Here’s what the world’s leading experts want you to know about ESWT treatment.
If you’ve ever dealt with the frustrating, persistent pain of conditions like plantar fasciitis or tennis elbow, you know how disruptive it can be. In the search for relief, many people seek Extracorporeal Shockwave Therapy (ESWT) treatment (also known as shockwave therapy) as an option.
A 2025 Delphi study published in the British Journal of Sports Medicine brought together 41 international experts in sports medicine, orthopedics, and physical therapy, all with at least 5 years of practice experience, to build a consensus on how, when, and why ESWT treatment should be used.
In the study, questions were emailed, responses were summarized, and questions were asked again to gather and refine their opinions.
After multiple rounds of voting via email, they established a clear set of best practices for ESWT treatment.
A threshold of 75% agreement or disagreement was used as consensus.
The study established clear consensus on several key aspects of treatment application for both tendon and bone conditions.
One of the first things the experts agreed on is that the general term ESWT is imprecise. They strongly recommend that clinicians and researchers stop using it as a catch-all term and instead be specific, because there are two distinct forms of therapy.
Focused shockwave therapy: This method generates true sound waves that can penetrate and treat deeper structures in the body. The expert panel proposes reserving the term "ESWT" specifically for this type of treatment.
Radial shockwave therapy: This method produces pressure waves that don't penetrate as deeply and primarily affect superficial tissues. The experts note this is more accurately called "radial pressure wave therapy."
Tendinopathies and Fasciopathies
Consensus was reached for the use of these therapies in the following conditions, with the first four achieving 100% agreement among the expert panel:
Bone Pathologies
A consensus was reached on the appropriateness of ESWT treatment for several bone-related pathologies, particularly in cases of delayed healing where it may help expedite recovery.
The following indications were agreed upon:
The experts added a crucial clarification: they support this therapy as an adjunctive treatment—meaning ESWT should be used as part of a larger, multimodal approach that includes things like physical therapy exercises, not as a standalone cure.
If you're undergoing shockwave therapy, your instinct might be to reach for a common pain reliever like ibuprofen to manage discomfort. However, the expert panel came to a clear consensus on this point: non-steroidal anti-inflammatory drugs (NSAIDs Advil, Aleve..) should be avoided throughout the entire course of shockwave treatments.
The core principle of shockwave therapy is to create a controlled, micro-inflammatory response that triggers your body's natural healing cascade. NSAIDs, by design, suppress this very inflammation, effectively working against the treatment and undermining its potential to promote long-term tissue repair.
For pain management during the treatment period, the experts agreed that acetaminophen or other non-NSAID medications are acceptable alternatives.
They also agreed that fluoroquinolone antibiotics should be avoided to reduce any potential risk of tendon rupture.
Many people wonder what shockwave therapy actually feels like. The expert consensus provides a clear set of expectations. A typical treatment course involves 3 to 5 sessions, usually spaced one to two weeks apart. Each procedure should begin at a low energy level that is easily tolerated and then be gradually increased to a therapeutic level based on the patient's real-time feedback.
To make this objective, the experts proposed specific pain thresholds. During the procedure, your pain level should not exceed a 6 out of 10 for tendon conditions or a 7 out of 10 for bone conditions. This controlled level of discomfort is considered part of the therapeutic process.
Crucially, the panel also agreed that local anesthesia is not recommended during treatment. By avoiding anesthesia, you become an active partner in your own treatment. Your real-time feedback ensures the therapist targets the precise source of your pain and uses an energy level that is therapeutic without being harmful.
When treating tendon and fascia conditions, how should the clinician know exactly where to apply therapy? While you might expect them to rely on an ultrasound or MRI image, the experts recommended a different approach: "clinical focusing."
Clinical focusing is simple: the treatment should be applied directly over the areas of maximal pain as reported by you. The panel explicitly recommended this client-guided method over using imaging to pinpoint the treatment area for these specific issues.
This highlights the vital importance of your own experience and feedback in guiding the therapy. For tendon and fascia conditions, where you feel the pain is the most reliable map for successful treatment.
Managing activity and mechanical loading of the treated area is a key post-procedural consideration. An advantage of ESWT treatment is it allows for activities as tolerated, which is appealing for those who want minimal downtime.
There are no range of motion restrictions necessary following treatment for tendinopathies or fasciopathies.
There are no weight-bearing precautions required when treating low-grade partial tendon tears.
The use of ESWT treatment does not require additional activity restrictions beyond the best practices already established for managing the underlying injury.
The expert panel reached a strong consensus on two absolute contraindications for therapy:
Other possible contraindications as noted by the International Society for Medical Shockwave Treatment can include difficulty forming blood clots, pacemakers, and pregnancy in the area of treatment.
The expert panel reached consensus on the following common and generally mild side effects associated with both focused and radial therapies:
These guidelines establish a framework for standardizing the clinical application of focused shockwave and radial pressure wave therapies in musculoskeletal injuries. By establishing clear recommendations these aim to reduce variability, enhance treatment efficacy, and improve outcomes.
At Stretch Affect, our physical therapists are highly trained in getting you back to moving better. If you are in the San Diego area and are looking for ESWT treatment in a safe environment with people who will guide you on best practices, reach out to us, we are ready to help.
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