Shockwave therapy for Achilles tendinopathy and tennis elbow

Achilles tendinopathy and tennis elbow are two of the most common reasons people are offered shockwave therapy in UK sports injury and physiotherapy clinics. They are also two conditions where the evidence has shifted noticeably in the last few years, and not in shockwave's favour. This article sets out what the trials and NICE say for each, how shockwave is combined with loading programmes, and what a realistic timeline looks like. For background on how the technology works, the different device types and the wider list of conditions, see our complete guide to shockwave therapy.

Tendinopathy in brief

Tendinopathy is the umbrella term for a painful, usually overloaded tendon. The old names "tendinitis" (inflammation) and "tendinosis" (degeneration) have largely been replaced because the tissue changes are mixed and inflammation is not the main driver in chronic cases. The core treatment for almost every tendinopathy is a progressive loading programme: exercises that gradually expose the tendon to more load so it adapts. Everything else, including shockwave, is an adjunct.

Shockwave for Achilles tendinopathy

Mid-portion vs insertional

Achilles tendinopathy comes in two forms, and the distinction matters for treatment. Mid-portion tendinopathy affects the tendon two to six centimetres above the heel bone and is the more common form, particularly in runners. Insertional tendinopathy affects the point where the tendon attaches to the heel and is often more stubborn, partly because the tendon is compressed against the bone when the ankle is bent upwards, which is why stretching and full-range heel drops can aggravate it [1].

What the evidence shows

For about a decade, the evidence for Achilles shockwave was cautiously encouraging. A 2018 systematic review in the British Journal of Sports Medicine found low-level evidence that shockwave was comparable to eccentric loading and better than a wait-and-see approach for mid-portion tendinopathy at four months, and better than eccentric loading for insertional tendinopathy at four months [2]. A 2022 systematic review summarised the individual RCTs: for mid-portion cases, adding shockwave to a loading programme beat loading alone in two trials, while for insertional cases results were mixed, with one trial finding no difference from sham at 24 weeks and another concluding that shockwave did not add anything to eccentric strengthening [3].

The picture changed in 2025 and 2026. A sham-controlled RCT in 76 adults with insertional Achilles tendinopathy gave three sessions of radial shockwave or sham alongside identical education and exercise, and found no difference in pain, function or activity at six or twelve weeks [4]. Then a meta-analysis of nine sham-controlled RCTs (557 participants), published in the Journal of Orthopaedic and Sports Physical Therapy in 2026, found no clinically meaningful benefit of shockwave over sham for insertional tendinopathy (low to moderate certainty) and no significant differences in pain or disability for mid-portion tendinopathy at any time point. Neither radial nor focused devices came out ahead, and two Achilles ruptures were recorded after focused shockwave. The authors concluded that shockwave should not be a routine treatment for either form of Achilles tendinopathy [5].

Why did earlier reviews look more positive? Mostly because the early trials compared shockwave with wait-and-see or with exercise alone rather than with a convincing sham, were small, and often could not blind participants. When shockwave is tested against a sham device that looks and sounds the same, the advantage largely disappears. That does not prove shockwave does nothing for every patient, and the 2026 authors note that most estimates rest on low-certainty data, but it means that any clinic offering Achilles shockwave should present it as uncertain, not as proven.

What NICE says

NICE's guidance on shockwave for Achilles tendinopathy was published in December 2016 as IPG571, replacing the 2009 guidance IPG312, and has since been renumbered HTG426 [1]. It states that there are no major safety concerns but that the evidence on efficacy is inconsistent and limited in quality and quantity, so the procedure should be used only with special arrangements for clinical governance, consent and audit or research. Clinicians are asked to make sure patients understand that effectiveness is uncertain and to audit outcomes. The guidance pre-dates the 2026 meta-analysis.

Shockwave for tennis elbow

What tennis elbow is

Tennis elbow, or lateral epicondylalgia (formerly lateral epicondylitis), is pain on the outer side of the elbow where the wrist extensor tendons attach to the bone. Despite the name, most cases come from repetitive gripping and lifting at work or in DIY rather than from racquet sports. Most cases improve within a year without any specific treatment, which makes the natural history an important comparison when judging any therapy.

What the evidence shows

Tennis elbow is one of the longest-studied shockwave indications and the results have been consistently disappointing against placebo. The Cochrane review, published in 2005, pooled nine placebo-controlled trials with 1,006 participants and found that eleven of thirteen pooled comparisons showed no significant benefit of shockwave over placebo. The authors rated this "Platinum" level evidence of little or no benefit for pain and function. One trial of 93 participants found a corticosteroid injection more effective than shockwave at three months [6].

Later reviews have not overturned this. A 2021 meta-analysis of 27 RCTs (1,871 patients) found low to moderate certainty evidence that shockwave offered no clinical benefit over sham or corticosteroid injection, with only isolated short-term advantages over laser and ultrasound and no clinically important differences between comparators overall [7]. Some meta-analyses that pool shockwave against a mixture of other treatments have reported better pain and grip strength, but these compare shockwave with active treatments of uncertain value rather than with sham, and their authors acknowledge the limited quality of the included trials [8].

What NICE says

NICE's guidance on shockwave for refractory tennis elbow was published in August 2009 as IPG313, now renumbered HTG201 [9]. As with plantar fasciitis and the Achilles, the recommendation is special arrangements for governance, consent and audit, with patients told that effectiveness is uncertain.

Combining shockwave with a loading programme

Whatever the tendon, shockwave on its own is not a treatment plan. The trials that reported benefit almost always delivered shockwave on top of exercise, and the trials that compared shockwave plus exercise against sham plus exercise are the ones that have found little difference. A sensible structure for a clinic or a patient is:

1. Load management first. Reduce the activities that provoke pain to a tolerable level rather than stopping entirely. Complete rest tends to weaken the tendon further.
2. A progressive loading programme. For mid-portion Achilles tendinopathy this traditionally means heel drops or heavy slow resistance work; for insertional cases, heel raises on the flat rather than off a step, to avoid compressing the tendon. For tennis elbow it means graded wrist extensor and grip strengthening. Twelve weeks is a typical minimum.
3. Consider shockwave only if progress has stalled after three to six months of consistent loading, and only after an honest conversation about the evidence above.
4. If shockwave is used, keep loading. The usual protocol is three sessions about a week apart, with 48 hours off high-impact activity after each and no anti-inflammatories or ice on the area [10]. Loading continues throughout.
5. Review at three months. If nothing has changed, more shockwave is unlikely to help.

Practitioners interested in manual adjuncts sometimes use cupping on the calf or forearm alongside tendon loading. The evidence for that is sparse; our cupping therapy guide and the article on cupping side effects and contraindications set out what is known.

Realistic timelines

Tendons adapt slowly. For a loading programme, most people need six to twelve weeks before pain clearly improves and several months before they are back to full activity, with insertional Achilles tendinopathy often slower than mid-portion. Where shockwave is added, any benefit is usually judged at around twelve weeks after the final session, and the trials with longer follow-up suggest that whatever difference exists tends to narrow over a year as the comparison groups catch up [2, 5]. Anyone promising a fix in three sessions is overselling.

Safety

Side effects are usually minor and short-lived: pain during and for a day or two after treatment, redness, bruising, swelling, and occasionally numbness or tingling [10]. The serious risk specific to the Achilles is tendon rupture. Two ruptures were reported following focused shockwave in the trials included in the 2026 meta-analysis [5], and NICE's guidance records two ruptures within a fortnight of treatment in one RCT, both after falls [1]. Clinics should avoid treating a tendon with a suspected partial tear, and should not treat people who have had a steroid injection into the area within six weeks, who take anticoagulants, who are pregnant, or who are taking fluoroquinolone antibiotics, which independently raise the risk of tendon rupture [10].

Where this leaves patients and clinics

For plantar fasciitis, the evidence that shockwave helps more people than sham is reasonably consistent, and we cover it separately in our article on shockwave for plantar fasciitis. For Achilles tendinopathy and tennis elbow, the best-quality sham-controlled evidence does not show a meaningful benefit. That does not mean clinics must stop offering it, but it does mean three things: patients should be told plainly that the evidence is weak, shockwave should never displace a loading programme, and outcomes should be tracked so that a clinic knows its own results rather than relying on manufacturer claims. Clinics weighing up whether a device still makes sense for their caseload may find our guide to choosing a shockwave machine useful, and the complete shockwave guide summarises the evidence across all the main conditions in one place.

References

1. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for Achilles tendinopathy. HealthTech guidance HTG426 (formerly IPG571, which replaced IPG312), December 2016. https://www.nice.org.uk/guidance/ipg571
2. 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
3. Paantjens MA, Helmhout PH, Backx FJG, van Etten-Jamaludin FS, Bakker EWP. Extracorporeal shockwave therapy for mid-portion and insertional Achilles tendinopathy: a systematic review of randomized controlled trials. Sports Medicine – Open. 2022;8(1):68. https://pmc.ncbi.nlm.nih.gov/articles/PMC9106789/
4. Alsulaimani B, Perraton L, Vallance P, Powers T, Malliaras P. Does shockwave therapy lead to better pain and function than sham over 12 weeks in people with insertional Achilles tendinopathy? A randomised controlled trial. Clinical Rehabilitation. 2025;39(2):174–186. https://journals.sagepub.com/doi/10.1177/02692155241295683
5. 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
6. 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
7. 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
8. Yao G, Chen J, Duan Y, Chen X. Efficacy of extracorporeal shock wave therapy for lateral epicondylitis: a systematic review and meta-analysis. BioMed Research International. 2020;2020:2064781. https://search.pedro.org.au/search-results/record-detail/60838
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. 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

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.