Search Results (71)

Polydeoxyribonucleotide (PDRN) activates the adenosine A2A receptor (A2AR), triggering anti-inflammatory signaling and providing essential nucleotides for the salvage pathway, thereby helping bypass metabolic bottlenecks and promoting tissue repair. Combining PDRN with biochemical agents and physical stimuli represents a significant shift in medical treatment, moving from monotherapy to an integrated, multi-target regenerative approach. These combinatorial strategies effectively address the limitations of PDRN, such as its rapid degradation and diffusion, by simultaneously meeting the structural, metabolic, and signaling needs of injured tissues. The mechanism of action for PDRN involves a synergistic effect with hyaluronic acid, amplification of growth factors (e.g., Platelet-Rich Plasma (PRP), Epidermal Growth Factor (EGF), Platelet-Derived Growth Factor (PDGF)), and enhancements from extracorporeal shockwave therapy (ESWT) and lasers. This results in a notable acceleration of the repair process for chronic wounds, musculoskeletal disorders, and neurological injuries. As intelligent delivery systems like responsive hydrogels and sustainable L-PDRN production continue to advance, these synergistic protocols are poised to redefine global standards of care in regenerative medicine and esthetic dermatology. Future clinical success will hinge on the standardization of sequence-specific protocols and large-scale validation to ensure long-term safety and efficacy. Full article

Background/Objectives: Groin pain syndrome (GPS) is a frequent and heterogeneous condition in athletes, often associated with persistent pain and functional limitation. Both focused extracorporeal shockwave therapy (f-ESWT) and exercise-based rehabilitation have been proposed as conservative treatment options, but evidence for their combined use in GPS remains limited. This prospective single-arm pilot study aimed to describe temporal changes in pain and function following a multimodal conservative program combining f-ESWT and structured rehabilitation in athletes with GPS, using validated groin-specific outcome measures. Methods: Thirty-one consecutive adult soccer players (mean age 28.4 ± 5.8 years; 77.4% male) with clinically and MRI-confirmed GPS underwent three weekly f-ESWT sessions (Duolith; 2400 pulses/session; 4 Hz; energy flux density 0.20 mJ/mm²) integrated within a supervised 16-week rehabilitation program (progressive adductor strengthening, core stabilization, and stretching). Outcomes were assessed at baseline (T0), 1 month (T1), and 4 months (T2): HAGOS (primary), VAS pain, and Roles and Maudsley (RM). Within-subject changes were analyzed using repeated-measures ANOVA with Bonferroni correction. Results: Statistically significant temporal changes were observed across all outcomes (all p < 0.001). HAGOSs changed from 47.23 ± 7.79 at T0 to 77.94 ± 16.18 at T1 and 90.00 ± 14.26 at T2 (partial η² = 0.89). VAS decreased from 6.81 ± 1.25 to 3.68 ± 1.11 and 1.90 ± 1.45 (partial η² = 0.91). RM decreased from 2.39 ± 0.50 to 1.52 ± 0.57 and 1.26 ± 0.63 (partial η² = 0.72). No adverse events were reported. Conclusions: In this single-arm pilot study, the multimodal program combining f-ESWT and structured rehabilitation was associated with temporal changes in groin-specific function and pain that exceeded established MCID thresholds. However, in the absence of a control group, these findings are purely descriptive and hypothesis-generating. The observed changes cannot be attributed to f-ESWT specifically, as the 16-week rehabilitation program likely contributed substantially to the outcomes. These preliminary observations require confirmation through adequately powered randomized controlled trials comparing the combined intervention to rehabilitation alone. Full article

This narrative review synthesizes evidence from 108 studies to provide the first comprehensive overview of extracorporeal shockwave therapy (ESWT) for plantar fasciitis across three key domains. First, assessment methodologies were evaluated, identifying 36 distinct tools classified into six categories, including pain (with the Visual Analog Scale being the most frequently used), function (most commonly the Foot Function Index), plantar fascia thickness, and other measures. Second, treatment protocols were analyzed, revealing commonly applied parameters of 2000 impulses per session and an energy flux density of 0.2 mJ/mm² or 3.0 bar. Third, the comparative status of ESWT relative to other interventions was examined. Across 18 alternative treatments, corticosteroid injections, platelet-rich plasma (PRP), dextrose prolotherapy, laser therapy, and ultrasound were the most frequently compared modalities. ESWT and comparator interventions demonstrated differential advantages across specific outcomes; however, these findings cannot be directly translated into clinical recommendations, due to the limitations of the available evidence. By consolidating fragmented data, the present review clarifies the current research landscape and provides a foundational reference to support outcome evaluation and individualized treatment selection. Full article

Background: Rotator cuff tendinopathy is a major cause of shoulder pain and disability. Focused extracorporeal shockwave therapy (ESWT) is an established conservative treatment option; however, the predictive factors influencing the treatment response remain poorly characterized. Objectives: To identify clinical, demographic, and metabolic predictors of pain reduction and functional improvement at four months following focused ESWT in patients with supraspinatus tendinopathy, with the goal of informing individualized treatment planning and early prognostic counseling. Methods: This retrospective cohort study analyzed patients with supraspinatus tendinopathy (calcific and non-calcific) treated with focused ESWT at a university rehabilitation center between June 2020 and December 2025. Outcomes were assessed at baseline and 4-month follow-up using the Visual Analog Scale (VAS), Roles and Maudsley, and Constant–Murley scores. Change score analysis with covariate adjustment and backward stepwise selection were performed to identify predictors of clinical improvement. Results: A total of 239 patients (97 males [40.6%], 142 females [59.4%]; mean age 60.2 ± 11.5 years; mean BMI 25.5 ± 4.0 kg/m²) were included, of whom 101 (42.3%) had calcific tendinopathy. Significant improvements were observed in all outcomes: VAS decreased from 6.50 ± 1.35 to 3.96 ± 2.09 (p < 0.001; Cohen’s d = 1.24), and Constant–Murley score increased from 60.38 ± 14.53 to 75.88 ± 15.52 (p < 0.001; Cohen’s d = 1.07). Patient-reported satisfaction (Roles and Maudsley score) showed a 91.2% success rate (excellent or good outcomes). Regression analysis identified baseline severity as the strongest predictor of improvement in all models. BMI emerged as a significant predictor of functional recovery (β = −0.95, p < 0.001 for Constant–Murley change), with each 1 kg/m² increase associated with approximately 1-point less improvement. Conclusions: Baseline clinical severity and body mass index were consistent predictors of ESWT effectiveness in rotator cuff tendinopathy. A lower BMI was associated with greater functional improvement, highlighting a potentially modifiable factor for treatment optimization. These findings support personalized treatment planning and early prognostic counseling in clinical practices. Full article

Background/Objectives: Insertional Achilles tendinopathy (IAT) is frequently associated with posterior calcaneal spurs; however, the prognostic significance of spur morphology for patient-centered treatment outcomes remains unquantified. This study aimed to establish treatment-specific minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds after extracorporeal shockwave therapy (ESWT) and to determine whether quantitative spur morphology independently predicts achievement of these patient-centered endpoints. Methods: In this retrospective cohort study, 201 patients with IAT and radiographically confirmed posterior calcaneal spurs received standardized ESWT (three weekly sessions, 0.20 mJ/mm², 8 Hz). Spur length and angle were measured on calibrated weight-bearing lateral radiographs. MCID and PASS thresholds for VISA-A, AOFAS, and VAS scores were determined using anchor-based receiver operating characteristic (ROC) analyses. Optimal spur morphology thresholds were derived from ROC curves using PASS achievement as the outcome criterion and the Youden index for cut-off selection. Multivariable logistic regression analyses, adjusted for age, sex, and body mass index, were performed to assess the independent prognostic value of spur morphology. Results: MCID thresholds were: ΔVISA-A ≥ 16.5 (AUC = 0.886), ΔAOFAS ≥ 11.5 (AUC = 0.830), and ΔVAS ≥ 2.5 (AUC = 0.897). PASS thresholds were: VISA-A ≥ 70.5 (AUC = 0.712), AOFAS ≥ 72.5 (AUC = 0.842), and VAS ≤ 3.5 (AUC = 0.753). While significant mean improvements occurred (all p < 0.001), only 36.8–43.3% of patients achieved MCID and 38.3–53.2% achieved PASS. ROC analysis identified spur length > 8.7 mm (AUC = 0.713) and spur angle > 16° (AUC = 0.738) as optimal thresholds predictive of PASS failure. In multivariable analysis, increased spur length (adjusted OR = 0.23–0.24, p < 0.001) and angle (adjusted OR = 0.16–0.23, p < 0.001) independently reduced the likelihood of achieving both MCID and PASS. Conclusions: This study provides the first anchor-based MCID and PASS thresholds for ESWT in IAT and demonstrates that posterior calcaneal spur morphology—specifically length > 8.7 mm and angle > 16°—independently predicts patient-defined treatment success. These findings support the integration of quantitative spur assessment into clinical decision-making for personalized management of IAT. Full article

Introduction: Extracorporeal shockwave therapy (ESWT) is used as an adjunctive treatment for canine osteoarthritis (OA), but its effects in dogs with treatment-refractory advanced disease remain unclear. This study compared the efficacy of one versus two sessions of focused ESWT administered approximately 28 days apart in dogs with refractory elbow or stifle OA. Methods: In this randomized, double-blinded clinical trial, twenty-four client-owned dogs with treatment-refractory elbow (n = 12) or stifle (n = 12) osteoarthritis received ESWT using an identical per-session protocol (X-Trode, 1000 pulses at 0.14 mJ/mm²; PulseVet-Zomedica, Ann Arbor, MI, USA), once (Group L) or twice (Group E). Orthopedic examination, goniometric and limb circumference measurements, and kinetic gait analysis (peak vertical pressure [PVP], vertical impulse [VI]) were performed on days 0, 28, and 56. Owner questionnaires (Canine Brief Pain Inventory [CBPI], Client Specific Outcome Measures [CSOM]) were collected on days 0, 28, 56, and 84. Data were analyzed using chi-squared tests, t-tests, and mixed effects models in R. Results: Age, weight, BCS, and radiographic osteoarthritis severity did not differ between groups at baseline. Improvement was small and limited to selected parameters. Vertical impulse and limb circumference increased more consistently in Group E, whereas peak vertical pressure increased in both groups, including before ESWT in Group L. No sustained or treatment-associated improvement was detected in symmetry variables or joint range of motion. Owner-reported outcomes showed variable patterns without consistent treatment effects. ESWT was well tolerated, and no major adverse events occurred. Conclusion: ESWT produced modest, inconsistent improvements in dogs with treatment-refractory OA, with slightly more consistent effects following two sessions. Therapeutic efficacy appeared limited in this end-stage population. Full article

Background: The traditional A1-centric paradigm for trigger finger (TF) management does not fully capture heterogeneous pathology spanning isolated pulley stenosis, tendon degeneration, and impaired tendon–sheath gliding. Methods: A comprehensive literature synthesis (2010–2025) integrating anatomy, biomechanics, and ultrasound-guided interventions was performed to develop a testable, phenotype-driven framework. Results: A continuum model is proposed emphasizing (i) origin-to-insertion assessment of the flexor apparatus, (ii) pragmatic ultrasound phenotyping into pulley-dominant, tendon-dominant, and mixed patterns, and (iii) a stepwise, phenotype-matched management pathway incorporating conservative care, ultrasound-guided injection, selected adjuncts (e.g., hydrodissection, prolotherapy, ESWT) for tendon-dominant or mixed presentations, and percutaneous or open release when an A1 bottleneck is confirmed. Conclusions: This framework is presented as a hypothesis to guide standardized reporting, reliability testing, and phenotype-stratified comparative trials, rather than as a validated clinical guideline. This article proposes a novel, phenotype-driven clinical framework to address this limitation. Contemporary evidence is integrated to construct a model emphasizing (i) a whole-length, origin-to-insertion assessment of the flexor apparatus, (ii) sonographic phenotyping into pulley-dominant, tendon-dominant, and mixed patterns, and (iii) a stepwise treatment algorithm integrating conservative care, ultrasound-guided injections, ultrasound-guided percutaneous release, and selected adjunctive approaches such as hydrodissection (HD), prolotherapy (Prolo), and extracorporeal shockwave therapy (ESWT). While evidence supports individual modalities, the framework’s primary innovation lies in matching interventions to phenotype. This sonographic phenotyping system is presented not as a validated tool, but as a testable hypothesis designed to guide future validation studies. The proposed framework establishes research priorities, including standardized criteria, reliability testing, and comparative effectiveness research for phenotype-stratified management. Full article

Anterior Cruciate Ligament (ACL) injuries are among the most common knee injuries sustained during sport. Following injury, only 65% of patients may return to their previous level of sport. Individuals who have suffered ACL injury are far more likely to develop post-traumatic osteoarthritis of the knee (PTOA). This suggests an unmet need for strategies to help advance return to play, reduce risk of PTOA, and provide additional options for pain management after ACL injury. Extracorporeal shockwave therapy (ESWT) and radial pressure waves (RPW) are non-invasive treatment options that have been shown effective for treatment of a variety of orthopedic injuries. This perspective proposes the use of ESWT and RPW as treatment options during the peri-operative and post-operative management of ACL injuries, with the goal of modifying risk for PTOA. The available literature indicates that ESWT may have chondroprotective effects after ACL injury, and numerous clinical trials demonstrate the effectiveness of ESWT and RPW for orthopedic conditions including tendinopathy or bone marrow edema. Limited data and a lack of consensus on standardized rehabilitation protocols present gaps in the literature and emphasize the need for research leading to evidence-based recommendations for the use of ESWT and RPW to modify risk for the onset of PTOA after ACL injuries. Full article

Purpose: In this systematic review, we compare the effectiveness of high-intensity laser therapy (HILT) and extracorporeal shockwave therapy (ESWT) in treating lateral elbow tendinopathy (LET). Methods: A comprehensive search of PubMed, the Cochrane Library, and EMBASE was conducted from database inception to 23 June 2025 to identify randomized controlled trials (RCTs) comparing the two interventions. The primary outcome was pain intensity (visual analog scale or numeric rating scale). Secondary outcomes included upper-limb disability (qDASH), grip strength (pain-free or maximal), ultrasound-measured common extensor tendon thickness, and safety (adverse events and withdrawals). Two reviewers independently extracted data and assessed methodological quality using the Physiotherapy Evidence Database (PEDro) scale; the certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effects were synthesized as SMD (95% CI) using random- or fixed-effects models based on heterogeneity (I²). Significance was set at p < 0.05. Results: Four RCTs met the inclusion criteria and 169 participants were included. Methodological quality was moderate, with moderate-quality evidence indicating a significant improvement in short-term and medium-term upper-limb function in favor of HILT (SMD = −0.42; 95% CI: −0.73 to −0.12 and SMD = −0.50; 95% CI: −0.94 to −0.06, respectively). Evidence ranging from low to moderate quality showed no significant differences between the HILT and ESWT groups in terms of short-term or medium-term resting pain (SMD = −0.50; 95% CI: −1.15 to 0.16 and SMD = −0.42; 95% CI: −1.06 to 0.22, respectively), short-term or medium-term activity pain (SMD = −0.38; 95% CI: −1.05 to 0.29 and SMD = −0.73; 95% CI: −1.65 to 0.19, respectively), short-term or medium-term grip strength (SMD = 0.24; 95% CI: −0.20 to 0.67 and SMD = 0.20; 95% CI: −0.16 to 0.55, respectively), or short-term or medium-term common extensor tendon thickness (SMD = 0.04; 95% CI: −0.50 to 0.59 and SMD = −0.00; 95% CI: −0.55 to 0.55, respectively). Conclusions: HILT appears to offer significant benefits in improving upper-limb function at short-term (<1 month) and medium-term (1–3 months) follow-up. Regarding pain, grip strength, and tendon thickness, the pooled effects did not show clear between-group differences. Evidence certainty ranged from low to moderate, demonstrating that trials with a follow-up period beyond 3 months are needed to evaluate long-term efficacy. Systematic review registration number: PROSPERO: CRD420251026387. Full article

Background: Plantar fasciitis is a prevalent musculoskeletal disease characterized by heel pain and functional impairment. Both high-intensity laser therapy (HILT) and extracorporeal shockwave therapy (ESWT) have demonstrated efficacy in managing plantar fasciitis; however, their relative effectiveness remains unclear. Purpose: This systematic review and meta-analysis aimed to compare the effects of HILT and ESWT for treating plantar fasciitis. Methods: A comprehensive literature search of PubMed, the Cochrane Library, EMBASE, and Scopus was conducted from inception to 13 July 2025 to identify randomized controlled trials (RCTs) investigating both interventions. Two reviewers independently extracted data and assessed the methodological quality of the trials using the Physiotherapy Evidence Database (PEDro) scale. The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The primary outcomes of this study were pain intensity and foot function. The visual analog scale (VAS) was used for pain assessment. Foot function was evaluated by the total scores of the Foot Function Index (FFI) and American Orthopedic Foot & Ankle Society Scale (AOFAS) and the activities of daily living (ADL) subscale scores of the Foot and Ankle Ability Measure (FAAM). Outcomes were assessed at the end of treatment and during short-, medium-, and long-term follow-ups. The meta-analysis utilized standardized mean differences (SMDs), assessed heterogeneity using the I² test, applied the inverse variance method for pooling continuous variables, and employed a random-effects model because of the variable study methods used across the included articles. Results with p < 0.05 were considered statistically significant. The I² test was used to objectively measure statistical heterogeneity, with I² ≥ 50% indicating significant heterogeneity. Results: Five RCTs met the inclusion criteria, with methodological quality scores ranging from 6 to 7 on the 10-point PEDro scale. In total, 120 participants received HILT and 116 received ESWT. Regarding pain intensity (VAS), no statistically significant differences were detected between HILT and ESWT at any time point, including short-term morning pain (SMD = −0.11, 95% CI −0.42 to 0.19, p = 0.40), resting pain (SMD = 0.01, 95% CI −0.48 to 0.49, p = 0.05), and activity pain (SMD = −0.08, 95% CI −0.41 to 0.26, p = 0.89), as well as medium-term morning, resting, and activity pain (all p > 0.05). For foot function (FFI), the pooled analysis of all studies showed no significant short-term difference (SMD = 0.37, 95% CI −0.22 to 0.95, p = 0.01; I² = 73%); however, a subsequent sensitivity analysis, which excluded one studyreduced heterogeneity to 0% and revealed a significant short-term advantage of ESWT (SMD = 0.64, 95% CI 0.32 to 0.95, p < 0.01). Medium-term FFI also favored ESWT (SMD = 0.53, 95% CI 0.14 to 0.92, p < 0.01). Overall, the certainty of evidence ranged from moderate to low, mainly due to risk of bias and heterogeneity, as assessed by the GRADE approach. Conclusions: While the pooled results suggested a trend toward greater functional improvement with ESWT than with HILT in the short- and medium-term, the effect sizes were small. No significant between-group differences were observed in pain-related outcomes. Given the limited number of available trials and variability in treatment protocols, current evidence remains insufficient to draw definitive conclusions about the comparative efficacy of ESWT and HILT. Further high-quality, large-scale randomized controlled trials with standardized methodologies are needed to better inform clinical decision-making. Full article

Background: Greater trochanteric pain syndrome (GTPS) is associated with structural tendon alterations and functional impairment. Extracorporeal shockwave therapy (ESWT) is a common treatment, but objective monitoring of tendon remodeling and motor recovery remains limited. Objective: This study aimed to integrate shear-wave elastography (SWE) expressed in m/s and wearable inertial measurement unit (IMU) as biosensing tools for the quantitative assessment of tendon elasticity, morphology, and hip motion after ESWT in GTPS. Methods: In a prospective cohort of adults with chronic GTPS, shear wave elastography (SWE) quantified gluteus medius tendon (GMT) elasticity and thickness, while hip abduction range of motion (ROM) was measured using a triaxial inertial measurement unit. Clinical scores on the Visual Analogue Scale (VAS), Harris Hip Score (HHS), Low Extremity Functional Scale (LEFS), and Roles and Maudsley score (RM) were collected at baseline (T0) and at 6 months (T1). Results: Thirty-five patients completed follow-up. Pain and function improved significantly (VAS, HHS, LEFS, RM; all p < 0.05). SWE values of the affected GMT increased, while tendon thickness decreased yet remained greater than on the contralateral side. Hip abduction ROM increased significantly from T0 to T1 (p < 0.05). Correlation analysis showed a negative association between abduction and pain at T1 (r = −0.424; p = 0.011) and, at baseline, between abduction and VAS (r = −0.428; p = 0.010) and RM (r = −0.346; p = 0.042), and a positive association with LEFS (r = 0.366; p = 0.031). SWE correlated negatively with VAS at T1 (r = −0.600; p < 0.05) and positively with HHS at T1 (r = 0.400; p < 0.05). Conclusions: Integrating elastography with inertial sensor-based motion analysis provides complementary, quantitative insights into tendon remodeling and functional recovery after ESWT in GTPS. These findings support combined imaging and wearable motion measures to monitor treatment response over time. Full article

Chronic musculoskeletal pain (CMP) is the leading global cause of disability and a major contributor to healthcare burden. Its pathogenesis reflects regenerative failure, driven by extracellular matrix (ECM) fibrosis, calcific deposition, mitochondrial dysfunction, and neuroimmune sensitization. Conventional pharmacological therapies such as NSAIDs, corticosteroids, and opioids offer only transient symptomatic relief while exposing patients to systemic complications. In contrast, energy-based, drug-free regenerative interventions directly address underlying pathology and restore physiological function. This Perspective synthesizes recent evidence (2020–2025) on three modalities that together form a regenerative triad: extracorporeal shockwave therapy (ESWT), high-intensity laser therapy (HILT), and ultrasound-guided mechanical needling with sterile water injection (SWI). ESWT promotes mechanotransduction, angiogenesis, and ECM remodeling; HILT enhances mitochondrial bioenergetics and downregulates inflammatory pathways; and SWI disrupts fibrosis and calcification while restoring neurovascular dynamics. Evidence from randomized controlled trials and meta-analyses supports moderate-to-high certainty (GRADE B–A–) for ESWT and HILT. SWI, initially supported by large observational cohorts and comparative studies, is now reinforced by a randomized comparative trial and meta-analyses of lavage effects, justifying an upgrade from moderate (B) to moderate-to-high certainty (B–A–). Risk of bias assessment using Cochrane RoB 2.0 and the Newcastle–Ottawa Scale (NOS) indicates overall low-to-moderate concerns across modalities. Together, these interventions integrate mechanistic biology with translational rehabilitation practice. This Perspective outlines their mechanistic foundations, clinical evidence, and alignment with the WHO decade of healthy ageing, offering a drug-free, mechanism-based framework for sustainable CMP management. Full article

Background/Objectives: Intramedullary (IM) nailing for hip fractures can cause iatrogenic abductor muscle injury, leading to pain and functional impairment. This study evaluated whether early extracorporeal shockwave therapy (ESWT) safely accelerates recovery. Methods: In this open-label randomized controlled trial, 51 patients (≥50 years; intention-to-treat: ESWT n = 26; control n = 25) received either standard postoperative care (control) or standard care plus three ESWT sessions. The primary outcome was pain (Visual Analog Scale, VAS); the secondary outcome was hip function (modified Harris Hip Score, mHHS), assessed at 3, 6, and 12 months. Results: Linear mixed-effects modeling showed significantly faster pain reduction in the ESWT group (group × time β = 0.086 points/month; p = 0.027), corresponding to an additional 1.0-point VAS reduction over 12 months. Functional improvement (mHHS) did not reach statistical significance (group × time β = 0.485; p = 0.462). No ESWT-related adverse events were observed. Conclusions: Early postoperative ESWT is a safe adjunctive therapy that accelerates pain relief after IM nailing for hip fractures. Although functional improvements were not statistically significant, pain reduction may facilitate early mobilization and rehabilitation. Full article

Knee osteoarthritis (OA) is a whole-joint disease involving subchondral bone lesion (BML) that predict treatment outcomes. This retrospective, non-randomized study compared extracorporeal shockwave therapy alone (ESWT), autologous protein solution and ESWT (APS), intra-articular mesenchymal stromal cell and ESWT (MSC-A), and combined intra-articular and intra-osseous MSC and ESWT (MSC-B) for knee OA with BML. We hypothesized that combination therapies would provide superior and earlier outcomes for advanced cases. The primary outcome was the change in the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 3 and 6 months. The results showed ESWT was effective, but only in the absence of articular surface collapse (KOOS IV (pre–6M) = 18.6 ± 13.9) vs. presence of collapse (4.4 ± 6.5). APS led to earlier improvement in cases without subchondral bone plate (SBP) tear (KOOS IV (pre–3M) = 18.4 ± 12.7) vs. ESWT 12.0 ± 14.0). MSC-A with SBP tear achieved significant early gain (KOOS IV (pre–3M) = 13.9 ± 10.1) but plateaued by 6 months. MSC-B without collapse showed significant 6-month improvement (KOOS IV (pre–6M) = 15.8 ± 8.6), but failed in collapse cases (KOOS IV (pre–6M) = −4.4 ± 7.7). ESWT is effective, APS provides early benefits, and MSC-B is promising for advanced SBP tear cases, but articular surface collapse limits efficacy across all therapies. Full article