Science
When bone fractures refuse to heal
How Extracorporeal Shockwave Therapy combined with movement training can help a patient with a chronic femur fracture achieve complete healing
Jakob Tiebel
Health Business Consultant
Not all bone fractures heal smoothly. Particularly complex are nonunion fractures – bone fractures where healing stops completely and the fracture gap remains open. A recent case report from Indonesia demonstrates impressively how Extracorporeal Shockwave Therapy (ESWT) helped a patient with a chronic femur fracture achieve complete healing – with modern rehabilitation devices like the THERA-Trainer playing a crucial role.
When the bone simply refuses to heal
The 40-year-old patient suffered an open fracture in the lower third of his left thigh bone (femur) in a road traffic accident. First-response treatment followed standard procedure: the fracture was surgically stabilised (known as open reduction and internal fixation), and the patient began a classic rehabilitation treatment. However, even after six months and despite all measures taken, almost no new bone tissue (callus) had formed. A dangerous situation because, if healing does not occur, there is a risk of permanent disability, pain and significant psychological distress.
A new approach: shockwaves instead of repeat surgery
As the classic therapy failed, the treating physicians decided on an innovative approach: Extracorporeal Shockwave Therapy (ESWT). High-energy sound waves are directed at the bone tissue. These stimulate various biological processes. They promote the formation of growth factors such as TGF-β1 and VEGF, activate bone-forming cells (osteoblasts) and improve blood circulation. This reactivates the healing cascade – without any further surgical intervention.
For this particular patient, ESWT therapy was provided once a week for a 23-week period. He also received Low-Intensity Pulsed Ultrasound (LIPUS) – a low-frequency ultrasound treatment that can also support bone healing.
For this particular patient, ESWT therapy was provided once a week for a 23-week period. He also received Low-Intensity Pulsed Ultrasound (LIPUS) – a low-frequency ultrasound treatment that can also support bone healing.
Therapeutic success when combined with movement training
A crucial factor for success was also the use of targeted exercise training. This included the THERA-Trainer – a specialised training device for medical rehabilitation. Despite the patient’s fracture, the THERA-Trainer allowed for early guided movement exercises without compromising the new bone formation. Such active but controlled loads are important as they stimulate bone metabolism, maintain muscle power and promote blood circulation.
After 23 weeks, the success was visible: X-rays showed complete callus formation. The fracture had healed completely, the patient returned to his daily routine.
After 23 weeks, the success was visible: X-rays showed complete callus formation. The fracture had healed completely, the patient returned to his daily routine.
A method with potential?
Shockwave therapy for bone healing disorders is being increasingly investigated worldwide. Studies show success rates between 54% and 98% – depending on fracture type, location and timing of treatment. ESWT demonstrates particularly promising results for hypertrophic nonunions, where biological healing potential still exists. In cases of atrophic nonunions, like the one presented here, successful outcomes have historically been rare – which makes this documented healing journey all the more remarkable.
At the same time, this case report shows that therapeutic success often depends on the combination of various methods: shock waves, ultrasound, nutritional supplementation and targeted exercise training using equipment such as the THERA-Trainer complement each other ideally.
Benefits of combination therapy with the THERA-Trainer
The combination of Extracorporeal Shockwave Therapy (ESWT) with targeted exercise training using the THERA-Trainer delivers multiple synergistic benefits in the treatment of nonunion fractures:
• Early functional mobilisation
Gentle, guided movements promote blood circulation in the affected area, which is essential for stem cell migration and bone regeneration.
• Stimulation of bone metabolism
Mechanical stimuli from active movement enhance the osteogenic effect of shock waves, additionally stimulate bone metabolism and support callus formation.
• Maintenance of muscle power and joint function
Through the early use of the THERA-Trainer, muscle atrophy and joint stiffening are prevented. The patient maintains higher performance levels and enjoys better overall rehabilitation outcomes.
• Psychological stability
Active participation in therapy increases patient motivation and confidence in the healing process. This can have a positive impact on the entire rehabilitation process.
• Reduced risk of complications
The combination therapy may help to avoid invasive follow-up surgery and reduce the overall risk of complications.
At the same time, this case report shows that therapeutic success often depends on the combination of various methods: shock waves, ultrasound, nutritional supplementation and targeted exercise training using equipment such as the THERA-Trainer complement each other ideally.
Benefits of combination therapy with the THERA-Trainer
The combination of Extracorporeal Shockwave Therapy (ESWT) with targeted exercise training using the THERA-Trainer delivers multiple synergistic benefits in the treatment of nonunion fractures:
• Early functional mobilisation
Gentle, guided movements promote blood circulation in the affected area, which is essential for stem cell migration and bone regeneration.
• Stimulation of bone metabolism
Mechanical stimuli from active movement enhance the osteogenic effect of shock waves, additionally stimulate bone metabolism and support callus formation.
• Maintenance of muscle power and joint function
Through the early use of the THERA-Trainer, muscle atrophy and joint stiffening are prevented. The patient maintains higher performance levels and enjoys better overall rehabilitation outcomes.
• Psychological stability
Active participation in therapy increases patient motivation and confidence in the healing process. This can have a positive impact on the entire rehabilitation process.
• Reduced risk of complications
The combination therapy may help to avoid invasive follow-up surgery and reduce the overall risk of complications.
Combination therapies open new pathways in fracture healing.
Effectiveness of shockwave therapy in nonunion
A systematic review by Sansone et al. evaluated 23 studies on the application of Extracorporeal Shockwave Therapy (ESWT) in nonunion of long bones. The most important results were:
Healing rates:
Overall, 73% of the nonunion cases healed after ESWT. Hypertrophic nonunions demonstrated success rates up to three times higher when compared to oligotrophic or atrophic cases.
Success by bone region:
• Metatarsals: 90%
• Tibia: 75.5%
• Femur: 66.9%
• Humerus: 63.9%
Treatment timing decisive:
The shorter the time between injury and commencement of shockwave therapy, the higher the chance of healing (p < 0.02).
Long-term therapeutic success:
Six months of follow-up monitoring is often insufficient. In many studies, further healing progress was also shown to occur significantly later (p < 0.01).
Conclusion:
ESWT is a promising, non-invasive treatment option for nonunion. The optimal treatment protocols are currently the subject of further research.
A systematic review by Sansone et al. evaluated 23 studies on the application of Extracorporeal Shockwave Therapy (ESWT) in nonunion of long bones. The most important results were:
Healing rates:
Overall, 73% of the nonunion cases healed after ESWT. Hypertrophic nonunions demonstrated success rates up to three times higher when compared to oligotrophic or atrophic cases.
Success by bone region:
• Metatarsals: 90%
• Tibia: 75.5%
• Femur: 66.9%
• Humerus: 63.9%
Treatment timing decisive:
The shorter the time between injury and commencement of shockwave therapy, the higher the chance of healing (p < 0.02).
Long-term therapeutic success:
Six months of follow-up monitoring is often insufficient. In many studies, further healing progress was also shown to occur significantly later (p < 0.01).
Conclusion:
ESWT is a promising, non-invasive treatment option for nonunion. The optimal treatment protocols are currently the subject of further research.
Opportunities for patients with difficult fractures
This case illustrates that even complicated bone healing disorders can be successfully treated under certain conditions when evidence-based and multimodal therapeutic approaches are utilised. Extracorporeal Shockwave Therapy (ESWT) is a potential alternative or adjunct to surgical procedures, particularly in situations where surgical interventions are associated with increased risk or are not suitable.
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Jakob Tiebel
Health Business Consultant
Jakob Tiebel is OT and studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of an agency for digital health marketing.
References:
- Tandiono T, Mintarjo J, Nugroho N (2025). Successful Treatment of a Nonunion Fracture of the Femur With Extracorporeal Shockwave Therapy: An Evidence-Based Case Report. Cureus 17(5): e84138. DOI: 10.7759/cureus.84138
- https://assets.cureus.com/uploads/case_report/pdf/365090/20250516-192633-dqo9mr.pdf
- Sansone V, Ravier D, Pascale V, Applefield R, Del Fabbro M, Martinelli N. Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis. J Clin Med. 2022 Apr 1;11(7):1977. doi: 10.3390/jcm11071977. PMID: 35407583; PMCID: PMC8999664.