Clinical Reference
ESWT Safety
Compiled May 2026
Anchors: Moya 2018 (JBJS) · Auersperg & Trieb 2020 (EFORT) · Schmitz 2015 (Br Med Bull) · Crevenna 2022 (PM&R)
ESWT — Contraindications & Adverse Events
Evidence-graded reference. Anchored on peer-reviewed orthopaedic journals; ISMST guidance kept as supporting only.
Tier A: real
Tier B: relative
Tier C: theoretical
Adverse events
High-energy definition
Bottom line. Hard contraindications for focused high-energy ESWT (Moya 2018 JBJS; Auersperg & Trieb 2020 EFORT): malignant tumor in focus, fetus in focus, lung tissue in focus, pacemaker/ICD in field, uncontrolled coagulopathy. For radial and low-energy focused ESWT, the hard list narrows to: malignant tumor in focus, fetus in field, pacemaker in field, and acute local infection at the application site. Everything else — growth plates, "over the spine," nerves, vessels, pregnancy as a status — is either a precautionary avoidance during application or a theoretical concern unsupported by clinical injury data.
What "high energy" actually means
ESWT energy is reported as energy flux density (EFD) in mJ/mm², measured at the focal point of a focused source. There is no single ISO/regulatory cutoff — the convention below is propagated through Rompe's early work, Moya 2018 (JBJS), Auersperg & Trieb 2020 (EFORT), and the wider clinical literature. Different device manufacturers (Storz, Dornier, Richard Wolf) use slightly different internal scales, so treat the numbers as bands, not bright lines.
| Category | EFD threshold (mJ/mm²) | Typical clinical use | Notes / source |
|---|---|---|---|
| Low energy | < 0.08 (some authors < 0.10–0.12) | Tendinopathies, plantar fasciitis, soft-tissue pain, cardiology (LI-ESWT), erectile dysfunction, wound healing | Moya 2018 JBJS classification; Auersperg & Trieb 2020 EFORT |
| Medium energy | 0.08 – 0.28 | Calcific tendinitis of the shoulder, chronic tendinopathies, myofascial trigger points | Most pain-adapted MSK ESWT (Moya 2018; Schmitz 2015 Br Med Bull) |
| High energy | > 0.28 (commonly 0.35–0.60+) | Pseudarthrosis / delayed union, stress fracture, AVN, lithotripsy (ESWL), high-energy Dupuytren up to 1.24 mJ/mm² | High-energy contraindication list applies (lung, brain/CNS, coagulopathy) — Moya 2018; Auersperg 2020 |
| Tissue-damage threshold | > 0.60 | Not used clinically in soft tissue | Rompe & Maier ex-vivo tendon experiments: structural damage demonstrated above this level |
Radial pressure waves are a separate class. Radial ESWT (rESWT) is reported in bar (typically 1–5 bar), not focal EFD. It is not "focused" and does not concentrate energy at depth — so "high-energy" thresholds above do not map cleanly onto radial devices. The "high-energy contraindication list" (lung, brain in field, etc.) is primarily a focused-source concern (Moya 2018 JBJS; Crevenna 2022 PM&R).
Practical reading. When a guideline or paper says "high-energy ESWT," assume
> 0.28 mJ/mm² focal EFD on a focused source unless stated otherwise. When in doubt, look at the actual EFD value reported, not the marketing label on the machine.
Tier A — Evidence-supported contraindications
Anchored on peer-reviewed orthopaedic reviews. Don't argue with these.
| Contraindication | Applies to | Why (mechanism / evidence) | Peer-reviewed sources |
|---|---|---|---|
| Lung tissue in field | High-energy focused only | Shockwave physics at air interfaces; pressure-to-tensile conversion; cavitation. Documented in human ESWL. |
Moya 2018 JBJS — explicit contraindication Auersperg & Trieb 2020 EFORT Open Rev Yi 2022 — lung contusion after ESWL Case 2010 — contusion + cavitation |
| Pacemaker / ICD in field | All sources | Device interference, electromagnetic field disruption, hardware damage |
Moya 2018 JBJS Crevenna 2022 PM&R best practices |
| Significant coagulopathy | High-energy focused (strict); other sources relative | Dose-dependent bleeding/hematoma risk; petechial bleeding documented at standard doses |
Auersperg & Trieb 2020 — "severe coagulopathy is a contraindication for high-energy ESWT" Moya 2018 JBJS Schmitz 2015 Br Med Bull — systematic review |
| Malignant tumor IN the focus | All sources | Local mechanical effect on tumor tissue. NOT a contraindication to having cancer elsewhere. |
Moya 2018 JBJS Crevenna 2022 PM&R best practices De la Corte-Rodríguez 2023 — explicit clarification |
| Fetus in field (pregnant uterus in field) | All sources | Pregnancy itself is NOT contraindicated — only the fetus being in the shockwave path. |
Auersperg & Trieb 2020 — "ESWT with focus on the foetus or embryo" Moya 2018 JBJS |
| Acute local infection / open wound at site | All sources | Risk of dissemination; documented as contraindication across orthopaedic reviews |
Auersperg & Trieb 2020 — "focus on severe infection" Moya 2018 JBJS |
Tier B — Relative contraindications
Use judgment, not reflex. Case-by-case evaluation.
| Contraindication | Why relative | What evidence actually says | Peer-reviewed sources |
|---|---|---|---|
| Brain / CNS in field | High-energy only | Theoretical concern. No human injury data in MSK ESWT. Moya 2018 notes as relative contraindication. | Moya 2018 JBJS |
| Vertebral bodies, ribs, skull bones | Bone-conduction & adjacent-organ concerns | Listed as relative. Paravertebral and rib-area rESWT performed routinely in practice without complication clusters in published series. |
Moya 2018 JBJS Crevenna 2022 PM&R |
| Complete tendon rupture | Risk of further damage / non-healing | Evidence thin and contradictory. Partial tears >50% treated without significant AEs (Notarnicola). Imaging recommended in patients >60 yo. |
De la Corte-Rodríguez 2023 Lin 2012 — Achilles rupture case |
| Well-controlled anticoagulation | Bruising / hematoma risk | Relative. Many clinicians treat with reduced energy without complication; no published rupture/bleed cluster. |
Crevenna 2022 PM&R — current NSAID/anticoagulation considerations Schmitz 2015 Br Med Bull |
Tier C — Theoretical only (do NOT treat as hard contraindications)
Repeated in older textbooks and device manuals; not supported by clinical injury data.
| Item | Why it's overblown | Peer-reviewed sources |
|---|---|---|
| Open growth plates / epiphyses | No clinical evidence of harm. Animal & ex-vivo data point to neutral-to-stimulatory effect on chondrogenesis and bone growth. Moya 2018 (JBJS) lists as relative — not absolute. De la Corte-Rodríguez 2023 repeats the warning but cites no injury data. |
Kiessling 2021 Bone — chondrogenesis, rabbit growth Hausdorf 2006 — adolescent rat (no harm) ESWT for leg length 2025 Fetal rat metatarsals — bone growth |
| "Over large vessels / nerve tracts" | These are application-technique notes (avoid direct targeting), not hard contraindications. Nerve irritation is transient and resolves. |
Moya 2018 JBJS Schmitz 2015 Br Med Bull |
| Pregnancy as a whole-body contraindication | The contraindication is fetus IN THE FIELD, not the pregnant patient. Shoulder/elbow/foot ESWT in a pregnant woman is mechanistically irrelevant to the fetus. |
Auersperg & Trieb 2020 EFORT — clarifies focus location Moya 2018 JBJS |
| Cancer history | Not a contraindication. The contraindication is tumor tissue IN THE FOCUS. History of cancer in remission elsewhere does not preclude MSK ESWT. Crevenna 2022 explicitly states "chronic infection and cancer diagnosis are no longer considered contraindications." |
Crevenna 2022 PM&R best practices Moya 2018 JBJS |
| Pediatric use generally | Not contraindicated. Published pediatric indications include delayed union, Osgood-Schlatter, Sever's disease, calcaneal apophysitis. |
Focused ESWT for ischial apophysitis in young gymnasts 2023 Moya 2018 JBJS |
Adverse events — frequency-graded
Auersperg & Trieb 2020 (EFORT Open Reviews): "ESWT is a safe therapy with only a few side effects known (such as pain during ESWT and minor haematomata) and no severe complications are to be expected if it is performed as recommended."
| Frequency | Adverse event | Peer-reviewed sources |
|---|---|---|
| Common | Pain during treatment |
Auersperg & Trieb 2020 Schmitz 2015 Br Med Bull |
| Common | Skin erythema / reddening |
Moya 2018 JBJS De la Corte-Rodríguez 2023 |
| Common | Petechial bleeding | Moya 2018 JBJS |
| Common | Mild bruising / hematoma |
Auersperg & Trieb 2020 — "minor haematomata" Schmitz 2015 Br Med Bull |
| Common | Transient pain flare 24–72 h post-treatment | Moya 2018 JBJS |
| Uncommon | Skin blistering (high-energy / thin-skin sites) | Moya 2018 JBJS |
| Uncommon | Headache / migraine flare | Schmitz 2015 Br Med Bull |
| Uncommon | Transient nerve irritation (paresthesia, numbness) |
Haake 2002 AOTS — ESWT side effects in epicondylitis Moya 2018 JBJS |
| Uncommon | Tinnitus (sensitive patients) | Moya 2018 JBJS |
| Uncommon | Transient hypertension (mostly ESWL) | Moya 2018 JBJS — extrapolated from lithotripsy |
| Rare | Tendon rupture — almost always with prior repeated steroid injection |
Lin 2012 — Achilles case Rompe & Maier — damage at >0.6 mJ/mm² |
| Rare | Ulnar neuropathy (single case) | Shim 2015 — PM&R case report |
| Rare | Calcaneal stress-fracture-like presentation | Erduran 2013 — Am Orth Foot Ankle Soc |
| Rare | Osteonecrosis of humeral head (single case, post-ESWL) | Durst 2002 — JBJS Br |
| ESWL / high-energy specific | Lung contusion, hemoptysis, cavitation, pleural effusion |
Yi 2022 — pancreatic ESWL Case — false positioning ESWL |
| ESWL / high-energy | Pulmonary bone-fragment embolism (animal model) | Maier 2003 — pig model, distal femur |
| ESWL | Renal rupture / hematoma | May 2004 — Akt Urol case report |
Primary peer-reviewed references
- Moya D, Ramón S, Schaden W, Wang CJ, Guiloff L, Cheng JH. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. J Bone Joint Surg Am. 2018;100(3):251-263.
- Auersperg V, Trieb K. Extracorporeal shock wave therapy: an update. EFORT Open Rev. 2020;5(10):584-592.
- Schmitz C, Császár NBM, Milz S, Schieker M, Maffulli N, Rompe JD, Furia JP. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015;116:115-138.
- Crevenna R, et al. Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration. PM&R 2022.
- De la Corte-Rodríguez H, et al. ESWT for the Treatment of Musculoskeletal Pain: A Narrative Review. Healthcare 2023;11:2830.
- Kiessling MC et al. Radial shockwave treatment promotes chondrogenesis in human growth plate and longitudinal bone growth in rabbits. Bone 2021.
- Hausdorf J et al. Effects of high-energy shock waves on the immature epiphysis. 2006.
- Does ESWT treat leg length discrepancy? Arthritis Res Ther 2025.
- Radial Shock Wave Treatment Promotes Bone Growth in Cultured Fetal Rat Metatarsals.
- Yi JH et al. Lung contusion after extracorporeal shock wave lithotripsy. 2022.
- Lung contusion and cavitation with pleural effusion following ESWL. 2010.
- Lin TC et al. Achilles tendon tear following SWT for calcific tendinopathy: case report. 2012.
- Focused ESWT for ischial apophysitis in young gymnasts. 2023.
- Rompe JD, Maier M — tendon damage experiments at energies >0.6 mJ/mm².
- Roerdink RL et al. Complications of ESWT in plantar fasciitis: systematic review. Int J Surg 2017.
- Haake M et al. Side effects of ESWT in epicondylitis. AOTS 2002.
- Shim JS et al. Ulnar Neuropathy After ESWT: A Case Report. PM&R 2015.
- Erduran M et al. SWT complication resembling calcaneal stress fracture. 2013.
- Durst HB et al. Osteonecrosis of the humeral head after ESWL. JBJS Br 2002.
- Maier M (2003) — Detection of Bone Fragments in Pulmonary Vessels after High-Energy ESW in in-vivo Animal Model. Z Orthop.
- Kiessling MC 2015 — Radial ESWT harms developing chicken embryos. Sci Rep.