How often are you treating tendon disorders in your practice, and what’s your approach?
Rest, NSAIDs, and physical therapy are key options offered as conservative treatment. Still, the fact remains, those approaches frequently fall short, leaving many patients caught in an endless cycle of pain, limited function, and delayed recovery.
Thankfully, Extracorporeal Shockwave Therapy (ESWT) is reshaping that bleak trajectory. This evidence-based technology, supported by clinical evidence across multiple tendon types and patient populations, offers a regenerative, non-invasive option that delivers measurable and long-lasting improvements, even in cases where other modalities have failed.
For forward-thinking medical practitioners, Shockwave therapy is fast becoming a first-line treatment for tendon dysfunction. Let’s explore the scientific details below.
Tendinopathy is indicative of tendon degeneration, which is marked by collagen disruption, neovascularization, and weak mechanical integrity. Conversely, acute tendinitis is generally an inflammatory response, whereas tendinopathy is a red flag for a failed healing response at the cellular level.
High-load, poorly vascularized, and frequently overused structures define the following tendon types. Each is ideally suited to regenerative intervention with ESWT.
Below is a list of additional tendinopathies that also respond well to ESWT, although they were not the focus of early shockwave studies. Particularly in the case of failed conventional treatments, consider Shockwave for the following:
Why Tendon Pain Persists Despite Conservative Care:
There are many reasons to offer patients advanced regenerative care as an alternative treatment. All too often, traditional care falls short of providing relief, despite all the effort. Take a look at some of the limitations of conservative approaches to tendinopathy treatment:
While symptoms improve, it’s typically only a temporary reprieve. That’s because the underlying matrix pathology often remains unresolved with conservative care, which may influence the recurrence and chronicity.
Given Shockwaves' impressive clinical evidence, offering it as the new and optimal standard of care at the outset makes sense.
The therapeutic value of Extracorporeal Shockwave Therapy (ESWT) for tendon dysfunction is substantial given its ability to trigger a cascade of biological responses that facilitate tissue regeneration, pain reduction, and restoration of function.
While the exact mechanisms continue to be studied, a growing body of published clinical studies has established several reliable, clinically pertinent effects that explain its efficacy across a range of tendinopathies.
Stimulates Type I Collagen Synthesis
Healthy tendon tissue has abundant type I collagen, which provides tensile strength and encourages structural integrity. By contrast, diseased and dysfunctional tendinopathic tissue often contains disorganized type III collagen, which does not support structural integrity.
Shockwave has been proven to activate tenocytes and promote the production of type I collagen, contributing to a more functional tendon matrix and improved load-bearing capacity⁴.
Enhances Collagen Fiber Realignment
Through mechanical stimulation, ESWT supports reorganizing collagen fibers into parallel bundles, a hallmark of healthy tendon architecture. This realignment improves the tendon’s ability to absorb and transmit mechanical forces, reducing microtrauma and risk of reinjury.
Breaks Down Fibrotic Adhesions
Chronic tendinopathy often leads to the accumulation of tough fibrotic tissue and adhesions that restrict normal tendon glide. Shockwave delivers high-energy acoustic pulses that mechanically disrupt these adhesions, helping to restore mobility and reduce pain associated with mechanical impingement⁴.
Promotes Neovascularization and Lubricin Release
ESWT triggers localized neovascularization, increasing microcirculation and improving nutrient delivery to the tendon-bone interface. Additionally, Shockwave has been associated with the release of lubricin, a glycoprotein that encourages tendon glide within its sheath. These changes are particularly valuable in anatomically confined regions such as the Achilles or peroneal tendons⁵.
Modulates Pain Through Neurological Pathways
In addition to its regenerative effects, ESWT exerts neuromodulatory influence through peripheral and central mechanisms. It is believed to alter nociceptive signaling by reducing substance P and other inflammatory mediators and effectively disrupting chronic pain pathways by interfering with pain signals before they reach the brain⁴.
As the demand for non-invasive, effective treatment options grows, Shockwave continues to be viewed as a game-changing standout due to an ever-increasing body of evidence. Below, we explore noteworthy studies and clinical findings that underscore Shockwaves' value in managing tendon disorders.
The following five studies provide essential clinical evidence establishing the efficacy of Shockwave (ESWT) in treating many tendon dysfunctions.
Recommendations for Use of Extracorporeal Shockwave Therapy in Sports Medicine: An International Modified Delphi Study
Authors: Rhim HC, Singh M, Maffulli N, et al.
Publication/Journal name: British Journal of Sports Medicine (2025)
Findings: This landmark study establishes expert consensus, which confirms shockwave as a preferential and recommended treatment for various tendinopathies, including Achilles, gluteal, and lateral elbow tendinopathy (commonly known as tennis elbow). The Delphi Study outlines optimal protocols, which we will discuss in the Best Practices and Clinical Integration section.
Effectiveness of Extracorporeal Shockwave Therapy in Three Major Tendon Diseases
Authors: Carulli C, Tonelli F, Innocenti M, et al.
Journal: Journal of Orthopedic Traumatology (2016)
Findings: In a study of 311 patients with chronic Achilles tendinopathy, lateral epicondylitis, and calcific shoulder tendinitis, ESWT demonstrated a statistically significant reduction in pain and functional improvement at 12 months post-treatment.
Extracorporeal Shockwave Therapy for Patellar or Quadriceps Tendinopathy in Runners
Authors: Katz NB, Fee JP, Nowak AS, Tenforde AS
Journal: Arthroscopy, Sports Medicine, and Rehabilitation (2025)
Findings: ESWT showed similar and meaningful functional gains in both male and female runners with patellar or quadriceps tendinopathy, with most reaching clinically significant improvement.
Combined Extracorporeal Shockwave Therapy and Exercise for the Treatment of Tendinopathy
Author: Ian Burton
Journal: Sports Medicine and Health Science (2022)
Findings: Evidence indicates that combining ESWT with eccentric loading diminishes pain and improves function for Achilles, plantar, and lateral elbow tendinopathies.
Effectiveness and Safety of Shockwave Therapy in Tendinopathies
Authors: Dedes V, Stergioulas A, Kipreos G, et al.
Journal: Mater Sociomed. (2018)
Findings: Amongst 384 patients, shockwave substantially improved pain, limb function, and quality of life compared to controls.
Altogether, these featured clinical outcomes demonstrate a compelling case for shockwave as a front-line treatment for tendon disorders. As evidence continues to be discovered, clinicians can feel confident incorporating this modality into care plans, knowing it’s backed by science (not just speculation).
The Delphi Study provides international consensus on how to apply ESWT for tendon pathologies:
This study is an exceptional resource for applicable clinical insights, making incorporating Shockwave into tendon treatment and rehab essential for physicians looking for tips and best practices.
Shockwave is valued for working well with other modalities, and evidence proves that it optimizes outcomes.
Communicating with patients and educating them on setting realistic expectations and adhering to treatment plans is crucial to achieving the best possible outcomes.
When a combination protocol is being utilized, it’s important to avoid NSAIDs and anesthesia to preserve the biologic response.
The evidence is in! Shockwave is a regenerative tool offering proven impact and optimal patient outcomes.
Whether used alone or as part of a complementary approach, it elevates patient outcomes and offers a new stream of income to fuel practice growth. Clinical evidence shows it delivers meaningful and long-lasting results for various tendon disorders.
If you're intrigued by what Shockwave could do for your patients and practice, consider integrating ESWT into your tendon care continuum.
Start optimizing outcomes. Make Shockwave part of your standard tendon care.
Contact us, and we’ll connect you with a Shockwave device expert.