Extracorporeal shock wave therapy for wound management: a comprehensive systematic review of clinical evidence, modalities and mechanisms

Chronic wounds - such as diabetic foot ulcers, venous leg ulcers, pressure ulcers and burns - remain a significant burden on patients and healthcare systems worldwide. Extracorporeal shock wave therapy (ESWT) has emerged as a promising non-invasive intervention capable of accelerating wound healing through stimulation of angiogenesis, modulation of inflammation and promotion of tissue regeneration. This systematic review synthesizes findings from 47 clinical studies published between 2005 and 2025, encompassing all major ESWT modalities - electrohydraulic, electromagnetic, piezoelectric, and radial - as well as 32 previously published reviews. Across diverse wound types and clinical settings, ESWT consistently led to improved healing outcomes. Randomized controlled trials demonstrated statistically significant reductions in wound size, faster re-epithelialization, enhanced perfusion, and increased rates of complete closure. These benefits were observed across all modalities, with no consistent superiority of one over another. Radial ESWT, often perceived as less potent because of its physical properties, performed comparably to focused modalities (electrohydraulic, electromagnetic and piezoelectric) in well-designed studies - particularly when treatment parameters were optimized. A central and unifying conclusion emerges from this broad evidence base: the clinical effectiveness of ESWT is less dependent on the specific device or ESWT modality and more contingent on the delivery of adequate energy to the wound tissue. Studies that carefully tailored energy flux density, frequency, impulse count and session frequency to the wound characteristics consistently reported better outcomes, regardless of ESWT type. In essence, while the technical generation of extracorporeal shock waves differs, their therapeutic impact converges when appropriately dosed. This finding underscores the need to shift focus from modality comparisons to treatment precision. Going forward, clinical success with ESWT will hinge on the thoughtful calibration of energy delivery, making it a flexible and effective tool across wound types and care settings.