Extracorporeal Shock Wave Therapy for Wound Management: Clinical Evidence, Energy Delivery Parameters and Mechanistic Insights—A Systematic Review

Background/Objectives: Chronic wounds such as diabetic foot ulcers, venous leg ulcers and burns are a major health-care burden. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment that promotes angiogenesis and tissue regeneration. This review synthesizes the clinical evidence for ESWT in wound management, and asks how contemporary reviews reflect it. Methods: PubMed and Ovid/Embase were searched from inception to 1 September 2026 according to PRISMA, regardless of wound type, study design or ESWT modality. Fifty-one clinical studies and 46 prior reviews were analyzed. Heterogeneity confined the primary synthesis to a qualitative one; an exploratory pooled analysis was performed for the one endpoint reported consistently enough to permit it. Results: None of the 46 previously published reviews covered the original evidence in its full breadth: each cited a median of 19.4% of the clinical studies available at its reference date (range 0–90.9%), and systematic reviews covered no more than narrative ones. Most studies reported improved healing across all four modalities. In seven controlled trials in diabetic foot ulcers reporting complete healing as events and denominators, the exploratory pooled risk ratio favored ESWT (1.51, 95% CI 1.22–1.87; I2 = 0%; 689 patients). Such data existed for three modalities only, resting on one trial for two, so modalities could not be compared. Conclusions: ESWT may be a useful adjunct in wound management, particularly for diabetic foot ulcers, although the evidence is heterogeneous and partly uncontrolled. Because no previous review reflected the evidence base as a whole, conclusions drawn from it should be read with caution. Head-to-head trials with matched physical dose are needed before any modality can be preferred.