Extracorporeal Shock Wave Therapy (ESWT): An Economical Treatment Option for Chronic Diabetic Foot Ulcers (DFUs)


Extracorporeal shock wave therapy (ESWT) technology is well known for repairing, remodeling, and regenerating tissue by sending high-speed energy waves through the body. ESWT has also been shown to increase blood flow, increase wound vascular density, and induce an antibacterial effect. ESWT has been demonstrated to be effective for a wide range of wound types, including diabetic foot ulcers, second-degree burns, post-surgical wounds, and traumatic lesions.

Diabetic Foot Complications and Economic Burden

Diabetic Foot Ulcers are among the most chronic foot conditions characterized by ulceration, infection, gangrene, recurrence of infection, and can lead to limb loss and even death. Chronic wounds are a burden for each patient and significantly reduce the quality of life. Diabetes patients have a 25% increased risk of developing foot ulcers, and one lower limb amputation in diabetes patients occurs every 30 seconds around the world.[11] As a result, cost-effective, non-invasive, and efficacious treatments like ESWT are a required alternative to move wound chronicity toward healing while lowering treatment-related costs.

Moving a chronic wound to an acute status requires adequate wound bed preparation, which can be accomplished through various strategies such as debridement, moisture balance, and reducing bacterial bioburden and inflammation.[7] Extracorporeal shockwave therapy was recently found to increase and expedite the healing of complex soft tissue wounds like DFUs compared to the traditional treatment techniques in DFUs. [5,6] In addition, ESWT appears to have distinct effects on intact and injured peripheral nerves, suggesting the presence of numerous mechanisms of action, such as neurogenesis. ESWT provides a cost-effective approach compared to hyperbaric oxygen therapy (HBOT), negative pressure wound therapy (NPWT), and cellular and tissue-based products (CTPs).

Physical Principles of ESWT Technology

Not all ESWT technologies are alike. The technology can be differentiated by equipment source, how generated, wave speeds, waveforms, density, and depths differ. ESWT is available in three variations.

  • Unfocused ESWT (uESWT) promotes both a physical and biological response to improve healing, by using a more acoustic planar wave that generating larger area shock waves.
  • Focused ESWT (fESWT) treats a defined wound area to penetrate a required depth using a higher peak waves and short rise in pressure.
  • Radial ESWT (rSWT) are a low-to-medium energy shock wave generated though a barrel of a handpiece device transferred to the skin.

Biological responses in DFUs include:

  • Promotes antimicrobial effects
  • Improved neovascularization
  • Stimulates anti-inflammatory effects
  • Increases formation of cytokines and growth factors
  • Encourages long-term angiogenesis and epithelialization
  • Facilitates tissue repair, remodeling, and regeneration.

Wound Chronicity and Biofilm

Evidence suggests that biofilm is present in the majority of chronic wounds. It is only present in 6% of acute wounds but over 90% of chronic wounds. During biofilm formation, the bacteria’s phenotype changes, leveraging building blocks from both the host and what they produce. As the biofilm forms, the bacteria continue to change their phenotypic to survive in a lower energy state and perform various functions within the colony while simultaneously passing on their resistance to antibiotics to the community. Because each colony of bacteria produces a unique biofilm with its own set of distinguishing characteristics, a clinical strategy must be adjusted to the particulars of that certain biofilm to be effective.

ESWT Sequence of Treatment

ESWT is an outpatient therapy that typically consists of one therapy session per week with a treatment time of 6-8 weeks. A licensed healthcare professional can easily perform this non-invasive therapy. During this treatment, patients reported little or no sensation or pain. There are no aesthetic agents required, and there are no side effects. Patients with cancer, coagulation disorders, pregnancy, morbid obesity (BMI >40), wounds larger than 16sq cm, and using on the anatomical locations head and lungs are all contraindications to shockwave therapy.


ESWT jump-starts the healing process and aids in eradicating biofilm. Furthermore, benefits include increased biological response growth factors, tissue regeneration, inflammatory modulation, and improved micro-vascularization and micro-circulation. Extracorporeal shock wave therapy (ESWT) can significantly shorten the healing time and minimize treatment inefficacy for diabetic foot ulcers (DFUs). ESWT provides patients with a more convenient and cost-effective approach to wound care management than standard wound care.


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