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Chapter 4

What Does the Scientific Evidence Say About Shockwave Therapy?

Understanding the Research Behind ESWT

One of the biggest advantages of modern healthcare is that treatments can be studied scientifically.

Rather than relying on opinion or tradition alone, physiotherapists increasingly use research evidence, clinical experience and patient preferences to help guide treatment decisions.

Extracorporeal Shockwave Therapy (ESWT) is no exception.

Over the last three decades, thousands of scientific papers have investigated whether ESWT can help people with long-standing musculoskeletal conditions. Some have reported encouraging results, while others have shown smaller benefits or no clear difference compared with other treatments.

So what should patients make of this?

The simple answer is:

Shockwave Therapy is not a miracle treatment—but for carefully selected patients with certain persistent tendon conditions, it can be a valuable part of an evidence-informed rehabilitation programme.

Understanding Medical Evidence

When reading about treatments online, you’ll often see dramatic claims:

“95% success!”

“Guaranteed cure!”

“Works for everyone!”

Healthcare doesn’t work like that.

No treatment is effective for every patient.

Instead, clinicians ask questions such as:

• Has this treatment been tested in high-quality studies?
• Is it better than doing nothing?
• Is it as good as, or better than, other available treatments?
• What are the potential benefits?
• What are the risks?
• Which patients are most likely to benefit?

These questions help clinicians make balanced recommendations.

Not All Research Is Equal

Scientific studies vary in quality.

A single patient’s experience is valuable, but it cannot tell us whether a treatment works for most people.

Researchers therefore combine information from many patients to identify overall patterns.

The strongest evidence often comes from:

Systematic Reviews

These analyse many studies on the same topic.

Researchers assess the quality of each study before drawing conclusions.

Meta-Analyses

These combine numerical results from multiple studies to estimate the average treatment effect.

Randomised Controlled Trials (RCTs)

Participants are randomly allocated to different treatment groups.

This helps reduce bias and allows researchers to compare treatments fairly.

Clinical Guidelines

Professional organisations review the available evidence and publish recommendations to help clinicians make decisions.

These guidelines are often more reliable than individual studies because they consider the overall body of evidence.

Why Do Some Studies Show Different Results?

Patients often wonder why one study says a treatment works while another appears less positive.

There are several reasons.

Different Patients

Some studies include:

• athletes
• older adults
• sedentary individuals
• people with recent symptoms
• people with pain lasting several years

These groups may respond differently.

Different Diagnoses

“Tendon pain” is not one condition.

Research may include:

• Achilles tendinopathy
• plantar fasciitis
• tennis elbow
• patellar tendinopathy
• shoulder calcific tendinopathy

Each condition has its own characteristics.

Different Shockwave Machines

Studies may use:

• radial shockwave
• focused shockwave
• different energy settings
• different treatment frequencies
• different numbers of sessions

These differences make direct comparison difficult.

Different Rehabilitation Programmes

One of the biggest variables is exercise.

Some studies combine ESWT with a structured strengthening programme.

Others use ESWT alone.

Since exercise is already an effective treatment for many tendon conditions, the way rehabilitation is delivered has a major influence on outcomes.

What Does the Evidence Generally Suggest?

Overall, research suggests that ESWT may improve pain and function for some people with certain chronic tendon conditions, particularly when used alongside an appropriate rehabilitation programme.

However, benefits vary between conditions and individuals.

The evidence is generally stronger for some diagnoses than for others.

Conditions with Stronger Evidence

Plantar Fasciitis

Persistent plantar fasciitis is one of the conditions most frequently studied.

Research suggests ESWT may reduce pain and improve function for some people whose symptoms have not improved with appropriate conservative treatment.

Mid-Portion Achilles Tendinopathy

There is supportive evidence for ESWT in some patients with chronic mid-portion Achilles tendinopathy, especially when combined with a progressive loading programme.

Calcific Rotator Cuff Tendinopathy

For calcific shoulder tendinopathy, ESWT has shown encouraging results in reducing symptoms and helping break down calcific deposits in some patients.

Tennis Elbow (Lateral Elbow Tendinopathy)

Research findings are more mixed.

Some patients experience meaningful improvement, while others respond better to different rehabilitation approaches.

Assessment remains essential.

Conditions Where Evidence Is Still Developing

Research continues for:

• gluteal tendinopathy
• proximal hamstring tendinopathy
• patellar tendinopathy
• insertional Achilles tendinopathy
• other chronic soft tissue conditions

Some studies report positive outcomes, but the evidence is less consistent than for the conditions above.

Does Shockwave Work Immediately?

No.

This is one of the most common misunderstandings.

Because ESWT aims to influence biological processes rather than simply block pain, improvement is often gradual.

Some people notice changes within a few weeks.

Others improve over several months.

Some people experience little or no benefit.

This variation is normal and highlights why realistic expectations are important.

Success Rates

Patients often ask:

“What are my chances of success?”

There is no single percentage that applies to everyone.

Success depends on factors such as:

• the condition being treated
• how long symptoms have been present
• the accuracy of the diagnosis
• adherence to rehabilitation
• overall health
• lifestyle factors
• activity levels

Rather than quoting guaranteed success rates, it is more helpful to discuss your individual situation with your clinician.

Is ESWT Better Than Exercise?

Current evidence does not suggest replacing exercise with shockwave therapy.

Instead:

Exercise remains the foundation of rehabilitation for most persistent tendon conditions.

ESWT may provide additional benefit for some patients when combined with an appropriate loading programme.

This is why many physiotherapists prescribe both treatments together.

What About Injections?

Patients often compare ESWT with corticosteroid injections.

These treatments work differently and are used for different clinical situations.

In some tendon conditions, corticosteroid injections may provide short-term pain relief but are not always associated with better long-term outcomes.

Whether an injection, ESWT, exercise rehabilitation or another treatment is most appropriate depends on the diagnosis, symptoms and individual patient factors.

The Importance of Clinical Expertise

Research alone cannot make treatment decisions.

Physiotherapists combine three key elements:

1. The best available research evidence.
2. Their clinical experience and assessment findings.
3. The patient’s goals, preferences and circumstances.

This is known as evidence-informed practice.

It recognises that treatment should be tailored to the individual rather than based on research findings alone.

A Balanced Perspective

The internet often presents treatments in extremes:

• “Shockwave is amazing.”
• “Shockwave doesn’t work.”

The truth is usually somewhere in the middle.

For the right patient, with the right diagnosis, delivered by an appropriately trained clinician and combined with progressive rehabilitation, ESWT can be a useful addition to treatment.

For other patients, a different rehabilitation approach may be more appropriate.

Good physiotherapy is about choosing the right treatment—not using the same treatment for everyone.

Key Takeaways

• ESWT has been extensively researched, particularly for chronic tendon conditions.
• The quality of evidence varies between conditions.
• Stronger evidence exists for persistent plantar fasciitis, mid-portion Achilles tendinopathy and calcific rotator cuff tendinopathy.
• Exercise remains the cornerstone of rehabilitation.
• ESWT may provide additional benefit for selected patients when combined with exercise.
• Improvement is often gradual rather than immediate.
• Treatment decisions should be based on a combination of research evidence, clinical assessment and individual patient goals.

Clinical Insight

When discussing ESWT with patients, it’s important to present the evidence honestly. Promising guaranteed outcomes or quoting inflated success rates is not supported by current evidence. A balanced explanation helps patients make informed decisions and builds trust in the therapeutic relationship.

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