I practice focused Extracorporeal ShockWave Therapy (ESWT) at Ri-AbilitySport in Como, using a new Piezowave system by Wolf. The therapy doesn’t need pre- or post-treatment preparation, pain killers or anaesthesia. Each therapy session has the duration of a few minutes and, usually, I need three sessions, one a week, to succeed in pain release and mobility restoration. In rare cases, when necessary, the treatment is repeated.



Heidi Ammermann

Cell +39 3396503988 (SMS o WhatsApp)

Extracorporeal Shockwave Therpapy (ESWT)

ESWT is a multidisciplinary device used in orthopaedics, rehabilitation and sport medicine for pain relief and mobility restoration. Being a non-surgical low-risk therapy, it is an ideal therapy to speed up recovery and cure many indications causing acute or chronic pain of bones, tendons and muscles.
There are two types of ESWT. ESWT with radial waves, using lower energy levels and expanding in the tissues in a radial way. ESWT with focused waves, using higher energy levels and allowing to choose the focus and the depth of the target, which use is reserved to the MD. I practice focused ESWT.

Physiology of ESWT

Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration. They have a single pulse, a wide frequency range and a high-pressure amplitude.
These characteristics produce a positive and negative phase of shockwave in the tissues. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves.
In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave.

Mechanisms and effects of ESWT described in the literature

• neovascularization at the tendon-bone junction
• amplification of release of growth factors such as TGF-ß1, VEGF
• amplification of protein synthesis to stimulate collagen synthesis and tissue remodelling
• Stimulation of proliferation of fibroblasts and tenocytes
• Stimulation of mesenchymal stem cell migration
• Local circulation promotion and suppression of proinflammatory processes
• Metabolic reactions leading to activation of healing processes of the tissue.

ESWT has been successfully used to treat chronic pain syndromes since the beginning of the 1990s. ESWT and trigger point shockwave therapy (TPST) are highly effective procedures for treating chronic pain in the skeletal muscles. Focused ESWT produced and administered by a Piezowave system, which I use, has significantly expanded the range of applications available to treat myofascial pain syndromes. Moreover, it permits precise diagnosis and treatment of active and latent trigger points. Trigger points are small, thickened, pain-sensitive areas in a tense muscle which can cause significant pain, even at some distance from the trigger point. I practice focused ESWT using a new Richard Wolf Piezowave piezo shockwave system.

Richard Wolf Piezowave System

• It offers effective treatment of chronic pain using an innovative piezo technology to generate shockwaves
• It permits focused, clearly defined, precise and variable penetration depths
• It’s effectiveness is supported by scientific studies published in literature

Indications for focused ESWT

The classic orthopaedic indications for focused ESWT are diseases of the tendon attachment sites. In sports medicine, tendon attachment tendinosis (enthesopathy) is one of the standard indications for treatment with focused ESWT.

Trigger point shockwave therapy

In trigger point shockwave therapy (TPST), the penetration depth, intensity, power and pulse frequency of the shockwave pulses can be easily applied for the various indications.
Before treatment, the trigger points can be exactly located by identifying a precisely defined focus point. Given the variable wave penetration depth offered by the Wolf Piezowave system, even trigger points localised in the depth of the muscles can be localized and treated with pinpoint accuracy. Thereby, treatment achieves maximum efficiency.

Most frequent indications

• Calcific tendonitis of the shoulder
• Tennis elbow, golf elbow
• Heel spurs, plantar fascia heel pain
• Achilles tendon pain
• Trochanteric bursitis or hip enthesitis
• Medial tibial stress syndrome
• Prepatellar bursitis
• Pseudarthrosis (false joints)
• Patellar tendinitis, patellar tip syndrome

Potential contra-indications for ESWT

• Malignant disease is known to be present in or near the treatment area
• Patient has a coagulation disorder or if taking anti-coagulant medications
• Epilepsy
• Patient wears pacemaker
• Pregnancy
• Presence of growth plate

Potential risks

ESWT is a low-risk therapy. Rarely after the treatment we can find a superficial haemorrhagic suffusion or transitorily redness.