Extracorporeal Shockwave Therapy · Review 03
Shockwave Therapy for Other Tendinopathies: Where It Works and Where It Doesn't
Shockwave therapy has real evidence behind it for mid-portion Achilles tendinopathy, and consistently weak or negative evidence for tennis elbow and insertional Achilles pain, which is why the exact diagnosis has to come before the treatment decision.
- PROCEDURE STATUS
- Established procedure with a well-characterized safety profile; used across multiple musculoskeletal indications
- INDICATION EVIDENCE
- Established for mid-portion Achilles tendinopathy; not supported for tennis elbow or insertional Achilles pain
- REVIEW STATUS
- Clinical review required
- NEXT REVIEW
- January 2027
In short
For mid-portion Achilles tendinopathy, ESWT combined with a tendon-loading exercise program has moderate-quality trial evidence behind it. For insertional Achilles tendinopathy, and for lateral epicondylitis (tennis elbow), the trial evidence is weak at best and, for tennis elbow specifically, has been largely negative across placebo-controlled trials. The two tendons, and the two subtypes within the Achilles tendon, do not respond the same way, so the diagnosis has to be precise before shockwave therapy is offered as a reasonable option.
The clinical question
Does extracorporeal shockwave therapy (ESWT) improve outcomes in lateral epicondylitis (tennis elbow) and Achilles tendinopathy, and does efficacy differ by tendon site and disease subtype (mid-portion versus insertional)?
What is established about shockwave therapy
Extracorporeal shockwave therapy delivers focused or radial acoustic pulses through the skin to an injured tendon or area of soft tissue. As a procedure, its delivery method, general safety profile and short-term side effects (local discomfort, bruising, mild swelling) are well documented across decades of orthopedic and sports-medicine use.
That procedural familiarity is often mistaken for blanket effectiveness. ESWT is used for a wide range of tendon and soft-tissue conditions, and the strength of supporting evidence varies enormously between them. This review looks specifically at two of the most common applications outside plantar fasciitis: lateral epicondylitis (tennis elbow) and Achilles tendinopathy, and at why the Achilles findings split further depending on exactly where on the tendon the problem sits.
What the evidence shows for Achilles tendinopathy
A 2022 systematic review pooled randomized controlled trials separately for the two recognized subtypes of Achilles tendinopathy. For mid-portion disease, three RCTs were included, and the review found moderate-quality evidence that ESWT added to a tendon-loading exercise program improves VISA-A scores, the standard patient-reported measure of Achilles tendon pain and function, compared with exercise alone or other comparators.[1]
For insertional Achilles tendinopathy, where the tendon problem sits at or near its attachment to the heel bone rather than in the tendon's midsection, the same review found very-low-quality evidence and no added benefit from ESWT. The authors were explicit that pooled sample sizes in both subgroups fell short of the optimal information size needed for a confident conclusion, and that the insertional finding in particular is fragile and could change with more or larger trials.[1]
Same tendon, different disease
Mid-portion and insertional Achilles tendinopathy share a tendon and a name, but they differ in blood supply, biomechanics and how they behave in trials. Evidence supporting ESWT for one subtype does not carry over to the other, and a diagnosis of Achilles tendinopathy is not specific enough on its own to justify the treatment.
What the evidence shows for tennis elbow
The most rigorous synthesis available is a Cochrane systematic review of nine placebo-controlled randomized trials, covering 1,006 participants with lateral elbow pain. Across the pooled analyses, 11 of 13 comparisons showed no statistically significant benefit of ESWT over a sham or placebo procedure.[2]
This review dates to 2005 and has not been fully superseded by an equally rigorous, more recent systematic review in the sources available to us. That is a genuine limitation, and later individual trials have produced mixed results. But the best available systematic evidence for tennis elbow specifically points toward no meaningful advantage over placebo for most outcomes measured, which is a materially different evidence picture than mid-portion Achilles tendinopathy.[2]
What remains uncertain, and what is a negative finding
Tennis elbow is not a case of thin or inconclusive evidence waiting to be filled in. It is one of the more consistently negative applications of ESWT in orthopedic practice, based on the largest placebo-controlled synthesis available, despite the treatment's continued popularity in general clinical use. That gap between popularity and trial evidence should be stated plainly rather than smoothed over.[2]
Insertional Achilles tendinopathy sits in a different but still uncertain place. The evidence is very low quality and did not show benefit, but the trials behind that conclusion were small, and the authors themselves flagged the finding as fragile. This is not the same as saying ESWT clearly does not work for insertional Achilles pain; it is saying the current evidence does not support claiming that it does.[1]
What this means for you
For Achilles pain, the physiotherapist's clinical assessment has to establish whether the problem is mid-portion or insertional before shockwave therapy is discussed as an option, because the evidence genuinely differs between the two. If you have insertional Achilles tendinopathy, you will be told that the trial support for ESWT in that specific location is weak, not offered the treatment on the assumption that all Achilles tendinopathy responds the same way.[1]
For tennis elbow, the honest position is that the best available placebo-controlled evidence has not shown a benefit for ESWT specifically. That does not rule out physiotherapist-led ESWT for you individually after other treatments have been tried and discussed, but the conversation with you reflects the actual evidence rather than general enthusiasm for the technology. There is no fixed shockwave protocol offered by default at AION; the physiotherapist's assessment of the specific tendon, subtype and stage of injury decides whether it is used at all.[2]
Source register
Every material source used in this review, with the study design and the limitation that matters when interpreting it.
- [1]Paantjens MA, Helmhout PH, Backx FJG, van Etten-Jamaludin FS, Bakker EWP. Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials.
Sports Medicine - Open · 2022 · Systematic review of randomized controlled trials (3 RCTs mid-portion, 4 RCTs insertional)
PMID 35552903 · DOI 10.1186/s40798-022-00456-5
- WHAT IT ADDS
- Moderate-quality evidence that ESWT plus tendon-loading exercise improves VISA-A scores in mid-portion Achilles tendinopathy; very-low-quality evidence showed no added benefit for insertional Achilles tendinopathy.
- LIMITATION
- Pooled sample sizes in both subgroups fell short of the optimal information size, and the insertional-tendinopathy conclusion is especially fragile and could change with further trials.
- [2]Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain.
Cochrane Database of Systematic Reviews · 2005 · Cochrane systematic review (9 placebo-controlled RCTs, 1,006 participants)
PMID 16235324 · DOI 10.1002/14651858.CD003524.pub2
- WHAT IT ADDS
- 11 of 13 pooled analyses showed no statistically significant benefit of ESWT over placebo for lateral epicondylitis (tennis elbow).
- LIMITATION
- The review dates to 2005 and has not been fully updated with newer trials in the sources available here, though later individual trials have continued to report inconsistent results rather than a clear reversal of this finding.
Research changes the question.
A physician owns the answer.
This review is educational and remains marked for clinical review. It does not determine whether any therapy is appropriate for an individual patient.