Chronic tendinopathy, persistent tendon pain that doesn't respond to rest, physio or steroid injections, is one of the most common and most frustrating musculoskeletal presentations. ESWT consistently produces results where conventional treatments have failed. The evidence is strong enough that it should be the first-line recommendation for many of these conditions, not the last resort.
What is a tendinopathy?
Tendinopathy is the term that has largely replaced 'tendinitis' in clinical practice, because the pathological picture in most chronic tendon pain is not primarily inflammatory. Histological studies of chronically painful tendons consistently show a degenerative process (tendinosis) characterised by disorganised collagen, neovascularisation, loss of the normal tendon architecture and absence of the inflammatory cells that 'tendinitis' implies.
This distinction matters for treatment. Anti-inflammatory approaches (NSAIDs, corticosteroid injections) may reduce pain temporarily but do not address the degenerative pathology, and steroid injection in particular has been shown to accelerate tendon degeneration with repeated use. What chronic tendinopathy needs is not inflammation suppression but tissue regeneration and remodelling. ESWT provides exactly this.
How shockwave works on tendons
Extracorporeal shockwave therapy delivers focused acoustic pressure waves, generated outside the body (extracorporeal) and transmitted through the tissue, to the pathological tendon. The biological effects are multiple and complementary:
- Hyperstimulation analgesia: the mechanical stimulus of the shockwave temporarily overwhelms and inhibits the nociceptive fibres responsible for pain perception, producing immediate post-treatment pain reduction
- Neovascularisation: ESWT stimulates the formation of new blood vessels in the treated tendon, restoring the vascularity that is reduced in chronic tendinopathy and essential for tissue repair
- Collagen synthesis stimulation: fibroblasts in the tendon and peritendinous tissue respond to the mechanical stimulus by increasing collagen production, gradually replacing the disorganised degenerative tissue with new, properly structured collagen
- Calcium fragmentation: in calcific tendinitis, the acoustic pressure waves physically fragment the calcium deposits, initiating their resorption by the surrounding tissue
Plantar fasciitis: the best-evidenced application
Plantar fasciitis, chronic pain at the insertion of the plantar fascia at the calcaneus (heel bone), is among the most painful and debilitating foot conditions, affecting approximately 10% of people at some point. It is also the condition for which ESWT has the largest and most consistent evidence base.
Multiple RCTs and systematic reviews have demonstrated ESWT success rates of 70–80% in chronic plantar fasciitis (defined as symptoms present for >3 months and unresponsive to conservative treatment). The landmark Rompe et al. studies showed ESWT significantly outperforming sham treatment, physiotherapy alone and corticosteroid injection at 6 and 12 months. Patients describe elimination or near-elimination of morning first-step pain, the characteristic and debilitating symptom of established plantar fasciitis.
Tennis and golfer's elbow
Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow), chronic tendinopathies at the common extensor and flexor origins respectively, are notoriously difficult to treat conservatively once established. Physiotherapy produces modest results; corticosteroid injection provides short-term relief but accelerates degeneration with repeated use; surgery is effective but carries significant recovery demands.
ESWT for lateral epicondylitis consistently produces results comparable to surgery at 12-month follow-up, without the risk, the recovery time or the cost. The evidence base includes multiple RCTs showing significant IIEF improvement. For golfer's elbow the evidence is somewhat smaller but follows the same pattern of consistent superiority over sham treatment.
Achilles tendinopathy
Both mid-substance and insertional Achilles tendinopathy respond to ESWT, though they require different application parameters and the evidence is stronger for mid-substance pathology. For insertional Achilles (pain at the heel-tendon junction), ESWT is often combined with specific eccentric loading protocols for optimal results.
ESWT combined with PRP: For resistant tendinopathies or those that have not fully responded to a standard ESWT course, the combination of ESWT with PRP injection produces superior outcomes. The shockwave prepares the tissue and initiates the healing response; the PRP growth factors amplify and sustain it. This protocol is available at Aesthetics Medispa for appropriate presentations.
What to expect from treatment
ESWT sessions take 15–20 minutes. The sensation is significant, typically rated 4–6/10, but the discomfort is brief and resolves rapidly after the session ends. An initial increase in symptoms for 24–48 hours following treatment is normal and expected: it reflects the biological response being initiated. Meaningful pain reduction typically begins after sessions 2–3 and continues to develop for weeks after the course completion as the tissue remodelling matures.
Treatments that work. Results you can see.
Every treatment at Aesthetics Medispa begins with a consultation, understanding your skin, your health and your goals.