Chapter 5: Which conditions can shockwave therapy help?

One of the first questions patients ask is: "Can shockwave therapy help my condition?" The answer depends on two important factors:

• Having the correct diagnosis.
• Whether research supports the use of ESWT for that particular condition.

Although shockwave therapy has become increasingly popular, it is not suitable for every painful joint, muscle or tendon. It is most commonly considered for persistent tendon conditions (tendinopathies) and a small number of other musculoskeletal disorders, particularly when symptoms have not improved despite appropriate conservative treatment.

An accurate assessment by a qualified healthcare professional is therefore the most important first step.

Understanding "persistent" pain

Most tendon injuries improve with time, appropriate exercise and gradual return to activity. Shockwave therapy is usually not the first treatment offered. It is generally considered when:

• symptoms have persisted for several months
• rehabilitation alone has not produced sufficient improvement
• the diagnosis has been confirmed
• surgery is not currently indicated or is something the patient wishes to avoid where appropriate

In many cases, ESWT forms part of a broader rehabilitation programme rather than replacing other treatments.

Conditions with the strongest evidence

Plantar fasciitis (plantar heel pain)

Plantar fasciitis affects the thick band of connective tissue running from the heel to the toes. Typical symptoms include pain under the heel, pain during the first few steps in the morning, discomfort after periods of rest, and pain after prolonged standing or walking.

Common contributing factors include sudden increases in activity, prolonged standing, running, reduced calf flexibility, reduced foot strength, higher body weight in some individuals and footwear changes.

Research suggests ESWT may help some people with persistent plantar heel pain, particularly when symptoms have not responded to a well-managed programme of exercise, load modification and advice.

Mid-portion Achilles tendinopathy

The Achilles tendon connects the calf muscles to the heel bone. This is one of the most frequently treated tendon conditions with ESWT. Symptoms commonly include pain during running, morning stiffness, swelling within the tendon, tenderness when squeezed and pain during jumping.

It usually develops because the tendon has been overloaded beyond its current capacity. Risk factors include increasing running too quickly, returning to sport after injury, reduced calf strength, limited ankle mobility and training errors.

Research suggests ESWT may provide additional benefit when combined with a progressive loading programme. Exercise remains the cornerstone of rehabilitation.

Insertional Achilles tendinopathy

Unlike mid-portion Achilles tendinopathy, this condition affects the tendon where it attaches to the heel bone. Symptoms often include pain directly on the heel, discomfort when walking uphill, pain during calf stretching and tenderness around the tendon insertion.

Rehabilitation often differs slightly because excessive compression at the tendon insertion may aggravate symptoms. Shockwave therapy may be considered for selected patients following assessment.

Tennis elbow (lateral elbow tendinopathy)

Despite its name, most people with tennis elbow have never played tennis. It commonly affects office workers, manual workers, tradespeople, gardeners, gym users and parents lifting young children.

Symptoms include pain on the outside of the elbow, discomfort when gripping, difficulty lifting objects, pain when shaking hands and reduced grip strength.

Research on ESWT for tennis elbow is mixed. Some patients improve, while others respond well to exercise-based rehabilitation alone. Your physiotherapist will help determine whether ESWT is likely to add value.

Golfer's elbow (medial elbow tendinopathy)

Golfer's elbow affects the tendons on the inside of the elbow. It often develops from repetitive gripping, lifting, manual work, racket sports, climbing and weight training. Treatment usually centres on load management and strengthening. ESWT may be appropriate in some long-standing cases.

Calcific rotator cuff tendinopathy

This condition involves calcium deposits within one of the rotator cuff tendons. Symptoms may include shoulder pain, difficulty reaching overhead, pain at night and reduced shoulder movement.

This is one of the conditions where ESWT has shown encouraging results, particularly for reducing symptoms and helping manage calcific deposits in selected patients.

Patellar tendinopathy (jumper's knee)

The patellar tendon connects the kneecap to the shin bone. It commonly affects volleyball players, basketball players, runners, footballers and gym enthusiasts. Symptoms often occur below the kneecap, during jumping, after sprinting and during stair climbing.

Exercise remains the main treatment, but ESWT may be considered when symptoms persist despite appropriate rehabilitation.

Gluteal tendinopathy

This condition affects the tendons on the outside of the hip. Typical symptoms include pain lying on the affected side, pain walking uphill, discomfort climbing stairs and pain standing on one leg.

Treatment usually includes education, load modification, strengthening and movement retraining. Some studies suggest ESWT may help selected patients, although evidence is still developing.

Proximal hamstring tendinopathy

This condition causes pain high in the back of the thigh, close to the sitting bone. Common symptoms include pain sitting for long periods, discomfort during running, pain bending forwards and difficulty accelerating.

Shockwave therapy may be considered alongside a structured strengthening programme for some persistent cases.

Conditions where ESWT is less commonly used

Research is continuing into the role of ESWT in other musculoskeletal conditions, but it is not routinely recommended for every painful problem. Examples include muscle strains, acute ligament injuries, recent tendon tears, osteoarthritis itself (although associated tendon problems may sometimes be treated) and general back pain without a suitable diagnosis.

The decision to use ESWT should always be based on an individual clinical assessment rather than on symptoms alone.

Why diagnosis matters more than symptoms

Two people can both say: "My heel hurts." One may have plantar heel pain. Another may have Achilles tendinopathy, a stress fracture, nerve irritation, inflammatory arthritis or heel fat pad pain. These conditions require different management. This is why a thorough assessment is essential before starting ESWT.

Is shockwave therapy always needed?

No. Many patients recover successfully with education, activity modification, progressive strengthening, improving flexibility where appropriate, balance and movement training, footwear advice (when relevant) and gradual return to activity. ESWT is considered when it is likely to complement these treatments – not replace them.

Summary table

Condition	Evidence for ESWT	Role of exercise
Plantar heel pain	Good	Essential
Mid-portion Achilles tendinopathy	Good	Essential
Insertional Achilles tendinopathy	Moderate	Essential (modified programme)
Tennis elbow	Mixed to moderate	Essential
Golfer's elbow	Emerging	Essential
Calcific rotator cuff tendinopathy	Good	Essential
Patellar tendinopathy	Moderate	Essential
Gluteal tendinopathy	Emerging	Essential
Proximal hamstring tendinopathy	Emerging	Essential

The strength of evidence continues to evolve as new research is published.

Key takeaways

• ESWT is most commonly used for persistent tendon conditions.
• Not every painful condition is suitable for shockwave therapy.
• Accurate diagnosis is essential before treatment.
• Exercise-based rehabilitation remains the foundation of recovery.
• ESWT may provide additional benefit for selected patients when combined with an appropriate rehabilitation programme.
• Treatment decisions should be individualised and based on clinical assessment, current evidence and patient goals.

Clinical insight

The most successful outcomes usually occur when the right patient receives the right treatment at the right stage of recovery. ESWT is a valuable tool, but it is most effective when integrated into a personalised rehabilitation plan rather than used as a standalone intervention.