What the latest evidence shows about shockwave therapy for Achilles tendinopathy and what it means for your practice

A recent systematic review of nine randomised controlled trials finds no clinically meaningful benefit of shockwave therapy over sham treatment for Achilles tendinopathy, with the clearest evidence against its use in insertional presentations and genuine uncertainty remaining for midportion cases.

A recently published systematic review and meta-analysis published in JOSPT concludes that shockwave therapy (SWT) does not provide clinically meaningful benefit for either insertional or midportion Achilles tendinopathy compared to sham treatment. Given the volume of discussion this topic generates in clinical practice, it is worth looking carefully at what the evidence actually shows, and where genuine uncertainty remains.

This study searched searched a wide range of databases and registries and included nine randomised controlled trials involving 557 adults with Achilles tendinopathy. Crucially, they separated insertional from midportion presentations throughout their analysis (a methodological step that previous reviews have often omitted) and used established minimal clinically important differences (MCIDs) to assess whether any statistically significant results actually translated into meaningful clinical change for patients.

For insertional Achilles tendinopathy, the findings are the most consistent in the review. Across all outcomes (disability, condition-specific scores and pain) at all follow-up timepoints, there were no significant differences between SWT and sham treatment, with low to moderate certainty evidence. Sensitivity and subgroup analyses did not change this picture. The authors are direct in their conclusion: SWT should not be recommended for insertional Achilles tendinopathy.

For midportion Achilles tendinopathy, the picture is less clear, and it is worth being cautious about both over-reading the negative headline and dismissing the genuine uncertainty. The meta-analyses showed no statistically significant differences in disability or pain between SWT and control groups at any timepoint. However, very low-certainty evidence from a small number of low-certainty analyses suggested that radial SWT might produce clinically meaningful improvements in both short- and long-term VISA-A and pain scores compared to sham or wait-and-see controls. The authors flag this carefully: the one trial showing the largest effects did not report whether participant blinding was successful. This is a significant limitation, because SWT is inherently painful while sham SWT typically is not, meaning participants are likely to know which group they are in, potentially inflating subjective outcomes. The practical significance of this is illustrated by the most recent insertional Achilles trial included in the review, in which 58% of participants believed they were receiving real treatment, and improved at the same rate as the active group. When sham believers improve identically to the treatment group, the machine is unlikely to be doing the specific work. Subgroup analyses found no clear advantage for radial over focused SWT. The honest summary for midportion presentations is that the evidence is genuinely uncertain, not that benefit is definitively ruled out.

There is an important safety signal that should feature in your practice and your informed consent conversations. Two Achilles tendon ruptures were reported following focused SWT in one included trial, both occurring within 2 weeks of the first treatment session. The authors acknowledge it is unclear whether these events were directly caused by the treatment, as tendon rupture can occur in the context of tendinopathy regardless of intervention. That said, given the broader evidence picture, this is a finding that warrants transparency with patients.

On methodology, it is worth noting that 89% of included trials were rated as high risk of bias, and the certainty of evidence across comparisons ranged from very low to moderate. The authors also highlight limitations of the VISA-A questionnaire itself, which is heavily weighted towards sporting activity and less sensitive to change in sedentary populations, a group that represents a substantial proportion of people presenting with Achilles tendinopathy in primary care.

Where does this leave your practice? Exercise-based rehabilitation remains the most robustly supported treatment for Achilles tendinopathy, a position the authors reinforce and which is reflected in existing clinical guidelines. The evidence does not currently support offering SWT routinely for either presentation. For patients where exercise has been exhausted and you are considering SWT, particularly for midportion presentations, an honest and balanced conversation about the current evidence (including what remains uncertain, the associated costs and the serious adverse events reported) is the appropriate approach.

Physiopedia pages are being updated to reflect this latest evidence. If you have seen other new research that you think should inform our content, we always welcome suggestions from the community.