The State of Extracorporeal Shockwave Therapy for Myofascial Pain Syndrome—A Scoping Review and a Call for Standardized Protocols

This scoping review addresses significant methodological inconsistencies in research on extracorporeal shockwave therapy (ESWT) for myofascial pain syndrome (MPS). Despite numerous studies and meta-analyses suggesting ESWT's effectiveness for MPS, the treatment outcomes are not substantially superior to conventional therapies like trigger point injection, dry needling, or laser therapy. This contrasts with ESWT's proven effectiveness for other musculoskeletal conditions like tendinitis and plantar fasciitis. The authors sought to understand why myofascial ESWT, which targets muscle and fascia tissues, shows less impressive results compared to its success in treating other conditions.

The researchers conducted a systematic search of PubMed, PEDro, and Cochrane Central Library databases through August 2025, focusing on existing meta-analyses and systematic reviews. They extracted data from 35 studies selected from 7 systematic reviews and meta-analyses, analyzing 83 initial studies after removing duplicates. The analysis examined diagnostic criteria for MPS and myofascial trigger points (MTrPs), shockwave application parameters, adherence to International Society for Medical Shockwave Treatment (ISMST) guidelines, follow-up periods, and treatment efficacy. They specifically evaluated examiner qualifications and experience, operator experience with ESWT, treatment protocols, and the distinction between radial pressure wave (RPW) and focused ESWT (fESWT).

The review revealed significant inconsistencies across multiple domains. Of 35 studies, 23 used RPW while 12 used fESWT, yet many reviews failed to distinguish between these fundamentally different technologies. Only 20 studies explicitly used Travell and Simons diagnostic criteria, and just 6 documented pain recognition—considered the primary diagnostic criterion. Examiner experience was reported in only 6 studies, while operator qualifications were documented in just 4 studies.

Treatment parameters varied widely: impulses per trigger point ranged from 300-2000, energy flux density from 0.03-0.38 mJ/mm², and frequencies from 1-20 Hz. Critically, 13 studies had follow-up periods of 2 weeks or less, with total follow-up ranging from immediate post-treatment to 15 weeks. Many protocols deviated from ISMST guidelines without documentation.

These methodological shortcomings compromise the reliability of current evidence supporting ESWT for MPS. The lack of standardized protocols, inadequate examiner training documentation, failure to distinguish between RPW and fESWT, and insufficient follow-up periods prevent definitive conclusions about ESWT's true efficacy for myofascial conditions. The review calls for future studies to implement quality standards including extended follow-up periods (minimum 4 weeks, preferably 12 weeks), detailed application descriptions, documented practitioner qualifications and experience, and adherence to ISMST guidelines. Without these improvements, the therapeutic potential of ESWT for MPS cannot be properly validated, explaining why results appear less impressive than for other musculoskeletal conditions.