Shockwave Therapy: Evidence-Based Treatment for Chronic Tendinopathy
Shockwave Therapy: Evidence-Based Treatment for Chronic Tendinopathy
Chronic tendon pain — such as Achilles tendinopathy, tennis elbow, or plantar fasciitis — can be
notoriously resistant to rest, medication, and conventional rehabilitation.
Increasingly, clinicians are
turning to Extracorporeal Shock Wave Therapy (ESWT) as an important tool in the management of
these persistent conditions.
What Is Shockwave Therapy?
ESWT is a non-invasive regenerative treatment that applies high-energy acoustic waves to injured
soft tissues. These waves create rapid fluctuations in pressure that stimulate mechanical, chemical,
and cellular responses within the tendon, initiating a healing cascade that conventional rest cannot
achieve.
Mechanisms of Action
Recent reviews in the Journal of Clinical Orthopaedics and Trauma (Simplicio et al., 2020) and related
studies have described several well-documented biological mechanisms through which ESWT
promotes recovery:
- Mechanotransduction for cell activation and tissue repair: Shockwave therapy converts
mechanical pressure into biochemical signals, stimulating the cells to produce and multiply
type I collagen, which is the main structural protein that gives tendons their strength. Over
time, this helps the tendon tissue reorganize and repair itself. - Reduced Inflammation and faster Healing (Inflammation Modulation)
Low-energy shockwaves can help shift the body’s immune response from an inflamed state
to a healing one. They encourage inflammatory cells (called macrophages) to move from a
“pro-inflammatory” type (M1) to a “repair and recovery” type (M2). This helps calm
irritation and inflammation, clear damaged tissue, and support tissue regeneration. - Improved Circulation and Blood Vessel Growth (Angiogenesis)
Shockwave therapy stimulates the release of natural growth factors such as VEGF, eNOS,
and BMP-2, which help new blood vessels form in the treated area. Better blood flow means
more oxygen and nutrients reach the tendon — essential for recovery, especially in tendons
that typically have a poor blood supply. - Pain Relief and Nerve Regulation (Neurogenic Effects)
The treatment also acts on the nerves that carry pain signals. It reduces certain chemicals
involved in pain transmission (like substance P and CGRP) and activates the body’s own
pain-control system. This helps to decrease pain sensitivity and provides longer-lasting relief. - Tissue Remodelling: By generating controlled microtrauma, ESWT restarts the healing
process in degenerative tendon tissue, encouraging proper collagen alignment and
functional recovery.
Clinical Outcomes
Multiple randomized controlled trials and meta-analyses have confirmed that ESWT leads to
significant reductions in pain (VAS) and improvements in functional scores for chronic
tendinopathies, confirming its role as a first-line conservative intervention before surgical
consideration.
In plantar fasciitis, a 2020 study from the Universidad Federal de São Paulo demonstrated notable
pain and function improvements within 3–12 weeks after a single session of focused ESWT.
.
Treatment Approach
In clinical practice, ESWT is typically applied once weekly for 3–6 sessions, using either focused or
radial shockwaves depending on the tissue depth and target area. Treatment parameters (energy
flux density, pulse frequency, and total impulses) are individualized according to patient tolerance
and pathology stage.
While ESWT alone can produce substantial pain relief, integrating progressive load-based
rehabilitation is essential for long-term tendon adaptation. Treatment protocols often combine
ESWT with isometric, eccentric, and heavy slow resistance exercises to restore tendon capacity and
prevent recurrence.
Summary
Extracorporeal Shock Wave Therapy represents a scientifically proven, non-invasive option for
chronic tendinopathy management. By activating tissue regeneration pathways, enhancing
vascularization, and providing pain relief without pharmacological intervention, ESWT helps restore
tendon structure and function — enabling a safe and lasting return to activity.
References
1.Simplicio, C. L., Purita, J., urrell, W., Silva Santos, G., dos Santos, R. G., & Duarte Lana, J.
F. S. (2020). Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative
medicine. Journal of Clinical Orthopaedics and Trauma, 11(Suppl 2), S309–S318.
2. Leão, R. G., Schutzer, M. E., Neto, F. S., & Tavares, R. L. (2020). Effectiveness of Shockwave
Therapy in the Treatment of Plantar Fasciitis. Acta Ortopédica Brasileira, 28(1), 7–10.
3. Sun, J., Gao, F., Wang, Y., Sun, W., Jiang, B., & Li, Z. (2020). Shock-wave therapy versus
ultrasound therapy for plantar fasciitis: A meta-analysis of randomized controlled trials. BMC
Musculoskeletal Disorders, 21(1), 51.
4. Wang, C.-J., Wang, F.-S., Yang, K. D. (2003). Biological effects of extracorporeal shockwave in
bone and tendon repair. International Journal of Surgery, 1(1), 43–50.
5. Vetrano, M., d’Alessandro, F., Torrisi, M. R., Ferretti, A., Vulpiani, M. C., & Visco, V. (2011).
Extracorporeal shock wave therapy promotes cell proliferation and collagen synthesis of
primary cultured human tenocytes. Knee Surgery, Sports Traumatology, Arthroscopy, 19(12),
2159–2168.
6. Gerdesmeyer, L., et al. (2023). The state of extracorporeal shockwave therapy for myofascial
pain syndrome—A scoping review and a call for standardized protocols. Life, 15(10), 1501
For More Help:
For more information and help, please contact Hesti at the Paarl Branch.
Hesti Steyn
Physiotherapist & Practice Owner
How can Potgieter & Partners Physiotherapists Help You?
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