Shockwave therapy is well studied in several tendinopathies, but direct iliopsoas-specific clinical evidence remains limited. That makes patient selection especially important: a load-related iliopsoas tendon problem is different from internal snapping, hip-joint pathology or post-arthroplasty mechanical impingement.
Iliopsoas shockwave evidence at a glance
Iliopsoas-specific trials
Limited
no condition-specific trial identified
Supporting evidence
Other tendons
plausibility, not a specific effect size
Most important step
Localize it
tendon, snap, hip joint or implant?
For the iliopsoas, the diagnostic research is currently stronger than the shockwave research.
Three levels of evidence
- Direct iliopsoas-specific data. A PubMed search for shockwave combined with iliopsoas, psoas, hip flexor or snapping hip, run in October 2026, did not identify a clinical trial of shockwave for iliopsoas tendinopathy. Most results concerned unrelated topics such as kidney stone treatment.
- Broader tendinopathy evidence. Supports shockwave as a treatment class in several tendons.
- Groin pain research. Shockwave has been studied in broader athletic groin pain, but not in a population defined as iliopsoas-related pain.
These levels should not be combined into a single iliopsoas effect size.
What the broader tendinopathy evidence shows
Broader tendinopathy research supports ESWT as a treatment class, but those data do not establish a specific effect size for iliopsoas tendinopathy.
A 2018 meta-analysis of 29 randomized trials found that shockwave had a positive overall effect on pain and function in lower-limb tendinopathy, with effects seen at short-term follow-up and at 3, 6 and 12 or more months, and suggested that shockwave type and dose may influence results (Liao, 2018). A later systematic review and meta-analysis of 22 randomized trials, published online in 2023, concluded that shockwave was effective for lower-limb and calcific tendinopathies but did not outperform other treatments for upper-limb and noncalcific tendinopathies (Elgendy, 2024).
Those reviews did not report iliopsoas-specific results. The iliopsoas is a deep tendon that crosses the front of the hip joint and is harder to define clinically than many of the tendons studied in shockwave trials. Results from other tendons support biological plausibility, not a predictable response in the iliopsoas.
Why the iliopsoas is a harder target to study
Several features make the iliopsoas difficult to study with shockwave. The tendon lies deep, directly in front of the hip joint, with the iliopsoas bursa between them, so pain from the tendon, bursa and joint can feel the same. Clinical tests are improving but are not definitive, imaging is often normal and the best available reference standard is the response to an image-guided injection. Patient groups are also mixed: athletes with load-related tendon pain, people with painful snapping and people with symptoms after hip replacement have different problems, and a trial that combined them would be hard to interpret. Until studies separate these groups, any shockwave result for "hip flexor pain" would be difficult to apply to an individual patient.
Groin pain research is not iliopsoas research
Focused shockwave is being studied in chronic athletic groin pain more broadly. A 2026 prospective study combined focused shockwave with structured rehabilitation in soccer players with groin pain syndrome, but it had no control group and did not enroll a population defined as iliopsoas-related pain (Santilli, 2026). It should not be read as iliopsoas-specific evidence. The groin research is reviewed in shockwave therapy for adductor tendinopathy and groin pain.
Diagnosis comes before any adjunct
Iliopsoas-related pain is diagnosed clinically. The newest systematic review found that no single examination test is definitive, but the HEC test and resisted seated hip flexion performed best among the available maneuvers, while supine provocation tests were sensitive but not specific. All three diagnostic studies were at high risk of bias (Vandeputte, 2026). In a 2026 injection-referenced study, MRI was only 19.2% sensitive for iliopsoas-related pain, so a normal scan does not exclude the problem (Johnstone, 2026).
Before shockwave is considered, it is worth answering four questions:
- Is the pain actually coming from the iliopsoas, or from the hip joint, adductors, rectus femoris or another structure? See iliopsoas pain vs. hip joint pain.
- Is painful snapping the main complaint? See internal snapping hip.
- Has the patient had a hip replacement?
- Has a structured, progressive loading program been tried?
What shockwave cannot do
Shockwave may be relevant to symptomatic tendon tissue, but it does not mechanically correct the tendon excursion that causes internal snapping. Specifically, it does not change:
- the path the tendon takes during hip motion
- tendon flipping around the iliacus
- a bifid (two-headed) tendon
- the shape of the iliopectineal region of the pelvis
- the position or prominence of an acetabular cup after hip replacement
It also does not treat hip-joint pathology such as femoroacetabular impingement or a labral tear, and it does not replace progressive loading.
Iliopsoas pain after hip replacement
Painful iliopsoas impingement after total hip arthroplasty is a mechanically distinct problem and should not be managed as routine athletic iliopsoas tendinopathy. In the 2026 systematic review, conservative treatment succeeded in only 16% to 50% of cases after hip replacement, compared with 77% to 100% in idiopathic and athletic populations, and both tenotomy and revision of the acetabular component improved pain and function in selected patients, with outcomes strongly dependent on implant position (Vandeputte, 2026). Shockwave is not a routine treatment for this group, which needs evaluation with the surgical team.
Exercise remains the foundation
Most idiopathic and athletic iliopsoas presentations improve with conservative care, although rehabilitation protocols vary and the evidence base remains heterogeneous. The review's 77% to 100% success range reflects many different programs, populations and definitions of success, so it should not be read as a universal success rate.
A typical progression moves from low-load hip flexion to seated resisted hip flexion, standing hip flexion and long-lever hip-flexion loading, then running, hills, sprinting, kicking and sport-specific demand, as appropriate. Dose depends on the presentation rather than a fixed program. Stretching may help selected patients, but if compression or tendon irritability is driving symptoms, aggressive stretching may reproduce pain and should not be prescribed automatically.
Manual treatment may be useful when surrounding soft-tissue restriction limits comfortable loading, but it should be paired with restoration of hip-flexor capacity.
Who might be a candidate
Shockwave is more reasonable to consider when:
- the iliopsoas has been identified as the pain source on examination
- the hip joint has been assessed and is not the main driver, or is being managed
- painful snapping is not the main problem, or has been assessed
- there is no history of hip replacement driving the symptoms
- a progressive loading program has been followed but symptoms persist
What a course of treatment looks like
When shockwave is used for a tendon problem, it is usually given as a short series of sessions spaced about a week apart, alongside the loading program rather than instead of it. Protocols vary between devices and clinics, and no iliopsoas-specific protocol has been established. Treatment can be uncomfortable but is generally well tolerated, and settings are adjusted to the patient's response.
How progress is judged
Progress is measured by function rather than by how the hip feels immediately after a session. Useful markers include pain and strength during resisted seated hip flexion, the response to the HEC test, tolerance of running, hills or kicking, and the ability to progress the loading program. If those measures are not improving after a reasonable course, the diagnosis is revisited, including the hip joint and other groin structures, rather than simply adding more sessions.
Radial or focused?
No study has compared radial and focused shockwave for the iliopsoas. Because the tendon lies deep at the front of the hip, focused energy may be better suited to reaching it, but that is a practical consideration rather than evidence that one device works better. The femoral nerve and vessels run close to the iliopsoas at the front of the hip, so treatment positioning avoids the neurovascular bundle. General device differences are covered in radial vs. focused shockwave.
What better evidence would look like
Useful future studies would enroll patients with iliopsoas-related pain confirmed by examination and, where appropriate, diagnostic injection; exclude or separately analyze hip-joint pathology, painful snapping and post-arthroplasty cases; compare progressive loading alone with loading plus shockwave; use sham controls; and report device type and energy settings in reproducible detail.
Where shockwave fits
Shockwave may be a reasonable adjunct for selected persistent iliopsoas tendinopathy after hip-joint pathology, significant snapping mechanics and other groin diagnoses have been considered. Direct iliopsoas-specific comparative evidence remains limited, so ESWT should not be presented as the default first-line treatment.
How Novo uses this evidence
We first determine whether the iliopsoas is the pain source, assess the hip joint, adductors and rectus femoris, check whether snapping is relevant and ask about prior hip surgery. When persistent load-related iliopsoas tendon pain is confirmed and loading alone has not been enough, focused or radial shockwave may be added to progressive hip-flexor loading and, where appropriate, manual treatment. See how we approach iliopsoas and hip flexor pain.
References
- Liao CD, Tsauo JY, Chen HC, Liou TH. Efficacy of extracorporeal shock wave therapy for lower-limb tendinopathy: a meta-analysis of randomized controlled trials. American Journal of Physical Medicine & Rehabilitation. 2018;97(9):605-619. PMID 29557811. (link)
- Elgendy MH, Khalil SE, ElMeligie MM, Elazab DR. Effectiveness of extracorporeal shockwave therapy in treatment of upper and lower limb tendinopathies: a systematic review and meta-analysis. Physiotherapy Research International. 2024;29(1):e2042. PMID 37493215. (link)
- Santilli G, Santoboni F, Checchi E, et al. Integrating focused shockwave therapy into rehabilitation for groin pain syndrome: a prospective study in soccer players. Life. 2026;16(3):509. PMID 41901027. (link)
- Vandeputte FJ, Sergooris A, Roose S, Timmermans A, Corten K. Clinical diagnosis and treatment of iliopsoas-related groin pain: a systematic review. Journal of Clinical Medicine. 2026;15(15):5912. PMID 42590015. (link)
- Johnstone T, Pierre K, Roh E, Fredericson M, Safran MR. Can a clinician accurately diagnose iliopsoas tendinitis on a physical examination? American Journal of Sports Medicine. 2026;54(7):1705-1711. PMID 41823309. (link)
