Abstract

Extracorporeal shockwave therapy (ESWT) is well established for delayed union and nonunion of fractures, but its role in acute-fracture care remains comparatively underexplored. This narrative review synthesizes mechanistic, preclinical, and clinical evidence on ESWT for bone healing and soft-tissue recovery during the acute post-fracture period, including several studies published between 2023 and 2026 that have not previously been discussed together in a single review. ESWT may promote fracture repair through mechanotransduction-mediated activation of osteogenic signaling, including bone morphogenetic protein-2, transforming growth factor-beta, and runt-related transcription factor 2; angiogenic signaling mediated by vascular endothelial growth factor; modulation of the inflammatory phase; and acceleration of endochondral ossification. Human clinical evidence remains limited to a small number of trials, most notably a 56-patient quasi-randomized controlled trial that suggested a lower risk of nonunion, although the estimate was imprecise. The 2023 Cochrane Review rated the certainty of evidence as very low, and a 2026 systematic review similarly emphasized limitations related to small sample sizes and heterogeneous protocols. Evidence for acute soft-tissue and muscle injury is comparatively more developed and has been extended by a 2023 systematic review of muscle injuries, a 2021 case series on return to play in elite athletes, and a 2025 randomized controlled trial evaluating ESWT for periarticular soft-tissue injury after hip fracture surgery. Open fractures, in which bone and soft-tissue healing are biologically interdependent, represent the strongest candidate indication for future dual-outcome research. Adequately powered randomized trials using standardized protocols remain the principal unmet need before ESWT can be recommended for routine use in acute fractures.

• Keywords: Extracorporeal shockwave therapy; Fracture healing; Wound healing; Bone regeneration; Soft tissue injuries