Shockwave therapy has one of its strongest recent evidence updates in patellar tendinopathy. A 2026 systematic review and meta-analysis of 13 studies found that patients treated with focused or radial ESWT improved an average of 2.53 points on a 10-point pain scale and about 20 points on the VISA tendon-function score. Control groups improved less, and both ESWT changes exceeded the clinically meaningful thresholds used by the authors.
That does not mean shockwave can stand in for rehabilitation. Patellar tendinopathy remains a load-related condition, and progressive tendon loading is the foundation of care. The more useful question is whether ESWT can improve outcomes when used as an adjunct in appropriately selected persistent cases.
Latest meta-analysis · 2026 · 13 studies
Pain (VAS)
5.24 → 2.71
−2.53 points after ESWT
Function (VISA)
54.65 → 74.86
+20.22 points after ESWT
Control improvement
−1.09 / +8.27
Pain / VISA points
Both ESWT improvements exceeded the clinically meaningful thresholds used in the review. These are pooled changes within groups, not the difference between ESWT and placebo.
What the newest meta-analysis found
Friedman and colleagues, in Archives of Rehabilitation Research and Clinical Translation (2026), searched PubMed, Embase and Web of Science through May 27, 2025, plus gray literature. They included 13 studies of focused or radial ESWT for patellar tendinopathy: randomized controlled trials, prospective cohort studies and retrospective chart reviews. When studies reported several follow-up points, the 12- to 16-week result was used.
Pain. The pain analysis included 13 studies and 530 participants (372 treated with ESWT and 158 controls). In the newest patellar-tendinopathy-specific meta-analysis, pain scores fell by an average of 2.53 points after ESWT, from 5.24 to 2.71. Control groups improved by about 1.09 points, from 4.89 to 3.80. The pooled ESWT effect size for pain was large (Cohen's d −1.54, 95% CI −2.06 to −1.03), compared with d −0.48 (−0.76 to −0.20) in the control groups, and the difference between groups was significant (P < .01). Every ESWT study arm showed a significant reduction in pain, compared with 2 of 7 control groups.
Function. The VISA analysis included 9 studies and 369 participants (246 ESWT, 123 controls). Function also improved substantially. VISA scores increased by about 20 points after ESWT compared with roughly 8 points in control groups: from 54.65 to 74.86 (+20.22) with ESWT and from 54.90 to 63.16 (+8.27) in controls. The ESWT effect size was again large (d 1.76, 95% CI 0.90 to 2.62), compared with d 0.56 (0.02 to 1.11) for controls, and the difference between groups was significant (P = .02).
The 530 and 369 figures are participants in two outcome analyses drawn from the same 13 studies. Many studies reported both outcomes, so the two numbers overlap and should not be added together as if they were separate patients.
Were the improvements clinically meaningful?
The authors compared the pooled changes with minimal clinically important difference thresholds of 1.2 points for pain and 7.3 points for VISA. The ESWT changes were 2.53 and 20.22 points. Both pooled improvements exceeded the clinically meaningful thresholds used by the authors.
These are average changes across studies. They do not mean every patient reached a meaningful improvement, and they are not themselves the treatment effect of ESWT over placebo, because part of any improvement reflects loading, time and other care received in both groups.
How consistent were the results?
Functional improvement was also relatively consistent across the ESWT literature: 10 of 11 ESWT study arms reporting functional outcomes showed significant improvement, compared with 2 of 5 control groups. That describes how many study arms improved, not the proportion of patients who responded.
How strong is the evidence?
The evidence base was not uniformly high quality, but the review included four high-quality and six moderate-quality studies, and the randomized trials generally had low risk of bias. Three studies were rated low quality. Nonrandomized studies carried a higher risk of bias, but the authors reported that they had relatively little influence on the pooled effect.
Heterogeneity was high. Treatment protocols and patient populations varied considerably across studies, so the pooled effect should not be interpreted as a universal response to one standardized ESWT protocol. Differences included radial versus focused devices, energy levels, the number of sessions, symptom duration, athletic status, the loading program used, the comparison treatment and the follow-up length.
Mean follow-up was about 12.5 ± 8.1 weeks for pain and 14.5 ± 7.1 weeks for function. These results primarily describe short- to intermediate-term outcomes rather than a permanent cure.
Why have some earlier shockwave trials been less positive?
Not every trial has been positive. The well-known TOPGAME sham-controlled trial found no additional benefit from ESWT in 62 competitive jumping athletes. Importantly, athletes continued training and competing during the study, creating a very different clinical context from a refractory patient whose training load is actively being modified.
In TOPGAME, volleyball, basketball and handball players with symptoms for 3 to 12 months were randomized to three sessions of ESWT (31 athletes) or sham treatment (31 athletes) during the first half of the season, with ESWT used as a solitary treatment. VISA-P scores moved from 59.4 at baseline to 66.8, 66.7 and 70.5 at 1, 12 and 22 weeks with ESWT, and from 62.4 to 66.3, 68.9 and 72.7 with sham. Both groups improved over time, with no significant treatment-by-time interaction (P = .82).
A 2021 network meta-analysis of 37 randomized trials covering 33 interventions and combinations reached a similar conclusion for that specific comparison. Only two randomized trials informed the ESWT-versus-sham comparison, and both groups also performed eccentric loading. Earlier randomized evidence found little short-term difference between ESWT and sham when both groups performed eccentric loading: pain differed by a mean of +0.1 points (95% CI −0.8 to 1) and function by −1.8 points (95% CI −8 to 4.4). The incremental benefit of ESWT becomes harder to demonstrate when both groups receive an active loading intervention.
A 2023 review similarly found little additional short-term benefit over placebo when eccentric exercise was included in both groups, but more favorable results when ESWT was compared with other conservative treatments.
Why do two 2026 reviews sound different?
A 2026 network meta-analysis by Guo and colleagues pooled 65 randomized trials and 3,921 cases across five tendinopathies. For patellar tendinopathy, ESWT did not show a significant benefit over placebo on VISA-P (standardized mean difference −0.15, 95% CI −0.42 to 0.12).
Two recent reviews illustrate why evidence synthesis can produce different conclusions. The patellar-specific Friedman meta-analysis found large clinically meaningful improvements after ESWT and greater improvement than control groups overall. A separate 2026 network meta-analysis restricted to randomized trials across multiple tendinopathies did not find a significant ESWT advantage over placebo for the patellar subgroup. The difference largely reflects study selection and the question being asked: whether patients improve after ESWT versus how much additional benefit ESWT provides over specific controls.
| Friedman 2026 | Guo 2026 | |
|---|---|---|
| Scope | Patellar tendinopathy only | Five tendinopathies, patellar as a subgroup |
| Study designs | RCTs, prospective cohorts, retrospective chart reviews | Randomized trials only |
| Main question | How much do patients improve after ESWT, and how does that compare with controls overall? | How much additional benefit does ESWT give over specific comparators, including placebo? |
| Patellar result | Large pooled improvement; controls improved less | No significant advantage over placebo |
ESWT combined with PRP
A small 33-athlete randomized trial evaluated PRP alone versus PRP plus ESWT. It is relevant to combination therapy, but it does not isolate the effect of ESWT itself. Both groups received a platelet-rich plasma injection; one group also received ESWT and the other sham ESWT. The combination produced faster pain reduction at one month, and both groups improved over one year of follow-up.
Shockwave does not replace tendon loading
Progressive loading remains the foundation of patellar-tendinopathy rehabilitation. A systematic review of 12 trials found that load monitoring and therapeutic exercise improved pain, function and strength in the short and medium term. A 2026 review that qualitatively synthesized 40 reports pooled six randomized comparisons between active loading programs and found a mean difference of 5.16 VISA points (95% CI 2.39 to 7.93) favoring the first-listed program, with low certainty. Current evidence continues to support structured tendon loading as the core treatment, although no single loading prescription has been shown to be universally superior.
Heavy slow resistance and progressive tendon-loading programs are reasonable alternatives to eccentric-only rehabilitation and may offer better long-term function in some studies. A 2024 network meta-analysis of seven studies reached that conclusion, while noting it could not compare the programs directly. Eccentric loading is not always best, and none of these approaches has been shown to be the right choice for every patient.
Rehabilitation should progress tendon demand rather than treating every exercise as equivalent. Squatting, hopping, jumping, running and cutting can be staged according to the magnitude and rate of tendon loading. In a laboratory study of 35 rehabilitation exercises in 20 healthy adults, the single-leg decline squat had one of the highest patellar-tendon loading indices, alongside the single-leg forward hop, single-leg countermovement jump and running cut, while step-ups and double-leg partial squats loaded the tendon far less.
What did treatment look like in the studies?
There is no single standard protocol. TOPGAME used three sessions during the competitive season. The PRP combination trial used a single session of 1,350 impulses at an energy flux density of 0.2 mJ/mm² at 4 Hz, one week after the injection. Across the 13 studies in the Friedman review, devices, energy levels, the number of sessions and the accompanying exercise program all differed, which is one reason heterogeneity was high. The most consistent thread is that ESWT was studied in persistent tendinopathy and usually alongside, rather than instead of, an exercise program.
That variability also means the pooled results do not tell an individual patient exactly how many sessions they need. Treatment frequency and number are set by the response to treatment and loading, not by a fixed package. Shockwave sessions are typically brief, and many people continue modified training while they are being treated, with the most provocative jumping or decline work adjusted rather than stopped altogether.
Radial or focused?
Both focused and radial ESWT have been studied in patellar tendinopathy. Current evidence does not establish that one is universally superior, and protocols vary substantially. The Friedman review included both. Device choice depends on the location of tenderness, the depth of the target and previous response. The difference is explained in radial vs. focused shockwave, and on the radial shockwave and focused shockwave pages.
Who may be a candidate?
ESWT is most reasonable when the pain is clearly localized to the patellar tendon, other sources of anterior knee pain have been considered, a progressive loading program is in place, and symptoms have persisted despite that rehabilitation. It is not selected because an ultrasound looks abnormal or simply because the knee hurts at the front. The diagnostic side is covered in patellar tendinopathy vs. patellofemoral pain.
A sudden pop, inability to straighten the knee or a palpable gap in the tendon is a different problem that needs urgent imaging and orthopedic assessment.
Questions worth asking before shockwave
- Is the tendon really the pain generator? Pain spread around or behind the kneecap, joint-line pain, swelling or catching point elsewhere.
- Is a loading program in place? Shockwave studied as an adjunct is a different question from shockwave used on its own.
- Is training load being managed? TOPGAME suggests that shockwave alone does little while high jumping loads continue unchanged.
- How long has it been present, and what has been tried? Most of the favorable evidence comes from persistent cases, not new, irritable tendons.
- How will progress be measured? Pain during a defined loading task and a function score such as VISA-P are more useful than how the tendon looks on a scan.
How Novo uses this evidence
The Friedman meta-analysis is the main reason Novo considers ESWT a reasonable option for persistent patellar tendinopathy. The earlier sham-controlled and network evidence is the main reason we do not offer it in place of rehabilitation. In practice, that means confirming the diagnosis, setting a starting point for tendon loading from the examination, adjusting sport and training load, and adding radial or focused shockwave when the tendon remains painful despite that work. Progress is reassessed with the same loading tasks used at the first visit, and imaging or referral is arranged when the picture does not fit tendinopathy or progress stalls.
The bottom line
The newest patellar-specific meta-analysis strengthens the case for ESWT in persistent patellar tendinopathy. Across 13 studies, pain and function improved substantially, and average changes exceeded commonly used thresholds for clinical importance. At the same time, older sham-controlled trials and a separate randomized-trial network meta-analysis show that the incremental benefit over a well-designed loading program is not guaranteed.
The practical takeaway is not that every jumper's knee needs shockwave. It is that ESWT is a reasonable evidence-supported adjunct when the diagnosis is correct, tendon loading is being managed appropriately and progressive rehabilitation alone has not been sufficient. See how we approach patellar tendinopathy, or book a new patient exam.
References
- Friedman A, Spicer S, Garfinkle J, Tahir H. Systematic review and meta-analysis assessing the effects of focal and radial extracorporeal shockwave therapy on pain and function in patellar tendinopathy. Archives of Rehabilitation Research and Clinical Translation. 2026;8(3):100657. PMID 42769704. (link)
- Zwerver J, Hartgens F, Verhagen E, van der Worp H, van den Akker-Scheek I, Diercks RL. No effect of extracorporeal shockwave therapy on patellar tendinopathy in jumping athletes during the competitive season: a randomized clinical trial. American Journal of Sports Medicine. 2011;39(6):1191-1199. PMID 21285447. (link)
- Challoumas D, Pedret C, Biddle M, et al. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ Open Sport & Exercise Medicine. 2021;7:e001110. PMID 34900334. (link)
- Charles R, Fang L, Zhu R, Wang J. The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Frontiers in Immunology. 2023;14:1193835. PMID 37662911. (link)
- Guo NY, Wang SQ, Liu W, et al. The effect of extracorporeal shockwave therapy in tendinopathy: a systematic review and network meta-analysis of randomized controlled trials. Orthopaedic Surgery. 2026;18:2060-2082. PMID 42733276. (link)
- Jhan SW, Wu KT, Chou WY, et al. A comparative analysis of platelet-rich plasma alone versus combined with extracorporeal shockwave therapy in athletes with patellar tendinopathy. Knee Surgery & Related Research. 2024;36(1):47. PMID 39690426. (link)
- Núñez-Martínez P, Hernández-Guillen D. Management of patellar tendinopathy through monitoring, load control, and therapeutic exercise: a systematic review. Journal of Sport Rehabilitation. 2022;31(3):337-350. PMID 34942594. (link)
- Bruna-Mejias A, Cañas-Jamett R, Valenzuela Fuenzalida JJ, et al. Exercise loading strategies for patellar tendinopathy: a systematic review and meta-analysis. Journal of Functional Morphology and Kinesiology. 2026;11(3):348. PMID 42783641. (link)
- Li Y, Sun D, Fang Y, et al. Mixed comparison of intervention with eccentric, isometric, and heavy slow resistance for VISA-P in adults with patellar tendinopathy: a systematic review and network meta-analysis. Heliyon. 2024;10(21):e39171. PMID 39559237. (link)
- Scattone Silva R, Song KE, Hullfish TJ, et al. Patellar tendon load progression during rehabilitation exercises: implications for the treatment of patellar tendon injuries. Medicine & Science in Sports & Exercise. 2024;56(3):545-552. PMID 37847102. (link)
