Radiotherapy for non-malignant diseases in orthopaedics: efficacy and safety
DOI:
https://doi.org/10.12775/JEHS.2025.83.60697Keywords
radiotherapy, non-malignant diseases, osteoarthritis, plantar fasciitis, heterotopic ossification, Dupuytren’s contracture, Ledderhose, Gorham-StoutAbstract
Introduction: This review aims to assess the current evidence on the efficacy and safety of low-dose radiotherapy (LDRT) in the treatment of non-malignant musculoskeletal and orthopaedic disorders, including osteoarthritis, plantar fasciitis, calcaneal spur, enthesopathies, Dupuytren’s contracture, Ledderhose disease, and heterotopic ossification. As the prevalence of such conditions rises due to aging populations and modern lifestyle factors, interest is growing in alternative therapies for patients unresponsive to standard conservative treatment.
State of the Art: LDRT has been used in Germany for decades and is now gaining wider clinical attention. Its mechanisms—primarily anti-inflammatory and immunomodulatory—include suppression of pro-inflammatory cytokines and modulation of macrophage phenotypes. Recent studies show pain reduction in 42–95% of patients, with complete remission in up to 81%, depending on the condition, dosage, and treatment schedule. Comparable efficacy is seen between lower (0.5 Gy/fraction) and higher (1.0 Gy/fraction) dosing regimens. LDRT has shown particular benefit in early-stage fibromatoses and in postoperative prevention of heterotopic ossification, where combination with NSAIDs enhances efficacy. Safety data indicate minimal adverse effects and no significant increase in malignancy risk. However, some randomized trials report outcomes similar to placebo, highlighting the need for further controlled research.
Conclusions: LDRT is a safe and promising adjunctive therapy in selected orthopaedic conditions, especially where conventional treatments have failed or are contraindicated. While long-term safety appears acceptable, further sham-controlled trials, biomarker studies, and treatment standardization are essential. This review is primarily intended for clinicians seeking evidence-based alternatives for managing chronic musculoskeletal disorders.
References
GBD 2021 Osteoarthritis Collaborators. Global, regional, and national burden of osteoarthritis, 1990–2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(9):e508–22. https://doi.org/10.1016/S2665-9913(23)00163-7
Courties A, Kouki I, Soliman N, Mathieu S, Sellam J. Osteoarthritis year in review 2024: Epidemiology and therapy. Osteoarthritis Cartilage. 2024;32(11):1397–1404. doi:10.1016/j.joca.2024.07.014
Verhaar JAN, Kjærsgaard-Andersen P, Limb D, Günther KP, Karachalios T, eds. The EFORT White Book: “Orthopaedics and Traumatology in Europe”. Lowestoft (UK): Dennis Barber Ltd; 2021.
Seegenschmiedt MH, Micke O, Muecke R; German Cooperative Group on Radiotherapy for Non-malignant Diseases (GCG-BD). Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines. Br J Radiol. 2015;88(1056):20159003. doi:10.1259/bjr.20159003
Weissmann T, Rückert M, Putz F, et al. Low-dose radiotherapy of osteoarthritis: from biological findings to clinical effects—challenges for future studies. Strahlenther Onkol. 2023;199:1164–72. https://doi.org/10.1007/s00066-022-02038-6
Ott OJ, Niewald M, Weitmann HD, Jacob I, Adamietz IA, Schaefer U, et al; German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD). DEGRO guidelines for the radiotherapy of non-malignant disorders: Part II: painful degenerative skeletal disorders. Strahlenther Onkol. 2015;191:1–6. doi:10.1007/s00066-014-0757-3
Mücke R, Micke O, Seegenschmiedt MH, Kriz J, eds. S2e Guideline: Radiotherapy of Benign Diseases. German Society for Radiation Oncology (DEGRO); 2022. Available from: https://www.degro.org
Deloch L, Fuchs J, Rückert M, Fietkau R, Frey B, Gaipl US. Low-dose irradiation differentially impacts macrophage phenotype in dependence of fibroblast-like synoviocytes and radiation dose. J Immunol Res. 2019;2019:3161750. doi:10.1155/2019/3161750
Wunderlich R, Ernst A, Rödel F, et al. Low and moderate doses of ionizing radiation up to 2 Gy modulate transmigration and chemotaxis of activated macrophages, provoke an anti-inflammatory cytokine milieu, but do not impact upon viability and phagocytic function. Clin Exp Immunol. 2015;179(1):50–61. doi:10.1111/cei.12344
Kaltenborn A, Bulling E, Nitsche M, Carl UM, Hermann RM. The field size matters: low dose external beam radiotherapy for thumb carpometacarpal osteoarthritis: importance of field size. Strahlenther Onkol. 2016;192(8):582–8. doi:10.1007/s00066-016-0995-7
Micke O, Seegenschmiedt MH, Adamietz IA, et al. Low-dose radiation therapy for benign painful skeletal disorders: the typical treatment for the elderly patient?. Int J Radiat Oncol Biol Phys. 2017;98(4):958–63. doi:10.1016/j.ijrobp.2016.12.012
Micke O, Ugrak E, Bartmann S, et al. Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome—early and late results of a prospective clinical quality assessment. Radiat Oncol. 2018;13(1):71. doi:10.1186/s13014-018-1025-y
Minten MJM, Leseman-Hoogenboom MM, Kloppenburg M, et al. Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial. Osteoarthritis Cartilage. 2018;26(10):1283–90. doi:10.1016/j.joca.2018.06.010
Koc BB, Schotanus MGM, Borghans R, et al. Short-term pain reduction after low-dose radiotherapy in patients with severe osteoarthritis of the hip or knee joint: a cohort study and literature review. Eur J Orthop Surg Traumatol. 2019;29(4):843–7. doi:10.1007/s00590-019-02377-8
Juniku N, Micke O, Seegenschmiedt MH, Muecke R. Radiotherapy for painful benign skeletal disorders: results of a retrospective clinical quality assessment. Strahlenther Onkol. 2019;195(12):1068–73. doi:10.1007/s00066-019-01514-w
Mahler EAM, Minten MJ, Leseman-Hoogenboom MM, et al. Effectiveness of low-dose radiation therapy on symptoms in patients with knee osteoarthritis: a randomised, double-blinded, sham-controlled trial. Ann Rheum Dis. 2019;78(1):83–90. doi:10.1136/annrheumdis-2018-214104
van den Ende CHM, Minten MJM, Leseman-Hoogenboom MM, et al. Long-term efficacy of low-dose radiation therapy on symptoms in patients with knee and hand osteoarthritis: follow-up results of two parallel randomised, sham-controlled trials. Lancet Rheumatol. 2020;2(1):e42–9. doi:10.1016/S2665-9913(19)30096-7
Álvarez B, Montero Á, Aramburu F, et al. Radiotherapy for osteoarticular degenerative disorders: when nothing else works. Osteoarthr Cartil Open. 2019;1(3–4):100016. doi:10.1016/j.ocarto.2019.100016
Hautmann MG, Hipp M, Neumaier U, et al. Radiotherapy for osteoarthritis of the ankle and tarsal joints—analysis of 66 joints. Strahlenther Onkol. 2020;196(6):569–75. doi:10.1007/s00066-019-01551-5
Donaubauer AJ, Zhou JG, Ott OJ, et al. Low-dose radiation therapy, particularly with 0.5 Gy, improves pain in degenerative joint disease of the fingers: results of a retrospective analysis. Int J Mol Sci. 2020;21(16):5854. doi:10.3390/ijms21165854
Rogers S, Eberle B, Vogt DR, et al. Prospective evaluation of changes in pain levels, quality of life and functionality after low-dose radiotherapy for epicondylitis, plantar fasciitis, and finger osteoarthritis. Front Med (Lausanne). 2020;7:195. doi:10.3389/fmed.2020.00195
Hermann RM, Trillmann A, Becker JN, Kaltenborn A, Nitsche M, Ruettermann M. Prospective evaluation of low-dose external beam radiotherapy (LD-EBRT) for painful trapeziometacarpal osteoarthritis (rhizarthrosis) on pain, function, and quality of life to calculate the required number of patients for a prospective randomized study. Med Sci (Basel). 2021;9(4):66. doi:10.3390/medsci9040066
Aramburu F, Montero A, Cabrera Alarcón JL, García de la Peña-Lefevre P. Radiotherapy treatment in benign osteoarticular disease. Reumatol Clin (Engl Ed). 2021;17(10):624–5. doi:10.1016/j.reumae.2020.03.001
Rühle A, Tkotsch E, Mravlag R, et al. Low-dose radiotherapy for painful osteoarthritis of the elderly: a multicenter analysis of 970 patients with 1185 treated sites. Strahlenther Onkol. 2021;197(10):895–902. doi:10.1007/s00066-021-01816-y
Álvarez B, Montero A, Alonso R, et al. Low-dose radiation therapy for hand osteoarthritis: shaking hands again? Clin Transl Oncol. 2022;24(3):532–9. doi:10.1007/s12094-021-02710-w
Weissmann T, Rückert M, Zhou JG, et al. Low-dose radiotherapy leads to a systemic anti-inflammatory shift in the pre-clinical K/BxN serum transfer model and reduces osteoarthritic pain in patients. Front Immunol. 2022;12:777792. doi:10.3389/fimmu.2021.777792
Niewald M, Moumeniahangar S, Müller LN, et al. ArthroRad trial: randomized multicenter single-blinded trial on the effect of low-dose radiotherapy for painful osteoarthritis—final results after 12-month follow-up. Strahlenther Onkol. 2024;200(2):134–42. doi:10.1007/s00066-023-02152-z
Kim BH, Shin K, Kim MJ, et al. Low-dose radiation therapy for patients with knee osteoarthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial. BMJ Open. 2023;13(2):e069691
Kriz J, Seegenschmiedt HM, Bartels A, et al. Updated strategies in the treatment of benign diseases—a patterns of care study of the German Cooperative Group on Benign Diseases. Adv Radiat Oncol. 2018;3(3):240–4. doi:10.1016/j.adro.2018.02.008
Yıldırım HC, Dinçbaş FÖ, Demircan V, et al. Radiotherapy for benign diseases in Turkey: a patterns of care survey of the Turkish Society for Radiation Oncology (TROD 05-002). Strahlenther Onkol. 2024;200(2):143–50. doi:10.1007/s00066-023-02154-x
Ott OJ, Jeremias C, Gaipl US, Frey B, Schmidt M, Fietkau R. Radiotherapy for benign achillodynia. Long-term results of the Erlangen Dose Optimization Trial. Strahlenther Onkol. 2015;191(12):979–84. doi:10.1007/s00066-015-0893-4
Gogna P, Gaba S, Mukhopadhyay R, et al. Plantar fasciitis: a randomized comparative study of platelet-rich plasma and low-dose radiation in sportspersons. Foot. 2016;28:16–9. doi:10.1016/j.foot.2016.08.002
Kędzierawski P, Stando R, Macek P. Retrospective evaluation of the effectiveness of radiotherapy in patients with plantar fasciitis (heel spurs). Rep Pract Oncol Radiother. 2017;22(2):209–11. doi:10.1016/j.rpor.2016.11.001
Prokein B, Holtmann H, Hautmann MG, et al. Radiotherapy of painful heel spur with two fractionation regimens: results of a randomized multicenter trial after 48 weeks’ follow-up. Strahlenther Onkol. 2017;193(3):229–37. doi:10.1007/s00066-017-1116-y
Zahnreich S, Rösler HP, Schwanbeck C, et al. Radiation-induced DNA double-strand breaks in peripheral leukocytes and therapeutic response of heel spur patients treated by orthovoltage X-rays or a linear accelerator. Strahlenther Onkol. 2020;196(11):1116–27. doi:10.1007/s00066-020-01662-4
Rudat V, Tontcheva N, Kutz G, et al. Long-term effect and prognostic factors of a low-dose radiotherapy of painful plantar calcaneal spurs: a retrospective unicenter study. Strahlenther Onkol. 2021;197(10):876–84. doi:10.1007/s00066-020-01741-6
Djiepmo F, Tamaskovics B, Bölke E, et al. Low-dose radiation treatment for painful plantar enthesophyte: a highly effective therapy with little side effects. Eur J Med Res. 2022;27:28. doi:10.1186/s40001-022-00642-x
Pluta E, Ciepiela M, Patla A, et al. Evaluating the efficacy of low-dose radiotherapy in the treatment of painful, benign musculoskeletal conditions. Med Rehabil. 2022;26(4):4–10. doi:10.5604/01.3001.0016.1441
Karimi K, Jazmati D, Boelke E, et al. Low-dose radiotherapy for heel spur treatment: a retrospective study of efficacy and safety. Int J Radiat Oncol Biol Phys. 2024;E322.
Galietta E, Gaiani L, Giannini C, et al. Personalizing prophylactic radiotherapy for hip heterotopic ossification: an AMSTAR-2 compliant review of meta-analyses. In Vivo. 2024;38(4):1530–6. doi:10.21873/invivo.13603
Kontokostopoulos AP, Gkiatas I, Vasileiadis GI, et al. Heterotopic ossification around the elbow revisited. Life (Basel). 2023;13(12):2358. doi:10.3390/life13122358
Mohamed R, Iqbal A, Elawadi AA. Fifteen years’ experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: outcome and side effects. J Egypt Natl Cancer Inst. 2022;34(48). doi:10.1186/s43046-022-00149-w
Boffeli TJ, Pfannenstein RR, Thompson JC. Radiation therapy for recurrent heterotopic ossification prophylaxis after partial metatarsal amputation. J Foot Ankle Surg. 2015;54(4):345–9. doi:10.1053/j.jfas.2014.07.010
Weng HK, Wu PK, Chen CF, et al. Total hip arthroplasty for patients who have ankylosing spondylitis: is postoperative irradiation required for prophylaxis of heterotopic ossification? J Arthroplasty. 2015;30(10):1752–6. doi:10.1016/j.arth.2015.04.022
d’Heurle A, Archdeacon MT, Hiratzka S, Casstevens C, Finnan R, McCoy B. Do surrogates of injury severity influence the occurrence of heterotopic ossification in fractures of the acetabulum? J Orthop Trauma. 2016;30(4):213–6. doi:10.1097/BOT.0000000000000494
Liu JZ, Frisch NB, Barden RM, et al. Heterotopic ossification prophylaxis after total hip arthroplasty: randomized trial of 400 vs 700 cGy. J Arthroplasty. 2017;32(4):1328–34. doi:10.1016/j.arth.2016.10.030
Müseler AC, Grasmücke D, Jansen O, et al. In-hospital outcomes following single-dose radiation therapy in the treatment of heterotopic ossification of the hip following spinal cord injury—an analysis of 444 cases. Spinal Cord. 2017;55(3):244–6. doi:10.1038/sc.2016.112
Ruo Redda MG, De Colle C, Bianco L, et al. Heterotopic ossifications: role of radiotherapy as prophylactic treatment. Radiol Med. 2018;123:463–8
Honore T, Salga M, Grelier A, et al. Effectiveness of radiotherapy to prevent recurrence of heterotopic ossification in patients with spinal cord injury and traumatic head injury: a retrospective case-controlled study. J Rehabil Med. 2020;52:jrm00066. doi:10.2340/16501977-2692
Georgakopoulos I, Kouloulias V, Kougiountzopoulou A, et al. Radiation therapy for the prevention of heterotopic ossification: efficacy and toxicity of single fraction radiotherapy. Orthop Rev (Pavia). 2020;12:8577. doi:10.4081/or.2020.8577
Lee DS, Kim Y, Cho HJ, et al. Hypofractionated radiation therapy for progressive heterotopic ossification: the relationship between dose and efficacy. Int J Radiat Oncol Biol Phys. 2020;106(5):993–7. doi:10.1016/j.ijrobp.2019.12.017
Pakos EE, Papadopoulos DV, Gelalis ID, et al. Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis? Hip Int. 2020;30(5):623–30. doi:10.1177/1120700019842724
Dass D, Singh RA, Chojnowski A. Management of recurrent digital heterotopic ossification with radiotherapy: a case report. J Hand Surg Eur Vol. 2021;0(0):1–2. doi:10.1177/1753193420976261
Geller JS, Allegra PR, Seldon CS, et al. Primary versus secondary radiotherapy for heterotopic ossification prevention about the elbow. J Orthop Trauma. 2022;36(2):e56–61. doi:10.1097/BOT.0000000000002188
Zorn D, Lombardo J, Poiset S, et al. Single-dose radiation therapy without additional surgery as a treatment for heterotopic ossification developing after transfemoral amputation. Am J Phys Med Rehabil. 2022;101(11):e158–61. doi:10.1097/PHM.0000000000002075
Osório T, Lemos J, Tkachuk O, et al. Surgical resection combined with adjuvant radiotherapy and non-steroidal anti-inflammatory drugs in the treatment of heterotopic ossification following total hip arthroplasty. Acta Med Port. 2023;36(3):202–5. doi:10.20344/amp.18230
Mohamed R, Iqbal A, Elawadi AA. Fifteen years’ experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: outcome and side effects. J Egypt Natl Cancer Inst. 2022;34(48). doi:10.1186/s43046-022-00149-w
Zampogna B, Laudisio A, Papalia GF, et al. Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications. Int Orthop. 2024;48:699–704. doi:10.1007/s00264-023-05993-6
Xin Z, Chen J, Huang F, et al. Peripheral inflammatory T cell subsets are effective predictive factors in the development of heterotopic ossification after posttraumatic elbow surgery. Heliyon. 2024;10:e33851. doi:10.1016/j.heliyon.2024.e33851
Miszczyk L, Grygutis I, Zając P, et al. An evaluation of radiotherapy effectiveness for epicondylitis humeri (EPH). Ortop Traumatol Rehabil. 2015;17(5–6):471–9. doi:10.5604/15093492.1186821
Hautmann MG, Beyer LP, Süß C, et al. Radiotherapy of epicondylitis humeri: analysis of 138 elbows treated with a linear accelerator. Strahlenther Onkol. 2019;195(4):343–51. doi:10.1007/s00066-018-1397-9
Hautmann MG, Beyer LP, Hipp M, et al. Re-irradiation for humeral epicondylitis: retrospective analysis of 99 elbows. Strahlenther Onkol. 2020;196(3):262–9. doi:10.1007/s00066-019-01493-y
Leist R, Micke O, Seegenschmiedt MH, et al. Radiotherapy for painful shoulder syndrome: a retrospective evaluation. Strahlenther Onkol. 2024. doi:10.1007/s00066-024-02302-x
Kaltenborn A, Carl UM, Hinsche T, et al. Low-dose external beam radiotherapy for greater trochanteric pain syndrome: target volume definition and treatment outcome. Strahlenther Onkol. 2017;193(4):260–8. doi:10.1007/s00066-016-1071-z
Staruch M, Gomez S, Rogers S, et al. Low-dose radiotherapy for greater trochanteric pain syndrome—a single-centre analysis. Strahlenther Onkol. 2023. doi:10.1007/s00066-023-02107-4
Zirbs M, Anzeneder T, Bruckbauer H, et al. Radiotherapy with soft X-rays in Dupuytren’s disease – successful, well-tolerated and satisfying. J Eur Acad Dermatol Venereol. 2015;29(6):904–11. doi:10.1111/jdv.12711
Seegenschmiedt MH, Olschewski T, Guntrum F. Radiotherapy improves control of early-stage Dupuytren’s disease: long-term results confirm safety and efficacy. Int J Radiat Oncol Biol Phys. 2015;92(1):192–8. doi:10.1016/j.ijrobp.2015.01.038
Ciernik IF, Goldschmidt P, Wösle M, et al. Feasibility of aponeurectomy in combination with perioperative 192Ir high dose rate brachytherapy for Dupuytren’s disease. Strahlenther Onkol. 2021;197(9):903–8. doi:10.1007/s00066-021-01801-5
Schuster J, Saraiya S, Tennyson N, et al. Patient-reported outcomes after electron radiation treatment for early-stage palmar and plantar fibromatosis. Pract Radiat Oncol. 2015;5(6):e651–8
de Haan A, van Nes JGH, Werker PMN, et al. Radiotherapy for patients with Ledderhose disease: long-term effects, side effects and patient-rated outcome. Radiother Oncol. 2022;168:83–8
de Haan A, van Nes JGH, Kolff MW, et al. Radiotherapy for Ledderhose disease: results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial. Radiother Oncol. 2023;185:109718
Yerganyan VV, Body JJ, De Saint Aubain N, et al. Gorham-Stout disease of the proximal fibula treated with radiotherapy and zoledronic acid. J Bone Oncol. 2015;4:42–6
Liu Y, Zhong DR, Zhou PR, et al. Gorham-Stout disease: radiological, histological, and clinical features of 12 cases and review of literature. Clin Rheumatol. 2016;35:813–23
Tolis K, Triantafyllopoulos IK, Tournis S, et al. Gorham-Stout disease of the pelvis: seven years follow-up with complete radiological evaluation. J Musculoskelet Neuronal Interact. 2016;16(1):79–82
Tateda S, Aizawa T, Hashimoto K, et al. Successful management of Gorham-Stout disease in the cervical spine by combined conservative and surgical treatments: a case report. Tohoku J Exp Med. 2017;241(4):249–54
Srivastava SK, Aggarwal RA, Nemade PS, et al. Vanishing bone disease of chest wall and spine with kyphoscoliosis and neurological deficit: a case report and review of literature. Indian J Orthop. 2017;51:107–14
Tena-Sanabria ME, Jesús-Mejenes LY, Fuentes-Herrera G, et al. A report of two children with Gorham-Stout disease. BMC Pediatr. 2019;19:206
Koto K, Inui K, Itoi M, et al. Gorham-Stout disease in the rib and thoracic spine with spinal injury treated with radiotherapy, zoledronic acid, vitamin D, and propranolol: a case report and literature review. Mol Clin Oncol. 2019;11:551–6
Dufek V, Zackova H, Kotik L, et al. Results of Czech National Study of radiation exposure radiotherapy of non-malignant diseases, in particular of heel spurs. Radiat Prot Dosimetry. 2019;186(2–3):386–90. doi:10.1093/rpd/ncz237
Burgess T, Wegener E, McClelland B, et al. Adverse events after adjuvant radiation therapy for Dupuytren’s disease in the DEPART randomized trial. J Hand Surg Eur Vol. 2025;0(0):1–7. doi:10.1177/17531934251321393
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