Shockwave therapy
Evidence: moderate
Extracorporeal shockwave therapy is the best-evidenced passive treatment in this group. For chronic Achilles tendinopathy, gluteal and proximal hamstring tendinopathy, and stubborn plantar fasciopathy it gives a real benefit beyond standard care, and works best added to loading rather than used alone. It is an adjunct for slow, loading-resistant cases, not a first move or a quick fix.
Not medical advice
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Extracorporeal shockwave therapy (ESWT) delivers pulses of acoustic energy to a tendon or fascia through the skin, in a course of weekly sessions. Among the passive injury treatments it has the strongest evidence base, which is why it earns a moderate grade where most of the others sit at limited or weak.
How it is thought to work
The mechanism is not fully settled, but the leading explanations are mechanotransduction (the mechanical pulses provoke a cellular healing and remodelling response in degenerative tissue), local neovascularisation, and a direct analgesic effect on sensory nerve endings (ESWT safety and mechanism review). The target is the kind of load-driven, degenerative tissue change that sits behind tendinopathy and plantar fasciopathy, which is why shockwave is used for those slow, structural problems rather than for acute pain. Devices come in focused and radial types, which differ in how deep the energy penetrates; both are used clinically.
What the evidence shows
For mid-portion Achilles tendinopathy, a systematic review of randomised trials found moderate-quality evidence that ESWT improves pain and function over standard care, with a pooled gain of around nine points on the VISA-A score, and the best results came when it was combined with eccentric loading rather than used on its own; for insertional disease the evidence was very low quality and did not support a benefit (ESWT Achilles review 2022). A separate meta-analysis across patellar tendinopathy, Achilles tendinopathy and plantar fasciitis found a large, high-certainty benefit only for plantar fasciitis, with negligible effects on patellar and Achilles tendinopathy (ESWT tendinopathy meta 2023).
For plantar fasciopathy specifically, a double-blind, placebo-controlled trial of focused shockwave (three weekly sessions) found a clinically relevant reduction in heel pain over sham at twelve weeks (Gollwitzer et al. 2015). The placebo response in these heel trials is large and not every trial separates active from sham cleanly, which is the honest reason shockwave is positioned as an adjunct for cases that have not settled rather than a first-line cure.
The evidence also reaches tendons higher up the chain that trouble runners. A systematic review of shockwave for tendinopathies around the hip and pelvis found focused ESWT reduced pain in greater trochanteric pain syndrome (gluteal tendinopathy) over the short and mid term, and moderate-level evidence that radial ESWT beat conservative care in proximal hamstring tendinopathy (ESWT hip and pelvis review 2025). The consistent thread across all sites is that ESWT helps most where the problem is chronic and loading-resistant, and performs best as an addition to a loading programme.
Where it fits
Loading remains the core treatment for these conditions, with the strongest evidence of anything in tendon and fascia rehabilitation (tendinopathy; plantar fasciopathy). Shockwave is the adjunct to reach for when a well-run loading programme has stalled, not the thing to try first or instead. It is also one of the passive add-ons mentioned for shin splints and other overuse injuries, though the evidence there is thinner than for the Achilles and the heel. Typical protocols run three to four weekly sessions of a couple of thousand pulses (ESWT hip and pelvis review 2025).
Safety
ESWT is generally safe, with side effects usually limited to discomfort during application and minor transient bruising or redness; serious complications are not expected when it is delivered as recommended (ESWT safety and mechanism review). It is contraindicated, or used only with caution, over a bleeding disorder or while on anticoagulants, over a pregnant uterus, over an active infection or tumour, near electronic implants such as a pacemaker, and over a complete tendon rupture. As with the rest of injury management, it works inside a plan that controls training load and rebuilds capacity through a sensible return to running, rather than as a standalone repair.