OLTHEShockw: Orthobiology by Local Transient Hyperbaric Effect with Shock Wave

Background: Extracorporeal shock wave therapy (ESWT) exerts its principal therapeutic effects through mechanotransduction rather than direct mechanical disruption. The absence of a unified conceptual framework linking its biophysical parameters to a coherent regenerative mechanism has impeded protocol standardization and formal classification within orthobiology. Hypothesis: We propose OLTHEShockw — Orthobiology by Local Transient Hyperbaric Effect with Shock Waves (Spanish: OHTLOc) — which posits that ESWT generates focal transient high-pressure microenvironments at tissue impedance interfaces, reaching peak pressures of 10–100 MPa in microseconds. These events exceed classical hyperbaric chamber pressures (0.1–0.2 MPa) by 50- to 1,000-fold, constituting a form of mechanical, pulsed, focal hyperbaria that activates mechanotransduction cascades releasing VEGF, BMP-2, TGF-β, eNOS/NO, and IGF-1. Significance: OLTHEShockw provides a unifying metrological criterion — peak tissue pressure (MPa) — reconciling disparate ESWT measurement systems (bar for radial devices, mJ/mm² for focused devices) and formally positioning focused ESWT as a biophysical orthobiologic. This framework supports evidence-based protocol standardization and regulatory classification.