The assessment that should come first
A shockwave session should never be the first thing that happens to you. Before any machine is switched on, someone needs to have taken a history, examined the area, formed a view on what is producing the pain, and established that the problem is a reasonable target.
That matters because shockwave is used in United Kingdom practice as a second-line option, after a loading programme has been tried and has not settled things. If nobody has asked what you have already done, the plan is being built on an assumption.
The assessment also covers the situations in which shockwave is not appropriate. Pregnancy when the treatment area is near the trunk, active infection or a tumour in the treatment field, and an open growth plate all fall into that group, and anyone taking an anticoagulant needs careful individual assessment. These questions should be asked before the first session, not discovered halfway through a course.
Arriving, and the first few minutes
At a follow-up session the appointment usually opens with a short conversation. How has the area behaved since last time? Did it flare, and for how long? Have you managed the exercises? This is not small talk. It determines the energy setting for the session you are about to have.
Then you get comfortable, with the area exposed and supported. For a heel that usually means lying face down with the foot over the end of the couch. For an elbow it means sitting with the arm resting.
Finding the tender point
The clinician presses around the area to locate the spot that reproduces your pain. This can be the least comfortable part of the whole appointment, and it is also the part that most determines whether the treatment lands where it should.
Some clinics mark the point with a pen. Some work from anatomical landmarks. Some use ultrasound imaging to confirm the target. The method varies; the intent is the same, which is to make sure the energy goes into the structure that hurts rather than the general neighbourhood of it.
The gel and the handpiece
Ultrasound gel is applied generously to the skin. Its job is to couple the handpiece to you so the energy passes into the tissue instead of being lost at the interface. It is cold, and there is more of it than you expect.
The handpiece is then held firmly against the skin. It is heavier than it looks and the pressure is deliberate. Whether that handpiece belongs to a radial or a focused machine changes the depth at which the energy concentrates, which is covered in the guide to radial and focused devices.
Turning the energy up
The device starts low and the clinician raises the setting in steps, asking as they go. The instruction is normally something like “tell me when it is at the edge of uncomfortable”. That is the level you stay at, and you set it.
Two things follow from this. First, the session is not something being done to you while you brace. You are an active part of the dial. Second, an area that felt tolerable at one setting last week may want a different setting this week, which is why the opening conversation matters.
What the pulses feel like
The machine produces a rapid tapping or knocking, mechanical and rhythmic. People compare it to a small hammer, or to a stapler firing repeatedly against the skin, and it is loud enough that conversation happens over the top of it.
Over the tender spot it feels sharper. Over surrounding tissue it fades to something closer to a firm vibration. Most people find the first thirty seconds the worst and then adjust. A minority find one specific angle genuinely painful, and that is worth saying out loud, because the setting can come down and the head can be repositioned.
The treatment portion runs to roughly five minutes. The clinician moves the handpiece across the area in passes rather than holding it still in one spot.
Immediately afterwards
The gel is wiped off and you stand up. Nothing is bandaged and there is no dressing.
Many people notice the area feels numb or oddly light for the first hour or two, and some describe a short window in which the original pain is quieter. Others feel a flare almost straight away. Both are ordinary and neither predicts anything about how the course will finish.
You can walk out, get on a train and go back to work. There is no downtime in the usual sense.
The 24 to 48 hours after a session
Expect the treated area to be sore. That is the common pattern, it usually starts within a few hours, and it typically settles inside two days.
Over that window, the sensible approach is to keep moving normally while avoiding heavy or provocative loading of the treated tendon. That means holding off on a long run, on heavy calf raises to failure, or on a hard racquet session the same evening. Gentle activity is fine and generally better than sitting still.
Clinics commonly advise keeping anti-inflammatory medication to a minimum around a course, on the reasoning that the treatment is meant to provoke a repair response rather than to damp one down. Ask your clinician about this specifically if you take one regularly for another reason. A fuller account of what to expect sits in the guide to shockwave therapy side effects.
How the course is spaced
A course is typically three to five sessions, roughly a week apart. The gap is deliberate. It gives the tissue time to respond and it lets the flare from the last session settle before the next one is added.
Sessions are usually shorter than the first appointment, because the assessment has already been done and the plan is set.
Where the loading programme fits
Alongside the course, and this is the part people skip.
Shockwave in United Kingdom musculoskeletal practice runs with a progressive loading rehabilitation programme, not instead of one. The exercises are what rebuild the capacity of the tendon that failed. A course delivered with nothing running alongside it leaves the underlying problem exactly where it was.
Expect exercises to be prescribed, reviewed and progressed at each session. If none appear, ask why.
When you find out whether it worked
Here is the thing that causes the most disappointment.
Very little changes during the course itself. People finish session three, notice they still hurt, and conclude the treatment has failed. The honest review point sits six to twelve weeks after the final session, because that is the timescale over which any tendon response plays out.
That does not mean waiting passively. It means keeping to the loading programme, tracking your symptoms against something concrete such as morning pain on the first steps out of bed, and holding the verdict until there is something real to judge. If you want the wider evidence picture before starting, read does shockwave therapy work.
Frequently asked questions
How does shockwave therapy work?
A handpiece delivers rapid pressure pulses through the skin into a painful tendon or heel, as a mechanical stimulus intended to provoke a repair response. NICE has reviewed several musculoskeletal uses and found the efficacy evidence inconsistent, so the mechanism is better described as intended than as proven.
Is shockwave therapy painful?
It is uncomfortable rather than unbearable for most people. The energy is turned up gradually and held at the level you can tolerate, so you set the ceiling. Tender points feel sharper than surrounding tissue. Tell the clinician during the session if it becomes too much, because the setting can be lowered.
How long does a shockwave therapy session take?
The pulses themselves take roughly five minutes. The appointment is longer because it includes checking how the area has responded since last time, locating the tender point, applying gel and going through the exercise programme, so allow a normal treatment appointment rather than five minutes.
What is the recovery time after shockwave therapy?
There is no downtime in the usual sense. The treated area is commonly sore for 24 to 48 hours afterwards and then settles. Most people walk out and carry on with their day, avoiding heavy loading of the treated tendon and anti-inflammatory medication over that window unless advised otherwise.
How many shockwave sessions will I need?
A course is typically three to five sessions spaced roughly a week apart. Very little changes during the course itself, and the honest review point sits six to twelve weeks after the final session, so judging the result at session three is the commonest reason people conclude it has failed.