Shockwave treatment for tendinopathy & plantar fasciitis – Does it work?

Maryke Louw
2 days ago
9 min read

If shockwave treatment is used correctly for a tendinopathy or plantar fasciitis, it might help to speed up the healing process. However, it is not a silver bullet. Learn how shockwave therapy works, how NOT to use it, and what else you need to do to get your tendinopathy or plantar fasciitis to recover fully.

Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call.

A therapist doing shockwave treatment on someone's Achilles tendon and the words: Does shockwave therapy work? Tendinopathy & Heel Pain

In this article:

Types of shockwave therapy
How shockwave is thought to help recovery
Does shockwave treatment work?
Why wait three months before using shockwave?
What type of shockwave therapy is most effective?
How many sessions should you have and how often?
Side effects and what to do about them
Additional treatments matter
How we can help

If you’re wondering why I’ve lumped tendinopathy and plantar fasciitis together in this article, it’s because the injury process is pretty similar. The plantar fascia isn’t a tendon, but it’s mainly made up of collagen, which is also the main building block of tendons. In general, the same treatments that work for tendinopathies also tend to work well for plantar fasciitis.

Types of shockwave therapy

Clinics use three types of shockwave therapy:

Radial shockwave therapy is the most common type. It produces a pressure pulse that spreads outward from the applicator – with the highest energy at (or near) the skin surface and a rapid loss of energy as it goes deeper. It’s generally used for targets close to the skin (up to 3–3.5 cm deep) and/or larger treatment areas.
Focused shockwave therapy generates a wave that is focused on a small zone at a selected depth, allowing greater penetration and more precise delivery than radial devices. The effective treatment depth varies by device but might be as deep as 12 cm.
Soft-focused (or defocused) shockwave therapy is delivered over a wider treatment zone rather than concentrated on a small focal point (as with focused shockwave) or dispersing more superficially, like radial shockwave devices. So, it sits somewhere between radial and focused shockwave therapy.

You might also see the term “extracorporeal shockwave therapy” used in research – it’s an umbrella term for all types of shockwave therapy. It simply means they used a device that generates sound waves outside the body and delivers them through the skin to influence tissue healing and pain pathways.

How shockwave is thought to help recovery

Shockwave therapy works by sending strong sound–pressure pulses into your tissues. Scientists don’t know every detail yet, but there are a couple of theories about why these pulses might help injuries to recover.

One of the main theories is that the pulses “wake up” cells and push the body into repair mode. For tendinopathy specifically, research suggests it might stimulate tendon and support cells (including stem cells) to switch on repair signals, increase collagen-building activity, reduce tissue-breakdown, and encourage the tendon to remodel damaged tissue into a healthier structure over time.

But there’s also evidence that shockwave might have a more direct effect on pain nerves. It’s thought that it might reduce tendon pain not only by stimulating tissue healing, but also by changing how pain nerves and pain-related chemicals behave – possibly helping to “dial down” an over-sensitive nervous system that keeps chronic pain going.

There’s also evidence that both focused and radial shockwave therapy can help to break up calcifications and improve healing in cases of calcific tendinopathy.

A man receiving shockwave therapy on his shoulder. — The research shows that shockwave therapy can help to treat calcific tendinopathy.

Does shockwave treatment work?

💡 The short answer is yes. Research suggests that shockwave therapy can reduce pain and improve recovery, but it doesn’t work for everyone.

The research-based recommendations are that shockwave should:

only be used for tendinopathies and plantar fasciitis that have lasted longer than three months and aren’t improving as expected
not be seen as a standalone treatment but used alongside an exercise-based rehab plan that strengthens the muscles and tendons.

Specific injuries for which shockwave has been shown to help include:

👉 This doesn’t mean shockwave can’t help for other tendon injuries – these are just the ones that have been researched so far.

Why wait three months before using shockwave?

As with all injuries, overuse tendon injuries (tendinopathy or tendonitis) go through different stages of healing. When you first overwork your tendon, it is in the reactive phase – the body is reacting to the overuse by activating inflammatory and other cell processes to stimulate healing.

Plantar fasciitis and tendinopathies have the potential to heal naturally if you provide the injured area with the right mix of rest and strength training in this phase.

Shockwave is more likely to help when the body’s natural healing process have stalled, as it might help to kickstart recovery by triggering a controlled inflammatory response. If you use shockwave too early – while the injury is still very sensitive, easily irritated, and trying to heal – it often flares up excessively or simply has no obvious effect.

What type of shockwave therapy is most effective?

Most research studies have used either radial or focused shockwave therapy, and both types seem equally effective for tendinopathy and plantar fasciitis cases that aren’t associated with calcification.

For calcific tendinopathies, research suggests that a high-energy protocol using focused shockwaves – or a combination of focused and radial shockwave – might provide the most noticeable improvements in pain and calcification size.

Soft-focused shockwave is a relatively new technology and hasn’t been well researched yet, so we don’t know whether it’s effective, or how effective it might be. I could only find one study that looked at soft-focused shockwave therapy for plantar fasciitis (and none for tendinopathy), but it didn’t include a control group – which means that we can’t tell whether the treatment worked any better than a placebo (“fake” therapy) would.

How many sessions should you have and how often?

In research, the total number of treatments ranged from 1 to 11, and it usually depended on the shockwave's intensity how the patient responded.

This means therapists didn’t continue treatment if it clearly wasn’t helping, and they also stopped once they felt enough progress had been made.

💡The shortest gap between treatments was four days, but most studies used shockwave only once a week. Having a recovery period between sessions is important because it allows the body to react to the treatment and recover properly.

My own experience

In practice, I’ve found that most patients need around four treatments (once every five to seven days) to get a good response. If they haven’t had significant improvements after six sessions, they’re unlikely to respond to even more shockwave.

If a patient has seen good results after a few sessions, it can often be useful to pause shockwave treatment for two weeks and then review the situation. If they’ve continued to improve during that period, it suggests that the healing process has been sufficiently stimulated, and they probably don’t need any more sessions. At that point, I’d focus on rehab only.

Side effects and what to do about them

None of the research studies that I reviewed reported any serious side effects from shockwave. The main complaints after treatment included skin irritation, bruising, and a temporary increase in pain. This increase in pain typically occurred during the 24 hours immediately after treatment and settled with the use of pain medication.

It is normal to have pain after shockwave therapy

In my experience, it’s very common to have increased pain for a day or two after shockwave treatment. If this happens, using ice or pain medication (like paracetamol) can help.

It’s usually best to avoid strong anti-inflammatory medication during that period, because one of the aims of shockwave therapy is to trigger an inflammatory response, which can then kick-start the healing process.

However, in some cases, shockwave therapy might cause a more significant increase in pain after treatment – one that progressively gets worse rather than better. In that situation, treatment should be stopped. This type of painful reaction usually settles back down over a couple of weeks. It typically means that shockwave therapy just isn’t the right option for you.

A woman placing an ice pack on her painful tendonitis. — It is normal to experience increased pain for a couple of days after shockwave treatment.

Can shockwave therapy cause damage?

It is rare for shockwave to cause serious injuries when used in a sensible way. But, as with most treatments, shockwave therapy might cause more serious side effects when it’s used excessively – too often, at too high an intensity, for too long per session, over too long a period, or when patient feedback is ignored.

I found a case report of a woman with Achilles tendinopathy who then tore her Achilles tendon after she had been treated with ten daily sessions of radial shockwave therapy followed by physical therapy exercises and ice therapy. This is clearly a case of overtreatment!

It can also injure nerves. I once saw a patient who had sustained permanent nerve damage affecting her glutes from overusing shockwave – but this was an extreme case. The therapist had administered more than 21 sessions and ignored her complaints of worsening nerve symptoms. They were clearly not following recommended guidance.

However, there are also case reports (one, two) of patients experiencing ulnar nerve injuries after only a few sessions of shockwave.

One should also be careful when using shockwave therapy on someone with low bone density or osteoporosis, as it might cause stress fractures.

💡 Shockwave, like all treatments, is not right for every case or for every person, but serious side effects can easily be avoided when clinicians do a thorough assessment and follow the recommended guidelines.

Additional treatments matter

To give shockwave treatment the best chance of working, it’s important to look at what else you’re doing alongside it.

In many of the studies I reviewed, researchers wanted to see whether healing is faster when shockwave therapy is added to an exercise programme for hamstring or gluteal tendinopathy – but then they included exercises like hamstring or glute stretches, which we know often irritate these injuries. So, their results might have looked more positive if they’d used better evidence-based exercises that were less likely to increase pain.

We tend to advise patients to take things easy for two days after shockwave to allow the body time to react and recover. Then, they can usually ease back into their rehab exercises – and it can be useful to have a day or two of low-load exercises before returning to higher-load work. But the exact balance of exercise and rest will depend on your specific situation and what you’ve been doing up to this point.

We find that it’s important to tailor this to each patient.

How we can help

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

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About the Author

Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.