Optimizing Shockwave Therapy for Supraspinatus Tendinopathy

Identifying the Ideal Candidate

Not every patient with shoulder pain is a good candidate for shockwave. The sweet spot is often those with chronic supraspinatus tendinopathy- typically defined as pain lasting longer than 3 months- who have failed to respond to initial conservative measures like rest, activity modification, and physical therapy. Before reaching for the shockwave device, consider these key factors:

• Pain Location: Is the pain primarily localized to the greater tuberosity? Diffuse shoulder pain may indicate other underlying issues.
• Provocative Tests: Positive Neer's and Hawkins-Kennedy tests suggest rotator cuff involvement, but these aren't definitive.
• Imaging: While not always necessary, ultrasound or MRI can help confirm the diagnosis and rule out full-thickness tears. A partial tear may still respond to shockwave, but full tears require surgical consideration.
• Functional Limitations: Assess the patient's ability to perform overhead activities and daily tasks. Shockwave aims to improve function, so a clear baseline is crucial.

Remember, shockwave isn't a magic bullet. It works best when combined with a comprehensive rehabilitation program. Patients who are unwilling to actively participate in physical therapy are unlikely to experience optimal results.

Contraindications

Before initiating shockwave therapy, it's essential to rule out any contraindications. These include:

• Full-Thickness Rotator Cuff Tears: Shockwave is unlikely to heal a complete tear and may even exacerbate the condition.
• Infection: Active infection in the treatment area is an absolute contraindication.
• Tumors: Avoid applying shockwave near known or suspected tumors.
• Bleeding Disorders: Patients with bleeding disorders or those taking anticoagulants may be at increased risk of hematoma formation.
• Pregnancy: The safety of shockwave therapy during pregnancy hasn't been established.
• Metal Implants: While not an absolute contraindication, exercise caution when treating near metal implants.

A thorough medical history and physical examination are crucial to identify any potential risks. When in doubt, err on the side of caution.

A Sample Protocol

While specific protocols may vary depending on the device and the patient's individual needs, here's a general framework you can adapt:

• Patient Positioning: Position the patient comfortably, typically in a seated or side-lying position, with the shoulder exposed.
• Gel Application: Apply a generous amount of ultrasound gel to the treatment area to ensure good contact between the probe and the skin.
• Energy Flux Density: Start with a low energy flux density (e.g., 0.08-0.12 mJ/mm²) and gradually increase it as tolerated.
• Frequency: A frequency of 10-15 Hz is commonly used.
• Number of Impulses: Deliver approximately 2000-3000 impulses per session.
• Treatment Duration: Each session typically lasts 10-15 minutes.
• Treatment Frequency: Perform treatments once a week for 3-6 weeks.

It's crucial to monitor the patient's response during the treatment. If they experience excessive pain, reduce the energy flux density or pause the session. Post-treatment, advise patients to avoid strenuous activity for 24-48 hours.

Setting Realistic Expectations

Honest communication is paramount. Patients need to understand that shockwave therapy isn't a guaranteed cure. While many experience significant pain relief and improved function, some may not respond at all. Be upfront about the potential benefits and limitations of the treatment.

Explain that multiple sessions are typically required and that adherence to the post-treatment rehabilitation program is crucial for long-term success. Emphasize the importance of a gradual return to activity to avoid re-injury. Manage patient expectations and you will find a more compliant and content patient.