Shockwave therapy has substantial randomized evidence for persistent plantar fasciitis. Two large multicenter placebo-controlled trials reported meaningful benefit, one with focused shockwave and one with radial shockwave, and several recent meta-analyses support improvements in pain and function. The research is not uniformly positive. A 200-patient trial published in 2024 found no added six-month benefit from radial shockwave when every patient already received advice and custom foot orthoses. The best reading is not that shockwave always works or never works. Diagnosis, patient selection, protocol, and what shockwave is compared against all shape the result. This review covers what the strongest studies found, why they sometimes disagree, and what that means for choosing treatment.
What is plantar fasciitis, and why is plantar fasciopathy sometimes more accurate?
The plantar fascia is a thick band of connective tissue running from the heel to the base of the toes. Plantar fasciitis describes pain where it attaches to the inner heel, usually worst with the first steps after rest. In persistent cases, many clinicians and researchers prefer plantar fasciopathy, because long-standing pain can involve structural changes such as thickening and altered collagen organization, not just inflammation. This article uses both terms, following the language of each study.
Does shockwave therapy actually help plantar fasciitis?
For selected patients with chronic symptoms, the evidence says it can. The clearest support comes from large placebo-controlled trials, and it is backed by several meta-analyses. The more nuanced question is how much shockwave adds compared with other good care, and for whom.
What the strongest trials found
- Focused ESWT: Gollwitzer et al., 2015. 250 patients enrolled in a multicenter, double-blind FDA trial. Composite heel-pain score fell 69.2% with focused shockwave versus 34.5% with placebo at 12 weeks.
- Radial ESWT: Gerdesmeyer et al., 2008. 245 patients in a multicenter placebo-controlled trial. Composite pain score fell 72.1% versus 44.7%, and overall success was 61.0% versus 42.2% at 12 weeks.
- Long-term radial: Ibrahim et al., 2017. 50 patients. Pain and function differences favoring radial shockwave over placebo were still present at 24 months.
- ESWT vs. corticosteroid: Cortés-Pérez et al., 2024. 16 studies, 1,121 patients. Pain and foot function favored shockwave at three and six months.
- Intensity network: Zhao et al., 2025. 22 trials, 2,299 participants. All intensity levels improved treatment success versus placebo, but certainty of evidence was low to very low.
- No added benefit: Heide et al., 2024. 200 patients, all given advice and custom orthoses. Adding radial shockwave did not reduce heel pain further at six months.
The percentages from the first two trials describe reductions in a pain score, not the share of patients who recovered.
The strongest focused-shockwave evidence
Gollwitzer and colleagues ran a prospective, multicenter, double-blind, randomized, placebo-controlled trial for the U.S. Food and Drug Administration, published in the Journal of Bone and Joint Surgery in 2015. Patients with chronic heel pain diagnosed as plantar fasciitis received three weekly sessions of focused shockwave (0.25 mJ/mm², 2,000 impulses) or placebo, without local anesthesia. Of 250 enrolled, 246 were analyzed at 12 weeks.
The primary pain measure combined first-step morning pain, pain during daily activities, and pain with a standardized pressure test. That composite score fell by 69.2% with focused shockwave compared with 34.5% with placebo, and the Roles and Maudsley functional score also favored shockwave. The authors reported success rates of 50% to 65%, depending on the definition. Temporary pain and swelling were the only device-related side effects.
The strongest radial-shockwave evidence
Gerdesmeyer and colleagues reported a confirmatory randomized, placebo-controlled, multicenter trial in The American Journal of Sports Medicine in 2008. Its 245 patients with chronic plantar fasciitis received three sessions of radial shockwave (0.16 mJ/mm², 2,000 impulses) or placebo. At 12 weeks the composite pain score fell 72.1% with radial shockwave and 44.7% with placebo, and overall success was 61.0% versus 42.2%. Secondary outcomes also favored radial shockwave.
These two trials used different devices, patients, and protocols, so their numbers should not be compared head to head to decide which modality is better.
Do the benefits last?
In the Gerdesmeyer trial, the advantage over placebo was reported to be even more pronounced at 12 months. A separate and smaller trial by Ibrahim and colleagues in the Journal of Orthopaedic Research (2017) randomized 50 patients to two weekly sessions of radial shockwave or placebo. Pain and Roles and Maudsley scores favored radial shockwave at 1, 3, 6, 12, and 24 months. It is one small study, but it suggests benefit can persist for some patients.
Why do some shockwave studies look much better than others?
Shockwave trials are not all asking the same question. Results differ with:
- Who was enrolled: diagnostic criteria, how long symptoms had lasted, and what treatment patients had already tried
- The comparator: placebo alone, or placebo on top of other active care
- Background care: whether every group also received orthoses, exercise, or advice
- The device and dose: focused or radial, energy, pressure, pulse count, frequency, and number and spacing of sessions
- Technique: how the treatment area was located and treated
- Measurement: which pain or function scale was used, and when it was measured
- Study quality: blinding, dropouts, and risk of bias
A trial comparing shockwave with placebo alone tests whether the treatment has an effect. A trial adding shockwave to already effective care tests whether it adds anything more. Both are useful, and they can reach different answers without either being wrong.
A 200-patient trial found no added benefit. What does that mean?
Heide and colleagues published a four-arm, sham-controlled trial in the British Journal of Sports Medicine in 2024. Before randomization, all 200 patients with plantar fasciopathy received advice plus customized foot orthoses. They were then assigned to radial shockwave, sham shockwave, a supervised exercise program, or no additional treatment (50 per group). At six months, none of the added treatments reduced heel pain during activity more than advice and orthoses alone.
This is an important result and should not be ignored. It does not show that shockwave has no effect. It shows that, in this population and protocol, adding radial shockwave to advice and custom orthoses did not give extra pain relief at six months. For a patient who has not yet tried well-fitted orthoses and education, that is useful to know.
What do recent meta-analyses show?
Pooled analyses mostly support shockwave while showing it is not the best option on every measure:
- Tung et al., 2025 (Foot and Ankle Surgery): 15 randomized trials and 1,123 patients. Shockwave produced significantly better pain scores than placebo.
- Lippi et al., 2024 (European Journal of Physical and Rehabilitation Medicine): 11 randomized trials. Pain fell by about 2.8 points with focused shockwave and about 3.0 points with radial shockwave on a 10-point scale.
- Zhao et al., 2025 (PM&R): a network meta-analysis of 22 trials and 2,299 participants comparing intensity levels.
- Cortés-Pérez et al., 2024 (Clinical Rehabilitation): 16 studies comparing shockwave with corticosteroid injection.
Shockwave versus corticosteroid injection
Cortés-Pérez and colleagues pooled 16 studies with 1,121 patients. At three months, shockwave reduced pain more than corticosteroid injection (SMD −0.60), reduced plantar fascia thickness more (SMD −0.40), and improved foot function more (SMD 0.27). At six months, shockwave remained better for pain (SMD −0.81) and function (SMD 0.67). Local pain and mild redness were the most common shockwave side effects. This is some of the stronger comparative evidence for shockwave at the mid-term, though it does not mean shockwave is the right choice for every patient.
Shockwave versus PRP, orthotics, and other active care
The 2025 Tung meta-analysis is a useful counterweight. Shockwave beat corticosteroid injection on the Foot Function Index. Platelet-rich plasma (PRP) outperformed shockwave for both pain and foot function, and custom orthotics outperformed shockwave on foot function. No other comparison showed a significant difference. These findings depend on the outcome and the studies included, and they do not make PRP or orthotics universally better either. They do show that no single treatment wins for every patient.
Focused vs. radial shockwave
Tezen and colleagues compared radial and focused shockwave in 112 patients with clinically and radiologically diagnosed plantar fasciitis (Journal of Foot and Ankle Surgery, 2025). Both groups improved in pain and Foot Function Index scores, with no significant difference between them through 12 weeks. That is not proof the two are equivalent, because the study was not designed to show equivalence. Lippi's pooled estimates were also similar for the two. The physics of the two modalities are covered in radial vs. focused shockwave, with more detail on our focused shockwave and radial shockwave pages.
Does dose matter?
Probably, but the best dose is not settled. Lippi's meta-regression found that treatment parameters, including energy, pressure, pulse number, and frequency, were associated with pain outcomes and with treatment dropout. Those associations come from comparing studies, not individual patients, and the studies were heterogeneous, so they do not establish one optimal dose or show that more energy is always better.
Zhao's network meta-analysis found that every intensity level improved treatment success compared with placebo. For pain, medium-intensity (SMD −0.60) and high-intensity (SMD −0.28) shockwave were better than placebo, while no intensity level clearly improved function, and the intensity levels did not differ significantly from one another. Seven of the 22 trials were at high risk of bias and the rest were unclear, and certainty was low to very low.
Does shockwave reduce plantar fascia thickness?
A 2024 meta-analysis by Simental-Mendía and colleagues in Archives of Orthopaedic and Trauma Surgery pooled 14 randomized trials with 867 participants. Shockwave reduced plantar fascia thickness by about 0.2 mm compared with other non-surgical treatments, but pain relief was not significantly better than those treatments.
Does a thinner fascia mean it is healed?
Not necessarily. A small change on ultrasound is a structural finding. It does not show that scar tissue has been removed or that the fascia has regenerated, and it does not by itself explain pain relief. Thickness and pain do not move in lockstep, which is why outcomes that matter to patients, such as pain and function, remain the main measures.
What about heel spurs?
Heel spurs are common and can coexist with plantar heel pain, but a spur on X-ray does not identify the source of pain. Plantar fasciitis research measures success by pain and function, not by a spur getting smaller, and spur size alone should not drive treatment decisions.
How many shockwave sessions do studies use?
It varies. The two large placebo-controlled trials used three sessions, the Ibrahim trial used two, and the Tezen comparison used nine over three weeks. Energy, pressure, pulse count, and spacing also differ. At Novo, a course of shockwave is typically four to six weekly sessions, adjusted to the response. That is a clinical protocol, not a schedule the research has proven best.
Why diagnosis comes before shockwave
The positive trials enrolled patients who met defined criteria for chronic plantar fasciitis. A heel that hurts does not automatically meet them. Fat-pad irritation, nerve irritation near the inner heel, tarsal tunnel symptoms, a calcaneal stress injury, and insertional Achilles pain can all feel similar, and each calls for a different approach. Shockwave is a treatment, not a diagnosis. The first question is whether the presentation actually fits plantar fasciopathy. Only then does it make sense to ask whether shockwave, and which kind, fits.
Who may be a reasonable candidate?
Shockwave is most often considered for adults whose heel pain fits plantar fasciopathy and has persisted despite an appropriate trial of conservative care, such as load modification, stretching, exercise, footwear changes, and orthoses. The 2023 heel pain clinical practice guideline from the Journal of Orthopaedic & Sports Physical Therapy reviews these options for non-arthritic heel pain. Even good candidates are not guaranteed a result. Trial success rates describe groups, not any one person.
When heel pain needs another evaluation
Some features point away from straightforward plantar fasciitis or call for imaging or referral: burning, numbness, or tingling; significant night pain; a recent injury; marked swelling; pain in an unusual location; or symptoms suggesting a systemic or inflammatory condition.
How Novo uses this evidence clinically
The research contains several large positive placebo-controlled trials, multiple supportive meta-analyses, and newer trials showing little or no added benefit when shockwave is layered on top of other effective care. Taken together, it supports shockwave as a legitimate treatment option, not a universal answer to heel pain. The clinical question comes first: does the presentation actually fit plantar fasciopathy, and if so, which approach best fits that patient?
At Novo, that means an exam before any treatment. We look at pain location and pattern, load tolerance, calf and ankle function, and signs of another cause. If shockwave fits, we explain why and what results are realistic. If it does not, we say so. See how we approach plantar fasciitis treatment, read our shockwave therapy overview, compare our tools on the services page, or book a new patient exam.
References
- Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. Journal of Bone and Joint Surgery (American). 2015;97(9):701-708. PMID 25948515. (link)
- Gerdesmeyer L, Frey C, Vester J, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. American Journal of Sports Medicine. 2008;36(11):2100-2109. PMID 18832341. (link)
- Ibrahim MI, Donatelli RA, Hellman M, et al. Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: a prospective, randomized, placebo-controlled trial with two years follow-up. Journal of Orthopaedic Research. 2017;35(7):1532-1538. PMID 27567022. (link)
- Heide M, Røe C, Mørk M, et al. Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial. British Journal of Sports Medicine. 2024;58(16):910-918. PMID 38904119. (link)
- Cortés-Pérez I, Moreno-Montilla L, Ibáñez-Vera AJ, et al. Efficacy of extracorporeal shockwave therapy, compared to corticosteroid injections, on pain, plantar fascia thickness and foot function in patients with plantar fasciitis: a systematic review and meta-analysis. Clinical Rehabilitation. 2024;38(8):1023-1043. PMID 38738305. (link)
- Tung WS, Daher M, Covarrubias O, et al. Extracorporeal shock wave therapy shows comparative results with other modalities for the management of plantar fasciitis: a systematic review and meta-analysis. Foot and Ankle Surgery. 2025;31(4):283-290. PMID 39572278. (link)
- Lippi L, Folli A, Moalli S, et al. Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression. European Journal of Physical and Rehabilitation Medicine. 2024;60(5):832-846. PMID 39257331. (link)
- Zhao P, He Y, Li M, et al. Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy in adults with plantar heel pain: a systematic review and network meta-analysis. PM&R. 2025;17(12):1481-1493. PMID 40709373. (link)
- Simental-Mendía M, Simental-Mendía LE, Sánchez-García A, et al. Effect of extracorporeal shockwave therapy on plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis of randomized controlled trials. Archives of Orthopaedic and Trauma Surgery. 2024;144(8):3503-3516. PMID 39023569. (link)
- Tezen Ö, Bilir EE, Arslan HB, et al. Investigation of the effectiveness of extracorporeal shock wave therapy in patients diagnosed with plantar fasciitis: comparison of radial and focus applications. Journal of Foot and Ankle Surgery. 2025;64(1):36-41. PMID 39222874. (link)
- Koc TA Jr, Bise CG, Neville C, et al. Heel pain – plantar fasciitis: revision 2023. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12):CPG1-CPG39. PMID 38037331. (link)
