Chapter 2: What is Extracorporeal Shockwave Therapy (ESWT)? A complete patient guide

Extracorporeal Shockwave Therapy (ESWT) is one of the most researched non-surgical treatments used in musculoskeletal physiotherapy for certain long-standing tendon conditions. It has become increasingly common in physiotherapy, sports medicine and orthopaedics because it offers a non-invasive option for people whose symptoms have not improved sufficiently with an appropriate rehabilitation programme.

The name can sound intimidating. Many patients imagine "electric shocks" or assume it is similar to ultrasound, laser therapy or injections. In reality, none of these are true.

ESWT uses mechanical acoustic waves (pressure waves) that are delivered through the skin into the affected tissue. These waves are not electrical and do not involve radiation.

The aim is not to mask pain temporarily but to support the body's response to long-standing tendon problems while rehabilitation exercises address the underlying causes.

What does "Extracorporeal Shockwave Therapy" mean?

Extracorporeal simply means outside the body. The treatment is delivered through the skin using a handheld applicator. No needles or incisions are required.

Shockwave describes a high-energy acoustic pressure wave. Although the word "shock" sounds dramatic, the treatment is carefully controlled by your clinician. Different settings allow the energy delivered to be adjusted according to your diagnosis, the tissue being treated, your comfort and your rehabilitation goals.

Therapy means the treatment is used to support recovery. It is not intended to replace exercise rehabilitation, education or a comprehensive assessment.

A simple analogy

Imagine dropping a pebble into a pond. The impact creates ripples that spread out from the centre. Shockwave therapy creates a controlled mechanical wave that travels into the target tissue.

Unlike ultrasound, which uses continuous sound energy to create gentle vibrations, ESWT delivers short, powerful pulses over a very brief period.

How is ESWT different from other treatments?

Treatment	Primary purpose
Exercise rehabilitation	Improve strength, load tolerance and function
Sports massage	May help relieve muscle tension and improve comfort
Manual therapy	Can improve movement and reduce symptoms for some conditions
Corticosteroid injection	May reduce pain in selected situations but is not appropriate for every tendon condition
Surgery	Considered for some patients when appropriate non-surgical care has not been successful
Shockwave therapy	May support rehabilitation in some persistent tendon conditions when combined with exercise

No single treatment is suitable for everyone. A thorough assessment helps determine which options are most appropriate.

Radial vs focused shockwave therapy

There are two main forms of ESWT.

Radial shockwave therapy (RSWT) generates pressure waves that spread outward from the treatment head. It is commonly used in physiotherapy clinics for a range of tendon and soft tissue conditions. Characteristics include a broader treatment area, generally lower peak energy, suitability for many superficial tissues and wide use in clinical practice.

Focused shockwave therapy (FSWT) concentrates energy at a chosen depth. It is often used in specialist centres and may be selected for particular clinical situations. Characteristics include more targeted energy delivery, deeper penetration and a different method of wave generation.

Both systems are used in healthcare. The choice depends on the equipment available, the condition being treated and the clinician's judgement.

How does the equipment work?

A typical ESWT machine includes the main control unit, a handheld applicator, interchangeable treatment heads, adjustable energy settings and adjustable pulse frequency.

A coupling gel is applied to the skin to help transmit the acoustic waves efficiently. Your physiotherapist positions the applicator over the affected area and delivers a series of pulses.

What does treatment feel like?

Patients often ask: "Will it hurt?" The honest answer is that it can be uncomfortable, but it should usually be tolerable. The sensation varies depending on the condition, how sensitive the area is, the treatment settings and individual pain sensitivity.

People commonly describe it as rapid tapping, firm pressure, repeated pulses, or mild to moderate discomfort. Your clinician can often adjust the settings if needed.

How long does treatment take?

The treatment itself is usually brief. Many appointments include discussion of symptoms, reassessment, rehabilitation review, exercise progression and ESWT treatment where appropriate.

The shockwave application itself often lasts only a few minutes, while the full appointment is longer because rehabilitation remains the central part of care.

Is ESWT safe?

When delivered by appropriately trained healthcare professionals after assessment, ESWT has a well-established safety profile. Common temporary effects may include soreness, redness, mild swelling, a temporary increase in symptoms and tenderness for a short period. These effects usually settle without further treatment.

Is it a cure?

This is probably the biggest misconception. ESWT is not a miracle cure. It does not instantly repair tendons, eliminate the need for exercise, guarantee success or work for every diagnosis.

Instead, it may help support recovery for selected persistent tendon conditions as part of a broader rehabilitation programme.

Why isn't everyone offered ESWT?

Not every painful tendon needs shockwave therapy. Many patients improve with education, progressive strengthening, activity modification, load management and time.

ESWT is generally considered when symptoms have persisted despite appropriate conservative management or when the clinician believes it may be a suitable addition to rehabilitation.

What happens before treatment?

A responsible clinician should never simply begin ESWT without first carrying out an assessment. This should include a detailed history, examination, confirmation of the diagnosis, discussion of treatment options, explanation of expected benefits and limitations, and consideration of factors that might make ESWT unsuitable.

This ensures treatment is tailored to the individual rather than applied routinely.

Common myths

"Shockwave is electric." False. It uses mechanical acoustic pressure waves.

"It breaks scar tissue." This is an oversimplification. ESWT influences biological processes, but it should not be thought of as physically "breaking up" scar tissue.

"One session fixes everything." No. Most rehabilitation programmes involve multiple sessions combined with exercise and gradual progression.

"If it hurts more during treatment, it works better." There is no simple relationship between treatment discomfort and outcome. Your clinician should aim for an appropriate balance between therapeutic settings and your comfort.

Key takeaways

• ESWT uses acoustic pressure waves – not electricity.
• It is non-invasive and does not require surgery or injections.
• Radial and focused shockwave systems work differently but both are used in clinical practice.
• Treatment is usually combined with exercise rehabilitation, not used on its own.
• Some discomfort during treatment is common, but it should generally be manageable.
• ESWT may be appropriate for selected persistent tendon conditions following a professional assessment.
• It is one component of an evidence-informed rehabilitation programme rather than a standalone cure.