Shockwave Therapy: What the Science Says

You may have heard of shockwave therapy as a treatment option for tendonitis that won’t go away. This treatment has been around since the 1990s and is one of the tools used in musculoskeletal physical therapy. But it’s not a miracle cure, nor is it the primary approach used by all physical therapists.

Here is what controlled studies say about this treatment method, in which cases it can help, and how Physioactif addresses tendinopathies beyond the use of shock waves.

What is shockwave therapy?

Shockwave therapy is a treatment that uses high-intensity acoustic waves delivered through the skin to a specific area. These waves trigger a cascade of biological responses in the targeted tendon.

The technology was first developed to break up kidney stones in the 1980s and was later adapted for musculoskeletal treatment. It has been used in physical therapy for over 30 years.

There are two main types of shock waves:

Radial shock waves are generated by an accelerated projectile that strikes an applicator in contact with the skin. The energy propagates in a dispersed manner from the surface toward deeper tissues, with maximum intensity at the surface that gradually decreases. This type is generally used for superficial conditions such as plantar fasciitis or Achilles tendinitis, where the targeted tissues are located 3 to 4 cm deep.

Focused shock waves are concentrated on a specific point using an acoustic lens. They can penetrate up to 12 cm deep without losing their energy. They are the treatment of choice for tendon calcifications or deep structures.

How does shockwave therapy work?

Shock waves act on several physiological mechanisms simultaneously.

Local analgesia. Repeated acoustic pulses stimulate the release of endorphins, which may explain why relief is sometimes felt immediately after a session. The analgesic effect helps break the pain-tension cycle that perpetuates certain chronic tendinopathies.

Creation of controlled micro-injuries in the tendon tissue. These micro-injuries are not harmful; rather, they trigger an active healing response. The body perceives these micro-injuries as a signal to repair the tissue, which reactivates a process that is sometimes stalled in chronic tendinopathies.

Vascular stimulation. Shock waves induce hypervascularization and neovascularization: they increase blood flow and stimulate the formation of new capillaries. This improved blood supply facilitates the delivery of the growth factors necessary for tissue repair.

Reorganization of scar tissue. Shock waves help break up adhesions and disorganized scar tissue that forms in chronic tendinopathies, and promote better alignment of collagen fibers.

For tendon calcifications (such as certain forms of rotator cuff tendinitis), shock waves have a direct decalcifying effect. They gradually break down the calcium deposits, which the body then reabsorbs over the following weeks.

It is important to note that these mechanisms have been documented in laboratory settings, and clinical studies show real but variable benefits. The magnitude of the effect depends on the condition, the protocol, and the combination with other interventions, particularly exercise.

What conditions are examined in the literature?

Shockwave therapy has primarily been studied for chronic tendinopathies—that is, tendon problems that have persisted for more than three to six months. According to meta-analyses, reported success rates range from 60% to 80%, depending on the condition.

Plantar fasciitis is one of the best-documented indications. Several randomized controlled trials have demonstrated a reduction in heel pain and an improvement in function after 3 to 4 sessions of radial shockwave therapy, compared to placebo.

Shoulder tendinopathies also respond well to treatment, particularly calcific tendinitis. In cases of calcifications, focused shock waves can break up the calcium deposits and improve mobility in the majority of cases.

Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow) show greater efficacy than placebo in meta-analyses, particularly with radial shock waves.

Patellar tendinopathy (jumper's knee) responds to treatment in varying degrees. The best results are achieved when shockwave therapy is combined with a supervised program of eccentric exercises.

Shockwave therapy can be beneficial for Achilles tendinopathy, especially in its insertion form. Here too, the effect is more pronounced when combined with an exercise program.

Other conditions studied include tibial periostitis, trochanteric bursitis, gluteus medius tendinopathy, and iliotibial band syndrome. For stress fractures and pseudarthrosis, certain specialized medical indications exist.

Effectiveness varies depending on the chronicity of the condition, the quality of the diagnosis, and the precision of the treatment approach. For tendinopathies that have been present for less than six months, with a clear diagnosis and an appropriate treatment protocol, success rates are higher. For very chronic conditions (lasting more than 12 to 24 months) or significant partial tears, outcomes are less predictable.

What happens during a shockwave therapy session?

Understanding how a session works can help you know what to expect.

The initial assessment begins with a discussion of the patient's medical history, current symptoms, and previous treatments. The physical therapist examines the affected area to identify tender points and assess range of motion. The success of the treatment depends largely on precise targeting.

The patient is positioned on an examination table in a position that provides good access to the area to be treated.

Applying the conductive gel to the skin allows sound waves to be transmitted to deep tissues.

The treatment involves moving the applicator over the affected area for 5 to 10 minutes. The device emits audible rhythmic pulses. The intensity is gradually adjusted based on tolerance. The sensation is generally described as small taps or repeated percussions.

The sensation varies from person to person. Some people feel only slight pressure, while others experience moderate discomfort. Areas with severe inflammation are often more sensitive during the first few sessions. The discomfort tends to decrease as the sessions progress.

Immediately afterward, the area may be slightly red or tender. Some people feel immediate relief, while others experience soreness for 24 to 48 hours. These reactions are normal.

The usual number of sessions is 3 to 5, spaced one week apart. Some conditions respond after 2 sessions, while others require up to 6.

Between sessions, recommendations are provided to promote healing: temporary adjustments to daily activities, therapeutic exercises, and applying ice as needed.

FAQ on Shockwave Therapy

Does shockwave therapy hurt?

Most people describe the sensation as tolerable discomfort rather than severe pain. The level of discomfort depends on the sensitivity of the area, the degree of inflammation, and the intensity setting. The first few sessions are often the most uncomfortable. The intensity can be adjusted at any time. No anesthesia is required.

How long until I see results?

Results vary. Some people report relief within the first few days due to the pain-relieving effect. Improvements related to tissue healing generally take 3 to 12 weeks. Studies typically assess results 3 and 6 months after treatment.

What are the possible side effects?

Side effects are generally minor and temporary: skin redness (about 21% of cases), small bruises (3%), local swelling (less than 5%), and temporary increased sensitivity. These effects disappear within 36 to 48 hours. Unlike anti-inflammatory drugs or cortisone, shock waves have no systemic effects. Serious complications are rare.

What are the contraindications?

Absolute contraindications include pregnancy, bleeding disorders or the use of anticoagulants, the presence of cancer or a tumor near the treatment area, active infections, and venous thrombosis. Areas near joint replacements, pacemakers, or electronic implants should be avoided. In growing children, shock waves are not applied to growth plates. A medical screening is performed prior to any treatment.

How much does a shockwave therapy session cost?

The cost varies by clinic, generally ranging from $60 to $120 per session in Quebec. Since this is a physical therapy treatment, some private insurance plans cover it partially or fully, depending on your policy. The RAMQ does not cover this treatment.

Does shockwave therapy replace exercise?

No. Shock waves can reduce pain and promote healing, but they do not strengthen the tendon or correct the biomechanical factors that contributed to the injury. A supervised progressive exercise program remains essential for strengthening the tendon, restoring full function, preventing recurrence, and correcting imbalances. The combination of shockwave therapy and exercise generally yields better results than either approach alone.

Can shock waves break up calcifications?

Yes. Focused shock waves are particularly effective for this purpose. They gradually break down calcium deposits into fragments that the body reabsorbs. The process takes anywhere from several weeks to several months. Follow-up X-rays often show a reduction or disappearance of the calcifications.

Can I continue my activities after a session?

It is generally recommended to avoid strenuous activities that put strain on the treated area for 24 to 48 hours. Light activities are permitted. The physical therapist will provide specific instructions based on the condition.

What should you do if shockwave therapy isn't working?

If no improvement is seen after a full course of treatment (usually 4 to 5 sessions), the diagnosis should be reevaluated. Other factors may contribute to the symptoms: muscle weakness, biomechanical issues, referred pain, or nerve damage. Other options may be considered (PRP, dry needling, injections, and in some cases, surgery). A consultation with a specialist may be recommended if the condition is severe.

Our Approach to Tendinopathies at Physioactif

At Physioactif, shockwave therapy is not our primary approach to treating tendinopathies. While it may be included in the treatment plan in certain specific cases, our work begins elsewhere: with a thorough differential diagnosis and the implementation of a progressive loading program.

First, make sure it really is tendinopathy

Several conditions mimic tendinopathy. Pain commonly referred to as “tendinitis” may actually stem from bursitis, subacromial impingement, referred pain from a deeper structure, peripheral nerve damage, or central pain associated with nervous system sensitization. If “tendinitis” that isn’t actually tendinitis is treated, the results will be disappointing regardless of the treatment method used.

Our initial assessment aims to confirm the diagnosis before proposing a plan. This step is the most critical for what comes next.

Next, progressive loading rather than simply "resting"

Tendons do not heal through rest alone. They require appropriate mechanical loading to rebuild their structure. Current scientific understanding has moved far beyond the notion that “you just need to do eccentric exercises.” The modern approach combines several phases: isometric, isometric with controlled loading, followed by the integration of functional and sport-specific movements.

The progressive training program is tailored to your tendinopathy, your pain level, your current ability, and your goals. This is what drives most of the lasting changes.

When we consider shock waves

Shockwave therapy may be appropriate in specific cases: calcific tendinitis of the rotator cuff where calcification is confirmed by imaging, chronic plantar fasciitis that does not respond after several months of active treatment, and certain refractory insertion tendinopathies. In these situations, patients may be referred for shockwave therapy as a supplement to the active treatment program, without making it the mainstay of treatment.

If you have previously undergone shockwave therapy elsewhere and the results were disappointing, it is not necessarily the treatment itself that is at fault: often, the diagnosis was inaccurate or the progressive exercise regimen was not implemented at the same time.

Products by Condition

Here are our detailed guides to the most common tendinopathies:

• Tendinopathy or tendinitis in the shoulder
• Calcific tendinitis in the shoulder
• Patellar Tendinopathy
• Patellar tendonitis or tendinopathy
• Achilles tendonitis or tendinopathy
• Gluteal muscle tendinitis or tendinopathy
• Goosefoot tendinitis or tendinopathy
• Adductor tendinitis or tendinopathy

Each guide covers the specific characteristics of the condition, differential diagnosis, the phases of active treatment, and situations in which a medical consultation or a complementary treatment such as shockwave therapy may be considered.