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Jul 20, 2022

Shockwave for Achilles Tendon injuries: What is the Evidence?

What is Achilles Tendonitis/Tendinopathy?

The Achilles tendon connects the calf muscle to the heel bone and is the largest tendon in our body. This tendon controls lower leg movement when you walk, run, jump and stand up on your tip toes. Achilles tendonitis is a common condition that occurs when this tendon becomes irritated or inflamed after overuse from high impact activities such as running and jumping.

We often hear the different terms “tendonitis” and “tendinopathy” associated with Achilles tendonitis. “Tendonitis” is an acute inflammation of a tendon, which is the body's natural response to injury. “Tendinopathy” is a term used to describe a condition in which the tendon develops microscopic degeneration as a result of chronic damage over time. There are also two types of Achilles tendonitis based on which part of the tendon is inflamed – mid-substance vs. insertional.

How are chronic Achilles Tendon injuries treated?

In most cases of Achilles tendinitis, nonsurgical treatment options will provide adequate pain relief, although it may take a few months for symptoms to completely subside.

Nonsurgical treatment includes:

  • RICE
  • Activity modification
  • NSAIDs
  • Orthotics/shoe inserts
  • Physical therapy/stretching
  • Shockwave therapy

Minimally invasive Injections:

  • Cortisone injections
  • Platelet rich plasma (PRP) injections
  • Percutaneous needle tenotomy procedures/Tenex

When these invasive treatment options fail after at least 6 months, surgical options can be considered. Surgical options include one or any combination of the following:

  • open debridement (removal of damaged tissue)
  • tendon transfer
  • gastrocnemius recession
  • endoscopically assisted debridement

The type of surgery that will be recommended will depend on the location and amount of damage to the tendon.

What is Shockwave Therapy?

Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment cleared by the FDA that uses a unique set of pressure waves to stimulate the metabolism, enhance blood circulation and accelerate the healing process. The research suggests that ESWT stimulates of the wound healing cascade by introducing microtrauma to the affected area. This allows chronic damage to become acute damage and initiate the normal wound healing process by application of high intensity pressure waves into the body.

What does the evidence show?

Recent studies have shown improvement in pain and function with ESWT, especially when combined with other nonsurgical treatments such as eccentric exercises.

Rompe et. al. (2008 and 2009)

Rompe and his colleagues completed 2 randomized controlled trials in 2008 and 2009 that demonstrated the effectiveness of combining repetitive low-energy shockwave therapy with eccentric loading of the Achilles tendon in both insertional and mid-substance tendinopathy patients.

Mani-Babu et. al. (2015)

A systematic review and meta-analysis were performed in 2015 evaluating the evidence on ESWT on lower limb tendinopathies, including patellar tendinopathy (PT), Achilles tendinopathy (AT), and greater trochanteric pain syndrome (GTPS). They found that moderate evidence indicates that ESWT is more effective than eccentric loading for insertional AT and equal to eccentric loading for mid-substance AT in the short term.


  1. Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Am J Sports Med. 2015 Mar;43(3):752-61.
  2. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009 Mar;37(3):463-70.

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