Current concepts of shockwave therapy in stress fractures

• Extracorporeal shockwave treatments (ESWT) stimulate bone turnover and neovascularization in delayed unions and avascular necrosis.
• ESWT is a safe and effective non-invasive outpatient procedure.
• Medium and high energy focused ESWT has shown excellent results in treating stress fractures, with faster return to competition and athletic activity.

Stress fractures are common painful conditions in athletes, usually associated to biomechanical overloads. Low risk stress fractures usually respond well to conservative treatments, but up to one third of the athletes may not respond, and evolve into high-risk stress fractures. Surgical stabilization may be the final treatment, but it is a highly invasive procedure with known complications. Shockwave treatments (ESWT), based upon the stimulation of bone turnover, osteoblast stimulation and neovascularization by mechanotransduction, have been successfully used to treat delayed unions and avascular necrosis. Since 1999 it has also been proposed in the treatment of stress fractures with excellent results and no complications. We have used focused shockwave treatments in professional athletes and military personnel with a high rate of recovery, return to competition and pain control. We present the current concepts of shockwave treatments for stress fractures, and recommend it as the primary standard of care in low risk patients with poor response to conventional treatments.