What the question is really asking

Shockwave therapy delivers rapid pressure pulses through the skin into a painful tendon or its attachment. A course is usually three to five sessions about a week apart, each delivering roughly five minutes of treatment, running alongside a loading rehabilitation programme.

Asking whether it works is really asking three separate questions. Does it beat doing nothing? Does it beat a convincing sham? And does it add anything on top of the loading programme that is going to happen anyway? UK guidance has looked hard at the first two for four musculoskeletal conditions, and the answers are more careful than most clinic websites suggest.

What UK guidance concludes, condition by condition

NICE has renumbered its interventional procedures guidance into HealthTech guidance. The numbers changed and the guidance text did not, so both are given below.

Plantar fasciitis

NICE interventional procedures guidance IPG311, now HealthTech guidance HTG200, was published on 26 August 2009 and covers extracorporeal shockwave therapy for refractory plantar fasciitis. Recommendation 1.1 reads:

The evidence on extracorporeal shockwave therapy (ESWT) for refractory plantar fasciitis raises no major safety concerns; however, current evidence on its efficacy is inconsistent. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.

Recommendation 1.2 goes further and tells clinicians to ensure that patients understand the uncertainty about the procedure’s efficacy, and to provide them with clear written information. Note the word refractory in the title. This guidance is about heel pain that has already failed to settle with first-line care, which is a different population from someone six weeks into their first episode. The condition itself is covered in more depth on the plantar fasciitis page.

Achilles tendinopathy

IPG571, now HTG426, was published on 21 December 2016 and replaced the older guidance on this condition. Its title does not contain the word refractory. Recommendation 1.1 reads:

The evidence on extracorporeal shockwave therapy (ESWT) for Achilles tendinopathy raises no major safety concerns. Current evidence on efficacy of the procedure is inconsistent and limited in quality and quantity. Therefore, ESWT for Achilles tendinopathy should only be used with special arrangements for clinical governance, consent and audit or research.

This is the most recent of the four and it is the most explicit. The efficacy evidence is called both inconsistent and limited in quality and quantity, which are two separate criticisms. Inconsistent means the trials disagree with each other. Limited in quality and quantity means there are not many of them and they are not strong.

Tennis elbow

IPG313, now HTG201, was published on 26 August 2009 alongside the heel guidance, and recommendation 1.1 uses the same construction:

The evidence on extracorporeal shockwave therapy (ESWT) for refractory tennis elbow raises no major safety concerns; however, current evidence on its efficacy is inconsistent. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.

Again the word is refractory. The reference population is elbow pain that has persisted through first-line management. See tennis elbow for what that management usually involves.

Greater trochanteric pain syndrome

IPG376, now HTG248, was published on 26 January 2011, and it does not read like the other three:

Evidence on the efficacy and safety of extracorporeal shockwave therapy (ESWT) for refractory greater trochanteric pain syndrome is limited in quality and quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.

The phrase raises no major safety concerns is absent. For the hip, the safety evidence itself is called limited, and recommendation 1.2 adds a specific consent requirement: patients should be informed about the possibility of pain during and after treatment, and the risk that symptoms may worsen.

It would be wrong to summarise all four documents as saying shockwave is safe but of uncertain benefit. Three of them say something close to that. The hip one does not, and anyone quoting the safety reassurance while discussing hip pain is quoting the wrong document.

The shoulder, and the conditions with no guidance

Calcific tendinopathy of the shoulder has its own much older and separate piece of NICE guidance, IPG21.

There is no NICE guidance at all on shockwave therapy for hamstring tendinopathy. That is worth stating plainly, because absence gets misread in both directions. It is not evidence that the treatment fails, and it is not permission to assume the heel findings transfer. It means the reassurance and the caveats available for the four conditions above simply do not exist for that one, so a decision rests entirely on individual clinical judgement and a frank conversation. The condition itself is described on the hamstring tendinopathy page.

What the word inconsistent is doing in that sentence

It is easy to read no major safety concerns as approval. It is not. NICE reviewed the published evidence and found trials pointing in different directions, which is what inconsistent means. The conclusion drawn from that was a conditional one, and the condition attached is the governance sentence that appears in all four documents.

Nowhere in these four pieces of guidance does NICE recommend shockwave therapy as a standard treatment. Nowhere does it advise against it either. That genuinely is the state of the evidence, and a page that resolves it into a clean yes or no is telling you something the documents do not say.

Why clinic results look better than trial results

Anyone who has treated a lot of tendon pain with shockwave will tell you they have seen it help. That impression is real, and it is also exactly what you would expect to see even if the machine added nothing, for three reasons.

These conditions often improve on their own. Plantar fasciitis, tennis elbow and mid-portion Achilles pain frequently settle over months regardless of what is done to them. A course of treatment that runs across several weeks, reviewed at six to twelve weeks after the final session, is measuring a period during which improvement was reasonably likely anyway.

People arrive at their worst. Nobody books when the pain is mild and improving. They book in the bad week, which is the point from which things are most likely to get better, whatever happens next.

Tendon pain responds strongly to expectation. Pain is not a direct readout of tissue damage, and treatments that involve equipment, a course of appointments and a confident explanation reliably produce better reported outcomes than the same physical input delivered without them. This is why the sham arm exists in a trial, and why the gap between uncontrolled and randomised results is not a scandal.

None of that means the treatment does nothing. It means clinic before-and-after numbers cannot separate the treatment from those three effects, and only a controlled trial can.

What special arrangements mean for you

The governance phrase is not administrative filler. Translated into what should actually happen in the room:

  • Consent that names the uncertainty. IPG311 requires clinicians to make sure patients understand the uncertainty about efficacy and to give them clear written information. If nobody mentions uncertainty, the consent process is not the one the guidance describes.
  • Audit of outcomes. The service should be recording what happens to the people it treats, using a measure agreed at the start rather than an impression at the end.
  • A pre-agreed review point. Six to twelve weeks after the final session, with the outcome compared against the baseline that was taken before the first session.
  • A stated plan for a course that does not help. This should be decided before you start, not improvised afterwards.

Device type changes what the evidence covers

Radial devices deliver energy that dissipates near the surface. Focused devices concentrate energy at depth. They are different physical treatments delivered by different machines, so evidence gathered with one does not automatically transfer to the other. Ask which type is being proposed and why that one suits the tissue in question. The difference is set out in radial and focused shockwave compared.

When a course is a reasonable next step

Pulling the above together, shockwave becomes a defensible option when several things are true at once. There is a clear diagnosis rather than a guess. Symptoms have persisted despite a properly progressed loading programme run for long enough to have worked. The loading programme continues alongside the course rather than stopping. A review point is agreed in advance, along with what happens if the answer at that point is no change.

If most of those are missing, the more useful conversation is about the diagnosis and the loading programme. Where the NHS route and the private route differ on access to any of this is covered in shockwave therapy on the NHS.

Frequently asked questions

Does shockwave therapy work for tendonitis?

UK guidance describes the evidence as inconsistent for the tendon problems it has reviewed. For plantar fasciitis, Achilles tendinopathy and tennis elbow, NICE found no major safety concerns but concluded that efficacy evidence is inconsistent, so the treatment is recommended only under special arrangements for governance, consent and audit or research.

What does NICE say about shockwave therapy?

NICE has published separate guidance for each condition. For plantar fasciitis, Achilles tendinopathy and tennis elbow it states that the evidence raises no major safety concerns while efficacy evidence is inconsistent. For greater trochanteric pain syndrome it describes evidence on both efficacy and safety as limited in quality and quantity.

How long does shockwave therapy take to work?

A course is usually three to five sessions about a week apart, so treatment itself spans a few weeks. Tendon problems change slowly, and the honest point to review the outcome is six to twelve weeks after the final session rather than immediately afterwards.

Is shockwave therapy better than exercise for tendon pain?

The comparison is not settled by the current evidence, and shockwave is not offered as a replacement for loading. In practice a course runs alongside a progressive loading rehabilitation programme, and the exercise component is the part with the stronger and longer-established evidence behind it.

Does shockwave therapy work for hamstring tendinopathy?

There is no NICE guidance on shockwave therapy for hamstring tendinopathy. That absence is not a verdict either way, but it does mean the reassurance available for the heel, the Achilles and the elbow does not exist for this one, so any decision rests on individual clinical judgement.