
MTPs has confirmed this theory [15,16]. interferential currents, laser therapy) and lately ESWT [5,10].
When a muscle is injured a series of substances are released Invasively MPS can be treated by dry needling, without
which activate muscle nociceptors and cause pain. It is accompa- injecting any substance at all, in order to reach the MTP and destroy
nied by a facilitation of ACh release, inhibition of ACh breakdown it [23]. Tekin (2013) recognized this as the treatment of choice. A
and removal from the Ach Receptor (AchR), and an up-regulation of systematic review concluded that dry needling for the treatment of
AchR which, in turn, leads to the development of the persistent MPS in the lower back appeared to be a useful adjunct to standard
muscle fiber contractions, typical of MTPs. therapies, but this is currently under investigation [24]. Further-
MPS may include muscle pain from taut bands with TP and/or more, Gerber (2015) demonstrated that dry needling reduces pain
tender points. The muscles are in spasm, with increased tension from the TP, and is associated with improved mood, function, and a
and decreased flexibility. It usually occurs together with regional lessening of disability [25].
muscular pain, distributed through one or two quadrants of the In a recent systematic review and meta-analysis, Tough (2009)
body [17]. compare dry needling with acupuncture for the management of
Trigger points (TP) are defined as areas of muscle that are MTPs and find that the available evidence is inconclusive [26].
painful to palpation. They present taut bands and generate a Liu (2015) published a systematic review and meta-analysis
referral pattern of pain, characteristic to MPS. TP can be classified as about the effectiveness of dry needling for myofascial trigger
“active” or “latent”. An active TP is a spontaneous focus of pain, points associated with neck and shoulder pain. He concluded that
accentuated with pressure, and which the patient recognizes as trigger point dry needling can be recommended for relieving
familiar. A latent TP is a focus of hyperirritability in a muscle or its myofascial pain in the short and medium term, but wet needling is
fascia that is clinically quiescent in terms of spontaneous pain and found to be more effective than dry needling in the medium term
is painful only when palpated [18,19]. [27].
Tender points are areas of tenderness occurring in muscle, TP injections using local anesthetics, such as lidocaine, is a
muscle-tendon junctions, bursas, or fat pads. When they are controversial treatment, either when injected on their own [28], or
distributed throughout the body they are considered a feature of together with corticosteroids [29]. There is insufficient evidence
fibromyalgia. The two forms of painful points may coexist. available regarding the treatment of MPS with botulinum injections
Taut bands (TB) are groups of muscle fibers found to be hard [13].
and painful on palpation. The detection of TB with the palpation of A novel therapy for the treatment of muscular pain is Extra-
the muscle is considered an objective finding consistent with corporeal Shockwave Treatment (ESWT), as an empirically
myofascial pain. Table 1. extended indication for regenerative shockwave therapy.
The criteria to establish a diagnosis of MPS are: regional pain; Muscular shockwave therapy has come to be referred to as
palpation of a trigger point elicits a stereotypic zone of referred “trigger point shockwave therapy” because shockwaves are able to
pain specific to that muscle; identification of a palpable taut band trigger the referred pain that is characteristic of TP and treat the
as well as a palpable and exquisitely tender spot along the length of clinical symptoms associated with these TP [30].
that taut band; and a restricted range of motion of the involved ESWT uses biphasic acoustic energy that goes from positive high
muscle [2]. It has been suggested that certain other, minor, criteria peak pressures (10e100 MPa megapascalseMPa-for Focused F-
may further aid in the diagnosis of myofascial pain syndrome: ESWT; 0.1e1 MPa for Radial R-ESWT) to negative phase (10 MPa);
palpation of a trigger point should reproduce the clinical pain short rise times (10e100 ns for F-ESWT; 0.5e1 ms for R-ESWT),
complaint; a local twitch response may be obtained by transverse short duration (0.2e0.5 ms for F-ESWT; 0.2e0.5 ms for R-ESWT)
snapping or needling of the trigger point, and the alleviation of pain (Fig. 3). Focused and radial shockwaves are generated in different
by trigger point inactivation. ways. Focused shockwaves are generated electrically, either within
The palpable band is considered to be critical to the identifica- the applicator (electrohydraulic technique), or externally to it in the
tion of a trigger point. Three methods have been established for focal zone (electromagnetic or piezoelectric techniques), and then

Table 1
Differences between trigger points and tender points [20,21].

Trigger points Tender points

Local tenderness, taut band, local twitch response, jump sign Local tenderness
Singular or multiple Multiple points
May occur in any skeletal muscle and are mostly located Occur in specific locations that are symmetrically located
in the muscle belly
May cause a specific referred pain pattern Do not cause referred pain, but often cause increase in pain sensitivity over the whole body
The point itself may or may not be tender The specific point itself is tender
Trigger points refer pain to other areas Tender points do not cause referred pain
204 S. Ramon et al. / International Journal of Surgery 24 (2015) 201e206

Fig. 3. Typical parameters of focused shockwaves and radial shockwaves [1,2].

propagate to a designated focal point in order to treat it. Radial weekly is as effective as TENS and TP injection, measuring the re-
shockwaves are ballistic pressure waves generated at lower pres- sults in terms of pain (visual analog scale e VAS e and McGill Pain
sures over a longer time and propagate divergently within the Questionnaire), as well as on the Roles and Maudsley scale [37].
tissue [30]. The induced energy is propagating in the tissue and Ji used an electromagnetic device (Dornier AR2) to demonstrate
converges into a focal or radial area, depending on the equipment the same results on MPS of upper Trapezius compared to placebo.
used and the settings selected for intensity, angle and other pa- In this study they separated treatment of the taut band (700 im-
rameters. The effect varies, depending on the tissue through which pulses) and of the surrounding area (300 impulses) at energy levels
the wave passes and how it absorbs, reflects, refracts or transmits of 0.056 mJ/mm2, with 2 sessions per week for 2 weeks [38].
the energy, depending on the specific impedance [31]. Multimodal therapy has been studied for myofascial pain,
There have been several publications on ESWT for MTP since combining ESWT with shoulder exercises, demonstrating pain
1999, using Focused low-energy ESWT [32]. reduction and functional recovery in the combined therapy group
Most research in shockwave therapy has focused on under- [39].
standing the mechanism which results in the establishment of a In 2014, Moghtaderi studied the use of ESWT (Duolith SD1) on
mechano-sensitive feedback loop between the acoustic impulse the gastroc-soleus MTP for the ESWT treatment of plantar fasciitis.
and the stimulated cells, and involves specific transduction path- He concluded that using ESWT for both regions (plantar fasciitis
ways and gene expression [31]. and gastroc-soleus) is more effective than treating only the plantar
How do shockwaves affect myofascial pain? While today we fascia [40].
have certain hypotheses regarding how MTP are formed, it remains In a randomized study, Gür (2014) demonstrated that low-
unclear how ESWT may affect them. Taking as valid the Energy energy ESWT (Storz Minilith SL1: 1000 pulses at 0.25 mJ/mm2)
Crisis Hypothesis, and considering the mechanotransduction effect for MPS may be more effective when administered as a three-
of ESWT in other diseases [16,33,34], it could be posited that ESWT session treatment regime [41].
in MPS may increase perfusion, promote angiogenesis and alter the
pain signaling in ischaemic tissues caused by the influx of calcium.
On the other hand, recent articles have demonstrated that free 2. Extracorporeal shockwave treatment and fibromyalgia
nerve endings degenerate after the application of ESWT, and that
ESWT produces a transient dysfunction of nerve excitability at the FM is a separate category of muscle pain condition, defined by
neuromuscular junction [35], by bringing about the degeneration of the American College of Rheumatology as chronic widespread pain
AChR. Although this test was performed on spastic muscles, it could and reduced pain thresholds to palpation [22].
also be extrapolated to MTP and to the Energy Crisis Hypothesis. The pain is widespread or diffuse, distributed symmetrically
And finally, following a pure mechanistic approach, shockwaves above and below the waist. Although MPS and fibromyalgia are
might be able to break-up the ActineMyosin links, as they are separate conditions, they may occur concomitantly. FM patients
propagating perpendicularly to the sarcomere contractions. may develop MPS. FM patients have tender points; some may also
Table 2 shows evidence of the efficacy of Extracorporeal have trigger points. Taut band with TP and tender point may appear
Shockwave Treatment on Myofascial Pain Syndrome. in the muscles [17].
Müller-Ehrenberg (2005) demonstrated the efficacy of focused Treatment of FM includes pharmacological treatment (espe-
ESWT on MTPs (Piezoelectric device: Piezo Son100), alleviating cially antidepressants) and non-pharmacological approaches (ed-
pain in 95% of the 30 patients in his group at 3 months, (800 im- ucation, therapeutic exercises: strengthening, low-impact physical
pulses of energy level: 0.04e0.26 mJ/mm2; 6 Hz; average 7 treat- activity, acupuncture, injections, cognitive behavioral therapy, non-
ments, 2 sessions per week) [36]. invasive brain stimulation) [22,42].
In a study on 30 patients with MPS in trapezius muscle, Jeon As yet no literature is available on ESWT and FM. Since ESWT is
demonstrated that 3 sessions of 1500 pulses of low energy (0.10 mJ/ indicated for myofascial syndrome but not yet for FM, Ramon et al.
mm2) with focused ESWT (Electrohydraulic: Evotron RFL0300) conducted a randomized clinical trial in an attempt to gather evi-
dence on the treatment of the known myofascial points present in
 S. Ramon et al. / International Journal of Surgery 24 (2015) 201e206 205

Table 2
Evidence on extracorporeal shockwave treatment for myofascial pain syndrome.

Author Study Application Dose Results

Müller-Ehrenberg Diagnosis and treatment of MPS with ESWT Focused: 800e1000 pulses on MTPs Decrease in VAS score at 3 months
MOT 2005 [36] Piezoelectric 6 Hz
(PiezoSon100) 0.04e0.26 mJ/mm2
7 sessions
Jeon Compare ESWT and TENS þ TP injection for Focused: 1500 pulses on trapezius muscle. ESWT as effective as TENS and TP
Ann Rehabil MTP on Upper Trapezius Electrohydraulic 0.10 mJ/mm2 injection in VAS and R&M scores
Med 2012 [37] (Evotron) 3 sessions
Ji Compare ESWT with placebo on MTP on Focused: 1000 pulses on trapezius muscle. ESWT effective therapy in VAS, pain
Ann Rehabil Trapezius Electromagnetic 0.056 mJ/mm2 threshold and R&M scores
Med 2012 [38] (Dornier) 4 sessions (2 sessions per week,
in 2 weeks)
Cho Combined ESWT in upper trapezius myofascial Radial 1000 pulses on tender points. Combined therapy obtains better
J Phys Ther Sci pain syndrome and stabilization shoulder (Jest 2000 e 0.12 mJ/mm2 results for both pain and functional
2012 [39] Exercise Joeun medical) 12 sessions (3 sessions per week scores
in 4 weeks)
Moghtaderi ESWT for gastroc-soleus MTP in treatment of Focused: 40 patients Combined therapy obtains better
Adv Biomed Res plantar fasciitis Electromagnetic and Heel: results
2014 [40] Radial 3000 pulses
(Duolith SD1) 0.2 mJ/mm2 þ Each MTP:
400 pulses 0.2 mj/mm2
Gür Compare ESWT: one single session versus 3 Focused: 1000 impulses Three-session treatment improve pain
Arch Rheumatol sessions Electromagnetic 0.25 mJ/mm2 compared to one session
2014 [41] on Upper Trapezius MPS (Storz Minilith SL1) 3 sessions

MPS: myofascial pain syndrome; VAS: visual analog scale; ESWT: extracorporeal shockwave treatment; TENS: transcutaneous nerve stimulation; TP: trigger point; R&M: Roles
and Maudsley.

FM. A cohort of 24 FM patients was randomly divided into 2 groups, radial treatment of 1000e1500 pulses on each tender or
receiving 5 sessions either radial ESWT or placebo. The treatment trigger point, at 2 bar intensity and 10 Hz frequency.
group received 500 pulses, at 1.5 bar pressure, 15 hz frequency;
followed by 1000 pulses, at 2 bar and 8 Hz, and finally 500 pulses at In all the cases, ESWT should be accompanied by a compre-
1.5 bar and 15 hz, thus completing 2000 pulses in each of the 3 most hensive supervised exercise program.
painful points selected. For the placebo application, we used a soft In conclusion, muscular pain and especially myofascial pain are
rubber cap and leaving a gap between the cap and the skin, new indications for ESWT, since ESWT shows satisfactory results
rendering it impossible for the pulses to actually reach the patient. for both conditions. FM can no longer be considered an exclusion
Placebo patients received the same number of pulses at a constant criterion for ESWT.
pressure of 1.5 bar. The Radial ESWT patients showed significant ESWT is a promising new possibility for the management of
improvement in subjective measures (such as local pain according MPS, but studies with larger series of patients, using the best
to VAS) and objective measures (algometer, Roles and Maudsley, methodological parameters to improve evidence, are required to
Fibromyalgia Impact Questionnaire FIQ, pain dimension in SF-36 at confirm these results.
3 months after treatment, without any side effects. We concluded
that in a multidisciplinary approach, rESWT appears to be a safe
Ethical approval
and effective early adjunctive therapy in patients suffering from
FM. The long-term benefits of ESWT will be evaluated in order to
Not required.
establish the right moment to repeat treatment and to find a new
treatment paradigm for FM [43].
Funding

2.1. Suggested protocol for MPS and FM No funding was received by the authors.

A) We suggest the following MPS Treatment Protocol, based on

the area to treat, its depth and surface area. The treatment Author contribution
range should always be kept at low (and medium) energy
levels:
n: Writing, coordinating.
Silvia Ramo
1 Focused ESWT: 1000e2000 pulses (depending on the
generator and muscle size); 4 Hz; 0.1 mJ/mm2
Conflict of interest
(0.05e0.35 mJ/mm2) 1e3 sessions
2 Radial ESWT: 1000 pulses; 1e1.5 bar (for medium-sized
None of the authors have any conflict of interest.
muscles); 1.5e2 bar (big muscles); 6e10 Hz; 3e5 sessions
Markus Gleitz: Writing, pictures, revision.
▪ Application interval: 1 week
Leonor Hernandez: Writing.
▪ Follow-up: 6 weeks; 3, 6, 12 months after treatment
Luis Romero: Final revision.

No local anesthesia.
Guarantor
B) In Fibromyalgia patients, we suggest the inclusion of radial
ESWT for treating the myofascial component of pain with a Silvia Ramon ([email protected])
206 S. Ramon et al. / International Journal of Surgery 24 (2015) 201e206

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