If you see people with persistent heel, elbow, knee, or low-back symptoms after multiple treatments, it can feel as if the tissue has stopped healing. But chronic symptoms are not a diagnosis, and a new device is not a substitute for finding the right target.
Shockwave therapy is one option clinicians may consider for selected musculoskeletal presentations. To use it well, you need to understand what the technology delivers, what the research has and has not shown, and how it fits with assessment and progressive loading. In the FAKTR webinar “Nobody Told You Why It Works: Focused shockwave therapy and the patient you didn’t have to refer,” Dr. Jacob Knapton, D.C., discussed these questions and the practical decisions behind shockwave therapy in clinical practice.
What is shockwave therapy and how does it work?
Extracorporeal shockwave therapy (ESWT) delivers acoustic pressure pulses through the skin to a target area. A shockwave has a rapid, high-pressure rise followed by a lower-pressure phase. In simple terms, the treatment delivers a mechanical stimulus; the body’s response, rather than the device itself, is what may influence symptoms and tissue adaptation.
The field has evolved from using shockwaves to break up kidney stones to investigating orthopedic applications. A frequently recounted historical account links early interest to injuries observed after wartime depth-charge exposure. A shockwave generator patent followed in the 1950s, and the first kidney stone was treated with a Dornier lithotripter in Munich in 1980. In 1991, Dr. Gerald Haupt reported observing new bone formation during pelvic lithotripsy research. In the United States, orthopedic device clearances later included chronic plantar fasciitis in 2000 and lateral epicondylitis in 2002.
The webinar described a broad literature, with more than 1,000 peer-reviewed studies and 100-plus reported indications. Those numbers do not mean every condition has the same quality or volume of evidence. The research needs to be considered indication by indication, and matched to the device and protocol studied.
Radial pressure wave vs. focused shockwave
These terms are often used interchangeably, but radial pressure wave and focused shockwave systems deliver energy differently. The webinar’s simplified comparison described radial pressure waves as divergent and more superficial, while focused shockwaves converge energy at a focal zone and can target deeper structures. The presenter cited broad pressure and depth ranges for each type; these values are not universal specifications, and device readouts and treatment parameters vary.
The practical point is to select the modality and applicator based on the clinical target, not on the assumption that all “shockwave” devices are equivalent. Both approaches have been studied, but evidence from one technology should not automatically be applied to another.
Use sufficient coupling gel to maintain contact between the applicator and skin. Air at the interface can interfere with energy transmission. Follow the device’s instructions for use and training guidance.
What does the shockwave therapy research show?
Research findings vary by condition, device, energy, comparison treatment, and follow-up. These studies are useful for clinical reasoning, not guarantees for an individual patient.
Plantar fasciitis
A 2024 meta-analysis by Cortés-Pérez and colleagues included 16 randomized controlled trials (RCTs) and 1,121 participants. Compared with corticosteroid injection, shockwave therapy showed better pain and foot-function results at three and six months, and reduced plantar fascia thickness at three months. Local pain and slight redness were among the commonly reported side effects. Read the meta-analysis.
The results support ESWT as a treatment option for this studied population, but they do not establish one best protocol for every patient. The included studies’ methods and device parameters matter.
Lateral epicondylitis
A 2025 umbrella review by Zhu and colleagues evaluated nine meta-analyses. It reported that ESWT reduced pain compared with placebo and had better pain outcomes than ultrasound therapy and corticosteroid injection in the pooled comparisons. The review rated its evidence level highly, but it also reported substantial variation in some comparisons. Grip-strength findings were less compelling: the difference versus placebo was not considered clinically important. Read the umbrella review.
For practice, that distinction matters. A change in pain does not automatically mean a meaningful improvement in strength or function.
Calcific tendinitis of the shoulder
A systematic review by Bannuru and colleagues considered 28 RCTs of shoulder conditions. In a 2003 randomized trial of 144 people with chronic calcific rotator-cuff tendinitis, Gerdesmeyer and colleagues found that high-energy shockwave therapy improved pain and function compared with sham. At six months, calcifications had fully resolved on X-ray in 60% of the high-energy group, compared with 11% of the sham group; at 12 months, the figures were 86% and 25%. Read the review and the trial.
This is evidence for a specific condition and treatment context. It should not be generalized to all shoulder pain or all shockwave devices.
Knee osteoarthritis and chronic low-back pain
A 2024 umbrella review of eight meta-analyses on knee osteoarthritis found that, compared with sham, ESWT was associated with about a two-point reduction in pain on a 10-point scale, improvements on WOMAC and Lequesne function measures, and roughly 17.5 degrees more range of motion. Read the review.
For chronic low-back pain, Wu and colleagues’ 2023 review included 22 studies and 1,749 participants. It reported reductions in pain and Oswestry Disability Index scores, with gains maintained at three months. The authors also reported improvement in Beck Depression Inventory scores and fewer adverse reactions than comparison therapies. The study combined varied populations and comparison treatments, so those results should be interpreted cautiously. Read the review.
Across the literature, ESWT has also been compared with surgery for specific bone-healing indications. Such studies cannot establish equivalence across other conditions. The key lesson is not “shockwave works for everything”; it is that the evidence depends on the indication, target, device, energy, and protocol.
Proposed mechanisms: stimulus, response, and time
One proposed mechanism is mechanotransduction: cells respond to mechanical signals by changing biochemical activity. Laboratory and animal research has described signaling involving growth factors such as VEGF, TGF-beta, and BMP, alongside processes related to collagen remodeling and angiogenesis. These findings help explain biological hypotheses, but they do not prove that shockwave causes tissue regrowth in humans. The extent to which these pathways explain clinical outcomes remains under study.
A second proposed mechanism is cavitation. The lower-pressure phase may create microscopic bubbles that collapse, potentially producing local mechanical effects near hard surfaces such as calcification or bone. This is a proposed explanation, not a complete account of clinical response.
Dr. Knapton’s webinar emphasized two different timelines: a possible short-term change in pain sensitivity, and a slower biological response that may take weeks. That is a useful clinical framework, not a reason to delay reassessment. Track the patient’s symptoms and function, and discuss a longer follow-up window when appropriate; an early response after one or two visits may not tell the full story.
Clinical applications and practical considerations
The webinar focused on chronic and degenerative presentations, particularly tendinopathy, plantar fasciitis, lateral epicondylitis, calcific shoulder tendinitis, knee osteoarthritis, selected knee soft-tissue conditions, and chronic low-back pain. Chronic tendinopathy makes up a substantial share of the research discussed. Evidence for one diagnosis should not be assumed to apply to another.
Start with assessment. Identify the working diagnosis, relevant tissue, functional limitation, and appropriate treatment target before choosing a device setting. In one case discussed in the webinar, a patient initially treated for thumb CMC arthritis showed no improvement. Reassessment shifted the working diagnosis toward tenosynovitis; after changing the target and dose, the clinician reported about 50% improvement after one session. That is an educational case example, not controlled evidence, and a reminder that better decisions begin with better assessment.
Dose deliberately. Studies often report energy flux density in mJ/mm², while device interfaces and scales differ. Do not assume that a number on one machine maps directly to another, or that a more painful treatment is more effective. Use device-specific training, patient response, the target, and the relevant research to guide dosing.
Pair treatment with rehabilitation. The webinar emphasized that shockwave is not a replacement for loading. Dr. Knapton discussed overcoming isometrics at approximately 60–70% of maximum voluntary contraction (MVC) as one adjunct for tendons, drawing on tendon research by Dr. Keith Baar. The chronic-tendon example discussed was 10 seconds of contraction followed by 50 seconds of rest, for about 10 sets daily. This is a specific example from the webinar, not a universal protocol. Apply it only when clinically appropriate and within your scope.
Set realistic expectations and observe precautions. The webinar noted that stem-cell effects have been described in laboratory and animal studies, not demonstrated as tissue regrowth in humans, and that it found no research on hip or shoulder labral tears. Follow your scope of practice and the device’s instructions for use. Use caution when treating directly over a nerve. Any treatment over an open growth plate should be considered only when clinically indicated and in accordance with appropriate low-intensity guidance and device instructions; the webinar referenced pediatric apophysitis case-series findings, which should not be treated as proof of general safety.
Integrating shockwave therapy into clinical practice
Shockwave can fit within a familiar care sequence: assess, provide appropriate care, apply the modality to a justified target, then load and reassess. A typical plan discussed in the webinar was four to six sessions, home loading between visits, and rechecks at four and 12 weeks. Treat those intervals as an example, not a prescribed schedule for every patient.
Before investing, consider whether the technology matches the needs of your patient population, whether you can access appropriate provider education, and how treatment will fit into your workflow. The webinar noted that some practices use a self-pay model and cited approximately $100–$200 per session as a general market example. Pricing varies by location and practice; this is not a revenue forecast or a promise of financial return. Make any business decision using your actual costs, local market, and clinical rationale.
Watch the free webinar replay
Want to hear Dr. Knapton walk through the research, mechanisms, and clinical decision-making? Register for the recorded one-hour training. Registration includes three complimentary resources:
- Shockwave Research Reference Pack
- Full Presentation Slide Deck
- Lesson Notes and Clinical Takeaways
Click here to watch the recorded webinar replay and access these free resources.
Frequently asked questions
Is shockwave therapy supported by research?
Yes. Research includes systematic reviews and randomized trials for conditions such as plantar fasciitis, lateral epicondylitis, calcific shoulder tendinitis, knee osteoarthritis, and chronic low-back pain. The findings vary by diagnosis, device, protocol, and comparison treatment.
What is the difference between radial and focused shockwave?
Radial pressure waves spread outward from the applicator and are generally used for more superficial, broader targets. Focused shockwaves converge energy at a focal zone and can target deeper structures. They are distinct technologies, so match evidence and treatment parameters to the device used.
How long can results take to appear?
A short-term change in pain sensitivity may occur sooner, while biological remodeling, if it occurs, may take weeks. The webinar discussed reassessment over a longer timeline, including around 12 weeks; individual responses vary, and you should monitor both symptoms and function.
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