Shockwave therapy (ESWT)

Acoustic pressure waves are transmitted into the tissue through the skin. In chronic tendon problems this appears to restart a stalled healing response — increasing local blood flow, prompting cellular repair activity, and breaking down calcific deposits.

Treatment is typically three to five sessions a week apart. It is uncomfortable during application and there is often some soreness for a day or two afterwards.

A systematic review of soft tissue conditions found focused shockwave effective in plantar fasciitis and calcific shoulder tendinopathy, while the evidence in lateral epicondylitis (tennis elbow) was mixed 1. In greater trochanteric pain syndrome, pooled trials show short-term pain relief, though most are at high risk of bias 5; in patellar tendinopathy, adding shockwave to eccentric exercise did no better than sham treatment 6.

The common factor is chronicity: shockwave is for problems that have persisted for months, not for acute injuries. Applied to an acute injury it is at best useless.

Shockwave without an exercise programme underperforms: in chronic plantar heel pain, shockwave combined with a plantar fascia stretching programme did better at two and four months than shockwave alone, although the difference had gone by two years 7. Tendon adapts to progressive load, and that is what produces the lasting change; shockwave reduces pain enough to make the loading possible.

It is contraindicated over open growth plates, in the presence of infection or tumour, and in patients on anticoagulation. We check these rather than assume.

Shockwave therapy is used for tendon problems that have not responded to a genuine loading programme — plantar heel pain, calcific shoulder tendinopathy, tennis elbow, Achilles tendinopathy.

The ordering matters. Offered before loading has been tried it substitutes for the treatment that works; offered after, it is a reasonable next step for a resistant problem.

The effect is not immediate. Symptoms frequently worsen briefly after the first session and improvement is typically judged some weeks after the course ends rather than at the last appointment.

This timeline matters because people conclude it failed at week two and stop the loading programme alongside it — which is the part that determines whether anything lasts.

It depends on the condition, and even the better results rest on low-certainty evidence. In plantar heel pain, a 2025 network meta-analysis of 22 trials found shockwave more effective than placebo at every intensity level, but rated the certainty of the evidence low to very low 2. In rotator cuff disease, with or without calcium deposits, a Cochrane review found very few clinically important benefits, while noting it could not tell whether some trials had used doses too low to work 3. In tennis elbow, a 2021 meta-analysis found, on low- to moderate-certainty evidence, no clinically meaningful benefit over sham treatment or steroid injection 4.

Dose matters too: an earlier systematic review found that where focused shockwave helps, the benefit appears greater with higher-dose regimens 1. The practical questions for a patient are therefore which condition is being treated, what dose is planned and which exercise programme runs alongside it.