Shockwave therapy explained: a complete guide for UK clinics and patients

Shockwave therapy has moved from a niche hospital procedure to a treatment that many UK physiotherapy, podiatry and sports injury clinics now offer for stubborn tendon and heel problems. It is also one of the most asked-about treatments we hear about from clinic owners weighing up whether to buy a machine. This guide explains what shockwave therapy is, how the two main types differ, which conditions have reasonable evidence behind them and which do not, what NICE says, what a course involves, what it costs privately, and how to think about choosing a device.

If you are here for a specific condition, we have separate articles on shockwave therapy for plantar fasciitis and shockwave for Achilles tendinopathy and tennis elbow. Clinic owners comparing devices should read our guide to radial vs focused shockwave machines.

What shockwave therapy is

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment in which acoustic pressure waves are delivered through the skin to a painful tendon, fascia or muscle. "Extracorporeal" simply means the waves are generated outside the body. The technology was adapted from lithotripsy, the procedure that breaks up kidney stones, in the 1990s when clinicians noticed effects on nearby soft tissue and bone.

A session typically lasts a few minutes. A practitioner applies contact gel, places a handheld applicator on the painful spot and delivers a set number of pulses (often 1,500 to 3,000) at a chosen energy and frequency. No needles, anaesthetic or recovery time are normally involved, though the treatment itself can be uncomfortable.

Radial vs focused shockwave

There are two families of device, and the distinction matters for both patients and buyers.

• Focused shockwave devices generate a true shock wave (an extremely steep pressure rise measured in nanoseconds) using electrohydraulic, electromagnetic or piezoelectric sources, then concentrate it to a focal point at a chosen depth. Energy is highest at the focus, which can be several centimetres below the skin. These are the machines used in the older hospital studies and in treatments such as calcific shoulder tendinopathy.
• Radial pressure wave devices (often called radial shockwave, RPW or rESWT) fire a projectile down a barrel into an applicator head resting on the skin, either with compressed air or, in newer designs, an electromagnetic accelerator. The resulting pressure wave spreads outward from the applicator and is strongest at the surface, fading with depth. Physically it is not a true shock wave, but the term "radial shockwave" is now standard.

Most high-street physiotherapy and podiatry clinics in the UK use radial devices because they are cheaper, more portable and simpler to operate. A 2015 systematic review of trials listed in the PEDro database (Schmitz and colleagues, British Medical Bulletin) argued that the common shorthand of radial as "low energy" and focused as "high energy" is misleading, and found no clear evidence favouring one type over the other for outcomes [1]. Direct head-to-head trials remain scarce. Our radial vs focused guide goes into the physics and buying implications in detail.

How it might work

The honest answer is that the mechanism is not fully understood. NICE's own guidance states that how ESWT might affect tendinopathy is unknown [2]. The leading hypotheses, drawn from laboratory and animal work, are:

• Mechanotransduction: mechanical stress on cells triggers biochemical signalling that may stimulate tissue repair and new blood vessel formation.
• Pain modulation: intense stimulation of nerve endings may reduce pain signalling (sometimes described as hyperstimulation analgesia).
• Breaking up calcium deposits: in calcific tendinopathy of the shoulder, higher-energy focused shockwave appears to help disperse calcifications.

It is worth being clear that these are plausible explanations rather than settled science, and that trial results, not theories, should drive treatment decisions.

Conditions with evidence, and how strong it is

Shockwave is marketed for a long list of problems. The evidence is far better for some than others, and it has shifted in recent years. Here is a summary; the condition-specific articles go deeper.

Two patterns stand out. First, the evidence for plantar fasciitis is the most consistent of the common radial-shockwave indications. Second, for the two tendons most commonly treated in sports clinics, the Achilles and the lateral elbow, the better-quality recent reviews do not support shockwave over sham. Any clinic offering it for those conditions should say so to patients.

What NICE actually says

NICE has issued interventional procedures guidance on shockwave therapy for several conditions. NICE has recently migrated this guidance to a new "HealthTech guidance" (HTG) numbering system, so you will see both old and new numbers quoted. The content was unchanged in the migration. The current references are:

• Refractory plantar fasciitis: HTG200 (formerly IPG311, August 2009). No major safety concerns; evidence of efficacy inconsistent; use only with special arrangements for clinical governance, consent and audit or research [5].
• Achilles tendinopathy: HTG426 (formerly IPG571, December 2016, which replaced the 2009 IPG312). Same "special arrangements" recommendation [2].
• Refractory tennis elbow: HTG201 (formerly IPG313, August 2009). Same "special arrangements" recommendation [9].
• Calcific tendinopathy of the shoulder: HTG645 (formerly IPG742, November 2022, which replaced the 2003 IPG21). Evidence on efficacy judged inadequate; use only in a research setting [11].
• Refractory greater trochanteric pain syndrome: HTG248 (formerly IPG376, January 2011). Special arrangements, and only by clinicians with specific training in the procedure [14].

"Special arrangements" is NICE's way of saying: the procedure is safe enough to offer, but because efficacy is uncertain, clinicians should tell their governance leads, give patients clear written information that benefit is not guaranteed, and audit outcomes. This applies formally to NHS settings, but it is a sensible standard for private clinics too. Note that these are interventional procedures assessments, not clinical guidelines that recommend shockwave as a first-line treatment.

What a course of treatment involves

Protocols vary between studies and clinics, but a typical UK course looks like this:

1. Assessment. Shockwave is normally reserved for symptoms that have lasted at least three to six months and have not responded to rest, footwear changes, exercise or physiotherapy. The Royal National Orthopaedic Hospital's patient leaflet describes exactly these criteria [15].
2. Three sessions, roughly a week apart. The most widely cited protocol, and the one recommended by the 2015 PEDro-based review, is three sessions at weekly intervals, around 2,000 pulses per session, at the highest energy the patient can comfortably tolerate [1]. Some clinics extend to five or six sessions.
3. Each session takes about five minutes of actual treatment. Gel is applied, the applicator is pressed onto the painful spot and pulses are delivered. It is often uncomfortable, and the practitioner can reduce the energy if needed.
4. Aftercare. Patients are usually advised to avoid strenuous or high-impact activity for about 48 hours after each session, and to avoid anti-inflammatory drugs (ibuprofen, naproxen) and ice on the treated area, on the theory that the inflammatory response is part of how the treatment works [15]. Paracetamol is generally acceptable.
5. Review at around three months. Benefit, where it occurs, tends to build over weeks rather than appearing immediately.

Shockwave is almost always combined with a loading or stretching programme. In trials that showed benefit, the comparison was usually shockwave plus exercise versus sham plus exercise, so the exercise component should be treated as the foundation, not an optional extra.

Side effects and who should not have it

Across the NICE assessments, no major safety concerns were identified. Common, short-lived effects include:

• Pain during treatment and for a day or two afterwards
• Redness, bruising or swelling at the site
• Temporary numbness or tingling

Rare but serious risks include tendon rupture. The 2026 Achilles meta-analysis noted two Achilles ruptures following focused shockwave in the included trials [6], and NICE's Achilles guidance records two ruptures within a fortnight of treatment in one RCT, both after falls [2]. This is one reason clinics should screen carefully.

Based on the contraindications listed in NHS patient leaflets [15], shockwave is generally not offered to people who:

• have had a steroid injection into the area within the last six weeks
• have a bleeding or clotting disorder, or take anticoagulants such as warfarin or rivaroxaban
• are pregnant or trying to conceive
• have a pacemaker or other implanted electronic device
• have cancer or a tumour at or near the treatment site
• have an infection, acute inflammation or a current thrombosis at the site
• have epilepsy, osteogenesis imperfecta, or are taking fluoroquinolone antibiotics (which are themselves linked to tendon damage)

Treatment over open growth plates in children, over the lungs, or near major nerves and blood vessels is also avoided. If you are unsure whether any of this applies to you, say so at assessment.

Shockwave therapy cost in the UK

Private shockwave treatment in the UK is normally priced per session or as a package of three to six sessions. Costs vary considerably by region, by whether the provider is a physiotherapy clinic, podiatrist or consultant-led practice, and by whether the first session includes an assessment. We have deliberately not quoted figures here because published prices change frequently and there is no independent UK-wide survey to cite. Before booking, ask what a full course costs rather than a single session, whether an initial assessment is extra, and what happens if you do not respond after three sessions.

Private physiotherapy insurance may cover shockwave when it is recommended by a physiotherapist or consultant; check your policy, as some insurers class it as an unproven treatment.

Is shockwave available on the NHS?

Sometimes, but not everywhere. Some NHS trusts run ESWT services through orthopaedic foot and ankle, podiatry or physiotherapy departments, typically for plantar fasciitis and Achilles tendinopathy that have failed conservative treatment [15]. Others do not fund it routinely: Bristol, North Somerset and South Gloucestershire ICB, for example, lists ESWT as not routinely funded and available only through an exceptional funding request [16]. Your GP or physiotherapist will know the local position. Waiting lists for NHS physiotherapy can be long, which is one reason people turn to private clinics.

Shockwave compared with other options

For the conditions where shockwave is most often used, the main alternatives are a structured loading or stretching programme, footwear and orthotic changes, corticosteroid injection, and, rarely, surgery. A few points worth knowing:

• Exercise and load management remain first-line for almost every tendinopathy. Shockwave is an add-on for people who have not improved after months of this.
• For tennis elbow, the Cochrane review found a single trial in which steroid injection outperformed shockwave at three months [7], though steroid injections carry their own concerns about long-term outcomes.
• For plantar fasciitis, a 2018 meta-analysis comparing shockwave with ultrasound-guided steroid injection favoured higher-intensity shockwave [17], but trial quality was variable.

Shockwave is also sometimes used alongside manual therapies such as cupping and massage for muscle pain and trigger points. The evidence base for that use is thin. If you are mainly interested in recovery from training rather than a specific tendon problem, our guides to cupping therapy and recovery compression may be more relevant.

Choosing a shockwave machine for a clinic

For physiotherapists and sports therapists considering a purchase, the main decisions are radial versus focused (radial covers most musculoskeletal work at a fraction of the price), compressed-air versus electromagnetic radial drive, the energy and frequency range, applicator options, portability, and the cost of handpiece servicing over the machine's life. Our clinic buying guide works through each of these and lists questions to put to a supplier.

As an example of a clinic-grade radial unit, the Zimmer enPuls 2.0 is a compressor-free electromagnetic radial device with an energy range of 60 to 185 mJ, a frequency range of 1 to 22 Hz, and interchangeable 6, 15 and 25 mm applicator heads. You can see current availability in our shockwave therapy collection.

Frequently asked questions

Does shockwave therapy work?

For chronic plantar fasciitis, placebo-controlled trials and meta-analyses show it helps more people than sham treatment, though effect sizes vary and not everyone responds. For calcific shoulder tendinopathy, high-energy focused shockwave has reasonable evidence. For Achilles tendinopathy and tennis elbow, the best recent reviews do not show a meaningful benefit over sham. For most other uses the evidence is limited.

How many sessions will I need?

Most protocols use three to six sessions, about a week apart. If there is no improvement after three, it is reasonable to stop and review.

Does it hurt?

Usually, yes, to a degree. It is often described as a strong tapping or stinging sensation. The practitioner can adjust the energy, and discomfort normally settles within a day or two.

Can I have shockwave if I have had a steroid injection?

Most clinics will wait at least six weeks after a steroid injection into the same area.

Is radial shockwave as good as focused?

There is no strong evidence that either is better for the common indications. Focused devices reach deeper and are used for calcific shoulder tendinopathy; radial devices are more practical for superficial tendons and fascia. See our radial vs focused guide.

References

1. Schmitz C, Császár NBM, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. British Medical Bulletin. 2015;116(1):115–138. https://academic.oup.com/bmb/article/116/1/115/401264
2. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for Achilles tendinopathy. HealthTech guidance HTG426 (formerly IPG571), December 2016. https://www.nice.org.uk/guidance/ipg571
3. Sun J, Gao F, Wang Y, et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Medicine (Baltimore). 2017;96(15):e6621. https://pmc.ncbi.nlm.nih.gov/articles/PMC5403108/
4. Wang YC, Chen SJ, Huang PJ, et al. Efficacy of different energy levels used in focused and radial extracorporeal shockwave therapy in the treatment of plantar fasciitis: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Medicine. 2019;8(9):1497. https://www.mdpi.com/2077-0383/8/9/1497
5. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for refractory plantar fasciitis. HealthTech guidance HTG200 (formerly IPG311), August 2009. https://www.nice.org.uk/guidance/htg200
6. Korakakis V, Kotsifaki R, Sotiralis Y, Malliaras P. Shockwave therapy for midportion and insertional Achilles tendinopathy: a nail in the coffin? A systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2026;56(5):282–299. https://www.jospt.org/doi/10.2519/jospt.2026.13985
7. Buchbinder R, Green S, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews. 2005;(4):CD003524. https://www.cochrane.org/evidence/CD003524_shock-wave-therapy-elbow-pain
8. Karanasios S, Tsamasiotis GK, Michopoulos K, Sakellari V, Gioftsos G. Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis. Clinical Rehabilitation. 2021;35(10):1383–1398. https://search.pedro.org.au/search-results/record-detail/67484
9. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for refractory tennis elbow. HealthTech guidance HTG201 (formerly IPG313), August 2009. https://www.nice.org.uk/guidance/htg201
10. Bannuru RR, Flavin NE, Vaysbrot E, Harvey W, McAlindon T. High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: a systematic review. Annals of Internal Medicine. 2014;160(8):542–549. https://www.mcmasteroptimalaging.org/full-article/fdb991b2d0245eade1b7ef825a3c1c30
11. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for calcific tendinopathy in the shoulder. HealthTech guidance HTG645 (formerly IPG742), November 2022. https://www.nice.org.uk/guidance/htg645
12. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British Journal of Sports Medicine. 2018;52(6):387–407. https://bjsm.bmj.com/content/52/6/387
13. Ramon S, Russo S, Santoboni F, et al. Focused shockwave treatment for greater trochanteric pain syndrome: a multicenter, randomized, controlled clinical trial. Journal of Bone and Joint Surgery (American). 2020;102(15):1305–1311. https://search.pedro.org.au/search-results/record-detail/61452
14. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for refractory greater trochanteric pain syndrome. HealthTech guidance HTG248 (formerly IPG376), January 2011. https://www.nice.org.uk/guidance/htg248
15. Royal National Orthopaedic Hospital NHS Trust. Radial extracorporeal shockwave therapy (ESWT): patient information. https://rnoh.nhs.uk/patients-and-visitors/patient-information-guides/radial-extracorporeal-shockwave-therapy-eswt
16. Bristol, North Somerset and South Gloucestershire ICB. Extracorporeal Shockwave Therapy (ESWT) commissioning policy, v2526, published December 2025. https://bnssghealthiertogether.org.uk/wp-content/uploads/2023/08/Extracorporeal-Shockwave-Therapy-ESWT-EFR-v2526.3.00.pdf
17. Li S, Wang K, Sun H, et al. Clinical effects of extracorporeal shock-wave therapy and ultrasound-guided local corticosteroid injections for plantar fasciitis in adults: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2018;97(50):e13687. https://pmc.ncbi.nlm.nih.gov/articles/PMC6320028/

This article is for general information only and is not medical advice. Always follow the instructions supplied with your equipment, and consult a qualified healthcare professional if you have a medical condition or are unsure whether a treatment is right for you.