TABLE 2.

Specific postulated mechanisms of action of extracorporeal shockwave therapy

Pathology	Mechanism of action
Tendons 1 , 13	Decreased edema and inflammatory cell infiltration within tendons Tissue regeneration via conversion of mechanical stimulation to biochemical signal Increase transforming growth factor beta‐1 and insulin‐like growth factor I levels to stimulate tenocyte and collagen proliferation (important in healing) Scleraxis upregulation (promotes tendon growth and development) Proliferation of anti‐inflammatory cytokines Increased proliferation and migration of tendon‐derived tenocytes Decreased metalloproteinase expression (enzymes that can degrade collagen) Reduction of inflammatory interleukins
Bones 15	Protein upregulation may enhance angiogenesis and neovascularization of the bone Osteogenesis and bone remodeling by release of growth factors Bone morphogenic protein 2 Vascular endothelial growth factor Promotion of periosteal bone formation Decreased osteoclast activity Increased osteoblast activity
Joints (knee) 16	Decreased inflammation Decreased edema Improvements in subchondral bone architecture Increased chondrocyte activity (cartilaginous repair)
Spasticity 17	Decreased spasticity at the level of the muscle and neuromuscular junction Reduced rigidity of connective tissues (muscle level) Stimulate synthesis of nitric oxide Neuromuscular junction formation Neovascularization