Shockwave Therapy
Shockwave Therapy for Achilles Tendinopathy
At a glance
Shockwave therapy (ESWT) can be a useful addition to a structured rehabilitation programme for mid-portion Achilles tendinopathy. A 2022 systematic review found moderate-quality evidence that ESWT added to a tendon loading programme improves outcomes for mid-portion Achilles tendinopathy (Paantjens et al., 2022). We use it as an addition to progressive exercise, not a standalone treatment, given as a short course of weekly sessions with the number guided by how you respond.
Achilles tendinopathy can be a frustrating condition for runners and active people. The tendon becomes painful and stiff, and the pain is brought on by activities that load it, such as running and jumping. Mid-portion tendinopathy (pain in the middle of the tendon) and insertional tendinopathy (pain where the tendon attaches to the heel bone) are the two main presentations, and the evidence for shockwave differs between them (Paantjens et al., 2022).
The foundation of Achilles tendinopathy treatment is progressive tendon loading. Guidelines recommend tendon loading exercise, with loads as high as tolerated, as the first-line treatment for mid-portion Achilles tendinopathy (Chimenti et al., 2024). That can include eccentric exercises (controlled lowering movements) and heavier, slower calf strengthening. When loading alone is not producing enough improvement, adding shockwave therapy to the programme can help.
A 2022 systematic review of randomised trials found moderate-quality evidence that shockwave added to a tendon loading programme improves symptom and function scores for mid-portion Achilles tendinopathy (Paantjens et al., 2022). In a randomised trial of 68 people whose mid-portion Achilles pain had lasted more than six months, 82% of those who had shockwave plus eccentric loading reported being completely recovered or much improved at four months, compared with 56% who did the loading programme alone (Rompe et al., 2009). An earlier trial from the same group found that shockwave on its own and eccentric loading gave comparable results at four months, and both did better than a wait-and-see approach (Rompe et al., 2007). A 2024 meta-analysis across several tendon conditions also found shockwave reduced pain in chronic Achilles tendinopathy (Majidi et al., 2024). Research into how shockwave works suggests it triggers biological responses in the tissue, including pain relief and the formation of new blood vessels (Simplicio et al., 2020).
This is how we deliver it at our Sandton practice. Radial shockwave therapy is paired with a progressive loading programme, calf and ankle mobilisation and a look at the rest of the lower limb, including the hip. We also talk through your training load and footwear, so the plan fits the way you run and train.
In pain now? Same-day appointments available at our Sandton rooms.
Book Shockwave TherapyWhen to consider adding shockwave for achilles tendinopathy
Shockwave may be worth adding to your Achilles rehabilitation when:
- A structured exercise programme has not produced enough improvement
- Mid-portion Achilles pain is persisting despite consistent loading exercises
- Pain has become long-standing despite loading alone
- You want a non-invasive addition to your rehabilitation
- Pain is limiting your ability to progress through your rehabilitation programme
- You would prefer to avoid injections
What to expect from a course of shockwave
Treatment is delivered as part of a broader rehabilitation approach:
- A thorough assessment at your first visit to confirm that adding shockwave to your rehabilitation is appropriate
- A short course of weekly sessions, with the number guided by how your tendon responds
- Each visit also includes a chiropractic assessment, calf and ankle mobilisation and progression of your loading programme
- A structured home exercise programme runs alongside the shockwave sessions
- Some patients notice mild tenderness or warmth in the tendon for a short time after each session, which is normal
- Speak to your GP or pharmacist about any medication during the course
- Improvement tends to build over the course and the weeks after it, as the loading programme progresses
- Progress is tracked through pain levels and tendon function at each visit, with the treatment plan adjusted as you respond
We use shockwave as part of a rehabilitation programme rather than on its own, and combined with that programme it can help a stubborn tendon move forward. If loading alone has stalled your progress, it is a non-invasive option supported by trials for mid-portion Achilles tendinopathy.
Located on Rivonia Road in Morningside, we serve patients from Sandton, Bryanston, Fourways, Randburg, Sunninghill, Rivonia and surrounding areas of Johannesburg.
Shockwave therapy at our practice is offered by Dr Matthew Proctor. Book a shockwave appointment directly with him or get in touch to discuss your Achilles before booking.
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Same-day appointments available at our Sandton rooms.
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Frequently Asked Questions
Yes, for mid-portion Achilles tendinopathy, as part of a combined approach. A 2022 systematic review found moderate-quality evidence that shockwave added to a tendon loading programme improves outcomes for mid-portion Achilles tendinopathy. In one randomised trial of 68 people with long-standing mid-portion Achilles pain, 82% of those who had shockwave plus eccentric loading reported being completely recovered or much improved at four months, compared with 56% who did the loading programme alone.
The trial evidence supporting shockwave is for mid-portion Achilles tendinopathy (pain in the middle of the tendon). For insertional tendinopathy (pain where the tendon attaches to the heel bone) the evidence is less clear, so insertional cases may need a different treatment approach. Your assessment will tell us which type you have.
There is no fixed number. Shockwave is given as a short course of weekly sessions, with the number guided by how your tendon responds, alongside a progressive exercise programme that gradually increases the load on the tendon. The two are designed to work together.
Shockwave delivers acoustic pressure waves into the painful part of the tendon. Research into how it works suggests the waves trigger biological responses in the tissue, including pain relief, the formation of new blood vessels and cell activity linked to tissue repair. We combine it with progressive loading, which is the foundation of Achilles rehabilitation.
Shockwave is worth considering when mid-portion Achilles tendinopathy has not settled with a consistent, structured loading programme and activity modification. It is used as an addition to rehabilitation, not a replacement for it.
The treatment feels like rapid mechanical tapping over the tendon. Over the tender area it can feel intense at first, and many patients find it eases as the treatment goes on. Most describe the discomfort as manageable. We adjust the energy level to your tolerance.
This depends on your pain levels and where you are in your rehabilitation. Some patients can maintain reduced running alongside treatment, while others need to modify their activity more significantly. Your chiropractor can help you find the right balance between loading the tendon enough to stimulate repair and avoiding further aggravation.
A structured loading programme is the foundation. Guidelines recommend tendon loading exercise, with loads as high as you can tolerate, as the first-line treatment for mid-portion Achilles tendinopathy. This typically involves controlled heel drops or gradually heavier calf raises, progressed over weeks. The trials we rely on used shockwave alongside this type of loading.
References
- 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.
- Majidi L, Khateri S, Nikbakht N, Moradi Y, Nikoo MR. The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials. BMC Sports Science, Medicine and Rehabilitation. 2024;16(1):93.
- Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463-470.
- Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374-383.
- Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2024. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(12):CPG1-CPG32.
- Simplicio CL, Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. Journal of Clinical Orthopaedics and Trauma. 2020;11(Suppl 3):S309-S318.