When Healing Stalls: Where Shockwave Offers a Pathway Forward
For patients with delayed union or nonunion fractures, not only is the unhealed bone a
problem, but the entire recovery pathway can stall, leading to a host of issues. Focused
extracorporeal shockwave therapy (ESWT) may offer clinicians a non-invasive, evidence-
supported option to consider within a coordinated fracture-healing plan. This could potentially
reduce prolonged periods of uncertainty, repeated low-yield visits, and delayed return to
function.
A 2026 systematic review of ESWT for bone pathologies found that the available higher-level
evidence, while limited, suggests focused shockwave can be an effective non-invasive
treatment option with a favorable reported safety profile. In the review, some Level I studies
reported outcomes comparable with surgery for long-bone nonunion fractures.
The review evaluated ESWT across several bone-related conditions including delayed and non-
union fractures, bone stress injuries, osteonecrosis, medial tibial stress syndrome, and bone
marrow edema syndrome. The review included 53 studies and 1,853 patients. While not every
delayed fracture should receive shockwave, the review’s conclusion supports ESWT as a viable
option when a patient’s healing is no longer on course.
Delayed Healing Impacts More Than Bone
A delayed union or nonunion is often discussed in terms of clinical progress, e.g. inadequate
callus, persistent fracture line, and pain with load-bearing beyond the expected window.
However, the consequences of a delayed or nonunion are much broader than the physical
symptoms. Patients may experience or express concerns about:
- Extended and unexpected time away from work, sports, family life, and usual activities
- Ongoing pain which can lead to physical dependence on and misuse of prescription drugs
- Guarded movement, reconditioning, and loss of confidence in the injured limb
- Repeated appointments for imaging referrals, brace adjustments, and rehabilitation
modifications with little tangible progress or improvement. - Difficulty progressing weight-bearing, strengthening, gait retraining, or return-activity plans.
- Escalating anxiety and frustration as clinicians and patients play a waiting game.
- Risk of additional surgery and the associated recovery burden, risk, cost, and time away
from normal life.
This can create a difficult clinical environment for patients and practitioners alike. If the
underlying issue of bone healing isn’t addressed, a patient’s functional progress will plateau
despite best efforts on the part of clinicians and patients. This is where focused shockwave can
build a bridge between passive observation and a more invasive escalation of treatment. The
review indicates that incorporating shockwave in a stalled recovery plan can improve patient
outcomes and alleviate the burden and stress that a stalled recovery path creates.
Focused Shockwave as a Non-Invasive Option
In bone healing, the goal is to stimulate the biological processes associated with repair such as
local mechanotransduction and osteogenic signaling. Healing and repair require more than
immobilization and time, though. They require an environment that supports vascularity,
cellular activity, mechanical stability, and appropriate loading. When one or more of these
elements is compromised, patients can get stuck in a vicious cycle of restricted activity and
incomplete healing.
Before considering shockwave as an appropriate treatment to stimulate tissue and support the
body’s healing response, a clinician should evaluate:
- Whether or not the fracture is adequately stable.
- If alignment and fixation are appropriate.
- If infection has been excluded.
- If major biological barriers exist such as smoking, diabetes, nutritional deficiency, poor
vascular status, medication effects, or severe bone health concerns. - Whether the pain pattern and image findings suggest delayed union or nonunion rather
than another symptom source. - If surgical reassessment is urgent and necessary.
Once a clinician has ruled out other potential causes of the delayed union or nonunion and
eliminated additional risk factors, shockwave becomes a viable modality to advance a patient’s
bone healing and recovery pathway.
A Guide to a More Efficient Recovery Plan
By the time a patient is definitively labeled a nonunion, they may have already experienced
months of pain, delayed recovery progress, and reduced function despite repeated visits to a
clinician’s office. It’s critical to recognize that delayed healing necessitates a change in the care
plan’s trajectory and should be addressed immediately. The original recovery pathway must be
reassessed and adjusted to best meet the patient’s needs.
This is precisely where shockwave can play a role in altering a patient’s outcomes for the better.
When evaluating the use of shockwave therapy in cases of delayed healing and nonunion,
clinicians should ask themselves what they can do to provide the most effective and efficient
intervention treatment.
A few simple steps can help determine if shockwave is a viable
treatment modality for a patient, but can save clinicians and patients alike months of
headaches over visits without results.
- Identify the plateau early
Rehabilitative care clinicians often see patients more during the recovery process than other
members of their care teams. They’re the first to notice a flattened recovery curve and the first
line of defense against it. Potential signs of a plateau include:- Persistent fracture site pain with loading that is not improving.
- Inability to advance weight-bearing or functional tasks as expected.
- Recurrent flare-ups even after modest progression.
- Ongoing dependence on a brace, boot, or assistive device beyond the anticipated phase.
- No meaningful change in pain, function, or tolerance over several visits.
- Fear of pain and reconditioning driven by persistent symptoms
- A mismatch between the elapsed time from the injury and the patient’s functional progress
- Reassess the healing environment
When recovery stalls, clinicians should evaluate what is preventing the patient from moving
forward. A coordinated reassessment including updated imaging, review of stability and
alignment, and an evaluation of the patient’s mechanical loading plan should be done to
definitively determine if the patient is experiencing a nonunion.
The recovery program shouldn’t necessarily change at this point, but the plan may shift
temporarily from aggressive progression to maintaining capacity, mobility, and confidence
while protecting the fracture site. - Discuss non-invasive treatment escalation before months of drift
Once the plateau has been identified and a reassessment of the injury and healing environment
has occurred, the initial recovery plan should be reconfigured to address the delay in healing
and ways in which the patient can move forward on their recovery path safely. This is where
the systemic review indicates that, for some patients, shockwave is a viable option for healing
and forward progress.
Addressing this as soon as signs of nonunion appear improves patient outcomes and
satisfaction. The longer clinicians wait to reevaluate recovery plans and incorporate shockwave
into a new program, the longer a patient suffers physically and mentally. The value of early
intervention is not only biological. Shockwave intervention may help prevent a long interval in
which the patient remains functionally suspended. They may attend appointments, but still
avoid activities, lose conditioning, and see little to no progress in recovery. Shockwave can offer
an active next step that improves functionality without committing the patient to an invasive
procedure or major deviations from the initial recovery program.
4. Pair treatment with purposeful rehabilitation.
Shockwave is not a passive add-on to an established recovery pathway. It should fit into a
coordinated plan that addresses:
- Protection over progressive loading
- Pain-guided activity modifications
- Maintenance of range of motion and adjacent-joint capacity
- Strengthening that respects fracture stability and healing status
- Gait and movement retraining once weight-bearing is approved
- Return to work and sport planning
- Modifiable health factors that influence healing
The clinician’s role is particularly valuable here. Focused shockwave may help address stalled
biology, but the clinician must continually manage and adjust the recovery path in
accordance with the patient’s healing and progress. The goal is for patients to regain
movement capacity, confidence, and functional tolerance as the physical healing occurs.
Changing the Outcomes
The emerging evidence supports a proactive perspective when it comes to delayed and
nonunion fractures, and the review emphasizes that shockwave can make meaningful changes
in a patient’s recovery trajectory when recovery has stalled due to delayed or nonunion of a
fracture. Clinicians no longer need to choose between continued observation or invasive
escalation. Shockwave can be used as a non-invasive adjunct to rehabilitative plans that puts
patients back on the road to recovery.
For many patients, early intervention with shockwave may mean more than a different
treatment modality. The implementation of shockwave in these cases may mean fewer months
of stalled care, fewer dead-end visits, and a more timely path back to normal living.
To discuss when Shockwave therapy may be the right intervention for your patients, contact
Kinas Medical at info@kinasmedical.com or 612-8245.
This article is based on the study Use of Extracorporeal Shockwave Therapy for the
Management of Bone Pathologies: A Systematic Review
https://pubmed.ncbi.nlm.nih.gov/41495929/
