Everything You Need To Know About Shockwave Therapy
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21. March 2019

everything you need to know about shockwave therapy

Physiotherapy offers a range of advanced treatments for persistent pain, and one of the most effective is Extracorporeal Shockwave Therapy. Known clinically as ESWT, this is a non-invasive, non-surgical treatment that utilises high-energy acoustic (sound) waves to target specific areas of injured tissue.1 A common misconception is that this treatment involves electrical shocks; however, the "shockwaves" are purely mechanical sound pulses, not a form of electro therapy.4

Within the UK healthcare framework, shockwave therapy is established as a clinically proven, second-line treatment. It is specifically intended for individuals suffering from chronic tendon disorders and other musculoskeletal conditions who have not found lasting relief from more conventional management strategies.5 This includes those for whom initial physiotherapy treatments, rest, medication, or even corticosteroid injections have failed to resolve their symptoms.5 This positions shockwave therapy as a crucial intervention for people who feel their recovery has stalled and are seeking an effective alternative to more invasive procedures.

Crucially, the treatment has been rigorously evaluated for safety and efficacy within the UK. The National Institute for Health and Care Excellence (NICE), the independent body that provides evidence-based guidance to the NHS, has deemed the procedure to be safe and has issued specific guidelines for its application in treating a number of common, painful conditions.2 This endorsement provides a strong foundation of trust and authoritativeness for patients considering this advanced physiotherapy treatment.

The technology itself is not new, which adds to its robust safety profile. It was originally developed in the 1990s and successfully used in urology to break down kidney stones non-invasively.2 Its principles were later adapted for orthopaedic and physiotherapy applications, where it has since become a valuable tool for treating chronic musculoskeletal pain and promoting tissue healing.2 This evolution from a different field of medicine underscores its long-standing safety record and the versatility of its therapeutic effects.

How Does Shockwave Therapy Work? The Science Behind the Sound Waves

shockwaveWhile the complete biological mechanisms of shockwave therapy are still the subject of ongoing research, the core principle is well-understood. The treatment works by initiating a controlled, pro-inflammatory response in chronic tissues where the natural healing process has become stagnant.4 For many chronic tendinopathies, the body is no longer in an active state of repair. Shockwave therapy effectively acts as a catalyst, creating a therapeutic micro-trauma that "re-awakens" the body's healing cascade. The application of acoustic waves stimulates a significant increase in local blood circulation and cellular metabolism, which in turn accelerates the body's own regenerative processes.4

Detailed Biological Mechanisms

The therapeutic effects of shockwave therapy are delivered through several key biological pathways, which work in concert to reduce pain and repair tissue:

  • Neovascularisation (Formation of New Blood Vessels): One of the hallmarks of chronic tendinopathies is a poor blood supply, which severely limits the tissue's ability to heal. The acoustic waves from the treatment stimulate the release of crucial growth factors, such as Vascular Endothelial Growth Factor (VEGF), which promotes angiogenesis—the formation of new blood vessels. This enhanced blood flow delivers more oxygen and nutrients to the injured area, which is essential for tissue repair.3
  • Pain Reduction (Hyperstimulation Analgesia): Many patients report an immediate, though sometimes temporary, reduction in pain following a session.4 This is achieved through two primary mechanisms. Firstly, the intense pulses over-stimulate the sensory nerve fibres that transmit pain signals to the brain, creating a "gating" effect that temporarily blocks the pain message. Secondly, the therapy helps to deplete the concentration of "Substance P" in the tissue. Substance P is a key neurotransmitter that is closely associated with the sensation of intense, persistent, and chronic pain. By reducing its presence, shockwave therapy can provide significant analgesia.3
  • Tissue Regeneration and Remodelling: The mechanical stimulus of the shockwaves promotes the activity of fibroblasts, the cells responsible for synthesising collagen.2 Collagen is the primary structural protein in tendons and ligaments. By stimulating its production, the therapy helps to build a stronger, more resilient tissue matrix, effectively repairing the damaged structures.
  • Breakdown of Calcification and Scar Tissue: In some chronic conditions, such as calcific tendinopathy of the shoulder, pathological calcium deposits form within the tendon, causing pain and stiffness. The mechanical energy of the shockwaves, through a process known as cavitation, creates and collapses tiny bubbles in the tissue. This force is sufficient to break down these calcific deposits and disrupt stubborn scar tissue or adhesions, which can then be absorbed and cleared by the body's lymphatic system. This process helps to restore mobility and alleviate pain.2

The Patient's Role: Why Anti-Inflammatory Medication Must Be Avoided

A critical component of a successful shockwave therapy treatment plan is patient adherence to a specific instruction: the avoidance of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for a designated period before, during, and after the course of treatment.6 This may seem counterintuitive to someone experiencing chronic pain, as the natural instinct is to take medication that reduces inflammation.

However, the effectiveness of shockwave therapy is fundamentally dependent on its ability to generate a new inflammatory response. Inflammation is the body's natural and necessary first step in the healing process. By creating this controlled, pro-inflammatory state, the treatment signals to the body that an injury needs attention, thereby initiating the cascade of blood flow, cell regeneration, and tissue repair. Taking NSAIDs would directly counteract this intended therapeutic effect by suppressing the very mechanism the treatment is designed to stimulate, ultimately undermining its potential for success.6 This is why the therapy is most suited for chronic conditions, where healing has stalled, rather than acute injuries, which are already in an active inflammatory phase.

The Best Technology for Shockwave Therapy: Focused vs. Radial

The term "shockwave therapy" is not a monolith; it encompasses two primary technologies with distinct physical properties and clinical applications: Radial Pressure Wave (RPW) therapy and Focused Shockwave (FSW) therapy.12 While both are often grouped under the general umbrella of ESWT, understanding their differences is crucial for appreciating which treatment is most appropriate for a specific condition.

Radial Pressure Wave (RPW) Therapy

Radial technology generates a pressure wave that radiates outwards from the applicator head, similar to the ripples created when a stone is dropped into a pond.2 The energy of this wave is at its highest point on the surface of the skin and gradually dissipates as it penetrates deeper into the tissue.

Its key characteristics are that it is best suited for treating more superficial conditions, with an effective treatment depth of approximately 3-4 cm, and for targeting larger, less specific areas of tissue.12 Because the peak energy is delivered at the skin's surface, some patients may find the treatment more uncomfortable.17 RPW therapy is commonly and effectively used for conditions such as plantar fasciitis and tennis elbow, where the target tissue is relatively close to the surface.12

Focused Shockwave (FSW) Therapy

Focused technology, by contrast, generates a true shockwave where the acoustic energy is concentrated at a single, precise, and adjustable focal point deep within the body's tissues. This is analogous to how a magnifying glass can focus sunlight onto a specific point.16

The primary advantage of FSW is its ability to penetrate much deeper—up to 12 cm—and with exceptional precision.16 The technology is designed to bypass the superficial tissues, delivering the maximum therapeutic energy exactly at the site of injury. This targeted delivery often results in a more comfortable experience for the patient, as there is less energy dispersed at the skin level.18 FSW is therefore the preferred technology for treating deeper or more specific injuries, such as gluteal tendinopathy, calcific deposits within a tendon, or certain bone injuries.17

Comparing Shockwave Technologies

shockwave technologyThe choice between radial and focused shockwave therapy depends heavily on the diagnosis and the anatomical location of the injured tissue. The following table summarises the key differences to help illustrate their distinct applications.

Feature

Radial Shockwave Therapy (RPW)

Focused Shockwave Therapy (FSW)

Wave Type

Divergent Pressure Wave (Radiates outwards)

Convergent Shockwave (Concentrates on a single point)

Penetration Depth

Superficial (approx. 3-4 cm) 12

Deep and adjustable (up to 12 cm) 16

Precision

Less precise; treats a wider area 16

Highly precise; targets a specific focal point 16

Energy Delivery

Highest energy at the skin surface, weakens with depth 12

Bypasses superficial tissue, delivers peak energy at depth 16

Patient Comfort

Can be more uncomfortable on the skin surface 17

Generally better tolerated as energy is focused deep 18

Typical Use Cases

Plantar fasciitis, Achilles tendinopathy, larger muscle areas 12

Deeper tendinopathies (e.g., gluteal), calcific deposits, bone injuries 17

Conditions Treated by Shockwave Therapy: UK Evidence and Patient Success

Shockwave therapy is a versatile physiotherapy treatment that has proven effective for a wide range of chronic tendon and soft tissue problems that have resisted first-line treatments.2 A typical course of treatment in the UK involves an initial assessment to confirm the diagnosis, followed by a series of three to five weekly sessions.4 Each treatment session is brief, lasting approximately 5-10 minutes to deliver the required number of acoustic pulses.1 It is essential that this treatment is delivered as part of a comprehensive rehabilitation plan that includes tailored exercises.1 While some patients experience immediate pain relief, the full therapeutic benefit unfolds over time as the body's healing process continues for several weeks or even months after the final session.6

Plantar Fasciitis (Chronic Heel Pain)

  • The Problem: Plantar fasciitis is a debilitating condition characterised by inflammation and degeneration of the thick band of tissue (plantar fascia) that runs across the bottom of the foot. Sufferers often experience a sharp, stabbing pain in the heel, which is typically most severe with the first steps in the morning or after long periods of rest, significantly impacting mobility and quality of life.23
  • The Evidence: Shockwave therapy is recognised as a highly effective treatment for chronic plantar fasciitis. Multiple scientific randomised controlled trials have demonstrated its benefits, with studies showing positive outcomes in approximately 70% of cases.11
  • NICE Guidance: In the UK, NICE has issued specific guidance on this procedure (IPG311).25 The guidance confirms that the procedure is safe but notes that the evidence on its efficacy can be inconsistent. Therefore, NICE recommends that it should be used with special arrangements for clinical governance, consent, and the auditing of patient outcomes.26 This transparent and cautious approach ensures patient safety while acknowledging the treatment's potential benefits.
  • Patient Experience: The impact of this treatment is powerfully illustrated by the case of Mike, an amateur runner who was forced to stop his beloved sport for over a year due to severe bilateral plantar fasciitis. Having found no relief from sports massage or acupuncture, he underwent a course of shockwave therapy. He described the sensation as "not as uncomfortable as I had feared," likening it to a deep tissue massage with a "good pain" feel. The outcome was transformative: within six weeks of starting the treatment, he was back competing in a 10k race, completely pain-free.23

Achilles Tendinopathy (Insertional and Mid-Portion)

  • The Problem: This common overuse injury affects the large tendon connecting the calf muscles to the heel bone. It is prevalent among runners and active individuals, causing persistent pain, stiffness, and swelling that can severely limit athletic performance and daily activities.28
  • The Evidence: A strong body of evidence supports the use of shockwave therapy for Achilles tendinopathy. Notably, research has shown that when ESWT is combined with a structured eccentric loading exercise programme, the results are superior to those achieved with exercise alone, making it a powerful adjunct to standard physiotherapy.11
  • NICE Guidance: The relevant NICE guidance is IPG571, which replaced an earlier version (IPG312).32 Similar to its guidance for plantar fasciitis, NICE states that the procedure raises no major safety concerns but that evidence for efficacy is inconsistent. It therefore recommends its use with special arrangements for audit and informed consent.29 The guidance also transparently notes that while there have been occasional reports of tendon rupture in treated patients, this is a known risk of the condition itself and may also occur in the absence of the procedure.34
  • Patient Experience: A compelling case study involves a 30-year-old woman who developed debilitating Achilles pain after childbirth, which persisted for 11 months. Her functional ability was severely impaired, with a VISA-A score (a validated measure of Achilles tendon pain and function) of just 24 out of 100. After four weekly sessions of shockwave therapy combined with physiotherapy exercises, her pain score dropped from a constant 7/10 to an intermittent 0-2/10, and her VISA-A score improved to 44/100. She was able to return to the gym and reported it was the best she had felt in 11 months.28 Another case involved a 55-year-old man whose pain score of 7 was reduced to 0 after five sessions, with the excellent result maintained at an 18-month follow-up.36

Lateral Epicondylitis (Tennis Elbow)

  • The Problem: Despite its name, tennis elbow affects a wide range of people, not just athletes. It is caused by overuse of the muscles and tendons of the forearm, leading to persistent pain on the outside of the elbow. This can make simple daily tasks, such as lifting a coffee cup, turning a doorknob, or shaking hands, extremely painful.1
  • The Evidence: Clinical studies have reported high success rates for shockwave therapy in treating tennis elbow, often ranging from 70% to 80%.37 Significantly, one study directly compared the outcomes of ESWT with surgical percutaneous tenotomy for resistant tennis elbow. It found that the results were comparable, positioning shockwave therapy as a highly effective non-invasive alternative for patients who might otherwise be considering surgery.40
  • NICE Guidance: Tennis elbow is included in the list of chronic tendinopathies for which NICE has provided guidance, supporting its use within the UK healthcare system as a recognised treatment option.14
  • Patient Experience: The clinical trial data itself speaks to the patient experience. For individuals facing the prospect of surgery, with its associated risks and lengthy recovery time, a non-invasive treatment that delivers comparable results in pain reduction and functional improvement offers a significant and preferable alternative.40

Greater Trochanteric Pain Syndrome (GTPS) / Gluteal Tendinopathy

  • The Problem: GTPS is a common cause of pain on the outer side of the hip. It is often caused by tendinopathy in the gluteal muscles (gluteus medius and minimus) where they attach to the thigh bone. The pain can make walking difficult, be aggravated by prolonged sitting, and frequently disturbs sleep when lying on the affected side.17
  • The Evidence: This is a condition where the choice of technology is particularly important. Due to the depth of the gluteal tendons beneath layers of tissue, Focused Shockwave (FSW) therapy is often considered superior to radial therapy for delivering effective energy to the site of injury.17 A clinical study using F-ESWT for this condition reported that 86.8% of patients achieved an "excellent" or "good" result just two months after treatment.17
  • NICE Guidance: NICE has issued guidance for this condition (IPG376), recommending that the procedure be used with special arrangements for clinical governance and consent, reflecting the limited quantity of high-quality evidence at the time of review.10
  • Patient Experience: The potential for life-changing results is highlighted in the testimonial of Marion Padgham, a retired nurse who had endured chronic bilateral hip pain for over ten years. Having failed to find relief with any conventional treatments, she undertook a course of ESWT. Just over a year after commencing the therapy, she reported being "very much improved" with "very little pain," which significantly enhanced her mobility and quality of life.41

Other Conditions

In addition to these primary conditions, shockwave therapy has demonstrated positive effects in the treatment of several other chronic musculoskeletal issues, including:

  • Patellar Tendinopathy (Jumper's Knee) 4
  • Calcific Tendinopathy of the shoulder 1
  • Medial Tibial Stress Syndrome (Shin Splints) 2

Conclusion: Is Shockwave Therapy the Right Physiotherapy Treatment for You?

In summary, Extracorporeal Shockwave Therapy is a safe, non-invasive, and NICE-recognised physiotherapy treatment for a range of chronic musculoskeletal conditions that have proven resistant to other forms of conservative therapy.2 Its primary benefits are the potential for significant pain relief and the restoration of normal function, offering a powerful alternative for individuals seeking to avoid more invasive options such as long-term medication, corticosteroid injections, or surgery.2

However, it is crucial to understand that shockwave therapy is not a standalone "magic bullet." Its greatest efficacy is realised when it is integrated into a comprehensive physiotherapy treatment plan.1 The therapy acts as a powerful catalyst to restart the body's stalled healing processes. Long-term success and the prevention of recurrence depend on addressing the underlying biomechanical faults or strength deficits that led to the injury in the first place. This is achieved through a tailored rehabilitation programme of specific stretching, strengthening, and loading exercises prescribed by a qualified physiotherapist.11

Therefore, the first and most important step for anyone considering this treatment is to undergo a thorough clinical assessment. This expert assessment ensures you receive the most effective and appropriate course of physiotherapy.

Frequently Asked Questions About Shockwave Therapy

How much does shockwave therapy cost in the UK?

The cost varies depending on the provider and location, but typically ranges from £60-£150 per session in private clinics, with most treatment courses requiring 3-5 sessions. Some NHS trusts offer shockwave therapy for eligible patients, though availability varies by region and clinical commissioning group.

Does shockwave therapy hurt?

Most patients experience mild to moderate discomfort during treatment, often described as tolerable and similar to deep tissue massage, with radial therapy typically causing more surface sensation than focused therapy. The treatment sessions are brief (5-10 minutes), and any discomfort usually subsides quickly after the session ends.

Are there any side effects of shockwave therapy?

Common side effects are mild and temporary, including redness, swelling, bruising, or numbness at the treatment site, which typically resolve within a few days. Serious adverse events are extremely rare when the treatment is performed by a qualified practitioner.

Who cannot have shockwave therapy?

Shockwave therapy is contraindicated for pregnant women, people with blood clotting disorders or taking anticoagulants, those with infections at the treatment site, and individuals with certain neurological conditions or pacemakers. A thorough assessment by a qualified physiotherapist will determine your suitability for treatment.

Is shockwave therapy available on the NHS?

Availability of shockwave therapy on the NHS varies significantly by region and depends on your local clinical commissioning group's policies and funding priorities. Many patients access the treatment privately due to limited NHS availability, though some NHS trusts do offer it for specific conditions when conservative treatments have failed.

How long do the results of shockwave therapy last?

When combined with appropriate rehabilitation exercises, the results of shockwave therapy can be long-lasting, with many patients experiencing sustained improvement for years. Long-term success depends on addressing underlying biomechanical issues and maintaining strength through a comprehensive physiotherapy programme.

Can I exercise after shockwave therapy?

You should avoid high-impact activities and vigorous exercise for 48 hours following each treatment session to allow the healing response to begin. After this initial period, gradual return to activity as guided by your physiotherapist is encouraged, as appropriate loading exercises are essential for optimal tissue repair and long-term recovery.

How soon will I see results from shockwave therapy?

Some patients notice immediate pain relief, though this may be temporary, while the full therapeutic benefits typically develop over 6-12 weeks as the body's natural healing processes continue after treatment. Maximum improvement is often seen 3-6 months post-treatment, with continued exercise rehabilitation.

Can shockwave therapy be repeated if symptoms return?

Yes, shockwave therapy can be safely repeated if symptoms recur, though it's important to identify and address any underlying causes of symptom recurrence through comprehensive assessment. Most patients who require repeat treatment do so because biomechanical factors or training errors were not adequately addressed after the initial course.

Do I need a referral for shockwave therapy?

A GP referral is not required for private shockwave therapy treatment, though many physiotherapists will request imaging or medical notes to confirm the diagnosis. If seeking NHS treatment, referral requirements vary by trust, so check with your GP or local musculoskeletal service about their specific pathway.

Works cited
  1. Shockwave Therapy - St George's University Hospitals NHS ..., accessed on October 8, 2025, https://www.stgeorges.nhs.uk/service/therapies/musculoskeletal-outpatient-physiotherapy/shockwave-therapy/
  2. Managing pain with shockwave therapy | King Edward VII's Hospital, accessed on October 8, 2025, https://www.kingedwardvii.co.uk/health-hub/managing-pain-with-shockwave-therapy
  3. Shockwave Therapy | Fay Pedler Physiotherapy Clinic, accessed on October 8, 2025, https://www.faypedlerclinic.co.uk/shockwave-therapy
  4. Shockwave Therapy - WWL NHS Foundation Trust, accessed on October 8, 2025, https://www.wwl.nhs.uk/media/.leaflets/6110de0259d2a0.36360639.pdf
  5. Shockwave Therapy | Homerton Healthcare NHS Foundation Trust, accessed on October 8, 2025, https://www.homerton.nhs.uk/shockwave-therapy/
  6. Extracorporeal shockwave therapy (ESWT) | Kent Community Health ..., accessed on October 8, 2025, https://www.kentcht.nhs.uk/leaflet/extracorporeal-shockwave-therapy-eswt/
  7. Extracorporeal shockwave therapy (ESWT), accessed on October 8, 2025, https://www.uhcw.nhs.uk/download/clientfiles/files/Patient%20Information%20Leaflets/Trauma%20and%20Neuro%20services/Trauma%20and%20Orthopaedics/Extracorporeal%20shockwave%20therapy%20(EWST).pdf
  8. www.homerton.nhs.uk, accessed on October 8, 2025, https://www.homerton.nhs.uk/shockwave-therapy/#:~:text=This%20is%20a%20successful%20second,body%20using%20a%20special%20device.
  9. Extra Corporeal Shockwave Therapy (ESWT) for Gluteal, Patella and Achilles tendinopathy or Plantar Fasciopathy - East Sussex Healthcare NHS Trust, accessed on October 8, 2025, https://www.esht.nhs.uk/wp-content/uploads/2021/09/0932.pdf
  10. Overview | Extracorporeal shockwave therapy for refractory greater ..., accessed on October 8, 2025, https://www.nice.org.uk/guidance/ipg376
  11. Shockwave Therapy Colchester | Plantar Fasciitis Bury St Edmunds, accessed on October 8, 2025, https://www.suffolkfootandankleclinic.com/shockwave-therapy-ipswich-colchester-essex.html
  12. Difference between radial and focused shockwave therapy, accessed on October 8, 2025, https://shock-wave-therapy-london.co.uk/blog/38-difference-between-radial-and-focused-shockwave-therapy
  13. What is the best shock wave therapy for plantar fasciitis?, accessed on October 8, 2025, https://plantarfasciitistreatmentlondon.co.uk/blog/what-is-the-best-shock-wave-therapy-for-plantar-fasciitis
  14. Extracorporeal Shockwave Therapy - Patient Leaflet Repository, accessed on October 8, 2025, https://plr.cht.nhs.uk/download/1223/Extracorporeal%20shockwave%20Therapy%20A4
  15. Extracorporeal shockwave therapy for refractory greater trochanteric ..., accessed on October 8, 2025, https://www.guysandstthomas.nhs.uk/health-information/extracorporeal-shockwave-therapy-refractory-greater-trochanteric-pain-syndrome-0
  16. Radial shockwave vs Focused shockwave – Physiquipe, accessed on October 8, 2025, https://www.physiquipe.com/news/radial-shockwave-vs-focused-shockwave/
  17. Compare Radial And Focused Shock Wave Therapy For ..., accessed on October 8, 2025, https://www.shock-wave-therapy-london.co.uk/blog/41-compare-radial-and-focused-shock-wave-therapy-for-trochanteric-pain-syndrome-gluteal-tendinopathy
  18. Focused Shockwave Therapy in Central London | Fleet Street Clinic, accessed on October 8, 2025, https://fleetstreetclinic.com/focused-shockwave-therapy/
  19. Focused vs Radial Shockwave Therapy | ED & Muscle Pain, accessed on October 8, 2025, https://bodytonicclinic.co.uk/blog/focused-vs-radial-shockwave-therapy-whats-the-difference/
  20. Shockwave Therapy | Complete Physio, accessed on October 8, 2025, https://complete-physio.co.uk/services/shockwave-therapy/

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