Shockwave therapy has randomized clinical evidence in chronic proximal hamstring tendinopathy. A 2011 trial in professional athletes found shockwave clearly outperformed traditional conservative treatment. A larger 2025 trial found shockwave and individualized physiotherapy produced similar results over 12 months, with no demonstrated superiority of either. Systematic reviews describe consistent improvement after ESWT across hip and pelvic tendinopathies but highlight varied protocols and low-certainty evidence. Shockwave is a legitimate nonoperative option for persistent high hamstring pain, alongside well-designed rehabilitation rather than as a guaranteed upgrade over it.
Two randomized trials · 2011 and 2025
2011 · 40 professional athletes
85% vs 10%
reached at least 50% pain reduction at 3 months with shockwave vs traditional conservative treatment
2025 · 100 participants
Similar outcomes
shockwave and individualized physiotherapy, with no significant difference at any point over 12 months
The 85% figure comes from one small 2011 trial against an older conservative program. It is not an expected success rate for shockwave today.
The key studies at a glance
| Study | Design and population | Comparison | Main finding | Key limitation |
|---|---|---|---|---|
| Cacchio 2011 | RCT, 40 professional athletes | Shockwave vs. traditional conservative treatment | 85% vs. 10% reached at least 50% pain reduction at 3 months | Small; older comparator; elite population |
| Rich 2025 | RCT, 100 participants in 10 physiotherapy practices | Shockwave vs. individualized progressive physiotherapy | Similar outcomes; no significant between-group difference over 12 months | Patients could not be blinded; no sham arm |
| Nasser 2021 | Systematic review, 12 studies, 424 participants | All interventions | Very low-level evidence favoring shockwave over a multimodal program | Only 2 RCTs; mostly case series |
| Rau 2025 | Systematic review, 18 studies (5 in PHT) | ESWT for hip and pelvic tendinopathies | 17 of 18 studies reported significant improvement | Mixed conditions; varied protocols |
The 2011 trial: shockwave vs. traditional conservative treatment
Cacchio and colleagues randomized 40 professional athletes with chronic proximal hamstring tendinopathy, enrolled between 2004 and 2006. Twenty received shockwave: 2,500 impulses per session at 0.18 mJ/mm², without anesthesia, delivered over four weeks. The other 20 received traditional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, physiotherapy and a hamstring exercise program.
At three months, average pain on a 10-point scale fell from 7 to 2 in the shockwave group and from 7 to 5 in the conservative group. On the Nirschl phase rating scale, the shockwave group improved from 5 to 2, while the conservative group did not improve (5 to 6). Seventeen of 20 shockwave patients (85%) achieved at least a 50% reduction in pain, compared with 2 of 20 (10%) in the conservative group. No serious complications were reported.
Six patients left the study for surgery, five of them from the conservative-treatment group. The mean observation period was 10.7 months.
Limitations. This was a small trial in professional athletes, a population with particular motivation, access to care and return-to-sport pressure. The comparison group received a traditional package that included anti-inflammatory medication rather than the individualized, progressive tendon-loading programs that are now considered the foundation of tendinopathy rehabilitation. The very poor result in that group, with no improvement on the Nirschl scale, may say as much about the comparator as about shockwave. The trial supports shockwave as an effective option, but its 85% figure should not be read as the expected success rate in a modern clinic.
The 2025 trial: shockwave vs. individualized physiotherapy
Rich and colleagues ran a larger, assessor-blinded randomized trial in 10 primary-care physiotherapy practices in Victoria, Australia. One hundred participants with proximal hamstring tendinopathy, who had symptoms for an average of about 110 weeks, were randomized to shockwave or individualized physiotherapy.
Both groups received six sessions over 12 weeks, matched for time with the physiotherapist, plus the same standardized information covering diagnosis, expected recovery and the role of compression, including sitting.
- Shockwave group: four weekly sessions of 2,000 shocks at the maximum tolerable intensity, following the 2011 trial's approach, using radial and semifocused devices. These participants were not prescribed exercise.
- Physiotherapy group: an individualized, multistage, progressive strengthening program, with a graded reintroduction of compressive load to the proximal hamstring.
The primary outcomes were global rating of change and the VISA-H, a hamstring-specific function score, measured at 4, 12, 26 and 52 weeks. Almost all participants received their allocated treatment, and 88% were followed up at 12 months.
There were no significant between-group differences in either primary outcome at any time point, and responder analyses showed no differences either. Among secondary outcomes, the shockwave group reported greater satisfaction with treatment at 26 weeks, greater satisfaction with results at 4 and 26 weeks, and better general health at 52 weeks.
Interpretation. This trial is best read as showing similar effectiveness, not as a negative result for shockwave. Four sessions of shockwave without a prescribed exercise program produced outcomes comparable to a structured, individualized rehabilitation program delivered by physiotherapists. What the trial does not show is that shockwave is better than good rehabilitation. Because patients could not be blinded, it also cannot separate either treatment's effect from nonspecific effects, although the long average symptom duration makes rapid natural recovery less likely.
Why did the two randomized trials reach different conclusions?
The trials asked different questions, so their results are less contradictory than they first appear.
- The comparator changed. In 2011, shockwave was compared with anti-inflammatories, physiotherapy and a hamstring exercise program of that era. In 2025, it was compared with an individualized, progressive loading program that included compression management, much closer to current best practice. A stronger comparator makes a between-group difference harder to find.
- The population changed. The 2011 trial enrolled 40 professional athletes. The 2025 trial enrolled 100 people from community physiotherapy practices with long-standing symptoms.
- The outcomes changed. The 2011 trial reported pain scores, the Nirschl phase rating scale and the proportion achieving at least 50% pain reduction. The 2025 trial used global rating of change and the condition-specific VISA-H.
- Trial size changed. With 20 patients per group, the 2011 trial was more vulnerable to chance and to optimistic estimates of effect size.
The most coherent reading is that shockwave clearly outperformed an older conservative package and performed about as well as modern, well-designed physiotherapy.
What systematic reviews add
A 2021 systematic review by Nasser and colleagues identified 12 studies with 424 participants, only 2 of them randomized trials. It found very low-level evidence that shockwave was better than a multimodal intervention for symptoms and function at long-term follow-up, and concluded that there was insufficient evidence to recommend any one intervention over another.
A 2023 systematic review by Dizon and colleagues included 13 studies, 5 of exercise alone and 8 of multimodal programs that combined exercise with shockwave or other treatments. Its recommendations favored a multimodal approach including tendon-specific loading at increased length, lumbopelvic stabilization and ESWT.
A systematic review by Rau and colleagues, published online in 2025, included 18 studies of ESWT for tendinopathies around the hip and pelvis: 9 in greater trochanteric pain syndrome, 7 in calcific tendinopathy and 5 in proximal hamstring tendinopathy. Seventeen of the 18 studies reported significant improvement in pain or function after ESWT. Six reported better outcomes than a comparison treatment, including conservative care in proximal hamstring or gluteal tendinopathy. Most studies used three to four weekly sessions and 2,000 to 3,000 pulses; 11 used radial and 7 used focused shockwave. Adverse events were reported in 6 of the 18 studies, affecting 12% of patients in those studies (65 of 557).
Two cautions apply. The reviews were completed before the 2025 randomized trial was published, and much of the underlying evidence comes from small or uncontrolled studies.
Where shockwave fits
ESWT is a reasonable nonoperative option for persistent proximal hamstring tendinopathy, particularly when symptoms have not settled with load management and progressive rehabilitation, or when pain is limiting a person's ability to progress loading. It should be offered as one evidence-supported option, not as a replacement for diagnosis or a guarantee of a better result than rehabilitation.
In practice that means:
- Confirming the diagnosis first, including screening for sciatic nerve involvement, lumbar radiculopathy and tears
- Managing compression, such as prolonged or deep-flexion sitting and aggressive stretching
- Continuing progressive hamstring and kinetic-chain loading where possible
- Using shockwave as an adjunct or alternative when the presentation and preferences support it
Radial or focused?
Both have been used. The 2025 trial used radial and semifocused devices, and the 2025 systematic review included both radial and focused protocols across hip and pelvic tendinopathies. Current evidence does not establish that either is superior for proximal hamstring tendinopathy. Device choice depends on the depth of the attachment, the location of tenderness and the response to treatment. More on the difference is in radial vs. focused shockwave.
Who may not be a candidate?
Shockwave is not used in place of assessment when a sudden injury suggests a partial tear or avulsion, when there are significant neurologic signs, or when another cause, such as lumbar radiculopathy or deep gluteal nerve entrapment, better explains the symptoms. The differences are explained in proximal hamstring tendinopathy vs. sciatic nerve pain.
How Novo uses this evidence
We first determine whether the proximal hamstring tendon is the pain generator and how much load and compression it currently tolerates. Treatment is then selected for the individual presentation: loading and compression management, radial shockwave, focused shockwave, manual treatment, or imaging and referral when needed. See how we approach proximal hamstring tendinopathy, or book a new patient exam.
References
- Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes. American Journal of Sports Medicine. 2011;39(1):146-153. PMID 20855554. (link)
- Rich A, Ford J, Cook J, Hahne A. Physiotherapy compared with shockwave therapy for the treatment of proximal hamstring tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2025;53(14):3396-3407. PMID 41243328. (link)
- Nasser AM, Vicenzino B, Grimaldi A, Anderson J, Semciw AI. Proximal hamstring tendinopathy: a systematic review of interventions. International Journal of Sports Physical Therapy. 2021;16(2):288-305. PMID 33842025. (link)
- Dizon P, Jeanfavre M, Leff G, Norton R. Comparison of conservative interventions for proximal hamstring tendinopathy: a systematic review and recommendations for rehabilitation. Sports. 2023;11(3):53. PMID 36976939. (link)
- Rau OR, Cheng J, Jivanelli B, et al. Extracorporeal shockwave therapy for tendinopathies around the hip and pelvis: a systematic review. HSS Journal. 2026;22(2):197-207 (published online 2025). PMID 40292269. (link)
- Nasser AM, Pizzari T, Grimaldi A, et al. Proximal hamstring tendinopathy: expert physiotherapists' perspectives on diagnosis, management and prevention. Physical Therapy in Sport. 2021;48:67-75. PMID 33378733. (link)
- Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):483-493. PMID 27084841. (link)
