Efficacy of extracorporeal shock wave therapy for anterior cruciate ligament reconstruction: A GRADE-assessed systematic review and meta-analysis of randomized controlled trials

Introduction and objectives
We aimed to investigate the efficacy of extracorporeal shock wave therapy (ESWT) on knee functionality, pain, range of motion (ROM), gait, postural control, and bone mineral density (BMD) in patients with anterior cruciate ligament reconstruction (ACLR).

Materials and methods
Six databases were systematically searched for randomized controlled trials (RCTs). The methodological quality was assessed using the Cochrane Risk of Bias tool (ROB 2.0). The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach (GRADE). Meta-analysis was conducted using Review Manager.

Results
We included five RCTs (n = 255). ESWT significantly improved knee function, as measured by IKDC at three months (MD: 7.83, 95% CI: 3.03, 12.62, P = 0.001; 95% PI: −52.58, 68.24) and 12 months (MD: 6.45, 95% CI: 3.27, 9.64, P < 0.0001; 95% PI: 76.14, 93.96), and as measured by the Lysholm score at three months (MD: 8.91, 95% CI: 2.02, 15.80, P = 0.01), 12 months (MD: 7.20, 95% CI: 6.33, 8.06, P < 0.00001), and 24 months (MD: 5.94, 95% CI: 3.18, 8.71, P < 0.0001). These changes did not exceed the clinically important difference. ESWT reduced pain after three months (MD: −1.26; 95% CI: −2.37, −0.15; P = 0.03; 95% PI: −15.53 to 13.01). Pooling data on other outcomes was unfeasible.

Conclusion
This systematic review indicates that ESWT may provide significant short and long-term functional improvements, with no clinically important benefits. Also, it may decrease short-term pain. Given low to moderate evidence, future high quality RCTs are indicated.