Shockwave Therapy

Targeted treatment for persistent tendon and soft-tissue pain

Shockwave therapy is a non-invasive treatment that uses mechanical pressure waves applied through the skin to a specific painful or affected area.

It is commonly considered for certain long-standing tendon and soft-tissue problems that have not improved sufficiently with exercise, activity modification or other conservative treatment.

Shockwave therapy is usually used as part of a wider rehabilitation plan. Treatment may therefore be combined with strengthening, mobility work, changes to activity and a gradual return to exercise or sport.

The aim is not simply to treat pain temporarily, but to support rehabilitation and help the affected area tolerate normal physical demands again.

What is shockwave therapy?

Shockwave therapy is also known as extracorporeal shockwave therapy or ESWT.

“Extracorporeal” means that the treatment is applied from outside the body.

A handheld device is placed against the skin and delivers a series of mechanical pressure waves into the targeted area.

Despite the name, shockwave therapy does not involve an electrical shock.

Treatment is applied directly to the area identified during assessment and the intensity can usually be adjusted according to the condition being treated and your comfort.

What conditions may shockwave therapy be used for?

Shockwave therapy may be considered for certain persistent musculoskeletal conditions, including:

• Achilles tendinopathy
• Plantar fasciitis or plantar heel pain
• Tennis elbow
• Some shoulder tendon problems
• Calcific shoulder problems
• Patellar tendinopathy
• Some other persistent tendon problems

Whether shockwave therapy is appropriate depends on the diagnosis, how long symptoms have been present and what treatment has already been tried.

Not every painful tendon or joint requires shockwave therapy.

When may shockwave therapy be considered?

Shockwave treatment is often considered when symptoms have continued despite a period of appropriate conservative treatment.

This may include:

• Strengthening exercises
• Activity modification
• Physiotherapy
• Gradual loading
• Footwear or orthotic advice where relevant
• Changes to training

An assessment helps determine whether shockwave therapy is suitable and whether another approach should be tried first.

What happens during your first appointment?

Before treatment begins, the clinician will assess the problem and discuss your symptoms.

You may be asked about:

• Where the pain is located
• How long symptoms have been present
• Activities that make symptoms worse
• Sport or exercise
• Previous treatment
• Previous injuries
• Medical conditions
• Medication
• Previous scans or investigations
• Your rehabilitation goals

A physical assessment may also look at:

• Strength
• Joint movement
• Tendon loading
• Walking or running where relevant
• Functional movements

Shockwave therapy should be used for an appropriate diagnosis rather than simply applied to any painful area.

What happens during shockwave treatment?

The painful or affected area is identified and a small amount of gel is usually applied to the skin.

The shockwave device is then placed against the area.

A series of pulses is delivered over several minutes.

You may hear a repeated tapping sound and feel rapid pressure against the skin.

The clinician can adjust:

• Treatment intensity
• Location
• Number of pulses

according to the condition and how you respond.

Does shockwave therapy hurt?

Shockwave therapy can feel uncomfortable, particularly when applied directly over a sensitive tendon or painful area.

People describe the sensation differently.

It may feel like:

• Repeated tapping
• Pressure
• Aching
• Brief sharp discomfort

Treatment does not need to be intolerably painful.

The intensity can usually be adjusted during the session.

Let the clinician know if the discomfort becomes excessive.

How long does a treatment session take?

The shockwave portion of an appointment is usually relatively short.

Additional time may be required for:

• Assessment
• Reviewing symptoms
• Exercise progression
• Rehabilitation advice

The exact length of your appointment depends on the condition and whether shockwave is being combined with physiotherapy.

How many shockwave sessions will I need?

Shockwave therapy is usually provided as a short course rather than a single treatment.

The exact number of sessions depends on:

• The condition
• How long symptoms have been present
• Response to treatment
• Clinical protocol

Your clinician can explain the expected treatment schedule after assessment.

Shockwave therapy for Achilles tendinopathy

Achilles tendinopathy can cause pain and stiffness around the tendon at the back of the ankle.

Symptoms may be noticeable during:

• Walking
• Running
• Jumping
• Stairs
• Getting up after rest

Shockwave therapy may be considered when symptoms have persisted despite an appropriate rehabilitation programme.

Treatment should usually be combined with progressive calf and Achilles strengthening.

The tendon needs to regain the capacity to tolerate the forces required during everyday activity and sport.

Shockwave therapy for plantar fasciitis

Plantar fasciitis commonly causes pain around the heel or underside of the foot.

Symptoms are often noticeable:

• During the first steps in the morning
• After sitting
• During prolonged standing
• During walking
• During running

Shockwave therapy may be considered when symptoms have remained persistent despite conservative management.

Rehabilitation may also address:

• Calf strength
• Foot and ankle strength
• Activity levels
• Walking or running load
• Footwear

Treatment should therefore look beyond the painful heel alone.

Shockwave therapy for tennis elbow

Tennis elbow affects the tendons around the outside of the elbow.

Pain may occur during:

• Gripping
• Lifting
• Carrying
• Racket sports
• Gym exercise
• Repetitive hand activity

Shockwave therapy may be considered for persistent symptoms.

Rehabilitation may also include progressive strengthening of the wrist and forearm muscles.

Simply avoiding use of the arm indefinitely is usually not the long-term goal.

Shockwave therapy for patellar tendinopathy

The patellar tendon sits at the front of the knee and is heavily loaded during jumping and running.

Symptoms may occur during:

• Jumping
• Landing
• Running
• Squatting
• Stairs

Shockwave therapy may sometimes be considered as part of treatment for persistent patellar tendon symptoms.

Progressive strengthening remains important because the tendon needs to tolerate increasingly demanding loads.

Shockwave therapy for shoulder problems

Shockwave therapy may sometimes be considered for selected persistent shoulder conditions, particularly where tendon or calcific changes are involved.

Treatment may be combined with:

• Shoulder strengthening
• Rotator cuff rehabilitation
• Shoulder blade exercises
• Gradual return to overhead activity

Shoulder pain can have many causes, so appropriate assessment is important before treatment begins.

Shockwave therapy and tendon rehabilitation

Shockwave therapy should not usually replace exercise-based tendon rehabilitation.

Tendons adapt to progressive loading.

Depending on the tendon involved, rehabilitation may include:

• Isometric exercises
• Slow resistance exercises
• Heavier strengthening
• Running
• Jumping
• Sport-specific loading

Shockwave may be used alongside this programme when appropriate.

The longer-term goal is to improve what the tendon can tolerate, not simply reduce tenderness during treatment.

Why exercise still matters

Shockwave therapy does not directly rebuild muscle strength or sporting capacity.

For example, reducing Achilles pain does not automatically restore:

• Calf strength
• Running tolerance
• Jumping ability

Similarly, reducing elbow pain does not automatically restore:

• Grip strength
• Lifting capacity
• Racket-sport tolerance

Exercise rehabilitation addresses these physical qualities.

Shockwave therapy can therefore be considered one part of the overall treatment plan.

Returning to activity after treatment

Most people can continue normal daily activity after shockwave therapy, although the treated area may feel temporarily sensitive.

Your clinician may advise temporary adjustment of demanding activity depending on:

• The condition
• Treatment intensity
• Current symptoms
• Rehabilitation stage

You may still be able to complete appropriate strengthening exercises.

The goal is usually to manage load rather than unnecessarily stopping all activity.

Can I exercise after shockwave therapy?

This depends on the area being treated and the exercise planned.

Normal rehabilitation exercises may often continue.

More demanding activities such as:

• Running
• Jumping
• Heavy lifting
• Intense sport

may occasionally need modification if the treated area feels particularly sore.

Your programme can be adjusted according to your response.

What might I feel after treatment?

After shockwave therapy, the area may temporarily feel:

• Tender
• Achy
• Sensitive
• Slightly uncomfortable

Some people experience little reaction.

Others notice increased soreness for a short period after treatment.

This does not necessarily mean that something has been damaged.

Significant or unexpected symptoms should still be discussed with the treating clinician.

When should improvement occur?

Response varies between individuals.

Some people notice changes relatively early, while others improve gradually during the weeks after treatment.

It is important to continue the rehabilitation programme even if symptoms begin improving.

Strength and physical capacity usually need to develop progressively over time.

Shockwave therapy is not an instant fix

Persistent tendon problems often develop over months and usually require ongoing rehabilitation.

Shockwave therapy should therefore not be viewed as a treatment that immediately repairs damaged tissue after one session.

Improvement may depend on several factors, including:

• How long symptoms have been present
• The condition being treated
• Strength
• Activity level
• Training demands
• Consistency with rehabilitation

Realistic expectations are an important part of treatment.

Shockwave therapy for runners

Runners may sometimes be offered shockwave therapy for persistent problems such as:

• Achilles tendinopathy
• Plantar heel pain

Treatment may form part of a wider running rehabilitation programme.

This may include:

• Calf strengthening
• Foot and ankle strengthening
• Running-load management
• Gradual return to running
• Running assessment where appropriate

Reducing pain without rebuilding running capacity may result in symptoms returning as training increases.

Returning to running

If running has been reduced because of tendon or heel pain, a gradual return may be required.

This might progress from:

• Walking
• Short jogging intervals
• Continuous easy running
• Longer running
• Faster running
• Hills

Progress should be based on the condition, symptoms and physical capacity.

Shockwave therapy for gym users

Persistent tendon symptoms may also affect:

• Squatting
• Lifting
• Pulling
• Pressing
• Jumping

Shockwave therapy may help form part of treatment while gym exercises are modified and progressively rebuilt.

The aim is usually to return towards normal training rather than permanently avoiding the movement that originally caused symptoms.

Training load

Persistent tendon pain may develop when physical demand increases faster than the area can adapt.

Examples include:

• Increasing running distance
• Adding sprint sessions
• Increasing gym resistance
• Starting more frequent sport
• Returning rapidly after a break

Shockwave therapy does not remove the need to address these training factors.

Rehabilitation should consider what the tendon needs to tolerate when normal activity resumes.

Shockwave therapy after a long period of pain

Shockwave therapy is particularly associated with persistent conditions rather than very recent injuries.

If symptoms have been present for a long period, rehabilitation may also need to address:

• Reduced strength
• Reduced confidence
• Avoided movements
• Reduced fitness

The longer symptoms have been present, the more important it can be to rebuild normal physical activity alongside symptom treatment.

Is shockwave therapy suitable for a new injury?

Not necessarily.

A new injury should first be assessed so that the correct diagnosis and stage of healing are understood.

Early management may involve:

• Appropriate activity
• Movement
• Gradual loading
• Rehabilitation

Shockwave therapy is generally considered more often for selected persistent problems rather than immediately after every acute injury.

Is shockwave therapy the same as ultrasound?

No.

Shockwave therapy and therapeutic ultrasound are different treatments.

Shockwave therapy produces mechanical pressure waves that are delivered to the targeted tissue.

The equipment, treatment sensation and intended use are different.

Is shockwave therapy an injection?

No.

Shockwave therapy is applied externally through the skin.

No needle is required.

This makes it a non-invasive treatment.

Does shockwave therapy break up scar tissue?

Shockwave therapy is sometimes described in simple terms as “breaking down scar tissue”, but this is an oversimplification.

Its effects are more complex and treatment is used to influence pain and the biological response of tissues.

The clinical focus should remain on whether the treatment is appropriate for the condition and whether physical function is improving.

Shockwave therapy and manual therapy

Shockwave therapy may sometimes be used alongside other physiotherapy treatment.

Depending on the condition, this might include:

• Exercise
• Mobility work
• Manual therapy
• Activity advice

Not every person needs every treatment.

The rehabilitation programme should focus on the approaches most relevant to the condition.

When shockwave therapy may not be suitable

Shockwave therapy is not appropriate for everyone.

Treatment may need to be avoided or modified in situations including certain:

• Blood-clotting disorders
• Medications affecting bleeding
• Active infections
• Tumours in the treatment area
• Pregnancy where the treatment area may create concern
• Significant neurological or vascular problems
• Recent serious injury
• Areas where treatment could affect vulnerable structures

The exact precautions depend on the body area and your medical history.

Your clinician should review this before starting treatment.

Medication

Tell your clinician about medication you are taking before shockwave therapy.

This is particularly important if you use:

• Anticoagulants
• Medication affecting blood clotting
• Other medication relevant to your current condition

Do not stop prescribed medication independently in preparation for treatment.

Any medication changes should be discussed with the appropriate medical professional.

Pregnancy

Shockwave therapy may not be appropriate during pregnancy depending on the treatment location.

If you are pregnant or think you may be pregnant, tell the clinician before treatment.

Alternative rehabilitation approaches can be considered where needed.

When further medical assessment may be required

Shockwave therapy should not be used to repeatedly treat an area when the diagnosis remains uncertain.

Further medical or physiotherapy assessment may be appropriate if you experience:

• Significant unexplained swelling
• Severe pain
• A recent major injury
• Inability to put weight through a limb
• Significant weakness
• Persistent numbness
• Unexplained night pain
• A rapidly changing lump or swelling
• Symptoms that are progressively worsening
• Signs of infection

These symptoms may require investigation before treatment is considered.

Treatment based on your condition

Shockwave therapy should be used because it is appropriate for the condition, not simply because an area is painful.

Your overall treatment plan may therefore include:

• Shockwave therapy
• Strengthening
• Mobility exercises
• Activity modification
• Gradual loading
• Return-to-running rehabilitation
• Return-to-sport rehabilitation

The combination depends on what you need to return to doing.

How long does treatment take to work?

There is no single timeline.

Response may depend on:

• Diagnosis
• Duration of symptoms
• Rehabilitation completed
• Strength
• Activity level
• General health

Improvement may continue after the shockwave treatment course has finished.

Exercise and loading programmes may need to continue for considerably longer than the shockwave sessions themselves.