68 Equine
Comments? Questions?
UPDATE ON EQUINE THERAPEUTICS
Extracorporeal Shock-Wave Therapy
for Equine Musculoskeletal Disorders
S. R. McClure, DVM, PhD, DACVS
Iowa State University
D. K. Merritt, DVM
Merritt and Associates
Wauconda, Illinois
ABSTRACT: Extracorporeal shock-wave
therapy uses high-pressure waves that
are focused at a point within tissue.
These high-pressure waves (through yet
unknown mechanisms) can stimulate
bone and soft tissue healing. Shock-
wave therapy is a proven mechanism for
treating musculoskeletal disease in many
species, including horses. Practitioners
must be aware of potential complica-
tions, however.
A
shock wave is a pressure wave
with a rise time of 5 to 10 ns
to a peak positive pressure (the
maximum pressure of the shock wave
generated by the system) of 20 to 100
megapascals.1 A megapascal is about
10 times atmospheric pressure. The
pressure wave then degrades exponen-
tially to baseline and typically has a
small negative component (about
10% of the peak positive wave) before
returning to baseline in a total pulse
time of about 300 ns. The actual
shock wave can vary considerably,
depending on the type of generator.
Shock waves behave like sound
waves in tissue: The energy is liberated
into tissue as a function of the differ-
ence in acoustic impedance of the
SERIES
EDITOR
adjacent tissues. An air–fluid inter-
face absorbs the greatest amount of
energy, whereas a muscle–fat inter-
face absorbs only a minimal amount
of energy. Shock-wave therapy
should not be used near air–tissue
interfaces such as the lungs because it
can cause pleural injury. Complica-
tions are usually confined to subcu-
taneous hemorrhage and pain caused
by certain equipment. Large nerves
and blood vessels are normally
avoided, and active physes should be
avoided because potential damage to
the physis has been reported.2 Neo-
plasia and septic foci should be
avoided to decrease the likelihood of
metastasis or spread of sepsis.
Shock-Wave
Generation
Focused Shock-Wave • Focused extracorporeal shock-wave therapy has
KEY POINTS
Generators
Each of the three
techniques used for • Appropriate use of extracorporeal shock-wave
focused shock-wave
generation has quite
distinct characteristics
in terms of focal volume and energy
flux. The focal volume is the size of the
focal zone (area affected by the shock
wave). At similar energy settings, a
small focal volume results in a higher
energy flux density because the energy
is more concentrated than when there
is a larger focal volume and the energy
is spread over a greater area.
All three generators initiate the pres-
Debra Deem Morris, DVM, MS
North Jersey Animal Hospital, PA, Wayne, New Jersey
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Compendium January 2003
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sure wave within a fluid medium, and
the wave is focused by reflection within
the generator to the focal point at the
treatment site. Each generator has its
own characteristics and limitations in
terms of pulse frequency and power
capabilities, which affect the way the
shock waves may be administered:
• Piezoelectric generators use
piezoelectric crystals arranged in
such a way that when a high cur-
rent is applied, the excitation of
the crystals produces the pressure
wave. The typical focal character-
istics of this generator include a
very small focal volume with very
high-energy flux values but a low
overall energy transfer.
been used successfully in humans and animals
for treating musculoskeletal disorders.
therapy in horses depends on the practitioner’s
knowledge of shock waves.
• Electromagnetic generators act
similar to a speaker in that a high-
voltage current passes through a
coil that propels a diaphragm,
which produces the pressure
wave. Characteristics of electro-
magnetic generators include
small focal volume and high-
energy flux, which is generally
Compendium January 2003 Shock-Wave Therapy 69

not as concentrated as the piezo-

Focused
Focused Shock
Shock Wave
Wave
electric system. 30
30
• Electrohydraulic generators pass

(MPa)
Pressure(MPa)
a high-voltage current across a 20
20
Radial
Radial Pressure
Pressure Wave
Wave
8
spark gap in a fluid-filled ellipsoid 8

(MPa)
6

Pressure

Pressure(MPa)
6
reflector. The expanding plasma 10
4
4
10 2
and gas bubble generate the pres- 2
0

sure wave. This generator gener-
ally produces one of the largest
focal volumes with lower energy
flux densities but overall high-
energy transfer.
Ballistic Shock-Wave Generators
A ballistic or radial generator does
not produce a pressure wave with the
rapid rise time and high energy that
defines a shock wave but uses
mechanical concussion. In terms of
shock-wave definition, the major dif-
ference is that the shock wave deliv-
ered by the ballistic machine has a
slower rise time and a negative com-
ponent that is of the same order as the
positive component. Because there is
no focusing system, the energy of the
wave declines in proportion to the
distance from the source (Figure 1).
Extracorporeal Shock-Wave
Therapy
Focused extracorporeal shock-wave
therapy (ESWT) was originally
developed over 20 years ago for the
noninvasive destruction of renal cal-
culi in humans. Using ESWT, kid-
ney stones are pulverized by a combi-
nation of direct and indirect forces.3
Combined with the direct shear
force of the shock wave, microscopic
gas bubbles within the calculi are
compressed to very high pressures
and liberate microjets of fluid that
contribute to stone destruction.
Soon after the development of
ESWT, clinicians noted that when
shock waves impinged on soft tissues
and bone in humans, certain changes
took place. In 1986, it was suspected
that shock waves stimulated
osteoblasts to increase bone deposi-
tion. 4 A 1991 laboratory study
demonstrated increased healing of
Pressure
0
–2
–2
–4
0 –4
0
–6
–6
–8
–4
–4
0
0
4
4
8
8
–8–5
–5
0
0
5
5
10
10
Time
Time (µsec)
(µsec) Time
Time (µsec)
(µsec)
50
50
Amount
Amount of
of
25 pressure
pressure
25
generated
generated
0 (MPa)
0 (MPa)
A B
Figure 1—An electrohydraulic generator (A) initiates a shock wave that comes
together, creating high pressures at the focal point. The shock wave has a very rapid rise
and drop-off. For a radial pressure wave (B), the maximal pressure is at the generator,
and pressure decreases proportional to the square of the distance from the generator.
(MPa = megapascal)
induced humeral fractures in rats. 5 production of nitric oxide in cells,
Since then, ESWT has been used which can lead to an increase in
extensively in humans for many con- bone remodeling.7 Increased concen-
ditions. However, the initial use of trations of transforming growth fac-
ESWT in animals in the United States tor–β1 and the subsequent increased
was not until 1998, when Dr. David division of osteocytes have been doc-
McCarroll used it to treat horses.6 umented in cell culture.8 A consis-
tent finding in shock-wave research
Mechanism is a dose–response effect. Too little
Little data are available to elucidate energy or too few pulses have no
the mechanisms by which shock effect, whereas excessive energy or
waves affect specific tissues. It was ini- pulses cause damage to tissues. Maxi-
tially believed that the effect of mal clinical effects can be obtained
ESWT on bone was simply to induce by using a middle range.
microfractures and that the healing The energy data for the various
response was due to the mechanical machines are obtained by the use of
effect. However, microfractures do hydrophones in a water or gelatin
not normally occur in the clinical set- bath. These data serve to differentiate
ting and have only been documented between machines and various settings
with the use of very high energy levels but actually predict poorly what is
in very small laboratory animals. Cur- happening in the body because there
rent research is focused on the effect are different interfaces through which
of the pressure waves on cells and the shock wave travels in a horse’s leg.
their response by production of If a good image can be produced by
growth factors. Shock waves induce an ultrasonographic scan of the region

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70 Equine Compendium January 2003

of interest, ESWT can be expected to

reach this area. Once a shock wave
hits bone, 35% of the energy is
reflected and 65% transmitted (with
80% to 90% reduction of the energy
within 1 to 2 cm of the bone).4 Can-
cellous bone—likely because of its
multitissue interfaces—is subjected to
greater attenuation of shock waves
than cortical bone. On passing
through tissue, the focal zone pro-
duces stress and strain on these tissues.
If the energy is high enough, physical
damage can result; however, with
appropriate ESWT equipment and
settings, complications are minimal.

Indications
The use of ESWT in horses has
roughly mirrored its use in humans.
Although one of the first applica-
tions of ESWT in humans was for
nonunion fractures, the typical
nonunion fractures seen in humans A B
are uncommon in horses. Stress frac-
tures are common, however, and one Figure 2—Radiograph of a 3-year-old thoroughbred filly with a dorsal cortical frac-
author (S. R. M.) and colleagues have ture of the third metacarpal bone showing a stress fracture in the dorsal cortex (A).
documented that ESWT can stimu- The horse was treated with ESWT three times at 3-week intervals and confined to a
stall for 30 days. After 30 days, the horse resumed hand walking. Radiograph taken
late bone remodeling in horses.
at 60 days when the horse resumed training (B).
Many cases of stress fractures have
responded well to ESWT (Figure 2).
In humans, insertional desmopathies, cally, suspensory desmitis in horses has injured suspensory ligaments treated
such as tennis elbow and calcific ten- responded well to ESWT. Results of a with ESWT healed faster than control
donitis of the shoulder, have been controlled study supported by the USA suspensory ligaments.9 ESWT has been
treated successfully with ESWT. Clini- Equestrian Foundation showed that attempted in patients with superficial
(text continues on page 75)

A B
Figure 3—Ultrasonograms of the forelimb superficial digital flexor tendon of a 3-year-old quarter horse stallion. The horse injured
the tendon during a western reining event and was treated three times with ESWT at approximately 3-week intervals. The lesion
healed well from the initial presentation (A) to 50 days later (B) when the horse was returned to light work. The horse qualified for
the finals of the Quarter Horse Reining Futurity 4 months later and continues to compete successfully 1 year after treatment.

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Compendium January 2003
Shock-Wave Therapy (continued from page 70)
digital flexor tendonitis, and some early
success has been realized (Figure 3).
One of the authors (D. K. M.) has
treated 25 cases of superficial digital
flexor tendonitis with ESWT, with
recurrences in only two patients. As
with bone, the mechanism by which
tendons and ligaments can be affected
by ESWT is unknown. One potential
outcome of treatment is increased neo-
vascularization of the bone–tendon
junction, which occurred in a dog cal-
caneal tendon model.10
ESWT is reported to induce post-
treatment analgesia. Multiple racing
jurisdictions and the Federation Equine
International have developed regula-
tions concerning the use of ESWT
before competition. Humans have a
bimodal response to ESWT character-
ized by an initial 3- to 4-day decrease in
pain, followed by a return of pain and
then a gradual reduction over the next
3 to 4 weeks.11 A similar response has
been seen clinically in horses. Scientific
data support this phenomenon12; how-
ever, the mechanism of the initial anal-
gesia is unclear.
References
1. Sturtevant B: Shock wave physics of
lithotriptors, in Smith A, Badlani GH,
Bagley DH, et al (eds): Smith’s Textbook
of Endourology. St Louis, Quality Med-
ical Publishing, 1996, pp 529–552.
2. Yeaman LD, Jerome CP, McCullough
DL: Effects of shock waves on the struc-
ture and growth of the immature rat
epiphysis. J Urol 141:670–674, 1989.
3. Fuchs GJ, Patel A: Treatment of renal
calculi, in Smith AD, Badlani GH,
Bagley DH, et al (eds): Smith’s Textbook
of Endourology. St Louis, Quality Med-
ical Publishing, 1996, pp 590–621.
4. Graff J: Transmission of shock waves
through bone: Treatment of iliac ureteral
stones in a supine position. J Urol
143:231–233, 1990.
5. Haupt G, Haupt A, Ekkernkamp A, et
al: Influence of shock waves on fracture
healing. Urology 39:529–532, 1992.
6. McCarroll GD: The use of extracorpo-
real shock wave lithotripsy for treat-
ment of distal tarsal arthropathies of
the horse. Proc Annu Meet Assoc
Equine Sports Med:40–41, 1999.
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Hydrallantois 75
7. Wang FS, Wang CJ, Sheen-Chen SM,
et al: Superoxide mediates shock wave
induction of ERK-dependent osteo-
genic transcription factor (CBFA1)
and mesenchymal cell differentiation
toward osteoprogenitors. J Biol Chem
277:10931–10937, 2002.
8. Wang FS, Yang KD, Wang CJ: Trans-
forming growth factor β-1 involved in
extracorporeal shockwave promotion
of bone marrow mesenchymalosteo-
progenitors growth (abstract). 3 rd
Congr Int Soc Musculoskeletal Shock-
wave Ther: 99, 2000.
9. McClure SR: In vivo evaluation of
extracorporeal shock wave therapy for
collagenase-induced suspensory desmi-
tis in horses (ESWT) [abstract]. 1 st
Symp Extracorporeal Shock Wave Users
Vet Med:23–24, 2002.
10. Wang CJ, Pai CH, Avery SY: Shock
waves enhanced neovascularization at the
tendon bone junction: An experimental
dog model. Proc 3rd Congr Int Soc Muscu-
loskeletal Shockwave Ther: 96, 2000.
11. Ogden JA, Ogden DA: Electrohy-
draulic SWT: Bimodal response
[abstract]. 5 th Congr Int Soc Muscu-
loskeletal Shockwave Ther: 21, 2002.
12. McClure SR: Extracorporeal shock
wave therapy: What? Why? Safety?
Proc Int Racing Chemist Vet Meet,
2002.