Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment that uses high-pressure acoustic pulses to stimulate biological responses in soft tissue, bone, and other musculoskeletal structures. Originally developed for lithotripsy in the 1980s, ESWT has since evolved into a widely used regenerative modality in sports medicine, orthopedics, physical therapy, and rehabilitation settings. Modern shockwave devices—especially focused shockwave devices—are engineered to deliver precisely controlled mechanical energy to targeted tissue depths, triggering a cascade of cellular changes that promote healing, reduce pain, and restore function.
There are two primary types of shockwave: focused and radial. Focused shockwave generates a converging acoustic wave that concentrates energy at a predetermined focal depth (up to several centimeters). Focused allows treatment of deep structures such as gluteal tendons, proximal hamstrings, and chronic enthesopathies. It delivers high peak pressures (up to 100 MPa) and very short rise times—key features responsible for biological effects. Radial shockwave, by contrast, produces a dispersing pressure wave with maximum energy at the applicator surface. It is best suited for superficial tissues, muscle trigger points, and tendinopathies close to the skin. While both modalities initiate mechanotransduction, focused shockwave produces more pronounced cellular effects due to its depth precision and concentrated energy delivery.
The therapeutic action of ESWT is primarily driven by mechanotransduction—the conversion of mechanical forces into biochemical signals. Shockwaves introduce rapid pressure gradients, microstress, shear forces, and brief mechanical stimulation that activate multiple intracellular pathways. These pathways regulate inflammation, angiogenesis (new blood vessel formation), collagen remodeling, and overall tissue regeneration. Key responses include upregulation of regenerative growth factors such as vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), bone morphogenetic proteins (BMPs), and insulin-like growth factor 1 (IGF-1). These molecules enhance microcirculation, stimulate cell proliferation, and support tissue repair.
Shockwaves also produce sonoporation, creating temporary micro-openings in cell membranes that increase ion exchange and promote healing. Focused shockwave has been shown to activate mesenchymal stem cells and enhance their migration to the treatment site, supporting regeneration in tendon, muscle, and bone.
Shockwave therapy reduces pain through several complementary mechanisms:
Reduction of substance P: ESWT lowers levels of substance P, a neurotransmitter associated with chronic pain and neurogenic inflammation.
Improved blood flow and metabolic recovery: Chronic tendinopathy is typically hypovascular and degenerative; shockwave-induced angiogenesis restores circulation and supports metabolic repair.
Neural modulation: By altering afferent input, ESWT influences pain signaling at the dorsal horn of the spinal cord.
These mechanisms make shockwave particularly effective for stubborn, chronic conditions such as plantar fasciitis, calcific shoulder tendinopathy, patellar tendinopathy, and gluteal tendinopathy.
Shockwave therapy also promotes cellular regeneration and tissue remodeling. Tenocytes respond to mechanical energy by increasing synthesis of Type I collagen, the primary structural component of healthy tendon. Tendinopathic tissue often contains disorganized, weakened collagen fibers; shockwave helps realign these fibers into a stronger, more functional orientation.
In calcific tendinopathy, shockwaves facilitate the breakdown of calcium deposits through microcavitation, weakening the deposits and enabling the body to gradually reabsorb them. Additionally, the controlled microtrauma induced by shockwave stimulates neovascularization, leading to improved oxygenation and enhanced healing potential.
ESWT provides both angiogenic and anti-inflammatory benefits. Many chronic tendinopathies are marked by poor blood supply, failed healing, and persistent pro-inflammatory cytokines. Shockwave helps reverse this process by enhancing nitric oxide (NO) production—supporting vasodilation and tissue repair—while decreasing inflammatory markers. Shockwave also promotes a beneficial shift in macrophage phenotype from pro-inflammatory (M1) to pro-repair (M2), accelerating tissue regeneration at the cellular level.
These cumulative effects are supported by numerous randomized controlled trials and meta-analyses demonstrating shockwave’s effectiveness for conditions including plantar fasciitis, tennis elbow, calcific shoulder tendinopathy, patellar and Achilles tendinopathy, proximal hamstring tendinopathy, gluteal tendinopathy, and greater trochanteric pain syndrome. Unlike therapies that merely manage symptoms, ESWT directly stimulates biological healing, making it one of the most evidence-supported regenerative treatments in musculoskeletal medicine.
References Wang CJ, et al. “Extracorporeal shockwave therapy in musculoskeletal disorders.” Journal of Orthopaedic Surgery and Research. 2012. PMID: 22433113 Gerdesmeyer L, et al. "Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study.".American Journal of Sports Medicine. 2008. PMID: 18832341 Furia JP. “High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy.” American Journal of Sports Medicine. 2008. PMID: 18006678 Notarnicola A, Moretti B. “The biological effects of extracorporeal shock wave therapy on tendon tissue.” Muscles Ligaments Tendons Journal. 2012. PMID: 23738271 Lohrer H, et al. “ESWT and mechanotransduction: Tissue responses and clinical relevance.” Foot and Ankle Clinics. 2017. PMID: 28336051