Shockwave Therapy: Innovative Treatment for Tendinitis

The persistent pain of tendonitis that doesn't go away despite rest and conventional treatments can quickly become frustrating. You may have heard of shockwave therapy as a treatment option, but you're wondering what it actually is and whether it could help you.

As physical therapists specializing in the treatment of chronic tendinopathies, we have been using shockwave therapy for several years with encouraging results. This treatment has proven particularly effective for conditions that do not respond to traditional conservative approaches.

In this article, we’ll demystify this therapeutic technique and help you determine whether it might be right for you.

What is shockwave therapy?

Shockwave therapy is a treatment that uses high-intensity acoustic waves to stimulate the healing of damaged musculoskeletal tissue. These waves are generated by a specialized device and transmitted through the skin to the injured area, where they trigger natural repair processes in the tendon.

This medical technology, which has been in use since the 1990s, was initially developed to break up kidney stones before being adapted for the treatment of musculoskeletal disorders. Today, it is a proven treatment option for various chronic tendon conditions.

There are two main types of shock waves used in physical therapy:

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 particularly suitable for superficial conditions such as plantar fasciitis, epicondylitis (tennis elbow), or Achilles tendinitis, where the targeted tissues are located at a depth of 3 to 4 centimeters.

Focused shock waves are generated inside the applicator and then concentrated on a specific point using an acoustic lens. These waves can penetrate up to 12 centimeters deep without losing energy, allowing for precise targeting of deep-seated structures. They are the treatment of choice for tendon calcifications, lesions near bone, or deep tissues that are difficult to access.

In many cases, combining both types of shock waves in a single treatment plan allows for simultaneous treatment of both superficial and deep tissues, resulting in optimal outcomes.

How does shockwave therapy work?

Shock waves act on several physiological mechanisms simultaneously to promote the healing of damaged tendons.

The first effect is local pain relief. Repeated acoustic pulses stimulate the release of endorphins, natural pain-relieving substances produced by the body. This mechanism explains why many patients experience pain relief even during the treatment session. The pain-relieving effect also helps break the pain-tension-pain cycle that often perpetuates chronic tendinopathies.

The second mechanism involves the creation of controlled micro-injuries in the tendon tissue. Contrary to what one might fear, these micro-injuries are not harmful; rather, they trigger an active healing response. The body perceives these micro-injuries as a signal that the tissue needs to be repaired, which reactivates a healing process that was often blocked in chronic tendinopathies.

The third major effect involves vascular stimulation. Shock waves cause hypervascularization and neovascularization in the treated area, meaning they increase existing blood flow and stimulate the formation of new microscopic blood vessels. This improved blood supply increases tissue oxygenation and facilitates the delivery of growth factors necessary for tendon repair.

A fourth mechanism involves the reorganization of scar tissue. Shock waves help break up adhesions and the disorganized scar tissue that often forms in chronic tendinopathies. They then promote the formation of new, better-structured, and more functional tendon tissue, with improved alignment of the collagen fibers.

Finally, for conditions involving tendon calcifications (such as certain forms of rotator cuff tendinitis in the shoulder), shock waves have a direct decalcifying effect. They gradually break down the calcium deposits, allowing the body to naturally reabsorb them over the weeks following treatment.

These multiple mechanisms of action explain why shockwave therapy is effective in treating conditions that have not responded to more conventional approaches such as rest, ice, or anti-inflammatory medications.

What conditions are treated with shock wave therapy?

Shockwave therapy is primarily used to treat chronic tendinopathies—that is, tendon problems that have persisted for more than three to six months despite conservative treatments. Scientific research shows success rates ranging from 60% to 80% for these conditions, with particularly promising results for certain specific conditions.

Plantar fasciitis is one of the primary indications for this treatment. High-quality studies demonstrate marked effectiveness in reducing heel pain and improving function. Patients suffering from this inflammatory condition of the plantar fascia often report significant relief after 3 to 4 sessions of radial shockwave therapy.

Shoulder tendinopathies also respond well to this treatment, particularly rotator cuff tendinitis, calcific tendinitis, and impingement syndrome. For tendon calcifications in the shoulder, focused shock waves can gradually break down calcium deposits while relieving pain and improving mobility.

Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow) are conditions in which shockwave therapy has been shown to be more effective than placebo treatments. Meta-analyses confirm a significant reduction in pain and an improvement in function, particularly with radial shockwave therapy.

Patellar tendinopathy (jumper's knee) frequently affects athletes who participate in sports involving repeated jumping. Although results vary more widely than with plantar fasciitis, many patients experience an improvement in their symptoms with this treatment, especially when combined with a supervised program of eccentric exercises.

Achilles tendinopathy can also be effectively treated with shock waves, particularly in its insertion form (where the tendon attaches to the calcaneus). Focused shock waves are sometimes preferred for this condition due to the depth of the tendon.

Other conditions treated include tibial periostitis (shin splints), trochanteric bursitis of the hip, gluteus medius tendinopathy, and iliotibial band syndrome. In some cases, shock waves are also used to accelerate the healing of stress fractures or to treat pseudarthrosis (fractures that do not heal).

It is important to note that the effectiveness of shock wave therapy varies depending on the condition being treated and the patient’s individual characteristics. For conditions that have been present for less than six months, when the diagnosis is well established and treatment parameters are appropriately adjusted, success rates reach 75 to 80%. Results tend to be less predictable for extremely chronic conditions (more than 12–24 months) or severe tendinopathies with significant partial tears.

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What happens during a shockwave therapy session?

Understanding how a session works can help you prepare for it and know what to expect.

The initial assessment begins with a discussion with your physical therapist to review your medical history, your current symptoms, and any treatments you have already tried. The therapist then examines the affected area to pinpoint the exact location of the pain and assess your range of motion. This step is crucial because the success of the treatment depends largely on accurately targeting the injured area.

The patient is usually positioned on a treatment table in a comfortable position that provides good access to the area to be treated. For Achilles tendinitis, for example, you will lie on your stomach with your feet hanging off the edge of the table. For elbow tendinitis, you will sit with your arm resting on a support.

Next comes the application of the gel. As with an ultrasound scan, a conductive gel is applied to the skin in the treatment area. This gel ensures optimal transmission of the sound waves to the deep tissues by eliminating the air between the applicator and the skin.

The treatment itself involves moving the applicator (which looks like a large ultrasound probe) over the affected area for 5 to 10 minutes. The device emits rhythmic pulses that you will hear and feel. The physical therapist adjusts the intensity gradually, starting gently and then increasing it based on your tolerance. Most patients describe the sensation as small taps or repeated percussions in the muscle or tendon.

The sensation during treatment varies considerably from person to person and depends on the condition being treated. Some patients feel only pressure or vibration, while others experience mild to moderate discomfort. Areas that are very inflamed or sensitive are generally more uncomfortable during the first few sessions. The intensity of the discomfort often decreases over the course of the sessions as the inflammation subsides. It is important to communicate with your therapist during treatment so they can adjust the intensity as needed.

Immediately after the session, the treated area may appear slightly red or feel tender to the touch. Some patients experience immediate pain relief due to the analgesic effect of the released endorphins, while others may feel sore for 24 to 48 hours, similar to the sensation after intense exercise. These reactions are normal and are part of the healing process.

The number of sessions required varies depending on the condition and its severity. The typical treatment plan consists of 3 to 5 sessions, each spaced one week apart. This weekly schedule allows the tissue to respond to the treatment between sessions. After each session, your physical therapist will reassess your symptoms and adjust the treatment plan as needed. Some conditions respond after just 2 sessions, while others require up to 6 sessions for optimal results.

Between sessions, you will typically receive recommendations to help you heal as effectively as possible. These may include making temporary adjustments to your daily activities, performing progressive therapeutic exercises, applying ice as needed, and avoiding certain activities that could irritate the treated area. Following these recommendations between sessions maximizes your chances of success.

FAQ on Shockwave Therapy

Does shockwave therapy hurt?

Most patients describe the sensation as tolerable discomfort rather than severe pain. The level of discomfort depends on several factors: the sensitivity of the treated area, the degree of inflammation present, and the intensity of the treatment. The first few sessions are often the most uncomfortable because the tissues are still very sensitive. The discomfort generally decreases during subsequent sessions. If the sensation becomes too unpleasant, your physical therapist can adjust the intensity at any time. Unlike an injection, no anesthesia is required.

How long until I see results?

Results vary considerably from person to person. Some patients report relief within the first few days following the initial session, thanks to the immediate pain-relieving effect. However, significant improvements resulting from tissue healing mechanisms generally take 3 to 12 weeks to fully manifest. Scientific studies typically evaluate results at 3 and 6 months post-treatment. It is important not to expect instant healing: tendon repair is a gradual process that requires patience.

What are the possible side effects?

The side effects of shockwave therapy are generally minor and temporary. The most common include: skin redness (in 21% of cases), bruising (3% of cases), localized swelling (less than 5% of cases), and temporary increased sensitivity in the treated area. These side effects usually disappear within 36 to 48 hours after treatment. Unlike anti-inflammatory drugs or cortisone injections, shock waves do not cause systemic side effects (those affecting the entire body). Serious complications are extremely rare when the treatment is administered correctly.

What are the contraindications?

There are certain situations in which shockwave therapy is contraindicated. Absolute contraindications include: pregnancy, blood clotting disorders or the use of anticoagulants, the presence of cancer or a tumor near the treatment area, active infections, and the presence of venous thrombosis. Areas near joint prostheses, pacemakers, or electronic implants must be avoided. In growing children and adolescents, shock waves must not be applied directly to growth plates. Major nerves and blood vessels must also be avoided. Your physical therapist will conduct a comprehensive medical screening before beginning treatment to ensure it is safe for you.

How much does a shockwave therapy session cost?

The cost of a shockwave therapy session varies by region and clinic, but generally ranges from $60 to $120 per session in Quebec. Since this is a physical therapy treatment, shockwave therapy sessions may be partially or fully covered by your private insurance, depending on the coverage limits of your policy for physical therapy treatments. The RAMQ (Quebec’s public health insurance) does not cover this treatment. It is recommended that you check with your insurer before beginning treatment. Some clinics offer packages for multiple sessions, which can reduce the cost per treatment.

Does shockwave therapy replace exercise?

No, shockwave therapy should be viewed as a complement to therapeutic exercises, not as a replacement. Shockwaves can accelerate the healing process and reduce pain, but they do not strengthen the tendon or correct the biomechanical factors that contributed to the injury. A progressive exercise program supervised by a physical therapist remains essential for: strengthening the healed tendon, restoring full function, preventing recurrence, and correcting muscle imbalances. The combination of shockwave therapy and exercise generally yields better results than either one alone.

Can shock waves break up calcifications?

Yes, one of the mechanisms of action of shock waves is precisely their ability to break down tendon calcifications. Focused shock waves are particularly effective at this decalcification process. They gradually break down calcium deposits into small fragments that the body can then naturally reabsorb through normal metabolic processes. This process of fragmentation and resorption usually takes several weeks to a few months. Imaging studies (X-rays or ultrasounds) performed a few months after treatment often show a significant reduction or complete disappearance of the calcifications, accompanied by an improvement in symptoms.

Can I continue my activities after a session?

Post-treatment recommendations vary depending on the condition being treated and the intensity of the treatment. In general, it is advisable to avoid strenuous activities or movements that place significant stress on the treated area for 24 to 48 hours after each session. This allows the tissue time to respond positively to the treatment without being subjected to excessive mechanical stress. Light activities and gentle movements are generally permitted. Your physical therapist will provide specific guidelines tailored to your situation. After the full course of treatment, a gradual return to full activities is planned based on the progression of your symptoms and the healing of the tendon.

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

If you don’t see any improvement after a full course of treatment (usually 4 to 5 sessions), there are several options available to you. Your physical therapist may first re-evaluate your condition to ensure that the initial diagnosis was correct and that other factors aren’t contributing to your symptoms. Other treatment modalities may be considered, such as platelet-rich plasma (PRP) injections, cortisone injections (though less favorable for tendons in the long term), dry needling, or Class IV laser therapy. In some cases, a consultation with a medical specialist (orthopedic surgeon or physiatrist) may be recommended to explore other options, including surgery if the condition is severe and disabling.

Our physical therapists can assess your condition and provide you with a personalized treatment plan.

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Next Steps

If you suffer from chronic tendinopathy that has not responded to standard conservative treatments, shockwave therapy may be a suitable option for you. This treatment is particularly effective for conditions such as plantar fasciitis, shoulder tendinitis, patellar tendinitis, and epicondylitis.

At Physioactif, our physical therapists are trained to incorporate shockwave therapy into a comprehensive treatment plan that also includes therapeutic exercises, patient education, and other modalities as needed. We use state-of-the-art equipment and evidence-based protocols to optimize your results.

If you recognize yourself in the conditions described in this article and would like to know if shockwave therapy could help you, please feel free to schedule an appointment at one of our five clinics in the Greater Montreal area. During your initial evaluation, we will work with you to determine whether this approach is right for your specific situation.

To learn more about our comprehensive approach to treating sports injuries, visit our page on sports physical therapy. If you’re specifically experiencing shoulder or knee pain, our comprehensive guides can provide you with detailed information about your condition.

Recovering from chronic tendinopathy requires patience and a multimodal approach. Shockwave therapy, combined with an appropriate exercise program and adjustments to your daily activities, can help you regain normal function and return to the activities you enjoy.