Edinburgh Osteopath - Helen How

Treatment parameters (2025 RCT protocol):
• Device: Storz DUOLITH SD1 (focused mode)
• Energy flux density: 0.35 mJ/mm²
• Pe*******on depth: up to 125 mm
• Target: facet joint and medial branch nerves
Primary reference:
Nedelka T, Katolicky J, Nedelka J, Hobrough P, Knobloch K. Efficacy of high-energy, focused ESWT in treatment of lumbar facet joint pain: a randomized sham-controlled trial. Int J Surg. 2025;111(7):4177–4186.
🔗 PubMed: https://pubmed.ncbi.nlm.nih.gov/40391994/
🔗 DOI: https://doi.org/10.1097/JS9.0000000000002538
Earlier comparative study:
Nedelka T, Nedelka J, Schlenker J, Mazanec R. Mechano-transduction effect of shockwaves in the treatment of lumbar facet joint pain: comparative effectiveness evaluation of shockwave therapy, steroid injections and radiofrequency medial branch neurotomy. Neuroendocrinol Lett. 2014;35(5):393–397.
Clinical image used with full written patient consent.

📚 Tendons Don’t Age Well — The Science by Decade
Tendons are built in adolescence. By age 17, the collagen core of the Achilles tendon has stopped renewing. What follows is a slow, largely irreversible decline.
Teens: Collagen type I peaks. Tendon stem cells (TSPCs) are abundant, proliferating and tenogenic. The ECM is organised, parallel and mechanically robust.
30s: TSPC numbers begin falling. Cell doubling time slows — aged fibroblasts take approximately 3x longer to divide than young ones. Focal adhesion proteins redistribute away from the cell surface, impairing migration to injury sites.
40s–50s: Collagen synthesis drops. MMP-2 and MMP-9 activity rises while their inhibitors (TIMP-1, TIMP-2) fall — the balance tips toward degradation. Advanced glycation end-products (AGEs) accumulate, crosslinking collagen fibrils and increasing rigidity. Cell senescence accelerates via the ROCK and JAK-STAT pathways.
60s+: “Inflammaging” — chronic low-grade inflammation driven by elevated mtDNA, PGE2 and reduced antioxidant defences. TSPCs that remain are senescent, stiff, poorly migratory and produce type III rather than type I collagen. Healing capacity is severely compromised.
Tendinopathy affects 25% of adults. Heavy slow loading over 12+ weeks remains our strongest intervention.
🔵 Kwan et al. 2023 https://doi.org/10.3390/ijms242015183 ✅
🔵 Korcari et al. 2023 https://doi.org/10.1080/03008207.2022.2102004 ✅
🟢 Magnusson & Kjaer 2019 https://doi.org/10.1113/JP275450 ✅

🟡 Millar et al. 2021 https://doi.org/10.1038/s41572-020-00234-1