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 evidence that ESWT combined with a tendon loading programme improves pain and function scores beyond loading alone. The evidence is strongest when shockwave is used as an adjunct to progressive exercises, not as a standalone treatment. A typical course is 3 to 5 weekly sessions alongside a structured loading programme.
Achilles tendinopathy is a common and often frustrating condition, particularly for runners and recreational athletes. The tendon becomes painful, stiff and thickened, usually from repetitive overload. 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 they respond differently to treatment.
The foundation of Achilles tendinopathy treatment is progressive tendon loading. Eccentric exercises (controlled lowering movements) and heavy slow resistance programmes (gradually increasing the weight the tendon has to handle) have the strongest evidence for driving tendon repair and reducing pain. But when loading alone is not producing enough improvement, or the condition has become chronic and the tendon has stopped responding, adding shockwave therapy to the programme can help.
A 2022 systematic review of randomised trials found moderate evidence that shockwave added to a tendon loading programme improves outcomes for Achilles tendinopathy, with a meaningful improvement in pain and function scores when shockwave was combined with standard care. The consistent finding across the literature is that shockwave is most effective for the Achilles when combined with a structured rehabilitation programme, not as a replacement for it.
This is how we deliver it at our Sandton practice. Shockwave using the EMS Swiss DolorClast Smart20 is paired with a progressive loading programme, calf and ankle mobilisation and assessment of contributing factors further up the chain. Hip weakness, calf tightness, training load errors and footwear are all factors that affect how the Achilles tendon loads, and addressing these alongside shockwave gives the tendon the best chance to recover.
WHEN 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 after 3 to 6 months
- Mid-portion Achilles pain is persisting despite consistent loading exercises
- The tendon has become chronic and appears to have stopped responding to loading alone
- You want a non-invasive adjunct to help stimulate the tendon's healing response
- Pain is limiting your ability to progress through your rehabilitation programme
- You are trying to avoid cortisone injections, which can weaken tendon tissue with repeated use
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
- 3 to 5 sessions delivered once a week, each lasting about 15 minutes of shockwave treatment
- Each visit also includes a chiropractic assessment, calf and ankle mobilisation and progression of your loading programme
- A structured home exercise programme is essential alongside the shockwave sessions
- Mild tenderness or warmth in the tendon for 24 to 48 hours after each session is normal and expected
- Avoid anti-inflammatory medication during the course where possible, as it can slow the healing response shockwave is designed to trigger
- Tissue remodelling continues for weeks after the course ends, with ongoing improvement 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
Shockwave is not a standalone fix for Achilles tendinopathy, but when combined with the right rehabilitation programme, it can help move a stubborn tendon forward. If loading alone has stalled your progress, it is a reasonable non-invasive option to try before considering more invasive interventions.
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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Frequently Asked Questions
The evidence is most supportive when shockwave is used as part of a combined approach alongside a structured tendon loading programme. A 2022 systematic review found moderate evidence that ESWT added to a loading programme improves outcomes for mid-portion Achilles tendinopathy, with a clinically meaningful improvement in pain and function scores.
The evidence is stronger for mid-portion Achilles tendinopathy (pain in the middle of the tendon) than for insertional tendinopathy (pain where the tendon attaches to the heel bone). Mid-portion Achilles tendinopathy responds better to the combination of shockwave and progressive loading. Insertional cases may need a different treatment approach.
Most protocols use 3 to 5 sessions delivered once a week, alongside a progressive exercise programme that gradually increases the load on the tendon. The shockwave and the exercises work together: shockwave stimulates blood flow and a healing response while the loading drives tendon repair.
Shockwave delivers acoustic pressure waves into the damaged tendon. This increases blood flow to the area, stimulates new blood vessel growth and triggers a healing response in tissue that has stopped repairing on its own. When combined with progressive loading, this creates an environment where the tendon can remodel more effectively.
Shockwave is worth considering when Achilles tendinopathy has not responded to a structured course of eccentric exercises, activity modification and other conservative measures over 3 to 6 months. It is used as an adjunct to rehabilitation, not a replacement for it.
The treatment feels like rapid mechanical tapping over the tendon. Over the tender area it can be intense for the first 30 to 60 seconds before the pain-modulating effect kicks in. Most patients describe the discomfort as a 3 to 5 out of 10 and entirely 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 essential. This typically involves controlled heel drop exercises or gradually heavier calf raises, progressed over weeks. The research shows that shockwave produces the best outcomes for Achilles tendinopathy when combined with this type of progressive loading, rather than used on its own.
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.