Shockwave therapy, also known as ESWT (Extracorporeal Shockwave Therapy), is an increasingly popular treatment option in sports medicine for chronic tendinopathies and other musculoskeletal conditions that have not responded to first-line conservative care. This non-invasive approach uses high-energy acoustic waves to stimulate the body's natural tissue repair mechanisms. This complete guide explains how shockwave therapy works, what conditions it treats, and what to expect during treatment.
How does shockwave therapy work?
Extracorporeal shock waves are very high-intensity acoustic waves that pass through tissue without causing superficial damage, but release their energy in a focused manner at a predetermined depth. Their mechanical action produces several biological effects:
- Neovascularization: stimulation of new blood vessel formation in the tendon, improving oxygen and nutrient supply
- Calcification destruction: mechanical fragmentation of calcium deposits in soft tissue (particularly effective for shoulder calcifications)
- Fibroblast stimulation: activation of collagen-producing cells, promoting tissue reconstruction
- Substance P reduction: decrease in the pain chemical mediator, providing symptomatic relief
- Reinitiation of controlled inflammatory process: in a chronic tendinopathy, the healing process is « stuck » in a quiescent degenerative state. The shockwave causes a temporary acute local inflammation that « reactivates » the body's natural healing cascade
There are two main types of shockwave:
Focused shockwaves
Focused waves concentrate acoustic energy at a precise point at a variable depth, allowing targeting of deep structures (deep tendons, bone). Primarily used for hip tendinopathies, shoulder calcifications, and certain pubalgias.
Radial shockwaves
Radial waves disperse in a fan pattern from the application point and treat larger but more superficial areas. They are more commonly used first-line for conditions such as plantar fasciitis, lateral epicondylitis (tennis elbow), and Achilles tendinopathy. They are generally less expensive and the equipment is more accessible.
The difference between the two is primarily a matter of energy and penetration depth. The choice depends on the location of the pathology and the sports medicine physician's prescription.
Conditions treated with shockwave therapy
ESWT is primarily used for chronic musculoskeletal pathologies that have responded inadequately to first-line conservative treatment (physical therapy, rest, medication). The main indications include:
Lateral epicondylitis (tennis elbow)
Lateral epicondylitis is one of the most studied and documented indications for shockwave therapy. Many controlled studies demonstrate significant pain and function improvement after 3 to 5 ESWT sessions. Clinique Sport Santé Laurentides uses shockwave as a therapeutic option for epicondylitis resistant to physical therapy. See our complete guide to lateral epicondylitis.
Plantar fasciitis and heel spur
Plantar fasciitis persisting beyond 6 months despite conservative treatment is a prime indication for ESWT. Shockwave therapy can help dissolve micro-calcifications under the fascia and significantly reduce heel pain.
Achilles tendinopathy
Achilles tendinopathies, whether insertional or mid-body, respond favorably to ESWT when an eccentric physical therapy program has not been sufficient. Pain at the heel and posterior ankle can improve in 3 to 5 sessions.
Shoulder calcifications (calcific tendinopathy)
Calcifications in the rotator cuff tendons, particularly the supraspinatus, respond very well to focused shockwaves. The mechanical energy progressively fragments the calcification, which is then resorbed by the body.
Other indications
- Iliotibial band syndrome (runner's knee)
- Pubalgia (groin and pubic pain)
- Hamstring tendinopathy
- Patellar tendinopathy (jumper's knee)
- Plantar fasciitis with heel spur
Tendinopathy in general is the most common condition treated with shockwave. See our complete guide to tendinopathy for a detailed understanding.
What to expect during a shockwave session
Each shockwave session typically lasts 15 to 20 minutes. The standard protocol is 3 to 5 sessions, spaced 5 to 7 days apart. The number of sessions depends on the condition being treated and the clinical response. Dr. Labrecque-Sauvé evaluates treatment response at each visit and adjusts the protocol as needed.
Session procedure
During the session, the patient is typically lying down or seated depending on the area being treated. The physician locates the painful area by palpation and/or MSK ultrasound, applies conductive gel to the skin (as for an ultrasound exam), then applies the applicator head to the target area. The device delivers acoustic impulses in a controlled manner. Most patients will feel « percussive » impulses during treatment — an uncomfortable sensation but generally well tolerated.
After the session
It is recommended to avoid high-impact activities or intensive use of the treated area for 24 to 48 hours after the session. Mild discomfort or redness at the application site is possible and usually disappears within a few hours. It is particularly important not to take anti-inflammatory drugs (such as ibuprofen or naproxen) during shockwave treatment — these antagonize the controlled inflammatory process that the shockwave intentionally triggers to stimulate healing. Acetaminophen is acceptable if an analgesic is needed.
Frequency and number of sessions
The classic protocol is 3 to 5 sessions, once per week. For shoulder calcifications, some intensive protocols use 3 sessions on 3 consecutive days. Frequency and intensity are adapted to each patient by the sports medicine physician. Most patients begin to feel relief after 2 to 3 sessions, with maximum improvement typically achieved 4 to 6 weeks after the last session.
Effectiveness and clinical evidence
Clinical evidence regarding ESWT effectiveness for musculoskeletal pathologies is generally positive. Several meta-analyses and systematic reviews have been published on the topic.
Success rates
Clinical studies report success rates of 70 to 80 % for chronic tendinopathies that have not responded to initial conservative treatment. The literature shows particularly good results for:
- Lateral epicondylitis: a meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy (2020) demonstrates significant ESWT effectiveness for lateral epicondylitis, with pain reduction superior to placebo and comparable to other conservative interventions
- Plantar fasciitis: a 2020 systematic review in the Journal of Foot and Ankle Research concludes that ESWT offers results superior to placebo with significant pain reduction at medium term (3 to 6 months)
- Shoulder calcifications: ESWT is considered an effective alternative to surgery for hard shoulder calcifications
Duration of effects
The effect of ESWT is generally durable, with most patients experiencing sustained improvement for 6 to 12 months. Maintenance sessions may be recommended in some cases.
Benefits and limitations
ESWT offers several advantages over other therapeutic options, but also has some limitations to consider.
Benefits compared to cortisone
Cortisone injection offers rapid relief but does not modify the underlying degenerative process. ESWT, on the other hand, aims to stimulate tissue regeneration. Cortisone can weaken tendons if repeated; ESWT does not carry this risk. ESWT can be particularly interesting for patients who have responded inadequately to cortisone or who wish to avoid repeated injections. See our complete guide to cortisone infiltration to compare options.
Benefits compared to PRP
PRP (Platelet-Rich Plasma) is another biological option for chronic tendinopathies. Comparatively, ESWT is generally less expensive, requires only one type of medical procedure (no lab visit to draw blood), and the evidence base for some indications is more robust. PRP may still be preferred in certain clinical situations. See our complete guide to PRP injection.
Non-invasive with rapid recovery
One of the main advantages of ESWT is its non-invasive nature. No surgery, no general anesthesia required, no incision. Treatment is performed in an outpatient clinic and the patient can return to normal daily activities after the session.
Limitations
- Variable results depending on the condition and patient
- May require multiple sessions (thus multiple medical visits)
- Not recommended for all conditions
- Often not covered by standard insurance in Quebec
Contraindications and side effects
ESWT is contraindicated in the following situations:
- Pregnancy: the effects of shockwaves on the fetus are not established — treatment is contraindicated in pregnant women
- Coagulation disorders or patients on anticoagulants (warfarin, apixaban, etc.) — increased bleeding risk
- Implants near the area to be treated: joint prostheses, plates, screws, pacemakers in direct proximity
- Active infections in the treatment area
- Growth plates (children and adolescents) — shockwaves should not be applied to active growth plates
- Tumor pathologies in the treatment area
- Severe neurological or vascular disorders in the treated area
Possible side effects
ESWT side effects are generally minor and temporary:
- Pain or discomfort during and after the session — generally well tolerated
- Redness or mild swelling at the application site — disappears in a few hours to a few days
- Mild local bruising — rare but possible
At Clinique Sport Santé, Dr. Labrecque-Sauvé evaluates each patient before treatment to ensure there are no contraindications and to discuss potential side effects.
Frequently asked questions about shockwave therapy
What does ESWT stand for?
ESWT stands for Extracorporeal Shockwave Therapy. The term « extracorporeal » means that the waves are generated outside the body (by a device) and applied to the body — without incision or surgery.
How many shockwave sessions are needed?
The standard protocol is 3 to 5 sessions, typically spaced one week apart. Treatment response varies from patient to patient — some feel relief after the first session, others need all sessions before noting significant improvement. Optimal results are typically observed 2 to 4 weeks after the last session.
Is ESWT effective for all tendinopathies?
ESWT has demonstrated effectiveness for several chronic tendinopathies, particularly lateral epicondylitis, plantar fasciitis, Achilles tendinopathy, and shoulder calcifications. Results may vary depending on the condition, its chronicity, and individual patient characteristics. An evaluation by a sports medicine physician is recommended to determine whether ESWT is appropriate for your condition.
Is shockwave therapy painful?
Treatment can be uncomfortable — most patients describe a sensation of « percussion » or « hammering » in the treated area. Discomfort is generally short-lived and the majority of patients tolerate it well. Intensity can be adjusted by the practitioner to maintain patient comfort while delivering an effective therapeutic dose.
What is the insurance coverage in Quebec?
ESWT coverage by insurance varies by plan. The CNESST (Commission des normes, de l'équité, de la santé et de la sécurité du travail) sometimes covers treatment for work-related injuries. Some private insurance plans may also cover a portion of costs. It is recommended to check with your insurer before treatment. The total cost of treatment and payment options will be discussed during the initial consultation with Dr. Labrecque-Sauvé.
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