Original Article | Vol 5 | Issue 2 | July-December 2025 | page: 2-12 | Tianyang Liu, Wei Sun, Fuqiang Gao
DOI: https://doi.org/10.13107/jrs.2025.v05.i02.171
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2025; The Author(s).
Submitted Date: 05 Aug 2025, Review Date: 23 Sep 2025, Accepted Date: 09 Nov 2025 & Published: 30 Dec 2025
Author: Tianyang Liu [1], Wei Sun [2], Fuqiang Gao [1]
[1] Department of Orthopedics, Osteonecrosis and Hip Dysplasia Hip Preservation Center, China-Japan Friendship Hospital, Beijing, China.
[2] Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, USA.
Address of Correspondence
Dr. Fuqiang Gao,
Department of Orthopedics, Osteonecrosis and Hip Dysplasia Hip Preservation Center, China-Japan Friendship Hospital, Beijing, China.
E-mail: gaofuqiang@bjmu.edu.cn/gaofuqiang@hsc.pku.edu.cn
Abstract
Non-traumatic osteonecrosis of the femoral head (NONFH) is a common and refractory orthopedic disease that leads to disability and is a frequent cause of hip joint dysfunction and pain. This condition imposes a significant burden on patients, their families, and society. Extracorporeal shock wave therapy (ESWT) is a non-invasive, safe, and effective treatment that has been widely used in the clinical management of musculoskeletal diseases, including NONFH. However, the current application of ESWT for NONFH lacks a unified consensus regarding treatment protocols and evaluation methods, limiting its widespread adoption. Consequently, developing standardized, scientific, and effective ESWT interventions for patients with early- and mid-stage NONFH remains a critical concern for clinicians. These guidelines have been developed under the organization of the Third Medical Center of the Chinese PLA General Hospital and the China–Japan Friendship Hospital, with contributions from the Shock Wave Medical Professional Committee of the Chinese Research Hospital Association and experts in ONFH and ESWT. It references the latest domestic and international literature, integrates domestic clinical experience and actual conditions, and employs the modified 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence and grades of recommendation. Guidelines are developed under the guidance of the WHO Handbook for Guideline Development (2014 Edition) and the Chinese Principles for the Development and Revision of Clinical Guidelines (2022 Edition). The Appraisal of Guidelines for Research and Evaluation II (AGREE II), Reporting Items for Practice Guidelines in Healthcare, and the Appraisal of Guidelines for Research and Evaluation in China (AGREE-China) were also referenced for evaluation. Nine clinical questions of utmost concern to physicians were selected, leading to the formation of nine evidence-based recommendations. These guidelines aim to provide constructive recommendations and a basis for the promotion and application of ESWT in the treatment of NONFH, thereby enhancing the scientific rigor and standardization of ESWT.
Keywords: Shockwave, Extracorporeal shock wave therapy, Osteonecrosis of the femoral head, Evidence-based medicine, Physical therapy
References:
1. Association Related To Circulation Osseous Chinese Microcirculation Society Csm-Arco. Expert consensus on clinical diagnosis and treatment technique of osteonecrosis of the femoral head (2022 version). Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2022;36:1319-26.
2. Zhao DW, Yu M, Hu K, Wang W, Yang L, Wang BJ, et al. Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the Chinese population: Results from a nationally representative survey. Chinese Med J (Engl) 2015;128:2843-50.
3. Xing Geng Yan, Bai Xiao Dong, Du Ming Kui, Li He, Ji Hui Ru, Jiang Chuan. Treatment of adult femoral head necrosis with extracorporeal shock wave therapy. Chin J Phys Med Rehabil 2003;25:472-4.
4. Chen Yaolong, Yang Kehu, Wang Xiaoqin, Kang deying, Zhan Siyan, Wang Jiyao, Liu Xiaoqing. Chinese principles for the development and revision of clinical guidelines (2022 Edition). Natl Med J China 2022;102:697-703.
5. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-42.
6. Chen Y, Yang K, Marušic A, Qaseem A, Meerpohl JJ, Flottorp S, et al. A reporting tool for practice guidelines in health care: The RIGHT statement. Ann Intern Med 2017;166:128-32.
7. Xing D, Wang Q, Yang Z, Hou Y, Zhang W, Chen Y, et al. Evidence-based guidelines for intra-articular injection in knee osteoarthritis: Formulating and evaluating research questions. Int J Rheum Dis 2018;21:1533-42.
8. OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available from: https://www.cebm.net/index.aspx?o=5653 [Last accessed October 20, 2026].
9. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br 1985;67:3-9.
10. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br 1995;77:34-41.
11. Hines JT, Jo WL, Cui Q, Mont MA, Koo KH, Cheng EY, et al. Osteonecrosis of the femoral head: An updated review of ARCO on pathogenesis, staging and treatment. J Korean Med Sci 2021;36:e177.
12. Sun W, Li Z. Interpretation of the 2019 revised version of Association Research Circulation Osseous staging system of osteonecrosis of the femoral head. Chin J Orthop 2020;40:889-92.
13. Li Z, Liu Z, Sun W, Shi ZC, Wang BL. The classification of osteonecrosis of the femoral head based on the three pillars structure: China Japan Friendship Hospital (CJFH) classification. Chin J Orthop 2012;32:515-20.
14. Ding H, Wang S, Feng H, Xu Y, Yan J, Duan X, et al. Clinical efficacy of individual extracorporeal shockwave treatment. Orthopade 2019;48:610-7.
15. Wang S. The Study of Extracorporeal Shockwave Treatment Effect for Early Necrosis of the Femoral Head by MRI Three-Dimensional Reconstruction Evaluation. China: Hebei Medical University; 2016.
16. Xing G, Xu Y, Geng H, Zhang H. Advances in extracorporeal shock wave therapy for bone tissue diseases. Med Philos 2018;39:7-10.
17. Xing G. The past, present and future of shockwave medicine. Chin J Front Med Sci 2014;6:1-2.
18. Xing G. Extracorporeal Shock Wave Therapy for Musculoskeletal Disorders. 1st ed. China: People’s Military Medical Press; 2007.
19. Shock Wave Medical Professional Committee of Chinese Research Hospital Association. Chinese guidelines for extracorporeal shock wave therapy for bone and muscle Diseases (2023 edition). Chin J Front Med Sci 2023;15:1-20.
20. Loske AM. Medical and Biomedical Applications of Shock Waves. Berlin: Springer International Publishing; 2017.
21. Auersperg V, Trieb K. Extracorporeal shock wave therapy: An update. EFORT Open Rev 2020;5:584-92.
22. Moya D, Ramón S, Schaden W, Wang CJ, Guiloff L, Cheng JH. The role of extracorporeal shockwave treatment in musculoskeletal disorders. J Bone Joint Surg Am 2018;100:251-63.
23. Haupt G. Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases. J Urol 1997;158:4-11.
24. Sun W, Li Z. Extracorporeal shockwave therapy for osteonecrosis of femoral head: Traps and challenges. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2019;33:659-61.
25. Császár NB, Angstman NB, Milz S, Sprecher CM, Kobel P, Farhat M, et al. Radial shock wave devices generate cavitation. PLoS One 2015;10:e0140541.
26. Hausdorf J, Lutz A, Mayer-Wagner S, Birkenmaier C, Jansson V, Maier M. Shock wave therapy for femoral head necrosis-Pressure measurements inside the femoral head. J Biomech 2010;43:2065-9.
27. d’Agostino MC, Craig K, Tibalt E, Respizzi S. Shock wave as biological therapeutic tool: From mechanical stimulation to recovery and healing, through mechanotransduction. Int J Surg 2015;24:147-53.
28. Jiang L, Zhang X, Ji Y, Shen X, Zhang F. Effect of a combination of alendronate sodium and radial shock wave on hemorheology and degree of pain in patients with femoral head necrosis. Trop J Pharm Res 2024;23:969-75.
29. Mei J, Pang L, Jiang Z. The effect of extracorporeal shock wave on osteonecrosis of femoral head: A systematic review and meta-analysis. Phys Sportsmed 2022;50:280-8.
30. Tan H, Tang P, Chai H, Ma W, Cao Y, Lin B, et al. Extracorporeal shock wave therapy with imaging examination for early osteonecrosis of the femoral head: A systematic review. Int J Surg 2025;111:1144-53.
31. Alkhawashki HM, Al-Boukai AA, Al-Harbi MS, Al-Rumaih MH, Al-Khawashki MH. The use of extracorporeal shock wave therapy (ESWT) in treating osteonecrosis of the femoral head (AVNFH): A retrospective study. Int Orthop 2023;47:2953-60.
32. Shi L, Yang X, Wang P, Ma X, Li D, Wu X, et al. Quantitative magnetic resonance imaging of femoral head articular cartilage change in patients with hip osteonecrosis treated with extracorporeal shock wave therapy. Int J Clin Pract 2022;2022:8609868.
33. Wang CJ, Wang FS, Yang KD, Huang CC, Lee MS, Chan YS, et al. Treatment of osteonecrosis of the hip: Comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg 2008;128:901-8.
34. Liu HJ, Wang QY, Niu CL, Wang GS, Huang GY. Clinical application study of multiple small-diameter drilling combined with extracorporeal shock wave therapy (ESWT) under C-arm positioning in the treatment of early femoral head necrosis. Zhongguo Gu Shang 2023;36:1014-20.
35. Zhai S, Wu R, Zhao J, Huang W, Hu W, Huang W. Effectiveness of various interventions for non-traumatic osteonecrosis: A pairwise and network meta-analysis. Front Endocrinol (Lausanne) 2024;15:1428125.
36. Zhao W, Gao Y, Zhang S, Liu Z, He L, Zhang D, et al. Extracorporeal shock wave therapy for bone marrow edema syndrome in patients with osteonecrosis of the femoral head: A retrospective cohort study. J Orthop Surg Res 2021;16:21.
37. Algarni AD, Al Moallem HM. Clinical and radiological outcomes of extracorporeal shock wave therapy in early-stage femoral head osteonecrosis. Adv Orthop 2018;2018:7410246.
38. Zhang Q, Liu L, Sun W, Gao F, Cheng L, Li Z. Extracorporeal shockwave therapy in osteonecrosis of femoral head: A systematic review of now available clinical evidences. Medicine (Baltimore) 2017;96:e5897.
39. Garcia TA, de Andrade AL, Von Keudell AG, Azevedo LP, Belangero WD. No dose response effect in shockwave therapy applied to bone conditions: A systematic review, meta-analysis and meta-regression. J Orthop 2024;49:90-101.
40. Wang J, Wang J, Zhang K, Wang Y, Bao X. Bayesian network meta-analysis of the effectiveness of various interventions for nontraumatic osteonecrosis of the femoral head. Biomed Res Int 2018;2018:2790163.
41. Wang CJ, Wang FS, Huang CC, Yang KD, Weng LH, Huang HY. Treatment for osteonecrosis of the femoral head: Comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am 2005;87:2380-7.
42. Goncharov EN, Koval OA, Nikolaevich Bezuglov E, Vetoshkin AA, Goncharov NG, Ramirez MD, et al. Conservative treatment in avascular necrosis of the femoral head: A systematic review. Med Sci (Basel) 2024;12:32.
43. Yang X, Shi L, Zhang T, Gao F, Sun W, Wang P, et al. High-energy focused extracorporeal shock wave prevents the occurrence of glucocorticoid-induced osteonecrosis of the femoral head: A prospective randomized controlled trial. J Orthop Translat 2022;36:145-51.
44. Luan S, Wang S, Lin C, Fan S, Liu C, Ma C, et al. Comparisons of ultrasound-guided platelet-rich plasma intra-articular injection and extracorporeal shock wave therapy in treating ARCO I-III symptomatic non-traumatic femoral head necrosis: A randomized controlled clinical trial. J Pain Res 2022;15:341-54.
45. Gao F, Sun W, Xing G. The interpretation on ESWT indications and contraindications of international society for medical shockwave treatment. Natl Med J China 2017;97:2411-5.
46. Liao CD, Xie GM, Tsauo JY, Chen HC, Liou TH. Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: A meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2018;19:278.
47. Wang CJ, Huang CC, Yip HK, Yang YJ. Dosage effects of extracorporeal shockwave therapy in early hip necrosis. Int J Surg 2016;35:179-86.
48. Abbas A, Khan Z, Veqar Z. Dose dependent effects of extracorporeal shockwave therapy on pain and function in osteonecrosis of femoral head: A systematic review. J Clin Orthop Trauma 2023;45:102275.
49. Xing G, Jing R, Li B, Wang Q. Effects of radial extracorporeal shock wave therapy by using ultrasonic versus pain-point orientation in treatment of soft tissue diseases in shoulders. Chin J Tissue Eng Res 2006;10:26-8.
50. Zhu JY, Yan J, Xiao J, Jia HG, Liang HJ, Xing GY. Effects of individual shock wave therapy vs celecoxib on hip pain caused by femoral head necrosis. World J Clin Cases 2023;11:1974-84.
51. Shock Wave Medical Professional Committee of Chinese Research Hospital Association. Chinese guidelines for extracorporeal shock wave therapy for bone and muscle diseases (2019 edition). Chin J Front Med Sci 2019;11:1-10.
52. Liu LH, Li ZR, Sun W, Wang YT, Gao FQ. Reliability and repeatability of the China-Japan friendship hospital typing classification for nontraumatic osteonecrosis of the femoral head. J Bone Joint Surg Am 2022;104:40-6.
53. Xing Gengyan, Liu Jianfeng, Liu yajun, Shi Bin, Zhao Zhe, Xu Zhuo, et al. Technical specifications for construction of shockwave therapy center. Chinese Reseach Hospital Association. July 25, 2024. T/CRHA 065-2024.
How to Cite this article: XLiu T, Sun W, Gao F. Guidelines for High-energy Focused Shock Wave Therapy in Non-traumatic Osteonecrosis of the Femoral Head in Adults (2025 Edition). July-Decemnber 2025;5(2):2-12.
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