Shockwave Therapy for Posterior Tibial Tendinopathy: What Does the Evidence Show?

Direct shockwave evidence for tibialis posterior tendinopathy is still limited. The main condition-specific study is a 10-patient case series that combined radial shockwave with progressive foot-core exercise after prior conservative treatment had failed. Nine of 10 patients achieved a clinically important improvement in daily-activity function and eight of 10 improved meaningfully in sport function. Because shockwave and exercise were delivered together and there was no control group, the study cannot determine how much improvement was caused by shockwave itself. Broader meta-analyses support shockwave for lower-limb tendinopathy as a class, but they are not posterior-tibial-specific evidence.

How this evidence compares with other tendons

Shockwave has been studied in randomized trials for several lower-limb tendon problems, including Achilles tendinopathy, plantar fasciitis and patellar tendinopathy. Posterior tibial tendinopathy is different. We did not identify a published randomized shockwave trial specific to the tibialis posterior tendon, and the direct evidence currently rests on a small case series.

That does not mean shockwave is ineffective for this tendon. It means the evidence has not yet been tested the way it has for other tendons, so claims about it need to be more cautious.

The direct study: radial shockwave plus foot-core exercise

Robinson and colleagues reported a case series of 10 patients with tibialis posterior tendinopathy who had failed standard conservative treatment. All received radial shockwave combined with a foot-core progression exercise program. The authors noted that nonoperative management is difficult because patients often present in later stages of the disease.

Median follow-up was four months. Outcomes were measured with the Foot and Ankle Ability Measure (FAAM), a validated questionnaire with separate scores for activities of daily living and sport.

• Daily activities: 9 of 10 patients (90%) reached a clinically important improvement.
• Sport: 8 of 10 patients (80%) reached a clinically important improvement.
• Safety: no adverse effects were observed.

Limitations. Because shockwave and exercise were delivered together and there was no control group, the study cannot determine how much improvement was caused by shockwave itself. The sample was small, follow-up was short, and patients were not randomized or blinded. Natural recovery, the exercise program and expectation could each have contributed. The study is best read as a promising signal that justifies further research, not as proof that shockwave works for this tendon.

What broader shockwave research adds

Broader lower-limb tendinopathy meta-analyses support ESWT as a class of treatment, but those pooled results should not be treated as posterior-tibial-specific evidence.

A 2018 meta-analysis by Liao and colleagues included 29 randomized trials of shockwave for lower-limb tendinopathy. It found a positive overall effect on pain and function, with significant effects at immediate follow-up and at 3, 6 and 12 or more months, and suggested that shockwave type and dose may influence results.

A systematic review and meta-analysis by Elgendy and colleagues, published online in 2023, included 22 randomized trials across upper- and lower-limb tendinopathies. It concluded that shockwave was effective for lower-limb and calcific tendinopathies but did not outperform other treatments for upper-limb and noncalcific tendinopathies.

These reviews show that shockwave can help tendons in the lower limb, but they pool different tendons, protocols and comparators. Their results cannot simply be transferred to the posterior tibial tendon, which has its own anatomy, loading demands and risk of progressing into foot deformity.

Why the tendon's role in foot alignment matters

The tibialis posterior tendon helps control the medial arch and hindfoot. In some people, tendon disease becomes part of progressive collapsing foot deformity, in which the arch lowers, the heel drifts outward and the forefoot angles away from the midline. That deformity usually involves supporting ligaments and joint alignment, not just the tendon.

Shockwave may be directed to symptomatic tendon tissue. It does not mechanically realign a collapsing foot. It cannot correct arch collapse, hindfoot valgus, forefoot abduction, spring ligament failure or a fixed deformity. When meaningful deformity is present, load management, orthotic or brace support, and sometimes orthopedic evaluation matter more than any tendon-directed treatment. When orthotics help is explained in when do orthotics help posterior tibial tendon dysfunction?

What the foundation of care looks like

Progressive tendon loading remains the core of treatment for early tibialis posterior tendinopathy. In a randomized trial of 36 patients with early-stage disease, all groups improved with orthotic support and stretching, but adding progressive resistance exercise, particularly eccentric loading, produced greater improvement in pain and function. A systematic review found a moderate signal favoring eccentric strengthening when combined with orthoses and stretching, although the number of trials was small.

In the shockwave case series, exercise was part of every patient's treatment. That is consistent with how shockwave is generally used in tendon care: alongside loading, not instead of it.

Who might be a candidate?

Shockwave may be considered when:

• The examination confirms the posterior tibial tendon as the pain generator
• Tendon pain has persisted despite an appropriate trial of load management and progressive exercise
• Foot alignment is preserved, or any deformity is being managed with appropriate support
• There is no suspected substantial tendon tear, rapidly progressing deformity or other feature that needs imaging or referral first

It is not a substitute for assessment when a single-leg heel rise has been lost, the arch is collapsing quickly, or symptoms suggest nerve, bone or joint pain instead.

Radial or focused?

The direct case series used radial shockwave. No study has compared radial and focused shockwave for this tendon, so neither is established as superior. Protocol selection depends on the diagnosis, the location of tenderness and tissue depth. The general differences are covered in radial vs. focused shockwave.

What better evidence would look like

The questions that remain open are practical ones. A randomized trial comparing progressive loading alone with progressive loading plus shockwave would show whether shockwave adds benefit beyond exercise. A sham-controlled design would help separate the treatment's effect from expectation and natural recovery. Trials would also need to describe their patients carefully, separating isolated tendinopathy with normal alignment from tendon pain within progressive collapsing foot deformity, because the two may respond differently. Longer follow-up, standardized protocols and reporting of how many sessions and what energy levels were used would make the results easier to apply. Until that work is done, clinicians should present shockwave for this tendon as a reasonable option with preliminary support, and patients should expect it to be combined with loading rather than offered on its own.

Where shockwave fits

Radial shockwave therapy is biologically and clinically plausible for persistent tibialis posterior tendinopathy, and preliminary direct clinical evidence is encouraging. But the posterior tibial tendon does not yet have the level of randomized shockwave evidence available for Achilles, plantar fascia or patellar tendon disorders.

For that reason Novo treats ESWT as an adjunct selected for persistent tendon pain, not as the automatic first-line treatment and not as a substitute for load management or mechanical correction when PCFD is present.

How Novo uses this evidence

We first determine whether the posterior tibial tendon is the source of pain, test it under load and assess foot alignment. Isolated tendinopathy, tendon pain with excessive mechanical load and progressive collapsing foot deformity call for different plans. Shockwave is one option within that plan when the tendon remains painful despite appropriate care. See how we approach posterior tibial tendinopathy, how it differs from plantar fasciitis and other medial foot pain, learn about radial shockwave and focused shockwave, or book a new patient exam.

References

• Robinson D, Mitchkash M, Wasserman L, Tenforde AS. Nonsurgical approach in management of tibialis posterior tendinopathy with combined radial shockwave and foot core exercises: a case series. Journal of Foot and Ankle Surgery. 2020;59(5):1058-1061. PMID 32360329. (link)
• 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)
• Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy. 2009;89(1):26-37. PMID 19022863. (link)
• Ross MH, Smith MD, Mellor R, Vicenzino B. Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport & Exercise Medicine. 2018;4(1):e000430. PMID 30271611. (link)
• Myerson MS, Thordarson DB, Johnson JE, et al. Classification and nomenclature: progressive collapsing foot deformity. Foot & Ankle International. 2020;41(10):1271-1276. PMID 32856474. (link)