Shockwave therapy for plantar fasciitis: does it work and what to expect

Plantar fasciitis is the most common cause of heel pain, and chronic cases are also the condition with the best-supported evidence for shockwave therapy. If you have had heel pain for months, tried stretching, insoles and rest, and someone has suggested shockwave, this article explains what the trials show, what NICE says, what a typical course looks like, and who it is and is not suitable for. For the broader picture, including how the technology works and how it is used for other conditions, start with our complete guide to shockwave therapy.

What plantar fasciitis is

The plantar fascia is a thick band of connective tissue running from the heel bone along the sole to the toes. Plantar fasciitis (increasingly called plantar fasciopathy, because the problem is degenerative rather than inflammatory) is pain where the fascia attaches to the heel. The classic sign is sharp pain on the first few steps after sleeping or sitting, which eases with movement and then returns after long periods on your feet [1].

Most cases settle with self-care over several months. NHS advice is rest, ice, cushioned supportive footwear, gentle stretching, low-impact exercise and weight loss if relevant, and to see a GP if there is no improvement after two weeks of self-care, if pain is severe, or if you have numbness, tingling or diabetes [1]. Physiotherapy and podiatry are the next steps. Shockwave sits further down that pathway, for cases that have not responded.

What the evidence shows

Shockwave for plantar fasciitis has been studied more than any other musculoskeletal use of the technology, with a number of placebo-controlled randomised trials and several meta-analyses pooling them. The headline findings:

• A 2017 meta-analysis of nine placebo-controlled RCTs (935 patients) found shockwave produced a higher rate of treatment success than sham, with an odds ratio of about 2.6. The pain-score result was less clear-cut, with wide variation between trials. Focused shockwave had the most consistent results; radial shockwave also favoured treatment but with fewer trials and more heterogeneity [2].
• A 2019 meta-analysis of 14 placebo-controlled RCTs grouped the trials by energy level. Medium-energy shockwave outperformed placebo for success rate at 3, 6 and 12 months. High-energy protocols showed benefit mainly at 3 months, and low-energy results were mixed. The authors concluded medium-energy shockwave was effective and that use of local anaesthetic appeared to reduce the effect [3].
• One of the larger individual trials, a multicentre placebo-controlled study of radial shockwave in 245 patients, reported a 61 per cent success rate versus 42 per cent with placebo at 12 weeks, with the gap widening at 12 months and no relevant side effects [4].
• A 2018 meta-analysis comparing shockwave with ultrasound-guided corticosteroid injection favoured higher-intensity shockwave for pain, though the included trials varied in quality [5].

Three honest caveats. First, "success" in these trials is usually defined as a meaningful drop in pain score, not a cure, and a substantial minority of people do not respond. Second, placebo response in heel pain trials is high, as the 42 per cent figure above shows, partly because plantar fasciitis tends to improve with time anyway. Third, the trials vary a great deal in device, energy, number of sessions and use of anaesthetic, which is why the pooled estimates have such wide confidence intervals. That said, the direction of the evidence is consistent, and plantar fasciitis is the one common radial-shockwave indication where the more recent reviews have not reversed the earlier optimism, unlike the picture for Achilles tendinopathy and tennis elbow.

What NICE says

NICE's guidance on shockwave for refractory plantar fasciitis was published in August 2009 as IPG311 and has since been renumbered HTG200 under NICE's HealthTech guidance system; the recommendations are unchanged [6]. NICE concluded that the procedure raises no major safety concerns but that the evidence on efficacy is inconsistent, so it should be used only with special arrangements for clinical governance, consent and audit or research. In practice that means clinicians should make sure patients understand the uncertainty, provide written information, and track outcomes. NICE also asked for better trials with at least a year of follow-up. Some of the meta-analyses above post-date the guidance, and NICE has stated it will review the topic only if new evidence is likely to change the recommendations.

Who it suits

NHS services that offer shockwave for plantar fasciitis typically require that symptoms have lasted at least three to six months and have not responded to conservative treatment such as rest, ice, orthotics, physiotherapy, painkillers or a steroid injection [7]. The trials that showed benefit generally recruited people with symptoms of six months or more. Shockwave is not a treatment for a heel that started hurting last month.

Shockwave is generally not offered to people who are pregnant, who take anticoagulants or have a bleeding disorder, who have had a steroid injection into the heel within the last six weeks, who have an infection, tumour or thrombosis at the site, or who have a pacemaker or epilepsy [7]. People taking fluoroquinolone antibiotics are also excluded, because those drugs are themselves linked to tendon and fascia damage.

A typical protocol

Protocols differ between clinics and between the trials that inform them, but a common approach in UK practice looks like this:

1. Three sessions, about a week apart. The 2015 review of PEDro-listed trials recommended three sessions at weekly intervals with around 2,000 pulses per session, at the highest energy the patient can tolerate [8]. The RNOH leaflet describes one session a week for three weeks, with scope to add sessions if needed and no more than two weeks between them [7].
2. Finding the spot. The practitioner locates the most tender point on the heel by pressing, and sometimes with ultrasound. Treatment is aimed there. Local anaesthetic is avoided, both because it seems to reduce effectiveness and because feedback from the patient helps target the treatment [3].
3. Delivery. Gel is applied, the applicator is pressed onto the heel and pulses are delivered for a few minutes. With a radial device the practitioner will usually start at a lower energy and increase it to the level you can comfortably manage. It is uncomfortable rather than agonising for most people, but tell the practitioner if it is too much.
4. Aftercare. Carry on with normal daily activity but avoid running, jumping or other high-impact activity for about 48 hours. Avoid anti-inflammatory painkillers such as ibuprofen and avoid icing the heel, as both may dampen the response the treatment is trying to provoke; paracetamol is fine [7].
5. Keep stretching. Shockwave is an addition to, not a replacement for, calf and plantar fascia stretching, footwear changes and load management. The trials that showed benefit generally delivered shockwave on top of these.
6. Review. Expect a review around three months after the last session. Improvement tends to build over weeks.

What to expect afterwards

Mild pain, redness, bruising or swelling of the heel for a day or two after each session is normal and usually settles within a week [7]. A temporary increase in heel pain is common. Serious problems are rare, but there is a small risk of plantar fascia rupture, and sudden severe pain or loss of function after treatment should be assessed urgently.

On outcomes, the fairest summary of the trials is that roughly six in ten people with chronic plantar fasciitis report a meaningful improvement after a course, against roughly four in ten with sham treatment [2, 4]. Some people improve a great deal, some a little, and some not at all. If there has been no change after three sessions, it is reasonable to stop and discuss other options rather than keep paying for more.

Alternatives and what to do first

• Stretching and strengthening. Calf stretches, plantar fascia stretches and progressive loading exercises are the foundation and have the best overall evidence for plantar heel pain. A physiotherapist can set these up.
• Footwear, insoles and night splints. Cushioned, supportive shoes and heel pads are first-line NHS advice; a podiatrist can advise on orthotics and splints [1].
• Corticosteroid injection. Often effective for short-term pain relief but with concerns about repeated use and a possible link with fascia rupture; the 2018 meta-analysis found higher-intensity shockwave compared favourably with injection for pain relief [5].
• Surgery. Uncommon and reserved for the small number of cases that fail everything else.

Shockwave is sometimes offered in the same clinics that provide cupping or massage for the calf and foot. There is little evidence for those as treatments for plantar fasciitis specifically, though some people find calf cupping helps with tightness; see our cupping therapy guide for an honest account of what is and is not known.

For clinics: devices and setup

Plantar fasciitis is a superficial target, which is why radial pressure wave devices are the usual choice in physiotherapy and podiatry settings, with the 15 mm applicator as the workhorse for the heel. Focused devices have the stronger trial record for this condition [2], but at a much higher purchase price, and the 2019 meta-analysis found radial devices effective at medium energy too [3]. For a detailed comparison of the two technologies, applicator choices, service costs and questions to ask a supplier, read our guide to choosing a shockwave machine. Current radial units stocked at cupping.com are listed in the shockwave therapy collection.

Summary

For chronic plantar fasciitis that has not settled with months of stretching, footwear changes and physiotherapy, shockwave therapy has reasonable evidence: more people improve than with sham treatment, the safety record is good, and NICE permits its use provided patients are told that benefit is not guaranteed. It is not a first-line treatment, it does not help everyone, and it works best alongside a stretching and loading programme rather than instead of one. For how shockwave fits with other conditions and other recovery tools, return to the complete guide to shockwave therapy.

References

1. NHS 111 Wales. Plantar fasciitis. Health A–Z, updated August 2025. https://111.wales.nhs.uk/encyclopaedia/p/article/plantarfasciitis/
2. 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/
3. 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
4. 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. https://journals.sagepub.com/doi/10.1177/0363546508324176
5. 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/
6. 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
7. 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
8. 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

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.