Shockwave therapy (ESWT)
A non-invasive treatment that passes acoustic shockwaves through the skin to a painful tendon or fascia, sometimes used for stubborn problems such as plantar fasciitis or Achilles or elbow tendinopathy when rehabilitation alone has not settled them.
✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review
In short
- ESWT is a non-invasive machine treatment sometimes used for stubborn tendon or heel pain that has not settled with rehabilitation.
- The evidence on how well it works is mixed and inconsistent, and NICE advises it be used with special arrangements and clear consent about that uncertainty.
- It is an adjunct to a progressive loading programme, not a replacement for it and not a guaranteed cure.
- Side effects are usually mild (pain during treatment, redness, bruising), but it should be avoided in certain situations, such as pregnancy or with bleeding problems.
A plain-English summary. The detail — including risks and recovery — is below.
At a glance
A general guide. Your specialist will give you advice for your situation.
Non-invasive, with no cuts, needles, anaesthetic or recovery downtime
You are pregnant and the area to be treated is over the abdomen or pelvis.
You can usually go back to normal activity. The area may be a little red, sore or tender for a short time.
A clear plan combining ESWT with a loading and rehabilitation programme.
You can usually go back to normal activity. The area may be a little red, sore or tender for a short time.
A mild flare of soreness is common and normally settles. Simple pain relief can help if needed, as advised.
Sessions are usually spaced about a week apart. You continue your loading exercises between sessions as advised.
Any benefit typically builds gradually over the following weeks rather than immediately. Results vary and are not...
What is extracorporeal shockwave therapy (ESWT)?
Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment in which a hand-held device passes acoustic pressure (shock) waves through the skin to a painful area, such as the heel (plantar fasciitis), the Achilles tendon, the outer elbow (tennis elbow) or the patellar tendon below the kneecap.
It is usually given as a short course of sessions and does not involve cuts, needles or anaesthetic. Exactly how it might help tendon problems is not fully understood, and NICE notes that the mechanism is not known.
ESWT is best thought of as an adjunct — an extra option to consider when a tendon or fascia has not settled with a progressive loading and rehabilitation programme — rather than a first-line treatment or a cure. The evidence on how well it works is mixed and inconsistent across conditions, and results vary from person to person.
NICE has reviewed ESWT for several refractory (stubborn) conditions and advises that, because the evidence on efficacy is inconsistent, it should be used with special arrangements for clinical governance, consent and audit, and that patients should be clearly told about the uncertainty.
Types, options & approaches
There may be different ways to do this. The right approach depends on the clinical question and your circumstances.
Shockwave therapy versus loading rehabilitation
| Feature | Loading rehab | Shockwave therapy |
|---|---|---|
| Role | Mainstay | Adjunct |
| Evidence | Strongest | Mixed / inconsistent |
| Invasiveness | None | Non-invasive, can be uncomfortable |
| Cost pattern | Sessions over time | Often a paid course of sessions |
ESWT is usually added to a rehabilitation programme for stubborn cases, not used instead of it.
Preparing for your treatment
- Tell the clinician about your full medical history, including any bleeding disorder or blood-thinning medicines, as ESWT is generally avoided in these situations.
- Tell them if you are or might be pregnant, as ESWT is not used over the abdomen or pelvis in pregnancy.
- Mention any nerve problems, poor circulation, infection or skin breakdown over the treatment area.
- Be clear about what rehabilitation you have already tried and for how long.
- Ask whether the device is focused or radial, how many sessions are planned, and what evidence supports it for your problem.
- Plan to continue your loading exercises around the course, as advised.
What happens
ESWT is given in an outpatient or clinic setting and usually takes only a few minutes per session. You stay awake and no anaesthetic is needed.
A gel is applied to the skin and the clinician places the device over the painful area, then delivers a series of pulses. You will usually feel a tapping sensation and some discomfort, and the intensity may be adjusted to what you can tolerate. No cuts or needles are involved.
Treatment is typically given as a course, often around three sessions about a week apart, though this varies. You can usually return to normal activities straight away, continuing your rehabilitation programme as advised.
Is this treatment right for me?
A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.
May not be suitable if…
- You are pregnant and the area to be treated is over the abdomen or pelvis.
- You have a bleeding disorder or take anticoagulant (blood-thinning) medicines that cannot be safely managed.
- There is infection, a tumour, broken skin or poor blood supply over the treatment area.
- The target is over the lung, a major nerve or blood vessel, or another contraindicated site.
- You have not yet tried a proper loading and rehabilitation programme, which should usually come first.
Delay or rearrange if…
- You have an active infection or skin breakdown over the area.
- You might be pregnant and this has not been clarified.
- Your symptoms are undiagnosed or have red-flag features that have not been assessed.
- You have recently started a blood thinner or had a change in bleeding risk that needs review.
- You are in a severe acute flare where settling it first is more sensible.
Alternatives to discuss
- A progressive loading and rehabilitation programme, which is the mainstay for most tendinopathy and plantar fasciitis.
- Activity and load management, footwear changes or orthotics for heel problems.
- Other adjuncts such as injections, with their own mixed or limited evidence, discussed on their merits.
- Watchful waiting, as many of these conditions improve with time and rehabilitation.
- Specialist or surgical opinion if a sustained programme has not worked.
Before you decide
Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.
What matters most to me?
Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.
What are all my options?
Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.
What would make me pause?
Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.
What happens if I do nothing today?
For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.
Benefits
- Non-invasive, with no cuts, needles, anaesthetic or recovery downtime
- Can be tried for stubborn problems that have not settled with rehabilitation alone
- May reduce pain and improve function in some people, particularly with conditions such as plantar fasciitis
- Avoids the risks of surgery or injections in those who want to try a non-invasive option first
- Can be combined with a loading programme rather than replacing it
Risks & complications
- Pain or discomfort during the treatment itself
- Reddening of the skin over the treated area
- Mild bruising or swelling afterwards
- A short-term increase in soreness for a day or two
- Tingling, numbness or temporary nerve irritation in the area
- Small skin marks or petechiae (tiny bruises)
- No useful benefit at all, given the inconsistent evidence
- Larger haematoma (collection of blood), particularly in people with bleeding problems or on blood thinners
- Damage to nearby structures if applied over the wrong area (which is why some sites and pregnancy are contraindications)
ESWT is generally low-risk, but its main limitation is uncertain benefit rather than danger: NICE found the evidence on how well it works inconsistent. It should be avoided in pregnancy (over the abdomen or pelvis), in people with bleeding disorders or on anticoagulants, and over infection, tumours, certain nerves or the lungs. Ask the clinician why they are recommending it for your specific problem and what the plan is if it does not help.
Published figures to discuss
Reported benefit from ESWT varies widely between studies, conditions and devices, and NICE concluded the evidence on efficacy is inconsistent. Success therefore cannot be expressed as a reliable single figure. Serious complications are uncommon when it is used appropriately, but minor effects such as pain during treatment and bruising are expected rather than rare.
| Figure | Reported range | How to interpret it | Source / confidence |
|---|---|---|---|
| Pain during treatment | Common | Discomfort is expected and intensity should be adjusted so treatment is tolerable. | Guide sourcesClinical context |
| Bruising, swelling or temporary symptom flare | Common to uncommon | Usually settles over days; aftercare should explain load modification. | Guide sourcesClinical context |
| Benefit uncertain | Condition- and protocol-dependent | NICE has described efficacy evidence as inconsistent for several tendinopathy indications, so guaranteed results are a red flag. | NICE — ESWT for refractory plantar fasciitis (IPG311)nice.org.ukSource-linked context |
| Contraindication missed | Avoidable | Pregnancy, tumour, infection, nerve/vessel targets, bleeding risk and some implants or growth plates need careful screening. | Extracorporeal shock wave therapy: an update — PubMedpubmed.ncbi.nlm.nih.govSource-linked context |
These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.
What happens afterwards
There is usually no recovery period: most people return to normal activity straight after a session, sometimes with mild soreness for a day or two. 'Afterwards' is mainly about continuing your rehabilitation and seeing whether benefit builds over the following weeks.
- Mild soreness, redness or tenderness over the treated area for a day or two
- A short-term flare of the original pain after a session
- No immediate change in symptoms — any benefit usually builds over weeks
- Being able to carry on with normal daily activities
- Continuing your exercise programme alongside treatment
Aftercare
- Continue your loading and rehabilitation exercises as advised — ESWT is an adjunct to these.
- Use simple pain relief such as topical anti-inflammatory gel or paracetamol if you have soreness afterwards.
- Avoid pushing into heavy or aggravating activity straight after a session.
- Attend the planned sessions in the course and the review appointment.
- Tell your clinician if you have more than mild or short-lived side effects.
- Be honest with yourself and your clinician at review about whether it is actually helping.
- A clear plan of how many sessions are in the course
- Your loading exercise programme to continue alongside
- Simple pain relief to hand if needed
- A review date to judge whether it has helped
- A note of which activities to ease off briefly after each session
- Contact details for questions or concerns
- An agreed plan B if it does not help
⚠ Get urgent help if…
- A large, spreading or rapidly increasing bruise or swelling after treatment
- Spreading redness, heat, fever or feeling unwell
- Sudden severe pain, a snap or weakness in the tendon — seek urgent assessment for possible rupture
- New numbness, tingling or weakness that does not quickly settle
- Skin breakdown, blistering or a wound over the treated area
- Any symptom that is severe or clearly out of proportion to a mild treatment
Who to contact: your clinician, clinic or test provider first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.
General guidance — it doesn't replace the specific advice your specialist gives you.
Results & realistic expectations
A good result is reduced pain and improved function, usually building over the weeks after a course and alongside a rehabilitation programme. Because the evidence is inconsistent, some people benefit and some do not, and ESWT cannot be promised to cure a tendon or heel problem.
If it has not helped after a properly delivered course, repeating it indefinitely is not the answer — the sensible step is to review the diagnosis and the overall plan.
Where ESWT helps, the benefit is variable and not guaranteed to be permanent, and symptoms can return, particularly if the underlying overload is not addressed. Maintaining a loading programme and sensible activity levels gives the best chance of lasting improvement.
Related tests, treatments or support
ESWT is typically combined with a progressive loading and rehabilitation programme, which remains the mainstay. It should not be presented as a stand-alone fix. Your clinician should explain how it fits with your exercises and any other treatment you are having.
Follow-up & long-term care
You should have a planned review after the course to judge, honestly, whether it has helped alongside your rehabilitation. If it has, you continue your maintenance exercises; if not, the clinician should revisit the diagnosis and discuss other options rather than simply repeat the course. NICE recommends that clinicians audit and review the outcomes of patients having ESWT.
- Keep up your loading and strengthening exercises after the course.
- Increase activity gradually rather than in sudden jumps.
- Return for review rather than assuming repeated courses are the answer if symptoms persist.
- Address contributing factors such as footwear, technique or training load.
Repeat, follow-on and what comes next
- If a course does not help, the answer is usually to review the diagnosis and overall plan rather than simply repeat it.
- Some clinicians offer a second course, but this should follow an honest review of whether the first helped.
- Persistent symptoms despite ESWT and rehabilitation may prompt specialist or surgical referral.
- Repeated, open-ended paid courses without clear benefit are a red flag, not normal care.
Ask what happens if the result is unclear or needs repeating, and what is included if further tests or follow-up are needed.
What good aftercare looks like
- A clear plan combining ESWT with a loading and rehabilitation programme.
- A defined number of sessions and an honest review of benefit afterwards.
- A named contact for questions or side effects.
- Auditing of outcomes, as NICE recommends.
- A sensible threshold to stop and reconsider, including specialist referral, if it is not helping.
What affects the cost
Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:
- Whether you are charged per session or for a whole course
- The number of sessions recommended
- Whether a specialist or physiotherapist delivers it, and the type of device used
- Whether an assessment and any imaging are included or charged separately
- Follow-up and review appointments
- Whether rehabilitation (physiotherapy) is bundled or extra
- The cost per session and the total cost of the planned course
- Exactly how many sessions are included
- Whether the initial assessment and any imaging are included
- Whether rehabilitation/physiotherapy is part of the package
- What follow-up or review is included
- The cancellation policy
- What happens, and what it costs, if the course does not help
On the NHS? ESWT is available in some NHS services with special arrangements for governance, consent and audit, reflecting uncertain evidence; many people access it privately for speed or choice.
You're entitled to your total cost in writing — including reports, follow-up and what happens if the result is inconclusive — before you decide.
Consent traps and marketing red flags
These are not small details. They are often where patients lose choice, time to reflect, or realistic expectations.
Consent traps
- Not being told that the evidence on whether ESWT works is mixed and inconsistent.
- ESWT presented as a cure rather than an adjunct to rehabilitation.
- No discussion of contraindications such as pregnancy, bleeding disorders or anticoagulants.
- Being committed to a long, expensive course with no built-in review.
- No agreed plan for what happens if it does not help.
Marketing red flags
- Claims that shockwave therapy 'cures' or 'heals' tendons as a certainty.
- Selling long, costly courses without reviewing whether earlier sessions helped.
- Downplaying or skipping rehabilitation in favour of the machine.
- Not mentioning that the evidence is uncertain or that NICE advises special arrangements.
- Failing to ask about pregnancy or bleeding risk before treatment.
Choosing a specialist safely
- Check the specialist is on the GMC Specialist Register for this area.
- Make sure they work at a CQC-registered service, and look for membership of the relevant Royal College or professional body.
- You're entitled to time to consider and to have your questions answered before you agree — the specialist who looks after you should explain it, not a salesperson.
- Be wary of pressure: time-limited offers or deposits taken before you've had time to think are red flags, not bargains.
- You're entitled to your total cost in writing — including any follow-up — before you decide.
Questions to ask your medical professional
Take this to your consultation. A good specialist will welcome every one of these.
- Why are you recommending shockwave for my specific problem, and what is the evidence?
- How many sessions are planned, and how will we judge whether it is working?
- Is this focused or radial shockwave, and does that matter for me?
- How does this fit alongside my rehabilitation programme?
- What are the side effects, and are there reasons I should not have it?
- What is the plan if it does not help — and will you stop rather than keep repeating it?
- Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
- Will you be the specialist who carries out my treatment, and who looks after me afterwards?
- What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
- What does a realistic result look like — and what can this treatment not achieve?
- What are my options, including waiting, doing nothing for now, or choosing a different approach?
- Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
- What is the total cost in writing, including any follow-ups, and how much time do I have to decide?
Frequently asked questions
Does shockwave therapy actually work?
Does it hurt?
How many sessions will I need?
Can I get ESWT on the NHS?
Is it safe?
Should I keep doing my exercises while having shockwave?
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How we made this page
Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →
Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.
Sources & standards: NICE — ESWT for refractory plantar fasciitis (IPG311) NICE HTG426 — ESWT for refractory tendinopathies (replaces IPG312) NICE — ESWT for refractory tennis elbow (IPG313) Versus Arthritis — Achilles tendinopathy Extracorporeal shock wave therapy: an update — PubMed NHS — Tennis elbow
Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.
Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.
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