Benefits of Shockwave Therapy in Physiotherapy Treatment

24. November 2020

an evidence-based guide to shockwave therapy in modern physiotherapy

Modern physiotherapy offers a diverse and evidence-based toolkit for managing musculoskeletal pain, particularly for chronic conditions that have failed to respond to traditional approaches. Many individuals suffer from persistent pain stemming from conditions like Achilles tendinopathy or tennis elbow, where the body's natural healing process has effectively stalled, leading to months or even years of discomfort and functional limitation.¹ For these challenging cases, a treatment modality known as Extracorporeal Shockwave Therapy (ESWT) has emerged as an innovative, non-invasive, and clinically proven component of a comprehensive physiotherapy treatment plan.⁴

It is best understood not as a standalone cure, but as a powerful catalyst that "re-boots" the body's own repair mechanisms, enabling more effective rehabilitation. This report aims to provide a detailed, trustworthy, and UK-focused guide for individuals considering shockwave therapy, demystifying the science behind it, outlining its benefits, and explaining what to expect from the treatment journey.

What is Shockwave Therapy? The Science Behind the Sound Waves

Extracorporeal Shockwave Therapy (ESWT), sometimes referred to as Radial Shockwave Therapy (RSWT), is a non-invasive medical procedure that utilises high-energy acoustic (sound) waves to stimulate the body's intrinsic healing capabilities.⁷ These waves are generated outside the body ("extracorporeal") and delivered to a specific area of injured tissue through the skin via a handheld applicator.³

Clarifying a Common Misconception: Acoustic Waves, Not Electrical Shocks

It is essential to address a common point of confusion. Despite the name, shockwave therapy has no connection to electrical shocks or other forms of electro therapy. The "shock" refers to a type of intense, short-duration mechanical sound pulse that travels faster than the speed of sound, not an electrical current.³ The waves are purely mechanical, creating pressure and tension forces within the targeted tissue.

The Biological Mechanism: How Sound Waves Trigger Healing

The therapeutic effects of shockwave therapy are driven by a process called mechanotransduction, where mechanical stimuli are converted into biochemical signals at a cellular level.⁹ The core mechanism is, perhaps counter-intuitively, the creation of a controlled, pro-inflammatory response in tissues where healing has become stagnant.⁸ This process effectively "re-boots" a failed healing cycle, prompting the body to mount a fresh and robust repair response.² This understanding is critical, as it directly informs aftercare protocols, such as the avoidance of anti-inflammatory medications, which would otherwise counteract the treatment's intended effect.¹⁶

This controlled microtrauma stimulates a cascade of beneficial biological effects:

Neovascularisation: The therapy promotes the formation of new blood vessels, a process known as neovascularisation. This enhances blood circulation to the injured area, delivering vital oxygen and nutrients required for tissue repair.³
Release of Growth Factors and Cellular Stimulation: The mechanical stress triggers the release of crucial growth factors and stimulates key cells. It activates fibroblasts, which are responsible for synthesising collagen and healing connective tissues like tendons and ligaments, and osteoblasts, which are essential for bone healing.⁷
Breakdown of Calcifications and Scar Tissue: The acoustic waves exert a mechanical force that can break down calcific deposits, which are a common feature of conditions like calcific tendinitis of the shoulder. The therapy also helps to disrupt fibrous, inelastic scar tissue, thereby improving tissue mobility and function.⁸

Mechanisms of Pain Relief

Shockwave therapy reduces pain through two primary mechanisms:

Hyperstimulation Anesthesia: The intense pulses overwhelm local nerve endings, creating an immediate but temporary analgesic effect by diminishing their activity.²⁰ This can provide instant relief during and shortly after a session.
Interruption of the Pain Cycle: On a longer-term basis, the therapy is thought to work via the "Gate-Control" mechanism, recalibrating the perception of pain signals sent to the brain. It also helps to disperse "Substance P," a key neurotransmitter that is strongly associated with the signalling of chronic, intense pain.²⁰

Types of Shockwave Therapy: Radial vs. Focused

There are two main types of shockwave devices used in clinical practice, and a qualified physiotherapist will select the appropriate one based on the specific condition being treated.

Radial Shockwave Therapy (RSWT): This is the most common form used in physiotherapy settings. It generates pressure waves via a projectile that strikes a metal applicator. These waves then radiate outwards from the applicator into a broad, relatively superficial area of tissue.²¹
Focused Shockwave Therapy (FSWT): This modality generates true shockwaves that are then converged onto a smaller, deeper, and more precise target point within the body. This is often used for treating deeper tissues, bone-related issues, or for breaking down dense calcifications.²⁰

The Clinical Benefits of Shockwave Therapy Treatment

The application of shockwave therapy within a structured physiotherapy treatment plan offers a cascade of interconnected benefits for individuals suffering from chronic musculoskeletal pain. Its primary value lies not just in passive healing but in its ability to act as a catalyst for active rehabilitation. By significantly reducing pain, it breaks down a major barrier that often prevents patients from effectively engaging in the crucial strengthening and loading exercises that are central to long-term recovery.²⁶

This innovative modality is particularly valuable as it fills a critical treatment gap. It offers a robust, evidence-based option for patients for whom standard conservative treatments (such as rest, ice, and basic exercises) have failed, but who are not yet ready for, or wish to avoid, invasive surgical procedures.³

The core clinical benefits include:

Accelerated Tissue Regeneration and Healing: By kick-starting the body's dormant repair mechanisms, the therapy can lead to a faster and more complete healing of injured tendons, ligaments, and other soft tissues.¹
Significant and Long-Lasting Pain Reduction: Through its dual-action effect on nerve endings and the healing of the underlying tissue, shockwave provides substantial pain relief that is sustained over the long term because it addresses the root cause of the problem, not just the symptoms.¹
Improved Mobility and Function: The breakdown of restrictive scar tissue and calcific deposits, combined with pain reduction, restores tissue elasticity and leads to measurable improvements in joint function, range of motion, and the ability to perform daily activities.¹
A Proven Non-Invasive Alternative to Surgery: For many chronic tendinopathies, shockwave therapy offers a successful alternative to surgery, allowing patients to avoid the associated risks, costs, and extensive recovery periods.¹
Reduced Reliance on Medication: By providing effective, drug-free pain management, the treatment is an excellent option for individuals seeking to minimise their use of long-term painkillers.¹

What Conditions Does Shockwave Therapy Treat? UK-Specific Cases and Success Rates

In the UK, shockwave therapy is a well-established treatment for a range of chronic musculoskeletal conditions, primarily tendinopathies that have persisted for several months and have not resolved with initial physiotherapy treatment.² Its use is supported by clinical evidence and, for several key conditions, is endorsed by the National Institute for Health and Care Excellence (NICE), the body that provides national guidance for health and social care in England. An accurate diagnosis from a qualified physiotherapist is essential to determine if it is the appropriate intervention.

Plantar Fasciitis (Heel Pain)

The Condition: A common and often debilitating condition characterised by sharp pain in the heel and arch of the foot, caused by degeneration or inflammation of the plantar fascia ligament.
How Shockwave Helps: The therapy stimulates a healing response in the fascia, increases blood flow to the tissue, and provides effective pain relief, allowing individuals to walk more comfortably.¹⁰
UK Evidence and Success Rates: Plantar fasciitis is one of the most successfully treated conditions. NICE has approved its use for cases that have not responded to other treatments.¹² Clinical outcomes are excellent, with UK-based NHS trusts like the Royal Orthopaedic Hospital reporting success rates of around 75-80%.¹⁰ Many patients report being able to resume long walks and daily activities pain-free after treatment.²⁹

Achilles Tendinopathy

The Condition: An overuse injury affecting the large tendon at the back of the ankle, common in runners and active people, causing pain, stiffness, and swelling.
How Shockwave Helps: It promotes the regeneration of tendon cells, improves circulation within the poorly vascularised tendon, and helps remodel dysfunctional tissue.¹⁴
UK Evidence and Success Rates: NICE guidance supports the use of shockwave therapy for Achilles tendinopathy.¹⁴ Evidence shows it is particularly effective when combined with a structured eccentric loading (strengthening) programme.³² A UK-based case study from Physiotherapy Matters detailed a client with chronic Achilles pain who, after four sessions of shockwave alongside rehabilitation, reported a 70% improvement in symptoms and a reduction in her pain score from a constant 7/10 to an intermittent 0-2/10.²⁷

Lateral Epicondylitis (Tennis Elbow) & Medial Epicondylitis (Golfer's Elbow)

The Condition: Painful conditions caused by overuse of the forearm muscles and tendons that attach to the outer (tennis elbow) or inner (golfer's elbow) part of the elbow.
How Shockwave Helps: It aims to reduce pain at the tendon insertion point, stimulate a healing response, and improve grip strength.²⁴
UK Evidence and Success Rates: The evidence for tennis elbow is more varied, and a trustworthy report must reflect this nuance. While NICE has issued guidance on its use, it notes that the evidence of its effectiveness is inconsistent.³⁴ Some studies report high success rates of up to 80% pain reduction ³³, and UK case studies show positive outcomes, such as a hockey player returning to his sport after six weeks of treatment.³⁷ However, other high-quality randomised controlled trials have found little to no benefit over a placebo treatment.³⁶ This highlights the importance of undertaking the treatment as part of a comprehensive
physiotherapy plan tailored to the individual.

Shoulder Pain (Calcific Tendinitis & Rotator Cuff Tendinopathy)

The Condition: Persistent shoulder pain often arising from degeneration of the rotator cuff tendons, which can be complicated by the formation of hard calcium deposits within the tendon tissue (calcific tendinitis).
How Shockwave Helps: This is another area where the therapy is highly effective. The mechanical energy of the shockwaves is uniquely suited to breaking up the calcific deposits, which the body can then reabsorb and eliminate. It also stimulates healing in the surrounding damaged tendon tissue.⁵
UK Evidence and Success Rates: There is strong evidence and a clear NICE recommendation for the use of shockwave therapy for calcific tendinopathy of the shoulder.²³ Studies report very high success rates, with one noting an 85% success rate in treating calcific shoulder tendons and another showing the elimination of calcifications in 84% of cases.¹⁹ Patient case studies from the UK are compelling, including a manual worker who avoided surgery for severe calcific tendinopathy and another patient who, after six years with a frozen shoulder, was able to lift her arm above her head again following treatment.⁴²

Patellar Tendinopathy (Jumper's Knee)

The Condition: An overuse injury of the patellar tendon, which connects the kneecap to the shinbone. It causes pain at the front of the knee and is common in sports involving frequent jumping.
How Shockwave Helps: The therapy initiates a healing response in the chronically stressed and degenerated tendon tissue.¹⁵
UK Evidence and Success Rates: The treatment is widely used in UK sports and physiotherapy clinics.¹⁹ Clinical studies demonstrate its efficacy, with one trial showing that 90% of patients in the shockwave group achieved a satisfactory functional outcome compared to only 50% in the group receiving conservative care alone. The recurrence rate was also significantly lower in the shockwave group (13% vs 50%).²⁸

The table below summarises the UK clinical guidance and typical efficacy for common conditions treated with shockwave therapy.

Condition	NICE Guideline Status (UK)	Typical Reported Success Rate	Common Number of Sessions
Plantar Fasciitis	Recommended for refractory cases ¹²	75-80% ¹⁰	3-4 ³²
Achilles Tendinopathy	Recommended for refractory cases ²³	70-80% ²⁷	3-5 ⁶
Tennis Elbow	Recommended, but with uncertain efficacy ³⁴	50-80% (evidence is mixed) ³³	3-5 ⁶
Calcific Shoulder Tendinopathy	Recommended ⁴⁰	>80% ¹⁹	3-6 ⁴⁵
Patellar Tendinopathy	Used in practice; NICE has no specific guidance	80-90% satisfactory outcome ²⁸	4-6 ²⁸
Greater Trochanteric Pain Syndrome	Recommended for refractory cases ⁴⁶	60-80% ⁴⁷	3 ⁴⁸

Your Treatment Journey: What to Expect Before, During, and After Shockwave Therapy

Understanding the patient journey from start to finish can help demystify the process and set clear expectations. The treatment is a structured process, managed by a qualified physiotherapist, that unfolds over several weeks.

The Initial Consultation and Assessment

The first and most critical step is a thorough assessment with a Chartered Physiotherapist. This will involve taking a detailed medical history, discussing your symptoms, and conducting a physical examination to confirm the diagnosis.⁸ The physiotherapist will determine if shockwave therapy is appropriate for your specific condition and will screen for any contraindications. These are specific situations where the treatment should not be used, such as during pregnancy, over active tumours or infections, in patients with blood clotting disorders, or too soon after a steroid injection in the area.¹⁰ In many clinical pathways, particularly within the NHS, having recent diagnostic imaging like an ultrasound or MRI scan is a prerequisite to confirm the tendon pathology before treatment can begin.³

Preparing for Your Session

Preparation is simple. Patients are generally advised to wear loose, comfortable clothing that allows the physiotherapist to easily access the area being treated.³ The most important instruction is to avoid taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for a specified period before, during, and after the treatment course. This is because these medications can suppress the pro-inflammatory healing response that the therapy is designed to stimulate.¹⁶

During the Treatment Session

A typical appointment lasts between 15 and 20 minutes, though the actual application of the shockwaves is much shorter, usually only taking 3 to 5 minutes.³ The process involves:

Locating the Area: The physiotherapist will identify the precise point of maximum tenderness by touch (palpation).¹³
Applying Gel: A water-based ultrasound gel is applied to the skin. This ensures that the acoustic waves are transmitted efficiently from the applicator into the body's tissues.⁸
Delivering the Treatment: The handheld applicator is placed firmly on the gel, and the machine is activated. You will hear a series of loud clicks and feel a strong tapping or pulsating sensation on the treatment site.¹⁷

Most patients report some level of discomfort or pain during the application, but it is typically described as manageable. A key feature of the treatment is that the physiotherapist can adjust the intensity of the shockwaves in real-time to a level that is therapeutic yet tolerable for the patient.3

Number and Frequency of Sessions

A standard course of shockwave therapy typically consists of 3 to 5 treatment sessions.³ These are usually scheduled one week apart to allow the tissue to respond and the initial healing process to begin between applications.³

After the Session: Aftercare and Recovery

Post-treatment care is straightforward but crucial for success.

Immediate Aftermath: You can walk and return to your normal, light daily activities immediately after the session.¹⁷ Some people experience a temporary reduction in pain right away.⁵¹
The 48-Hour Rule: It is strongly advised to avoid any strenuous, high-impact, or pain-provoking activities (such as running or heavy lifting) for at least 48 hours after each treatment. This allows the stimulated healing response to take hold without being disrupted.¹²
Managing Discomfort: It is common to experience a mild, dull ache in the treated area a few hours after the session, which may last for a day or two. If needed, you can take simple painkillers like paracetamol. As previously mentioned, you must continue to avoid NSAIDs and also refrain from using ice packs on the area, as both can interfere with the body's natural healing process.¹⁶
Side Effects: Side effects are generally minor and temporary. They can include redness, localised bruising, swelling, or numbness in the treated area. These typically resolve within a few days.¹² There is a very small risk of tendon rupture, which your physiotherapist will discuss with you.¹²

The Healing Timeline: Patience is Key

It is vital to have realistic expectations regarding the timeline for recovery. While some individuals feel improvement quickly, the full biological effects of the treatment take time to manifest. The most significant and lasting improvements in pain and function are typically observed between 6 and 12 weeks after the final treatment session.¹⁰ A follow-up appointment with your physiotherapist is often scheduled around the 3-month mark to formally assess the outcome of the treatment course.¹²

Where Can I Get Shockwave Therapy in the UK?

In the United Kingdom, there are two primary pathways to access shockwave therapy: through the National Health Service (NHS) and via private physiotherapy clinics.

Accessing Treatment via the NHS

Shockwave therapy is available on the NHS for certain approved conditions in many regions.³ Access is typically initiated by a referral from a General Practitioner (GP) to a specialist hospital department, such as a Musculoskeletal (MSK) Service, Orthopaedics, or Sports and Musculoskeletal Medicine clinic.³

The eligibility criteria for NHS-funded treatment are generally quite specific. It is almost always considered a second-line intervention, meaning patients must meet certain conditions ³:

The condition must be chronic, typically having persisted for a minimum of 3 to 6 months.
The patient must have already completed a course of conservative management (such as a structured physiotherapy exercise programme, orthotics, or activity modification) without achieving satisfactory improvement.
The diagnosis often needs to be confirmed by imaging, such as an ultrasound scan, prior to referral.³

Accessing Treatment Through Private Physiotherapy Clinics

A large and growing number of private physiotherapy clinics across the UK now offer shockwave therapy as part of their services.² The primary advantages of choosing the private route are significantly faster access to treatment, as patients can often self-refer without needing to see a GP first, and greater flexibility in scheduling appointments. In a private setting, the therapy is seamlessly integrated into a holistic physiotherapy treatment plan from the outset.

The Role of UK Professional and Governance Bodies

Patients in the UK can have confidence in shockwave therapy due to the oversight and endorsement of key national bodies.

NICE (National Institute for Health and Care Excellence): NICE has thoroughly reviewed the clinical evidence for shockwave therapy and has approved its use for several chronic musculoskeletal conditions, including plantar fasciitis, Achilles tendinopathy, and calcific tendinopathy of the shoulder. NICE has deemed the procedure to be safe, which provides a strong measure of assurance for both clinicians and patients.³
The Chartered Society of Physiotherapy (CSP): The CSP is the professional and educational body for physiotherapists in the UK. While it does not issue its own specific clinical protocols for individual modalities, it actively supports the professional development of its members in this area. The CSP's official channels are used to advertise and promote accredited continuing professional development (CPD) courses on shockwave therapy, ensuring that Chartered Physiotherapists have access to high-quality training.⁵⁶ This serves as a professional endorsement of the modality's place within the scope of modern
physiotherapy practice.

Choosing a Qualified Provider

When seeking treatment, it is advisable to choose a clinic where the therapy is delivered by a qualified and registered healthcare professional, such as a Chartered Physiotherapist who is a member of the CSP. It is also worth noting that the quality of the shockwave machine can impact results. High-quality, clinically tested systems are more capable of producing the necessary energy levels for a therapeutic effect, so it can be beneficial to inquire about the equipment a clinic uses.⁵⁷

Conclusion: A Sound Wave of Hope in Modern Physiotherapy

In summary, shockwave therapy stands as a scientifically-backed, safe, and effective non-invasive treatment for a range of chronic musculoskeletal conditions that have been resistant to other forms of care. By harnessing the power of acoustic waves to stimulate the body's own regenerative processes, it offers a robust solution for alleviating persistent pain, restoring function, and providing a viable alternative to surgery. However, its greatest strength is realised when it is not viewed as an isolated intervention.

The evidence consistently demonstrates that shockwave therapy is most effective when it is integrated into a comprehensive physiotherapy treatment program. This holistic approach, which includes an accurate diagnosis, patient education, manual therapy, and a tailored rehabilitation and exercise plan, ensures that the pain relief and tissue healing catalysed by the shockwaves are translated into lasting strength, resilience, and functional recovery. For those struggling with persistent soft tissue pain, this innovative modality represents a significant advancement in the field, offering a powerful new avenue for healing and recovery through expert physiotherapy.

Frequently Asked Questions: Shockwave Therapy Treatment

How much does shockwave therapy cost in the UK?

Private shockwave therapy sessions typically cost between £60-£120 per session, with most clinics offering package deals for a full treatment course. NHS treatment is provided free at the point of care for eligible patients who meet the clinical criteria.

How painful is the shockwave therapy procedure?

Most patients describe the treatment as uncomfortable rather than painful, rating it around 4-6 out of 10 on the pain scale. The physiotherapist will adjust the intensity to a tolerable level, and many clinics offer a "test pulse" approach where intensity is gradually increased to ensure comfort.

What is the success rate of shockwave therapy compared to surgery?

For conditions like plantar fasciitis and calcific shoulder tendinopathy, shockwave therapy shows success rates of 70-80%, comparable to surgical intervention but without the risks, recovery time, and cost. Long-term studies show that successful shockwave treatment can provide permanent relief without the need for surgery in the majority of cases.

Does private health insurance cover shockwave therapy in the UK?

Many UK private health insurers including BUPA, AXA, and Aviva now cover shockwave therapy when deemed medically necessary and prescribed by a consultant. Coverage typically requires pre-authorization and may specify a maximum number of sessions or require treatment to be performed by an approved provider.

How long do the benefits of shockwave therapy last?

The positive effects of successful shockwave therapy are typically long-lasting, with studies showing continued improvement up to 5 years after treatment completion. Unlike cortisone injections which often provide temporary relief, shockwave therapy addresses the underlying tissue dysfunction, creating sustainable healing in most successfully treated cases.

Can shockwave therapy be combined with other physiotherapy treatments?

Yes, shockwave therapy works most effectively when combined with manual therapy, exercise rehabilitation, and load management as part of a comprehensive treatment plan. The pain relief provided by shockwave creates an ideal window for performing corrective exercises that address the root biomechanical causes of the condition.

What should I expect at my first shockwave therapy session?

Your first session will include a thorough assessment to confirm your diagnosis, an explanation of the procedure, and typically a shorter treatment duration to help your body adapt to the sensation. The physiotherapist will establish your baseline pain levels, test your response to the treatment, and discuss the specific aftercare required for your condition.

Is there a difference between shockwave therapy delivered in a hospital versus a private clinic?

The treatment protocols and equipment in NHS hospitals and reputable private clinics are very similar, with both settings using CE-marked medical devices that meet UK standards. The primary differences are in the referral pathway, waiting times, and the integration with other specialist services, with NHS hospital treatment often requiring more extensive pre-treatment diagnostics.

What qualifications should a physiotherapist have to perform shockwave therapy?

A qualified provider should be an HCPC-registered physiotherapist who has completed a certified shockwave therapy training course recognized by the machine manufacturer or a professional body. The most experienced practitioners will have additional post-graduate qualifications in musculoskeletal or sports physiotherapy and membership in specialized clinical interest groups.

What follow-up care is needed after completing a course of shockwave therapy?

After completing your shockwave treatment course, a progressive loading program is essential to strengthen the healed tissue and prevent recurrence. Your physiotherapist will typically schedule a follow-up assessment 12 weeks post-treatment to evaluate your progress and may recommend maintenance exercises to continue independently.

Can the condition return after successful shockwave therapy?

While recurrence rates are generally low (10-20%) after successful treatment, the condition may return if the underlying biomechanical issues or activity patterns that caused the original problem are not addressed. Following your physiotherapist's advice regarding exercise, load management, and possibly orthotic use or equipment modifications is crucial for maintaining long-term results.

How should I prepare for a shockwave therapy session?

Avoid taking anti-inflammatory medications (NSAIDs like ibuprofen) for 3-5 days before treatment, as these can interfere with the therapeutic healing response. Wear loose, comfortable clothing that allows easy access to the treatment area, and inform your physiotherapist about any recent steroid injections or changes in symptoms.

Are there any age restrictions for receiving shockwave therapy?

Shockwave therapy is generally considered safe for adults of all ages but is typically not recommended for children and adolescents whose growth plates are still open. For elderly patients or those with thin skin or fragile tissue, the treatment parameters may be modified with reduced intensity to ensure safety and comfort.

How has shockwave therapy technology improved in recent years?

Modern shockwave devices offer more precise targeting, adjustable energy levels, and enhanced user interfaces that allow physiotherapists to deliver more comfortable and effective treatment. The latest generation machines can store individual treatment parameters for consistency across sessions and provide better visual feedback to guide accurate application.

How soon can I return to sports after shockwave therapy?

Light, non-impact activities can usually be resumed 2-3 days after each session, while high-impact sports or activities that stress the treated area should be avoided for 2-4 weeks. Your physiotherapist will create a graduated return-to-sport plan based on your specific condition, tissue healing timeline, and the demands of your particular activity.