Shockwave therapy has a meaningful clinical evidence base for chronic Achilles tendinopathy, particularly in patients who remain symptomatic despite rehabilitation. Classic randomized trials found low-energy radial shockwave superior to traditional eccentric loading for insertional disease, comparable with loading for midportion disease, and more effective when added to loading than loading alone in a refractory midportion population. Meta-analyses have also reported improvements in pain and function, although results vary substantially between studies. The key is not whether shockwave "works" in the abstract, but whether the patient has the type of Achilles presentation studied and whether shockwave is being used appropriately alongside tendon loading.
Why does insertional vs. midportion matter?
Insertional Achilles tendinopathy affects the tendon where it attaches to the heel bone. Midportion tendinopathy affects the tendon a few centimeters higher. The insertion is exposed to compression against the calcaneus as the ankle bends upward, in addition to tensile load, so the two presentations respond differently to the same exercise. The trials below enrolled one group or the other, and their results should be read that way. The distinction is covered in more detail in insertional vs. midportion Achilles tendinopathy.
The key studies at a glance
| Study | Population and design | Comparison | Main finding | Key limitation |
|---|---|---|---|---|
| Rompe 2008 | RCT, 50 insertional | Shockwave vs. eccentric loading | VISA-A 80 vs. 63; 64% vs. 28% success at 4 months | Traditional eccentric program as comparator; crossover after 4 months |
| Rompe 2009 | RCT, 68 midportion | Loading + shockwave vs. loading | VISA-A 87 vs. 73; 82% vs. 56% success at 4 months | No difference at 1 year after crossover |
| Rompe 2007 | RCT, 75 midportion | Loading vs. shockwave vs. wait and see | Both active treatments better than observation | Single research group |
| Fan 2020 | Meta-analysis, 5 RCTs + 3 case-control | Shockwave vs. other non-surgical care | Pain and function generally favored shockwave | Mixed designs; few trials |
| Majidi 2024 | Meta-analysis, Achilles subgroup | Shockwave vs. control | Pain SMD −1.38 | I² 96.44%: very high heterogeneity |
| Robinson 2022 | Retrospective cohort, 87 | Combined radial + focused vs. radial | MCID reached in 89.7% vs. 63.8% | Not randomized; mean change not significantly different |
What the insertional randomized trial found
Rompe, Furia and Maffulli randomized 50 patients with chronic insertional Achilles tendinopathy, all symptomatic for at least six months despite injections, anti-inflammatories and physiotherapy, published in the Journal of Bone and Joint Surgery in 2008. Half did an eccentric loading program; half received repetitive low-energy shockwave.
In a randomized trial of 50 patients with chronic insertional Achilles tendinopathy, low-energy shockwave produced substantially greater improvement than eccentric loading at four months: VISA-A improved from 53 to 80 versus 53 to 63, and 64% of shockwave patients reported being completely recovered or much improved versus 28% with eccentric loading. Pain fell from 7 to 3 with shockwave and from 7 to 5 with loading. Results in the shockwave group were stable at one year, although by then most of the loading group had crossed over to other treatment, so the later comparison is not randomized.
Shockwave vs. eccentric loading
This trial does not show that exercise fails in insertional tendinopathy. The comparison was with a traditional eccentric loading program. Traditional heel-drop programs performed below the level of a step may be poorly tolerated in insertional disease because they increase compression at the tendon insertion. Modern insertional programs usually limit dorsiflexion early and reintroduce range as tolerance improves. The comparison is with that traditional program, not with every form of loading.
What the midportion trials found
Shockwave, loading or wait and see. In an earlier trial in the American Journal of Sports Medicine in 2007, Rompe and colleagues randomized 75 patients with chronic midportion tendinopathy to eccentric loading, low-energy shockwave or wait and see. An earlier randomized trial found both low-energy shockwave and eccentric loading superior to observation, with broadly similar outcomes between the two active treatments. At four months, 60% with loading, 52% with shockwave and 24% with wait and see reported being completely recovered or much improved, and the two active groups did not differ significantly.
Loading plus shockwave vs. loading alone. In 2009, the same group randomized 68 patients with refractory midportion tendinopathy to eccentric loading alone or eccentric loading plus low-energy shockwave. For chronic midportion Achilles tendinopathy, shockwave appears especially useful as an adjunct to loading. In a 68-patient randomized trial, VISA-A increased to 87 with loading plus shockwave versus 73 with loading alone, and 82% versus 56% reported being completely recovered or much improved at four months. Pain fell from 7 to 2 with the combination and from 7 to 4 with loading alone.
The one-year groups were no longer directly comparable because many loading-only nonresponders crossed over to combined treatment. Fifteen patients from the loading group switched to the combination, and six patients from the combination group who did not improve had surgery.
What the classic Achilles trials suggest
- Insertional: shockwave outperformed traditional eccentric loading in the 2008 trial.
- Midportion: shockwave and loading were both effective in the 2007 trial.
- Refractory midportion: adding shockwave to loading improved four-month outcomes in the 2009 trial.
Taken together, these trials support shockwave as an effective treatment option, particularly when a tendon stays symptomatic despite loading, and as a potential addition to rehabilitation. They do not show that shockwave is better than exercise in general, and the answer depends on where the tendon hurts.
What protocol was studied?
The classic trials used low-energy radial treatment: three sessions of about 2,000 impulses at low pressure (2.5 to 3 bar), reported at roughly 0.1 to 0.12 mJ/mm². Those parameters show what was studied. They should not be treated as a universal prescription, and energy values reported for radial devices are not directly equivalent to focused-device energy flux density. Transient skin reddening was the main side effect reported.
What do the pooled reviews show?
Fan 2020. A meta-analysis in the Orthopaedic Journal of Sports Medicine combined 5 randomized trials and 3 case-control studies published between 2005 and 2018. Shockwave was associated with better scores than comparison treatments for pain (VAS), the AOFAS score, VISA-A, the Roles and Maudsley score and patient satisfaction. Benefit appeared at both low (0.06 to 0.11 mJ/mm²) and medium (0.12 to 0.25 mJ/mm²) energy levels, and at both shorter and longer follow-up. Tenderness and pressure-pain threshold did not clearly differ. With only eight studies of mixed design, this is supportive rather than definitive evidence.
Majidi 2024. A 2024 meta-analysis also reported a large pooled pain effect for chronic Achilles tendinopathy (standardized mean difference −1.38), but heterogeneity was extremely high (I² 96.44%), meaning the size of benefit varied substantially between studies. That figure should not be read as a precise prediction of how much any one person will improve.
Network evidence. A 2020 network meta-analysis of 22 trials in midportion tendinopathy (Rhim and colleagues) found larger longer-term VISA-A improvement when shockwave was added to eccentric exercise than with eccentric exercise alone. Comparative evidence generally supports shockwave as an addition to a well-designed loading program rather than a reason to replace one.
Results vary across studies, which is why ESWT should be selected for the individual Achilles presentation rather than applied automatically.
Radial vs. focused shockwave
The strongest classic Achilles trials used low-energy radial treatment. Radial shockwave spreads energy across a broader, more superficial field, which suits a superficial tendon like the Achilles. Focused shockwave concentrates energy at a selectable depth and also has Achilles research. Deeper penetration does not make focused treatment automatically better, and the use of radial devices in the classic trials does not make radial universally better. At Novo, the choice depends on location, tissue depth, the treatment target, previous response and the examination. For the broader comparison, see radial vs. focused shockwave.
What does combined radial and focused evidence show?
Robinson, Tan and Tenforde reviewed 87 patients whose Achilles tendinopathy had not responded to exercise, published in the Journal of Foot and Ankle Surgery in 2022. All were prescribed eccentric exercise; 58 received radial shockwave and 29 received combined radial and focused shockwave. In a retrospective cohort of patients who had already failed exercise, 89.7% treated with combined radial and focused shockwave met the prespecified VISA-A minimal clinically important difference versus 63.8% treated with radial alone. The mean VISA-A change, however, was not statistically different between groups (23.3 vs. 19.9 points), so the finding is supportive rather than proof that combined treatment is superior. No serious adverse events were observed.
Does shockwave regenerate the Achilles tendon?
No human trial has shown that. The Achilles studies measure pain, function and patient-rated recovery. Biological mechanisms have been proposed, but symptom and function improvement is the supported claim.
Does shockwave replace rehabilitation?
No. Progressive calf and Achilles loading remains foundational treatment. Shockwave is most compelling as a treatment option for persistent cases or as an adjunct when a well-designed loading program has not been sufficient. Rehabilitation may include isometrics, slow heavy loading, eccentric-concentric work, energy-storage loading and sport-specific progression, adapted to the stage and to whether the problem is insertional or midportion.
Who may be a reasonable candidate?
Shockwave is most often considered when Achilles pain has persisted for months despite appropriate loading and activity changes, and the examination points to insertional or midportion tendinopathy rather than another cause.
Who needs imaging or another pathway?
- A sudden pop, a feeling of being kicked in the back of the leg, or inability to push off
- Marked weakness or a palpable gap in the tendon
- Pain after significant trauma
- Numbness, burning or other nerve-type symptoms
- Significant swelling, redness or warmth around the tendon
A suspected tear or rupture needs assessment before any shockwave treatment.
How Novo approaches Achilles pain
We examine first. Radial shockwave and focused shockwave are options chosen by what the exam shows, alongside a loading program rather than in place of it. See how we approach Achilles tendinopathy, tendon problems elsewhere on chronic tendinopathy, or read about shockwave therapy in Denver and the four tools we use.
References
- Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomized, controlled trial. Journal of Bone and Joint Surgery (American). 2008;90(1):52-61. PMID 18171957. (link)
- Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463-470. PMID 19088057. (link)
- Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374-383. PMID 17244902. (link)
- Fan Y, Feng Z, Cao J, Fu W. Efficacy of extracorporeal shock wave therapy for Achilles tendinopathy: a meta-analysis. Orthopaedic Journal of Sports Medicine. 2020;8(2):2325967120903430. PMID 33283015. (link)
- Majidi L, Khateri S, Nikbakht N, et al. The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials. BMC Sports Science, Medicine and Rehabilitation. 2024;16(1):93. PMID 38659004. (link)
- Rhim HC, Kim MS, Choi S, Tenforde AS. Comparative efficacy and tolerability of nonsurgical therapies for the treatment of midportion Achilles tendinopathy: a systematic review with network meta-analysis. Orthopaedic Journal of Sports Medicine. 2020;8(7):2325967120930567. PMID 32728589. (link)
- Robinson DM, Tan CO, Tenforde AS. Functional gains using radial and combined shockwave therapy in the management of Achilles tendinopathy. Journal of Foot and Ankle Surgery. 2022;61(1):99-103. PMID 34274243. (link)
