Therapeutic ultrasound is a form of electrotherapy treatment that uses high-frequency sound waves (typically 1–3 MHz) to deliver energy into soft tissues. A physiotherapist applies a water-based gel to your skin and moves a handheld transducer over the treatment area, transmitting sound waves through the gel into your muscles, tendons, or ligaments.
Therapeutic Ultrasound in Physiotherapy: An Honest, Evidence-Based Guide
Therapeutic ultrasound is an electrotherapy treatment that uses sound waves to promote tissue healing and reduce pain—but the clinical evidence for many conditions is now considered weak or insufficient. At CK Physio in West London, we take an evidence-based approach: we use therapeutic ultrasound selectively where research supports it, always as part of a comprehensive treatment plan that prioritises therapeutic exercise and manual therapy.
lUnsure which treatment is right for you? Our physiotherapists will assess your condition and recommend the most effective approach.
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What Is Therapeutic Ultrasound?
The treatment works through two proposed mechanisms. Thermal effects occur when sound wave energy is absorbed by tissues, generating gentle heat that may increase blood flow and tissue extensibility. Non-thermal effects include acoustic streaming and cavitation—the movement of fluids and formation of tiny bubbles in tissues—which proponents suggest may stimulate cellular activity and promote healing.
Important distinction: Therapeutic ultrasound is completely different from diagnostic ultrasound (the type used for pregnancy scans or imaging injuries). Diagnostic ultrasound creates images; therapeutic ultrasound does not produce any images—it delivers energy to tissues with the aim of promoting healing.
At CK Physio, therapeutic ultrasound is one of several electrotherapy modalities we offer. However, as you will read below, the evidence for its effectiveness varies considerably depending on the condition being treated—and we believe you deserve honest information to make informed decisions about your care.
What Does the Clinical Evidence Say About Therapeutic Ultrasound?
The evidence landscape for therapeutic ultrasound has shifted significantly over the past decade. While the treatment was once widely used across physiotherapy practice, systematic reviews and clinical guidelines have increasingly questioned its effectiveness for many common conditions. Here is what the current research shows.
For low back pain, the UK's National Institute for Health and Care Excellence (NICE) explicitly states: "Do not offer ultrasound for managing low back pain with or without sciatica." This recommendation, published in NICE guideline NG59, places therapeutic ultrasound alongside TENS and interferential therapy—all recommended against for this condition.
For osteoarthritis, NICE guideline NG226 (published October 2022) goes further: it lists ultrasound therapy among electrotherapy treatments that should not be offered "because there is insufficient evidence of benefit." This applies to osteoarthritis affecting all joints.
However, the evidence is not uniformly negative. CK Physio believes in presenting the complete picture, including areas where some positive findings exist.
| Condition | Evidence Direction | Strength | Key Source |
|---|---|---|---|
| Low back pain | Against | Strong (NICE) | NICE NG59 |
| Osteoarthritis (general) | Against | Strong (NICE) | NICE NG226 |
| Rotator cuff tendinopathy | Against | Moderate | 2025 CPG |
| Knee osteoarthritis (specific) | Mixed | Moderate positive, low quality | Luo et al. 2024 |
| Myofascial pain syndrome | Supportive vs sham | Large effect, high heterogeneity | Li et al. 2024 |
| Calcific tendinitis | Cautiously supportive | Weak (limited RCTs) | Grazio et al. 2023 |
| Carpal tunnel syndrome | Neutral | Poor quality evidence | Cochrane Review |
The research on knee osteoarthritis specifically shows more promising results. A 2024 systematic review (Luo et al.) analysing 21 randomised controlled trials with 1,315 patients found moderate effects on pain and function, particularly with pulsed ultrasound at lower intensities. However, NICE still recommends against ultrasound for osteoarthritis generally, citing concerns about evidence quality.
What Do UK NICE Guidelines Say About Therapeutic Ultrasound?
NICE (the National Institute for Health and Care Excellence) produces evidence-based guidelines that inform healthcare practice across the UK. For therapeutic ultrasound, NICE has issued clear recommendations against its use for several major conditions commonly seen in physiotherapy practice.
NICE Guideline NG59: Low Back Pain and Sciatica
"Do not offer ultrasound for managing low back pain with or without sciatica."
This guideline, last updated December 2020, places therapeutic ultrasound alongside TENS and interferential therapy—all recommended against for back pain.
NICE Guideline NG226: Osteoarthritis
"Do not offer any of the following electrotherapy treatments to people with osteoarthritis because there is insufficient evidence of benefit: transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, interferential therapy, laser therapy, pulsed short-wave therapy, neuromuscular electrical stimulation (NMES)."
Published October 2022, this guideline prioritises therapeutic exercise, weight management, and education as first-line treatments for osteoarthritis.
At CK Physio, we take NICE guidelines seriously. This is why we do not recommend therapeutic ultrasound as a primary treatment for low back pain or osteoarthritis. Instead, we focus on treatments with stronger evidence: therapeutic exercise for arthritis, manual therapy, and active rehabilitation approaches.
However, NICE guidelines do not cover every condition. For some presentations—particularly certain soft tissue conditions and myofascial pain—the evidence is more nuanced, and therapeutic ultrasound may still have a role as part of a multimodal treatment approach.
Where Therapeutic Ultrasound May Still Have a Role
Despite the negative evidence for some conditions, therapeutic ultrasound is not universally ineffective. CK Physio takes a condition-specific approach, using ultrasound where research suggests potential benefit while being transparent about the evidence limitations.
Myofascial Pain Syndrome
A 2024 systematic review (Li et al.) analysing 16 randomised controlled trials found therapeutic ultrasound produced a large effect on myofascial pain compared to sham treatment. The treatment may help release painful trigger points in muscle tissue. However, the studies showed very high heterogeneity, meaning results varied considerably between trials.
Calcific Tendinitis
Calcific tendinitis—calcium deposits in tendons, commonly affecting the shoulder—has historically been considered therapeutic ultrasound's strongest indication. A 2023 study (Grazio et al.) found ultrasound therapy reduced calcium deposit size more than placebo. However, a 2025 clinical practice guideline for rotator cuff tendinopathy now recommends against therapeutic ultrasound even for calcific tendinitis, suggesting focused shockwave therapy may be more effective.
Scar Tissue and Soft Tissue Healing
Some practitioners use therapeutic ultrasound to help mobilise scar tissue and promote soft tissue healing following injury or surgery. While theoretical mechanisms support this application, high-quality randomised controlled trial evidence remains limited.
CK Physio's Position
We believe in being honest about evidence limitations. When we do use therapeutic ultrasound, it is always as one component of a comprehensive treatment plan—never as a standalone treatment. Effective physiotherapy for musculoskeletal conditions requires a multimodal approach combining exercise, manual therapy, education, and—where appropriate—adjunctive treatments like electrotherapy.
Therapeutic Ultrasound vs Shockwave Therapy: What's the Difference?
Patients often confuse therapeutic ultrasound with shockwave therapy—and understandably so, as both use acoustic energy. However, they are fundamentally different treatments with different evidence bases.
| Feature | Therapeutic Ultrasound | Shockwave Therapy |
|---|---|---|
| Energy type | Continuous or pulsed sound waves | High-energy acoustic pulses |
| Mechanism | Thermal effects, gentle tissue stimulation | Mechanical microtrauma, triggers healing response |
| Sensation during treatment | Generally painless, gentle warmth | Can be uncomfortable (2–5/10 pain scale) |
| Evidence for tendinopathies | Weak to moderate | Moderate to strong (NICE supported) |
| Best for | Myofascial pain, soft tissue conditions | Plantar fasciitis, Achilles tendinopathy, tennis elbow |
A 2025 systematic review found very low-certainty evidence that shockwave therapy provides greater pain reduction than therapeutic ultrasound for lateral epicondylitis (tennis elbow). For Achilles tendinopathy, research (Abd elazeem et al., 2024) found shockwave therapy superior for improving tendon structure on imaging.
At CK Physio, we invested in focused shockwave therapy technology (the Piezowave 2) because the evidence supports its effectiveness for chronic tendinopathies. We can honestly discuss which treatment—or combination of treatments—is most appropriate for your specific condition. Learn more about what to expect from shockwave therapy.
How CK Physio Uses Therapeutic Ultrasound: An Evidence-Based Approach
At CK Physio in Hanwell, West London, we take an evidence-based approach to all treatments. This means being honest about what therapeutic ultrasound can and cannot do—and never using it as a "filler" treatment while you wait for your physiotherapist's attention.
Our Principles
- Therapeutic exercise comes first. For most musculoskeletal conditions, active rehabilitation with targeted exercises produces the best long-term outcomes. Electrotherapy is an adjunct, never a replacement.
- We follow NICE guidelines. We do not offer therapeutic ultrasound for low back pain or osteoarthritis as primary treatments, in line with current UK clinical guidance.
- Condition-specific decisions. For conditions where research suggests potential benefit (certain myofascial and soft tissue conditions), we may include ultrasound as part of a comprehensive treatment plan.
- Regular reassessment. If therapeutic ultrasound is used, we monitor your progress closely. If you are not improving, we adjust your treatment plan rather than continuing ineffective interventions.
- Transparent communication. We explain the evidence—including its limitations—so you can make informed decisions about your care.
Our Full Range of Electrotherapy
Therapeutic ultrasound is just one modality within our comprehensive electrotherapy services. Depending on your condition, we may recommend:
- Focused shockwave therapy – stronger evidence for chronic tendinopathies
- Interferential therapy – for muscle relaxation and circulation
- TENS – for temporary pain relief (though not recommended for chronic conditions)
- Electroacupuncture – combining acupuncture with electrical stimulation
Frequently Asked Questions About Therapeutic Ultrasound
Not Sure Which Treatment Is Right for You?
Our Chartered Physiotherapists will assess your condition and recommend the most effective, evidence-based treatment approach—whether that includes therapeutic ultrasound, shockwave therapy, exercise rehabilitation, or manual therapy.
Book Your Assessment Call 020 8566 4113No GP referral needed • Appointments available within days • All major insurers accepted
References and Further Reading
- National Institute for Health and Care Excellence (2020). Low back pain and sciatica in over 16s: assessment and management [NG59]. Available at: https://www.nice.org.uk/guidance/ng59
- National Institute for Health and Care Excellence (2022). Osteoarthritis in over 16s: diagnosis and management [NG226]. Available at: https://www.nice.org.uk/guidance/ng226
- Luo L, et al. (2024). 'Therapeutic ultrasound for knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials.' Heliyon. Available at: https://www.cell.com/heliyon
- Li J, et al. (2024). 'Effects of therapeutic ultrasound on myofascial pain syndrome: A systematic review and meta-analysis.' BMC Musculoskeletal Disorders. Available at: https://bmcmusculoskeletdisord.biomedcentral.com/
- Desmeules F, et al. (2025). 'Clinical Practice Guideline for Rotator Cuff Tendinopathy.' Journal of Orthopaedic & Sports Physical Therapy (JOSPT). Available at: https://www.jospt.org/
- Chartered Society of Physiotherapy. Quality Assurance Standards for Physiotherapy. Available at: https://www.csp.org.uk/
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