Selecting a treatment is only one part of clinical decision-making. Determining when to modify the approach and whether a patient’s response represents meaningful progress can be equally challenging.

These questions guided ASMST’s inaugural Shockwave & Biologics Virtual Roundtable, featuring Dr. Jay Spector, Dr. Elizabeth Bondi, Dr. Michael Chin, and Dr. Robert Conenello. Drawing largely on foot and ankle practice, the panel explored treatment selection, reassessment, and outcomes while acknowledging gaps in the evidence for combining shockwave therapy and orthobiologics.

1. Individualize Treatment While Recognizing the Limits of the Evidence

Diagnosis, tissue involved, stage of pathology, biomechanics, prior treatment response, and patient goals all informed the panelists’ approaches to treatment selection. Dr. Conenello emphasized identifying the tissue and pathology rather than choosing a modality simply because it is described as regenerative. Imaging could contribute to that assessment, alongside clinical findings and the patient’s response to care.

When discussing combination therapy, panelists described different approaches to timing and sequencing. The distinction between clinical experience and established evidence was central to the discussion. Panelists noted that the limited combination-therapy literature, small reports, and variation in treatment methods make definitive conclusions difficult.

2. Reassess a Limited Response Before Changing Course

A limited response raises two questions: whether a contributing factor has been missed and whether enough time has passed to assess improvement. Dr. Conenello emphasized revisiting biomechanics, loading, strength, mobility, the kinetic chain, and the original diagnosis before escalating care. The discussion also considered whether persistent symptoms could reflect an unaddressed mechanical or neural source.

Recovery time adds another layer to that assessment. Panelists described the challenge of distinguishing slow improvement from treatment failure, while Dr. Bondi emphasized setting realistic expectations from the outset. Reassessment therefore involves considering both the factors contributing to persistent symptoms and the patient’s course of recovery. 

3. Evaluate Progress Beyond Pain Intensity

A pain score alone may not capture changes that matter to the patient. Dr. Chin described assessing three dimensions of pain: intensity, frequency, and recovery time after activity. A patient may report the same peak intensity while experiencing shorter episodes or recovering more quickly, changes that can otherwise go unrecognized.

Function and individual goals provide additional context. Returning to sport, walking comfortably, staying active, and resuming work represent different measures of success. The discussion emphasized considering these goals alongside symptom patterns when evaluating response, particularly when improvement is gradual or uneven.

Continue the Discussion

ASMST members can watch the full Shockwave & Biologics Virtual Roundtable in the Member Portal to hear the panel’s clinical perspectives, differing approaches, and questions for future research.

Details on ASMST’s next webinar will be announced soon. The conversation will also continue at the 2027 ASMST Annual Summit, April 30–May 1 in Chicago, where clinicians will explore emerging evidence and exchange clinical perspectives. Learn more here: https://www.asmst.org/summit2027/