Extracorporeal Shockwave Therapy

Extracorporeal means outside the body, which is the only part of the name that describes anything you will experience. A handpiece is pressed against the skin over the painful structure and fires a rapid series of pressure pulses through it. There is no radiation, no current and no medicine, and the machine is roughly the size of a printer.

The pulse is an acoustic pressure wave. It travels into the tissue and produces two effects that researchers think matter: a direct mechanical stimulus on the cells that maintain the tendon, and small pressure changes that briefly disrupt the local environment. Between them they appear to restart the repair signalling in tissue where that signalling has gone quiet, which is the situation in a tendon that has hurt for months without healing.

What the treatment is not is a painkiller applied to a machine. Nothing about a pressure wave removes the load that caused the problem, and every serious protocol pairs the sessions with a loading programme. A clinic that offers the machine on its own is selling half of the treatment that the trials tested.

There are two machine types and they are not interchangeable. A radial device fires a projectile against an applicator held on the skin, and the resulting wave spreads outward and loses energy quickly, so its effect is concentrated within a couple of centimetres of the surface. A focused device generates the wave electrohydraulically, electromagnetically or piezoelectrically and converges it at a chosen depth, which can be several centimetres down.

This matters when you read a result. A trial of focused shockwave on a calcific deposit in the rotator cuff says very little about a radial machine applied to the same shoulder, because the energy did not reach the same place. Reviews that pool the two are common and are one reason the published effect sizes swing so widely between papers.

Radial machines are far more common in United Kingdom physiotherapy and podiatry clinics, largely on cost. For plantar fasciitis and lateral elbow pain, where the target is shallow, that is a defensible choice and the evidence base includes both. For a deep target it is worth asking which machine is in the room and why. Radial and focused shockwave compared goes further into the difference.

The honest summary is that the evidence is mixed and the mixture is not random. It is strongest where the target is a shallow, chronic, degenerative tendon problem that has already failed conservative care, and it thins quickly outside that description.

NICE has published separate interventional procedures guidance on four musculoskeletal uses. For plantar fasciitis, Achilles tendinopathy and tennis elbow the conclusion is a pair: the evidence "raises no major safety concerns" while the evidence on efficacy is "inconsistent". That is genuinely useful and it is not the same as a recommendation. It means the treatment is unlikely to harm you and may or may not help, which is why the decision turns on what else is open to you and on how long the problem has run.

The fourth document does not say that, and the difference is worth knowing. For refractory greater trochanteric pain syndrome, NICE found the evidence on efficacy and safety both "limited in quality and quantity", and asked that patients be told about the risk that symptoms may worsen. Anyone quoting the safety reassurance while discussing hip pain is quoting the wrong document. Shockwave therapy for gluteal tendinopathy sets that out in full.

Two things distort what you read online. Placebo effects are large in tendon pain, so uncontrolled before-and-after series look far better than randomised trials with a sham arm. And the natural history of many of these conditions is slow improvement anyway, so a course delivered at month nine of a problem gets credit for month eleven. Ask any clinic quoting a success rate where the number came from and whether the comparison group existed.

This is the use with the most evidence behind it and the most people searching for it. Plantar fasciitis is a degenerative problem of the thick band of tissue running along the sole, and its signature is pain under the heel that is worst on the first steps of the morning and after sitting. Most cases settle within a year with loading, calf work and a change of footwear. A minority do not, and that minority is the group the trials studied.

NICE reviewed the procedure for refractory plantar fasciitis in interventional procedures guidance IPG311 (now HealthTech guidance HTG200) and concluded that the evidence "raises no major safety concerns; however, current evidence on its efficacy is inconsistent", and that the procedure "should only be used with special arrangements for clinical governance, consent and audit or research".

The practical reading is that shockwave is a reasonable next step for heel pain that has been properly loaded for three months and has not shifted. It is a poor first step. If nobody has yet checked your calf flexibility, your footwear and your loading history, that conversation is worth more than the machine. Shockwave therapy for plantar fasciitis goes into the sequence in detail.

The Achilles is the tendon where the location of the pain changes the answer. Midportion tendinopathy sits two to six centimetres above the heel bone and responds well to a structured eccentric loading programme, which remains the first treatment and outperforms most alternatives. Insertional tendinopathy sits at the bone itself, tolerates that same programme badly, and is the harder problem.

NICE assessed the procedure in interventional procedures guidance IPG571, now HealthTech guidance HTG426, which replaced the older IPG312. Its conclusion goes a step further than the plantar fasciitis wording: the safety evidence "raises no major safety concerns", while the efficacy evidence is "inconsistent and limited in quality and quantity". Inconsistent and thin are two separate criticisms, and only this document makes both.

Anyone offering you shockwave for an Achilles that has never been through a proper loading programme has the order wrong. The tendon needs load to remodel, and the machine does not supply load. Shockwave therapy for Achilles tendinopathy covers how midportion and insertional pain differ.

Tennis elbow, or lateral epicondylalgia, is pain on the outside of the elbow where the wrist extensor tendons attach. It is provoked by gripping and lifting, it usually has nothing to do with tennis, and it is one of the conditions with the strongest natural tendency to improve on its own over twelve to eighteen months.

That last fact makes the evidence hard to read. IPG313, now HealthTech guidance HTG201, covers the refractory presentation and reaches the same pairing as the heel and the Achilles: no major safety concerns, efficacy inconsistent. Randomised trials against sham have produced results in both directions, and the reviews that pool them tend to land on a small benefit that may not be large enough for a patient to notice. Shockwave therapy for tennis elbow covers what belongs before a course.

What is reasonably well established is that a corticosteroid injection gives faster relief and worse outcomes at one year, which is the reason many clinicians reach for shockwave instead. That is a comparison worth having explicitly rather than being steered through.

Knee is the term people search, and it covers several unrelated problems. The one with a genuine shockwave literature is patellar tendinopathy, the jumping-athlete tendon at the lower edge of the kneecap. Trials there are small, mostly in volleyball and basketball players, and the results are modest and inconsistent, but the condition is at least the right shape: a chronic, load-related, degenerative tendon.

For osteoarthritic knee pain the picture is much weaker. Some studies report short-term pain reduction and the mechanism proposed is a change in bone marrow oedema rather than anything happening to cartilage. Nothing in that literature supports offering shockwave as a treatment for arthritis, and NICE has issued no interventional procedures guidance for it.

If a clinic offers shockwave for a knee, the useful question is which structure they think is generating the pain. A specific tendon is a reasonable target. A knee in general is not.

These two get searched together and they are not the same condition. Frozen shoulder, or adhesive capsulitis, is a stiffening and thickening of the joint capsule that follows a long and fairly predictable course through pain, stiffness and recovery. Shockwave has a thin and low-quality evidence base here, and the mainstays remain time, movement, pain control and occasionally a hydrodilatation or an injection.

Calcific tendinopathy is different. A calcium deposit forms within a rotator cuff tendon and can be exquisitely painful, and it is the one shoulder problem with real shockwave evidence, assessed by NICE in IPG21. Focused machines and higher energy levels are what the positive studies used, which is directly relevant to the machine question above.

Both need imaging before anyone treats them, because the two present similarly and the treatment paths diverge completely. A shoulder that has been treated for months without an ultrasound or an X-ray has been guessed at. Shockwave therapy for calcific shoulder tendinopathy covers the presentation that does have guidance behind it.

The common effects are local and short-lived. Most people get soreness in the treated area for a day or two, some redness, occasional bruising, and sometimes a temporary increase in the original pain before it settles. Numbness or tingling immediately after a session is reported and is usually gone within hours.

The treatment itself is uncomfortable while it runs. That is not a complication, it is the dose: the energy level is set to what you can tolerate, and a session delivered at a level you barely feel is unlikely to be doing much. Five minutes is the usual length and it is over quickly.

Serious problems are rare and the important ones are about who should not be treated at all. Treatment is avoided in pregnancy near the trunk, over an active infection or a tumour, over an open growth plate in a child, and where a nerve or a major vessel lies immediately beneath the target. Anyone on an anticoagulant needs that discussed before the first session rather than after a bruise. Shockwave therapy side effects covers the full list and what to report.

Quotes for the same treatment differ widely between clinics, and the reason is that they are not quoting the same thing. What is worth knowing is what changes the number. A price that includes the assessment, the loading programme and the review appointments is not comparable to a price for the machine time alone, and both are advertised. Ask whether the quote is per session or for the course, whether the first assessment is included, and what happens at the review if the pain has not changed. What a course of shockwave involves paying for works through the itemisation.

Shockwave is available on the NHS in some services and not in others, and private medical insurance coverage varies by policy and usually needs the referral in place first. Both are worth checking before you pay, because the answer changes the sensible order of the next few steps. Shockwave therapy on the NHS covers the referral route.

Shockwave is delivered in the United Kingdom by physiotherapists, podiatrists, osteopaths and doctors, and all four of those titles are protected. A physiotherapist and a podiatrist must be on the Health and Care Professions Council register, an osteopath on the General Osteopathic Council register, and a doctor on the General Medical Council register. Every one of those registers is public, free and searchable in about a minute, and checking a name against one before a first appointment is the single most useful thing a patient can do.

Beyond registration, the thing to look for is whether you are being assessed or accepted. A clinician who takes your own diagnosis at face value and books five sessions has skipped the step that decides whether the treatment suits you at all. Several of these conditions look identical from the outside and take completely different paths, and a shoulder or a knee needs imaging before anyone treats it.

Assessment and treatment take place at one of four UNTIL clubs, in Marylebone, Soho, Liverpool Street or Canary Wharf, with a clinician who examines you in person before any course is agreed. The same registers named above apply to whoever treats you here, and you are welcome to check the name against one. No payment passes per enquiry, because a per-patient payment to a clinician carries referral-fee exposure under professional guidance.