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Ultrasound is ultra-popular
… & ultra-unproven.
Does Ultrasound Therapy Work?

Many concerns about the widespread usage of therapeutic ultrasound,
especially extracorporeal shockwave therapy (ESWT)
Paul Ingraham, updated Oct 26, 2018
Ultrasound therapy (US) is the use of sound waves above the range of
human hearing 1 2 to treat injuries like muscle strains or runner’s knee. It is
mostly used by physical therapists, and has been one of the Greatest Hits
of musculoskeletal medicine since the 1950s. 3 4 There are many flavours of
https://www.painscience.com/articles/ultrasound.php 1/23
therapeutic ultrasound, using different intensities and frequencies of

sound, but all share the basic principle of “stimulating” or even provoking
tissue 5 with sound waves above the range of human hearing. Vibration
therapy, in other words.
Almost everyone seems to assume that ultrasound is proven — good

technological medicine — but that just doesn’t seem to be the case.
Unfortunately — although there are some interesting exceptions and

tantalizing hopes for some conditions — ultrasound is not a promising
therapy for most of the painful problems it is used for. There is a jarring,
bizarre lack of quality research for such a popular, mainstream therapy.
What li le research is available paints a bland picture. Ultrasound therapy
isn’t even on good theoretical foundations. At best, it’s more complicated
and unpredictable than most therapists believe. At worst, there is no
rational basis for US at all.
Although ultrasound is almost certainly useful for some patients, some of

the time, it is not a reliable or evidence-based therapy, and enjoys far more
credibility than it deserves.
I do not like the principle of using magic machines

to treat.
~ “Nari,” physical therapist, in an

internet forum discussion
Flavours of therapeutic ultrasound
The vast majority of patients will encounter therapeutic ultrasound in one of

two forms:
1. the ordinary sort familiar to almost anyone who’s had any kind of
physical therapy
2. its more expensive, intense, painful, and high-tech and over-hyped
cousin, 6 Extracorporeal Shock Wave Therapy (ESWT)
Garden-variety therapeutic US is cheap and available everywhere. The

machines are small, even portable: you can buy small handheld ones.
Treatment is brief and painless, and applied (indiscriminately?) to almost
any common musculoskeletal problem.
ESWT uses much stronger sound waves

— shock waves! 7 (Radial “shock” wave Other uses of ultrasound.
therapy is a bit different. 8 ) Treatment is Ultrasound is used cleverly in
painfully intense and painfully pricey. 9 many ways. Diagnostic
ultrasound is one of the marvels
On the one hand, ESWT is just a “more is of modern medicine. It can also
be er” version of standard US, because it be used to inject drugs into
tissues (phonophoresis), or to
is often used with the same imprecise
violently vibrate the tip of an
clinical intention to stimulate/provoke
invasive probe (lithotripsy,
tissues. On the other hand, because it
usually used for gall stones).
was originally developed for smashing These are interesting cousins of
gall stones, ESWT is strong enough to ordinary therapeutic ultrasound
actually disrupt tissue, such as and not covered in this article.
calcifications in tendons — which is a
nice precise clinical goal and a whole different ke le of fish.
Therapeutic ultrasound: the lack of science
When I started studying for this article way back in the mid-2000s, I was
quite surprised by how li le there was to study. Back then, every scientific
paper about US pointed out there is not enough research on this topic, or at
least not enough good research … and not much has changed. A 2015
review of ultrasound for rotator cuff tendinopathy (cited below) found
only six trials, all poor quality.
That’s not a lot to go on, and it’s typical. It’s a bit shocking. We’re talking
about ultrasound, here: one of the staples of physical therapy! It’s not a
fringe treatment. It practically defines the experience of going to a
physiotherapist. Everyone has had that cold gel slapped on an injury, and
felt that tingling, penetrating … placebo?
Ultrasound is pseudo-quackery
The disconnect between the popularity of US and the more or less total
lack of informative research is troubling. A handful of good studies is a
joke for a therapy that is worth literally billions of dollars in the
marketplace. How can that much therapy be sold without a satisfactory
body of evidence that it works? Bizarre! This is the ultimate example of
pseudo-quackery: popular treatments that aren’t overt quackery (they are
plausible, not obviously at odds with established science) but fall well
short of validated, scientific medicine and are sold with excessive
confidence and usually considered mainstream.
This does not mean that US never works for anyone. It does mean that it
has been prescribed and sold to patients for decades with unjustified
confidence. And that is not cool.
The discouraging state of what little ultrasound evidence there is
In most cases I consider ultrasound less than

useless — that's 8-10 minutes wasted that could
be used doing something that might actually help.
~ Jason Silvernail, DPT, Board-Certified

in Orthopedic Physical Therapy, in an
internet forum discussion
Ultrasound is an unusually easy treatment to test scientifically. 10 If it

works reasonably well, then the results should be pre y clear. Just
compare results in patients who received real ultrasound to patients who
get a fake instead! And yet there are just a few dozen such experiments in
the scientific literature, and most of them are seriously flawed. Conclusions
from evidence reviews like this one from van der Windt et al are typical:
As yet, there seems to be li le evidence to support the use of

ultrasound therapy in the treatment of musculoskeletal disorders.
The large majority of 13 randomized placebo-controlled trials
with adequate methods did not support the existence of clinically
important or statistically significant differences in favour of
ultrasound therapy.
~ van der Windt et al , 1999, Pain
Did not support the “existence of”? Ouch! Ultrasound’s therapeutic effect
has an existential crisis.
Several reviews give a nod towards some ray of hope. For instance, van der
Windt et al , despite their overwhelmingly negative conclusion, also noted
that “findings for lateral epicondylitis [tennis elbow] may warrant further
investigation.” But, naturally, that optimism about tennis elbow is
contradicted by other studies. 11 The science is mostly a discouraging,
unimpressive mess — a classic case (yet another one) of a damning failure
to impress.
An overview of ultrasound reviews: lots of “garbage in, garbage out”!

van der Windt 1999 12 musculoskeletal strongly negative review of 13 “adequate” trials
disorders did not support “the existence” of therapeutic
effects
Robertson 2001 13 pain and injury “little evidence” of therapeutic benefit in 10
“acceptable” trials out of 35 candidates; 2
positive trials, 8 negative
Baker 2001 14 biological “insufficient biophysical evidence” to justify
effects therapeutic use for pain and injury
Buchbinder 2006 15 tennis elbow nine studies produced “platinum” level (better
than gold!) evidence of “little or no benefit” (for
ESWT)
Ho 2007 16 tennis elbow conflicting, “unconvincing” evidence of efficacy
from a few trials (of ESWT again)

Ho 2007 17 rotator cuff limited evidence “supports … ESWT for chronic
tendinopathy calcific rotator cuff tendinitis,” but no non non-
calcific
Rutjes 2010 18 osteoarthritis of a positive update to a previously negative review,
knee which is strange because it’s based on just 5
small, poor quality trials with trivial “positive”
results
Shanks 2010 19 lower limb inconclusive review of 10 of 15 candidates: “no
conditions high quality evidence available”
van den Bekerom 2011 20 ankle sprains inconclusive but discouraging review of “five
small placebo-controlled trials”; the “potential
treatment effects of ultrasound appear to be
generally small”
Page 2013 21 carpal tunnel inconclusive but slightly encouraging review of
syndrome “only poor quality evidence from very limited
data” from 11 trials
Ebadi 2014 22 chronic low inconclusive and underwhelming review of 7
back pain small trials, none of them good quality
Desmeules 2015 23 rotator cuff negative review “does not provide any benefit …
tendinopathy based on low to moderate level evidence” from
11 weak trials
The bottom line on standard therapeutic ultrasound
Standard therapeutic ultrasound probably does li le or nothing for most

people. A sliver of hope remains that some specific conditions will respond
to ultrasound with just the right se ings.
Ultrasound citation backfire
While writing about bogus citations lately, I got a fine example of one in my
inbox. I take good constructive criticism seriously, but sometimes it’s difficult
to tell which criticisms are actually worth paying a ention to. In this case, the
absence of citations in the initial email was probably enough of a clue that I
didn’t really need to inquire further. But I did, and the result was amusingly
lame …
POSSIBLY CREDIBLE CRITIC: You’re too negative about

therapeutic ultrasound. I’m writing a book about it. I know there’s a
lot of bad science, but there’s good science too, and you’re not citing
it. You’re just cherry picking the negative studies. There are tons of
good studies showing that it accelerates healing. It’s all about using
the right se ings. [No citations.]
ME: Okay, fine, but citation needed. Have you got 3 persuasive
trials of US for bone healing?
PCC: Here’s one on tendon healing.
ME [After reading]: I don’t think that study says what you think it
says. It’s one small uncontrolled study that shows that ultrasound
actually impairs tendon healing or, at best — with “less wrong”
se ings — is no be er than early mobilization. That’s not good
news. That’s not even a positive study, let alone a persuasive one.
“The backfire” bogus citation strikes again!
PCC: I’m sorry you don’t understand high-level research.
Who calls a crappy li le trial “high-level research”? A cluessless troll, that’s

who (one who is writing a book about ultrasound, apparently). I tried to find
this study again, so that keen readers could audit my take on it, but
unfortunately the email is nowhere to be found, like so much email (despite
supposedly having complete archives). No great loss in this case.
Ultrasound reborn as shockwave therapy
Therapeutic ultrasound … has fallen out of favor as research has

shown a lack of efficacy and a lack of scientific basis for proposed
biophysical effects.
~ Baker et al , 2001, Physical Therapy
Except it hasn’t fallen out of favour! It’s still widely used. The only
professionals it’s fallen out of favour with, I imagine, are a small minority
of scientists and unusually alert clinicians.
Not only that, but ultrasound has found new life in the marketplace as
shockwave therapy — faster, stronger waves, with a bigger price tag!
Consider this marketing language from a Canadian company, Shockwave
Institute, specializing in ESWT:
Provided you are a candidate for this type of treatment, clinical

studies suggest there is a 80–85% chance this technology will
improve your condition.
from the Shockwave Alberta FAQ, as of Nov 30,

2009
Shockwave Alberta certainly doesn’t think ultrasound has fallen out of

favour! Here we have an entire company devoted to delivery of
therapeutic US, and selling it with the implication that it is not only proven
to be effective, but exactly how effective — to within 5%!
Based on the available evidence, do you think it’s actually possible or

meaningful to declare that ESWT is exactly “80–85% effective”? Where are
the scientific review papers confirming this marvellous triumph of US over
whatever ails you? Where is the data to support such a specific promise of
therapeutic success? You sure couldn’t find them in 2009 …
And how about now? Update on ESWT science
Things seem to have changed for the be er, though “80-85% effective”
would still be a hard claim to defend.
Bizarrely, ESWT is being used to treat conditions as unexpected as erectile

dysfunction, stroke, and venous leg ulcers. There’s even some preliminary
evidence for such uses… though not all.
But there are now multiple positive reviews of ESWT for its more common
uses, like stubborn cases of plantar fasciitis, a painful irritation of the arch
of the foot. A good 2016 example is Lou et al , who concluded that “ESWT
seems to be particularly effective in relieving pain associated with
recalcitrant plantar fasciitis.” 24 Plantar fasciitis is by far the most widely
ESWT-treated condition for some reason: other conditions may be a
completely different ma er, but certainly the evidence for plantar fasciitis
is surprisingly good, almost amazingly so (it’s a stark contrast with the
vast majority of treatments for musculoskeletal conditions).
A 2009 test of shockwave therapy for hip pain (greater trochanteric pain
syndrome) was clearly positive on its face. 25
In a similar 2010 test for proximal hamstring tendinopathy, shockwave

therapy seemed to handily “win.” 26
But a few positive trials doesn’t mean much these days — musculoskeletal
medicine is badly polluted with underpowered studies with
untrustworthy “promising” results that are mostly good for the CV’s of the
researchers who produce them. Cynincism is justified. There’s never been
any replication of those hip and hamstring results.
And, despite all that, the evidence is predictably mixed.
Shockwave therapy for adhesive capsulitis, for instance, is being sold to

patients in the total absence of adequate evidence. There is scarcely any
evidence, just a tiny handful of weak studies — including that one that
seems most promising. 27 For full analysis, see my frozen shoulder article.
And not all reviews have happy endings. A notable general review in the
British Medical Journal of Sports Medicine in 2018, of ESWT for “common
lower limb conditions,” 28 found only a “low level of evidence” that it
“may” be effective for some conditions, which is ge ing pre y wishy-
washy. They rejected thirteen studies for a high risk of bias and noted that
“a relatively small number of research groups account for the majority of

research.” And finally:
There are no occasions where multiple high-quality studies exist

for a single pathology, hence for any individual pathology there
are low and very low levels of evidence.
In other words, this cannot yet be evidence-based medicine. There’s just

not enough (good) evidence. As usual.
Shockwave therapy equipment is generally bigger &

more badass.
Patient cynicism about therapeutic ultrasound
There is nothing a cold slimy prickling ultrasound

wand can do that a pair of warm hands can’t do
way better.
~ Diane Jacobs, Canadian

physiotherapist and writer
If only I had a buck for every time a patient or reader has told me that they
are skeptical about “that ultrasound thing they always do to you at
physiotherapy”!
Patients often express irritation with a common physical therapy business

model: working with several patients at once, rotating between rooms or
beds, often leaving patients with passive therapies (like a moist hot pack
from a hydrocollator — nice enough, but worth a steep fee?) Many patients
often go a step further and complain specifically about ultrasound and
TENS, skeptical that these treatments really do anything. 29 To the patient,
they seem therapeutically unremarkable
and also obvious ways for a To the patient, these
physiotherapist to get paid while not treatments seem
doing much. This perception really unremarkable & also obvious
pushes people’s “I don’t want to be a ways for a physiotherapist to
sucker” bu on. get paid while not doing
much.
And so few patients are singing the
virtues of standard US. It not only fails
to generate testimonials, but actually generates many annoyed
antimonials.
Patients do not (yet) feel the same cynicism about shockwave ultrasound.
As a more expensive and painful medicine, ESWT is a hope-generating
machine. Having spent their hard-earned dollars and endured the
discomfort of treatment, patients are more subject to expectation effects
(placebo) — and much less willing to entertain the possibility that it was all
a waste. At this stage in their quest to feel be er, more people will report
ambiguous results if they were positive (“Yeah, I think it did some good!”),
and even negative reports will often be toned down (“I didn’t seem to get
that much out of it, but I guess it works really well for some people.”) This
could go on for years.
Few if any patients are out there singing the virtues of

standard ultrasound. It not only fails to generate
testimonials, but generates many bitter antimonials.
How ultrasound supposedly works
The big idea is — this will blow your mind! — that cells and tissues
respond “well” to being shaken (not stirred). In theory, ultrasound works
by vibrating tissues back to health, which sounds like something you’d
hear on an infomercial, or the Dr. Oz Show. What, exactly, does vibration
do to tissues? Does anyone actually understand it?
No!
In 2001, Physical Therapy published a review of the biological effects of

ultrasound. More than ten years ago, the authors — Baker, Robertson, and
Duck — explained that it had already been at least two decades since it
was first pointed out that “physical therapists tended to overlook the
tenuous nature of the scientific basis for the use of therapeutic
ultrasound.” 30 They also point out — it’s the point of their whole paper —
that the situation had not improved in twenty years (before 2001):
The frequently described biophysical effects of ultrasound either

do not occur in vivo under therapeutic conditions or have not
been proven to have a clinical effect under these conditions. This
review reveals that there is currently insufficient biophysical
evidence to provide a scientific foundation for the clinical use of
therapeutic ultrasound …
There is lots of interesting ultrasound biology to consider, and scientists

may eventually nail down effects that might be the basis for new evidence-
based therapies. For instance, a decade later, Tsai et al declared that “There
is strong supporting evidence from animal studies about the positive effects
of ultrasound on tendon healing” 31 — but animal studies are notoriously
misleading, and they certainly can’t justify the use of ultrasound
(especially when US has already been tested on tendinopathy with
underwhelming results).
Another great example: the persistent

hope that ra ling cells with sonic Vibrating broken bones back
vibrations might speed the healing of to health, if proven, would
bone fractures, particularly low certainly be a delightful bit
intensity pulsed ultrasound (LIPUS). of weird good news about
Such an effect, if proven, would biology.
certainly be a delightful bit of weird
good news about biology. Unfortunately, it is probably dis-proven. In 2017,
the British Medical Journal published an excellent review with a very
negative conclusion for fresh fractures. 32 However, the authors have to
concede that “the applicability to other types of fracture or osteotomy is
open to debate … ” because it’s impossible to know for sure that there are
no black swans anywhere — one could be right around the corner!
Meanwhile, there is still just no basis for thinking that ultrasound has a
basis. The entire empire of ultrasound rests on the single, oversimplified
idea that “stimulation is good” and the hope that we might someday figure
out exactly why. Ultrasound is literally just tissue vibration therapy.
The gate control mechanism: a particularly bogus rationale for

ultrasound (especially ESWT)
Physical therapists often cite the “gate control” mechanism as a

justification for US and ESWT (and some other popular treatments,
especially TENS). This is nonsense and a great example of why patients
should be cautious, especially with the expense of ESWT.
The “gate control” mechanism is an important idea in pain science,

proposed in 1965 by Dr. Ronald Melzack and Dr. Patrick Wall, and still
accepted today as an explanation for a familiar phenomenon: the way we
rub injured body parts for a li le pain relief. The idea is that pain signals
pass through a “gate” in the spinal column. The state of the gate is
controlled by many factors. How much pain can get through depends on
competing signals and information from other sources, such as touch and
pressure, as well as emotional context.
So the idea with US is that the stimulation closes the gate and thus reduces
pain. This may well occur, but it’s nothing to write home about. It’s not a
“treatment” — it doesn’t fix anything— and it’s simply ridiculous as a
justification for an expensive therapy. It’s a minor and temporary effect,
and can be achieved just as easily by rubbing the area yourself! There is no
reason to think that any kind of ultrasound closes the gate be er or longer
than any other stimulus.
The reasons for doing ultrasound are not at all clear, and adding this one is
just a way to pad the list in a way that sounds scientific — especially handy
when you’re trying to sell expensive ESWT — but is actually almost
meaningless. It’s disturbingly marketing-savvy, but not at all medically

savvy.
A study of ultrasound therapy shows a clear effect on trigger point

sensitivity
File this one under “intriguing”:

Canadian researchers treated trigger Quick muscle knot orientation:
points (muscle knots) in 50 patients with Muscle knots — AKA “trigger
either ultrasound or a sham, and the points” — seem to be involved in

most of the world’s aches and
amount of pressure on the trigger point
pains. They are small patches of
required to induce pain was measured
mysteriously painful soft tissue;
before and after. Trigger points treated no one knows exactly what they
with ultrasound were more tolerant of are, and they may not even be a
pressure than those that were not muscle problem. They cause pain
treated, at 1, 3 and 5 minutes after and problems directly and also
treatment. 33 The improvement was no complicate other problems. Most
longer significant just 10 and 15 minutes doctors and therapists know
surprisingly li le about them.
later, however — so the effect in this case
For more information about how
was brief. The authors concluded:
trigger points might be involved
… low-dose ultrasound evokes in your own medical history, see
PainScience.com’s best-selling
short-term segmental
trigger point tutorial.
antinociceptive effects on trigger
points which may have applications
in the management of musculoskeletal pain.
They are not necessarily proposing that ultrasound is a useful treatment

for myofascial pain syndrome, but producing evidence of an interesting
effect that may prove to be clinically significant in time — an important
distinction.
Although it may be surprising in contrast to the generally unimpressive

evidence of the effectiveness about therapeutic ultrasound, it nevertheless
reinforces that ultrasound does indeed do some interesting things to
tissues: it’s just not clear exactly what. An important caveat is that there is
significant scientific debate about what “trigger points” really are. 34 Some
would say it’s hard to study the effect of ultrasound on a phenomenon that
may or may not even exist!
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About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at
ScienceBasedMedicine.org for several years. I have had my share of injuries and pain
challenges as a runner and ultimate player. My wife and I live in downtown
Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might
run into me on Facebook or Twitter.
Related Reading
PS Zapped! Does TENS work for pain? — The peculiar popularity of

being gently zapped with electrical stimulation therapy. TENS is a near
sibling to ultrasound: two nearly identical treatment ideas, differing only
in the form of stimulation delivered to tissues.
PS Tissue Provocation Therapies — Can healing be forced? The laws of
tissue adaptation & therapies like Prolotherapy & Graston Technique.
PS Cold Laser Therapy Reviewed — A critical analysis of treating pain
and injury with frickin’ laser beams.
PS The Chiropractic Controversies — An introduction to chiropractic
controversies like aggressive billing, treating kids, and neck manipulation
risks.
PS Pseudo-Quackery in the Treatment of Pain — The large, dangerous
gray zone between evidence-based care and overt quackery in
musculoskeletal and pain medicine. Ultrasound is one of the best
examples of something in that zone.
PS Repetitive Strain Injuries Tutorial — Five surprising and important
facts about repetitive strain injuries like carpal tunnel syndrome,
tendinitis, or iliotibial band syndrome.
What’s new in this article?
Five updates have been logged for this article since publication (2009). All
PainScience.com updates are logged to show a long term commitment to
quality, accuracy, and currency.
2018 — Some science updates for shockwave therapy.
2018 — A couple minor science updates on shockwave therapy (one good news,
one bad).
2017 — Science update, cited Schandelmaier et al , an excellent (and completely

negative) British Journal of Medicine review of LIPUS for acute fracture/osteotomy
healing.
2017 — Added a brief acknowledgement of the surprisingly positive evidence for

shockwave therapy for plantar fasciitis, plus a bunch of miscellaneous editing.
2016 — Big science update — Added a table of summarized recent reviews,

including six new citations from the last decade (basically all still about scanty,
crappy evidence). Several related editorial changes.
2009 — Publication.
Notes
1. Healthy young adults can hear sounds up to about 20 kiloher (20,000 her ). Ultrasound
machines produce sound waves from about that frequency and up. BACK TO TEXT
2. Below the range of human hearing is “infrasound,” which doesn’t come up much. Some
animals, like elephants, use infrasound for communication. Not therapy, as far as we know,
but I wouldn’t put it past them! Elephants are clever. Other infrasound communicators:
hippos, alligators, whales. Cat purring drops down almost to infrasound range. BACK TO TEXT
3. Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use
by physical therapists who are orthopaedic certified specialists. Phys Ther. 2007 Aug;87(8):986–
94. PubMed #17553923. ❐ PainSci #55380. ❐
Ultrasound is widely used. This 2007 survey of the usage of ultrasound, the first such
American survey for almost 20 years (see Robinson 1988), “examined the opinions of physical
therapists with advanced competency in orthopedics about the use and perceived clinical
importance of ultrasound.” They found that “ultrasound continues to be a popular adjunctive
modality in orthopedic physical therapy. These findings may help researchers prioritize
needs for future research on the clinical effectiveness of US.”
BACK TO TEXT
4. Armijo-Olivo S, Fuentes J, Muir I, Gross DP. Usage Pa erns and Beliefs about Therapeutic
Ultrasound by Canadian Physical Therapists: An Exploratory Population-Based Cross-
Sectional Survey. Physiother Can. 2013;65(3):289–99. PubMed #24403700. ❐ PainSci #53385. ❐
This 2013 Canadian survey of the usage of ultrasound found that “despite the questionable
effectiveness of therapeutic US, physical therapists still commonly use this treatment
modality, largely because of a belief that US is clinically useful. However, US usage has
decreased over the past 15 years.”
BACK TO TEXT
5. This is also the core principle of numerous other treatment modalities, particularly the
gadgets and widgets — your muscle vibrators and lasers and so on — they all stimulate in one
way or another, generally with unknown biological and clinical relevance. It would be going a
li le too far to say that they are all equally dubious (without citations), but after a few years of
studying this stuff they do start to seem awfully similar and under-impressive. BACK TO TEXT
6. If the Wikipedia page for a treatment sports the warning “appears to be wri en like an
advertisement,” that’s a bright red flag about its validity. Same with the “needs additional
citations” warning. As of early 2015, the ESWT page has both. BACK TO TEXT
7. Specifically, a strong (fast) sonic pulse for a short length of time (approximately 10
milliseconds). Shockwave therapies use waves travelling faster than the speed of sound (in
flesh), about 1500 meters per second. BACK TO TEXT
8. There are several different types of extracorporeal shockwave therapy. One of them, radial
shockwave therapy, is often called “shockwave” therapy, but probably shouldn’t be, because
it uses much lower velocity waves. Radial ultrasound is a couple orders of magnitude slower
than other shockwave ultrasound — about 100 meters per second, instead of 1500 — and
would be more properly described as a pressure wave therapy. It’s probably not quite fair to
lump them all in together when assessing shockwave therapy … but I’m going to do it
anyway for now (in my ultrasound article). Until such time as there’s compelling evidence
that one flavour has impressively different and be er effects than another, it’s all just
variations on a theme: stimulating tissues with different sorts of sound waves. Does that seem
reasonable? BACK TO TEXT
9. ESWT requires much more expensive and sophisticated machinery, and it was
extravagantly expensive for a long time. It’s come down a lot, but even now it will run you at
least $200 per visit, with a typical prescription of three to six treatments. This is not cheap
therapy! I last checked prices in early 2014. BACK TO TEXT
10. In particular, even though there are many “flavours,” it’s easy to standardize it for
apples-to-apples comparisons, and it’s really easy to fake treatment for a good controlled and
blinded test. It’s basically effortless to create a perfect “sham” version of ultrasound, so that
the study subjects can’t tell if they are ge ing the real thing. Many other popular
interventions in manual therapy are difficult or even impossible to standardize and/or fake —
so it makes more sense that there’s long-term uncertainty about their effectiveness.
Ultrasound has much less excuse in this regard. BACK TO TEXT
11. Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial
of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol.
2008 Oct;35(10):2038–46. PubMed #18792997. ❐ BACK TO TEXT
12. van der Windt DA, van der Heijden GJ, van den Berg SG, et al. Ultrasound therapy for
musculoskeletal disorders: a systematic review. Pain. 1999 Jun;81(3):257–71.
PubMed #10431713. ❐ BACK TO TEXT
13. Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys
Ther. 2001 Jul;81(7):1339–50. PubMed #11444997. ❐ PainSci #55377. ❐ BACK TO TEXT
14. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical
effects. Phys Ther. 2001 Jul;81(7):1351–8. PubMed #11444998. ❐ PainSci #55382. ❐ BACK TO TEXT
15. Buchbinder R, Green SE, Youd JM, et al. Systematic review of the efficacy and safety of
shock wave therapy for lateral elbow pain. J Rheumatol. 2006 Jul;33(7):1351–63.
16. Ho C. Extracorporeal shock wave treatment for chronic lateral epicondylitis (tennis
elbow). Issues In Emerging Health Technologies. 2007 Jan;(96 (part 2)):1–4. PubMed #17302021. ❐
BACK TO TEXT
17. Ho C. Extracorporeal shock wave treatment for chronic rotator cuff tendonitis (shoulder
pain). Issues In Emerging Health Technologies. 2007 Jan;(96 (part 3)):1–4. PubMed #17302022. ❐ BACK
TO TEXT
18. Rutjes AW, Nüesch E, Sterchi R, Jüni P. Therapeutic ultrasound for osteoarthritis of the
knee or hip. Cochrane Database Syst Rev. 2010 Jan;(1):CD003132. PubMed #20091539. ❐ BACK TO
TEXT
19. Shanks P, Curran M, Fletcher P, Thompson R. The effectiveness of therapeutic ultrasound

for musculoskeletal conditions of the lower limb: A literature review. Foot (Edinb). 2010
Dec;20(4):133–9. PubMed #20961748. ❐ BACK TO TEXT
20. van den Bekerom MP, van der Windt DA, Ter Riet G, van der Heijden GJ, Bouter LM.
Therapeutic ultrasound for acute ankle sprains. Cochrane Database Syst Rev. 2011 Jun;
(6):CD001250. PubMed #21678332. ❐ BACK TO TEXT
21. Page MJ, O'Connor D, Pi V, Massy-Westropp N. Therapeutic ultrasound for carpal

tunnel syndrome. Cochrane Database Syst Rev. 2013 Mar;(3):CD009601. PubMed #23543580. ❐ BACK
TO TEXT
22. Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van Tulder MW. Therapeutic
ultrasound for chronic low-back pain. Cochrane Database Syst Rev. 2014 Mar;(3):CD009169.
23. Desmeules F, Boudreault J, Roy JS, et al. The efficacy of therapeutic ultrasound for rotator
cuff tendinopathy: A systematic review and meta-analysis. Phys Ther Sport. 2015
Aug;16(3):276–84. PubMed #25824429. ❐ BACK TO TEXT
24. Lou J, Wang S, Liu S, Xing G. Effectiveness of Extracorporeal Shock Wave Therapy
Without Local Anesthesia in Patients With Recalcitrant Plantar Fasciitis: A Meta-Analysis of
Randomized Controlled Trials. Am J Phys Med Rehabil. 2016 Dec. PubMed #27977431. ❐ BACK TO
TEXT
25. Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock wave therapy as a
treatment for greater trochanteric pain syndrome. Am J Sports Med. 2009 Sep;37(9):1806–13.
PubMed #19439756. ❐
33 patients were given low-energy shockwave therapy for for greater trochanteric pain
syndrome, while 33 others were treated with other forms of conservative therapy. Those who
got shockwave therapy were the lucky ones: the results were clear and positive, both
statistically and clinically significant, and sustained as long as a year later. The study is
underpowered and cannot be taken too seriously, but it’s certainly positive on its face.
Conclusion: “Shock wave therapy can be an effective treatment for greater trochanteric pain
syndrome.”
BACK TO TEXT
26. Cacchio A, Rompe JD, Furia JP, et al. Shockwave Therapy for the Treatment of Chronic
Proximal Hamstring Tendinopathy in Professional Athletes. Am J Sports Med. 2010 Sep.
27. Hussein AZ, Donatelli RA. The efficacy of radial extracorporeal shockwave therapy in
shoulder adhesive capsulitis: a prospective, randomised, double-blind, placebo-controlled,
clinical study. European Journal of Physiotherapy. 2016 Mar;18(1):63–76.
This test of shockwave therapy for frozen shoulder hits all the highlights of well-designed
experiment. The researchers gave real shockwave therapy to one group of 52 patients weekly
for a month, and sham shockwave therapy to the other group, and measured pain and
function. The real shockwave group did “significantly” be er, with the researchers notably
claiming both statistical and clinical significance of the results … but not reporting the actual
effect sizes in the abstract, which is always suspicious (if they are impressive, they get
featured).
Despite the good design, a major concern here is that sham treatment. Shockwave therapy is
high energy, and uncomfortable at best, painful at worst. In the sham group, the shockwaves
were simply “blocked.” It seems like many or most patients would certainly know that they
weren’t ge ing the real shockwave therapy … which would spoil the data for sure.
The results are very promising, but it’s a mystery why shockwave therapy would work, the
effect they observed was probably not very large, and there’s probably one huge flaw that
would be a deal-breaker.
BACK TO TEXT
28. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of

extracorporeal shockwave therapy in common lower limb conditions: a systematic review
including quantification of patient-rated pain reduction. Br J Sports Med. 2018 Mar;52(6):387–
407. PubMed #28954794. ❐ BACK TO TEXT
29. TENS may be more evidence-based than ultrasound, particularly for some specific
medical situations, but its widespread, indiscriminate use is definitely dubious. Like
ultrasound, it is clearly sold to patients for more purposes than the evidence can possibly
support. For more information, see Zapped! Does TENS work for pain? BACK TO TEXT
30. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical
effects. Phys Ther. 2001 Jul;81(7):1351–8. PubMed #11444998. ❐ PainSci #55382. ❐ BACK TO TEXT
31. Tsai WC, Tang ST, Liang FC. Effect of therapeutic ultrasound on tendons. Am J Phys Med
Rehabil. 2011 Dec;90(12):1068–73. PubMed #21552108. ❐ BACK TO TEXT
32. Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone
healing: systematic review of randomized controlled trials. BMJ. 2017 Feb;356:j656.
PubMed #28348110. ❐ PainSci #52780. ❐ From the abstract: “trials at low risk of bias failed to show a
benefit with LIPUS, while trials at high risk of bias suggested a benefit” and “LIPUS does not
improve outcomes important to patients and probably has no effect on radiographic bone
healing.” BACK TO TEXT
33. Srbely JZ, Dickey JP, Lowerison M, et al. Stimulation of myofascial trigger points with
ultrasound induces segmental antinociceptive effects: A randomized controlled study. Pain.
2008 Oct 15;139(2):260–6. PubMed #18508198. ❐ BACK TO TEXT
34. The dominant theory is that a trigger point is basically an isolated spasm affecting just a
small patch of muscle tissue. Unfortunately, it’s still just a theory, and trigger point science is
a bit half-baked and somewhat controversial, and it’s not even clear that it’s a “muscle”
problem. The pain is certainly real, but it isn’t necessarily coming from the muscle at all. See
Trigger Point Doubts. BACK TO TEXT

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6/14/2019 Does Ultrasound Therapy Work?

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Does Ultrasound Therapy Work?

therapeutic ultrasound, using diﬀerent intensities and frequencies of

Almost everyone seems to assume that ultrasound is proven — good

Unfortunately — although there are some interesting exceptions and

Although ultrasound is almost certainly useful for some patients, some of

I do not like the principle of using magic machines

~ “Nari,” physical therapist, in an

Flavours of therapeutic ultrasound

The vast majority of patients will encounter therapeutic ultrasound in one of

Garden-variety therapeutic US is cheap and available everywhere. The

ESWT uses much stronger sound waves

Therapeutic ultrasound: the lack of science

The discouraging state of what little ultrasound evidence there is

In most cases I consider ultrasound less than

~ Jason Silvernail, DPT, Board-Certified

Ultrasound is an unusually easy treatment to test scientiﬁcally. 10 If it

As yet, there seems to be li le evidence to support the use of

~ van der Windt et al , 1999, Pain

An overview of ultrasound reviews: lots of “garbage in, garbage out”!

from a few trials (of ESWT again)

The bottom line on standard therapeutic ultrasound

Standard therapeutic ultrasound probably does li le or nothing for most

Ultrasound citation backfire

POSSIBLY CREDIBLE CRITIC: You’re too negative about

PCC: Here’s one on tendon healing.

“The backﬁre” bogus citation strikes again!

PCC: I’m sorry you don’t understand high-level research.

Who calls a crappy li le trial “high-level research”? A cluessless troll, that’s

Ultrasound reborn as shockwave therapy

Therapeutic ultrasound … has fallen out of favor as research has

~ Baker et al , 2001, Physical Therapy

Provided you are a candidate for this type of treatment, clinical

from the Shockwave Alberta FAQ, as of Nov 30,

Shockwave Alberta certainly doesn’t think ultrasound has fallen out of

Based on the available evidence, do you think it’s actually possible or

And how about now? Update on ESWT science

Bizarrely, ESWT is being used to treat conditions as unexpected as erectile

In a similar 2010 test for proximal hamstring tendinopathy, shockwave

And, despite all that, the evidence is predictably mixed.

Shockwave therapy for adhesive capsulitis, for instance, is being sold to

“a relatively small number of research groups account for the majority of

There are no occasions where multiple high-quality studies exist

In other words, this cannot yet be evidence-based medicine. There’s just

Shockwave therapy equipment is generally bigger &

Patient cynicism about therapeutic ultrasound

There is nothing a cold slimy prickling ultrasound

~ Diane Jacobs, Canadian

Patients often express irritation with a common physical therapy business

Few if any patients are out there singing the virtues of

How ultrasound supposedly works

In 2001, Physical Therapy published a review of the biological eﬀects of

The frequently described biophysical eﬀects of ultrasound either

There is lots of interesting ultrasound biology to consider, and scientists

Another great example: the persistent

The gate control mechanism: a particularly bogus rationale for

Physical therapists often cite the “gate control” mechanism as a