Shockwave therapy is a non-invasive treatment that delivers pulses of acoustic energy into injured tissue to stimulate healing. It’s used most commonly for chronic tendon problems and heel pain, but its applications range from breaking up kidney stones to treating erectile dysfunction. The FDA first cleared shockwave devices for plantar fasciitis in 2000 and lateral epicondylitis (tennis elbow) in 2002, and the list of recognized uses has grown considerably since then.
How Shockwave Therapy Works
The core idea is mechanotransduction: physical pressure waves enter the body and trigger a cascade of biological responses at the cellular level. When acoustic pulses hit damaged tissue, cells convert that mechanical stimulation into chemical signals that promote repair. In tendons, for example, shockwaves cause cells to ramp up production of growth factors that drive new blood vessel formation and collagen synthesis. Those new blood vessels bring fresh oxygen and nutrients to tissue that has often been starved of adequate blood supply for months or years.
The treatment also stimulates cell proliferation. Tendon cells exposed to shockwaves increase their production of the proteins that form the structural scaffolding of connective tissue, particularly type I and type III collagen. At lower energy levels, the waves trigger a sequence that begins with cell growth signals, progresses to the release of nitric oxide (a molecule that dilates blood vessels), and ends with new collagen being laid down. This is why the therapy works best for conditions where healing has stalled rather than for acute injuries that are already progressing normally.
Focused vs. Radial Shockwaves
There are two main types of shockwave devices, and they work quite differently. Focused shockwaves are generated inside the applicator and concentrated by a lens so the energy converges at a specific depth in the body. This allows precise targeting of deeper structures. Radial shockwaves are produced by firing a projectile with compressed air against an applicator held to the skin. The energy spreads outward from the surface and loses intensity as it penetrates deeper.
The practical difference matters most for deeper or denser tissues. For bone conditions like stress fractures, delayed unions, or shin splints, an international expert panel published in the British Journal of Sports Medicine recommends focused shockwaves with high energy levels, noting that roughly 65% of surveyed specialists would not recommend radial waves for bone problems. For superficial tendon issues like Achilles tendinopathy or plantar fasciitis, both types can be effective.
Conditions It Treats
The strongest evidence supports shockwave therapy for tendon and fascia problems that haven’t responded to rest, physical therapy, or other conservative measures. An international Delphi consensus identified the following as appropriate indications:
- Plantar fasciitis (the most studied application)
- Achilles tendinopathy (both midportion and insertional)
- Rotator cuff tendinopathy (calcific and non-calcific)
- Tennis elbow and golfer’s elbow
- Patellar tendinopathy (jumper’s knee)
- Hamstring tendinopathy (proximal and distal)
- Greater trochanteric pain syndrome and gluteal tendinopathy
- Low-grade partial tendon tears
Beyond soft tissue, shockwave therapy is also used for bone stress injuries, delayed union fractures, non-union fractures, sesamoiditis, and medial tibial stress syndrome (shin splints).
Kidney Stones
Shockwave lithotripsy is a distinct but related application where high-energy focused waves break kidney stones into fragments small enough to pass naturally. Success rates in the literature range from 46% to 91%, with the best outcomes for stones smaller than 5 mm and less dense on CT imaging. One cross-sectional study of 155 patients found an overall success rate of about 66% for stones between 3 and 20 mm.
Erectile Dysfunction
Low-intensity shockwave therapy has emerged as a treatment option for erectile dysfunction. The hypothesis is the same as for tendons: focused microtrauma triggers growth factors and new blood vessel formation in penile tissue. A randomized, sham-controlled trial tracked patients for three years. Erectile function scores improved significantly at 12 and 24 months after treatment but had returned close to baseline by 36 months, suggesting the benefits may last one to two years. Patients reported moderate satisfaction overall.
How Effective Is It for Plantar Fasciitis?
Plantar fasciitis is the condition with the most clinical data behind shockwave treatment. In a meta-analysis of randomized controlled trials, the results depended heavily on energy level. High-intensity shockwave therapy produced a success rate of about 66%, defined as at least a 50% reduction in pain. Low-intensity treatment had a lower success rate of around 42%. Interestingly, high-intensity shockwave outperformed corticosteroid injections (which had about a 49% success rate in those same trials), while low-intensity shockwave was less effective than injections.
This is a meaningful distinction. If you’re considering shockwave therapy for heel pain, the energy level used in your treatment matters for outcomes. The expert consensus defines low energy as below 0.10 mJ/mm², medium as 0.10 to 0.28 mJ/mm², and high as 0.29 mJ/mm² or above.
What a Treatment Session Looks Like
A typical course involves 3 to 5 sessions spaced 1 to 2 weeks apart. During each session, a clinician applies ultrasound gel to the skin and presses the applicator against the treatment area. For tendon and fascia problems, the recommended approach is “clinical focusing,” meaning the practitioner targets the spot where you feel the most pain rather than relying on imaging to guide placement.
The sensation ranges from a rapid tapping to a sharp, snapping feeling depending on the energy level. International guidelines recommend keeping pain below a 6 out of 10 for tendon conditions and below 7 out of 10 for bone conditions. Local anesthesia is not recommended before treatment, partly because your pain feedback helps guide the procedure and partly because numbing the area may reduce the biological response.
After a session, there are no range-of-motion restrictions or weight-bearing precautions for tendinopathies, fasciopathies, or low-grade partial tears. You can generally return to normal activity right away, though some soreness in the treated area is common for a day or two.
Safety and Contraindications
Shockwave therapy has a short list of absolute contraindications: active infection at the treatment site, malignant tumors in the treatment area (for focused shockwave), and pregnancy. Relative contraindications for high-energy treatments include having a nerve, brain tissue, or lung tissue in the treatment path, an open growth plate in children or adolescents, and significant clotting disorders.
The most common side effect is temporary bruising or hematoma formation at the treatment site, which is why people taking blood thinners or those with clotting problems need extra caution. Some patients experience redness, swelling, or numbness in the treated area for a few days. Serious complications are rare when the therapy is applied by a trained provider following established guidelines.