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What Is Extracorporeal Shockwave Therapy?
Extracorporeal shockwave therapy delivers acoustic pressure pulses through the skin. Musculoskeletal studies assess whether these exposures improve pain and function in a defined condition.
Evidence includes tendon-related diagnoses such as chronic GTPS and separate myofascial trials involving the upper trapezius, QL or piriformis syndrome. The treatment target and comparison differ across those studies.
Measure whether the treatment improves a specific painful activity, alongside the rehabilitation program.
Focused devices concentrate energy in a selected region; radial pressure waves disperse from the applicator. Anatomy, device characteristics and condition-specific evidence guide the choice.
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Types of Shockwave Therapy
Focused ESWT (fESWT)
Electromagnetic, electrohydraulic, or piezoelectric sourcesEnergy field: Energy concentrated at a selected focal regionPressure: Higher peak pressure than radial systems
- • Electromagnetic, electrohydraulic or piezoelectric generation
- • The focal region and energy distribution depend on the device and applicator
- • Target depth is selected from anatomy and imaging when indicated
- • A chronic-GTPS trial treated gluteal tendon insertions with ultrasound localization
- • Evidence for a tendon diagnosis does not establish treatment of an isolated muscle point
Application: An assessed target matched to a focused-device protocol
Radial Pressure Wave (rPWT / rESWT)
Ballistic applicator driven by compressed air or electromagnetic coilsEnergy field: Maximum pressure near the applicator; disperses into tissuePressure: Different pressure field and parameter definitions
- • Pressure waves spread from the skin-contact applicator
- • Applicator shape and settings influence the exposed region
- • Radial studies include upper-trapezius pain and assessed piriformis syndrome
- • Radial and focused settings are not interchangeable
- • Clinical selection depends on the diagnosis, anatomy and relevant study
Application: A condition studied with the selected radial protocol
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Proposed Mechanisms
Cell and animal studies describe possible signaling and vascular effects. Myofascial clinical trials primarily assess pain, tenderness and function; they do not establish structural repair as the cause of improvement.
Mechanotransduction
Mechanical pressure can initiate cellular signaling. Experimental evidence describes potential biological responses; clinical benefit must be established for the treated condition.
Local Pain Sensitivity
Myofascial trials measure pain and pressure sensitivity after treatment. These outcomes show symptom response, without demonstrating destruction or removal of a trigger point.
Blood-Vessel Responses in Animal Research
A rabbit Achilles-insertion study found new blood vessels and angiogenesis-related markers after shockwave exposure. It did not test repair of painful human muscle. PMID 14554209.PubMed 14554209
Nitric Oxide and Vascular Signaling
Shockwaves increased endothelial nitric-oxide-synthase activity in cultured human vascular cells. This laboratory finding is a proposed mechanism, not a demonstrated explanation for pain relief in patients. PMID 15740982.PubMed 15740982
Pain-Modulation Effects
Mechanical stimulation may alter nociceptor activity and pain processing. Current clinical trials do not establish one dominant pathway or show that immediate pain relief predicts lasting benefit.
Clinical Outcomes
Myofascial studies mainly track pain and pressure sensitivity; GTPS trials also assess hip function and daily activity. These endpoints describe what treatment changed.
Response Over a Treatment Course
Track the same painful activity over the studied follow-up period. Changes in tenderness alone do not establish recovery of strength or daily function.
What a Treatment Course Should Track
Clinical Target
Name the diagnosis and tissue region before selecting the device.
Delivered Protocol
Record device, energy, impulse count, repetition rate and visits.
Activity Response
Repeat the same movement or task to assess useful benefit.
Follow-Up
Review pain and function at an agreed interval after the course.
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Studied Parameters and Dose Selection
Energy Flux Density
0.20 mJ/mm² in one focused-GTPS trialRamon 2020 used this energy flux density with a Duolith SD1 Ultra focused device; sham received 0.01 mJ/mm². These are study settings for chronic GTPS, not a general muscle dose. PMID 32769596.PubMed 32769596
Pulse Count
2,000 impulses per session in that trialThe same GTPS study targeted the gluteal tendon insertion with ultrasound localization. Pulse count needs to be interpreted with the device, energy and treated field.
Pulse Repetition Rate
5 Hz in the focused-GTPS trialFrequency is the number of impulses delivered each second. It is distinct from energy flux density and does not by itself describe treatment intensity.
Number of Sessions
3 weekly visits in the focused-GTPS trialThe piriformis comparison also used three weekly visits, with a radial device; the 2025 upper-trapezius trial used four sessions. These are separate condition-specific courses.
Session Interval
Determined by the studied protocolDocument spacing with the device and treatment target. The cited trials do not establish one optimal interval for all myofascial presentations.
Session Duration
Application time follows pulse count and rateAssessment and setup add to exposure time. A longer appointment does not necessarily mean a larger delivered dose.
Anesthesia
No local anesthesia in the focused-GTPS trialAnesthesia use depends on the indication and protocol. Tolerance is monitored throughout; treatment settings are adjusted within the selected protocol.
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Clinical Evidence
Condition-specific trialsPopulation, device and follow-up vary
Hong et al. (2017) — quadratus lumborum; PMID 28971042
A retrospective comparison of 30 patients found greater pain improvement with ESWT than trigger-point injection, with no clear disability difference. Nonrandom allocation limits the conclusion.PubMed 28971042
Eftekharsadat et al. (2020) — QL; PMID 33076888
A 54-person trial compared radial ESWT with corticosteroid/lidocaine injection. Injection favored early pain and disability at two weeks; ESWT favored disability and quality of life at four weeks. The short comparison had no sham, and inconsistent schedule descriptions prevent extracting a reliable treatment course.PubMed 33076888
Şenlikci et al. (2025) — upper trapezius; PMID 41042302
A 57-person radial/focused/sham trial used four sessions and assessed outcomes through six months. Authors report greater pain improvement with both devices; small groups, unequal symptom duration and inconsistent abstract VAS wording limit certainty. General-function scores did not differ between groups.PubMed 41042302
Dede et al. (2026) — piriformis syndrome; PMID 42291383
48 randomized, 44 completed; three weekly ultrasound-assisted radial ESWT or ultrasound-guided DN sessions, with stretching in both arms. Pain, disability and lower-limb function improved at 1 and 3 months without a clear between-group difference. There was no sham or equivalence design.PubMed 42291383
Ramon et al. (2020) — chronic GTPS; PMID 32769596
103 patients received three weekly focused ESWT or low-energy sham sessions with the same exercises. At 2 months pain averaged 2.0 versus 4.7/10, from 6.3 in both arms; functional benefit generally persisted through six months. This concerns lateral-hip tendon/GTPS care, not isolated gluteal muscle points.PubMed 32769596
Song et al. (2024) — TMD; PMID 38685720
26 patients received three sessions of shockwave or sham added to routine treatment. Pain and opening favored active treatment after two weeks, with reassessment four weeks later. This preliminary study does not establish durable masseter/temporalis-specific efficacy or a standard device protocol.PubMed 38685720
Pain Reduction
Pain results differ across diagnoses and comparison groups
Pressure Pain Threshold
A pressure-sensitivity change is distinct from recovery of function
Range of Motion
Track the movement that was limited before treatment
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The Treatment Session
Assessment and Target Selection
Identify the diagnosis and a painful activity to follow. Examine the target region and nearby structures before choosing the device and treatment field.
Application of Coupling Gel
Gel is applied so the acoustic energy transmits effectively from the applicator to the skin and underlying tissues.
Applicator Positioning
Position the applicator for the diagnosed tissue target. Use anatomical landmarks and imaging when the selected protocol requires localization.
Protocol and Tolerance
Set the device, energy, impulse count and repetition rate for the selected protocol. Monitor comfort and stop or adjust the application if it becomes intolerable.
Feedback-Guided Treatment
Ask about the sensation during treatment while maintaining the planned anatomical field. Pain reproduction alone is not a reason to move onto a nerve, vessel or other excluded structure.
Movement and Exercise
Continue the exercise or loading plan selected for the diagnosis. The GTPS trial combined treatment with the same daily exercise program in both groups.
Activity Guidance
Agree on activity advice for the treated condition and any post-treatment soreness. Review persistent worsening before the next session.
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When Shockwave May Be Considered
Assessed Myofascial Pain
Consider a procedure when the painful region and activity limitation match a studied myofascial presentation, such as upper-trapezius pain. Palpable tenderness alone does not identify the diagnosis.
Needle-Avoidant Patients
A patient who prefers to avoid needling may discuss shockwave when it has evidence for the assessed condition. The piriformis comparison found no clear difference between the two procedures at one and three months.
Assessed Upper-Trapezius Myofascial Pain
The radial/focused/sham trial studied upper-trapezius myofascial pain. Pain findings were favorable, while general-function scores did not differ between groups.
Persistent Gluteal Tendon Pain / GTPS
Focused shockwave can be considered for diagnosed persistent lateral-hip tendon pain alongside loading care. GTPS trials do not establish the same benefit for isolated medius or minimus muscle tenderness.
Mixed Myofascial + Tendinopathy Presentations
When tendon pain and muscle tenderness coexist, identify the intended target. Evidence differs by condition: the 2025 JOSPT rotator-cuff guideline (Desmeules et al.; PMID 40165544) supports considering ESWT for calcific tendinopathy but not for noncalcific cuff tendinopathy.
A Defined Rehabilitation Goal
Agree on an activity to review, such as side-lying comfort or walking in GTPS. Keep the loading program appropriate to the diagnosis throughout the course.
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Contraindications & Side Effects
ISMST guidance on treatment fields and contraindications
When Treatment Must Be Avoided
Assessment Before Treatment
Side Effects
Monitor comfort and the treatment field
Trials report local pain, redness and bruising. Small efficacy studies do not establish a precise rate of uncommon complications; the device and anatomical field determine the relevant precautions.
Temporary Skin Redness
Mild local redness is common and usually settles quickly.
Mild Swelling
Some soft-tissue swelling or post-treatment reactivity can occur for a short time afterward.
Petechiae or Small Surface Bruising
Small pinpoint bruising can happen, especially at higher energies or in sensitive skin.
Pain During Treatment
Discomfort during the session is common, which is why energy is usually adjusted to a tolerable level.
Post-Treatment Soreness
Local soreness may persist into the following days. Review substantial, persistent or worsening pain before continuing treatment.
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ESWT vs Other Treatments
Comparison
Practical DifferenceClinical Interpretation
vs Dry Needling
Shockwave is non-invasive and avoids skin penetration
Neither procedure has a universal advantage; compare trials for the same diagnosis
vs Therapeutic Ultrasound
Shockwave delivers discrete pressure pulses; therapeutic ultrasound delivers a different acoustic exposure
Benefit cannot be ranked from the strength of the mechanical stimulus
vs TENS
Shockwave uses acoustic pulses; TENS applies electrical stimulation through skin electrodes
Different mechanisms do not establish longer-lasting benefit from shockwave
vs Manual Therapy
An applicator delivers a defined pulse protocol; manual care uses clinician-applied contact
Their relative value depends on the diagnosis, comparator and patient preference
§ 10
Treatment and Reassessment
3 weekly
Treatment SessionsThree weekly focused sessions were tested for chronic GTPS; other conditions used different courses.
Activity
Between SessionsContinue the agreed activity plan and record soreness, pain during a chosen task and useful change between visits.
2–6 months
Follow-Up AssessmentThe GTPS trial assessed pain at two months and followed participants through six months. Review pain during the same chosen activity at each follow-up.
Key Takeaways
Shockwave is an option for specific assessed conditions, including chronic GTPS and selected myofascial presentations.
Focused and radial devices have different pressure fields; their settings and indications should be matched to the evidence.
Three weekly focused sessions plus exercise improved chronic-GTPS outcomes in a sham-controlled trial.
Upper-trapezius, QL, piriformis and jaw studies have different comparisons and follow-up periods.
Use pain during a chosen activity and daily function to decide whether further treatment is useful.
High-energy focused treatment has specific anatomical and bleeding-related contraindications.