Benefits of Shock Wave Therapy to Treat Achilles Tendinopathy


The Achilles tendon plays a key role in all types of physical activity, including walking and running gait, jumping and landing, and a broad range of sports movements. Acute and overuse injuries to the Achilles tendon can severely restrict your ability to move about and participate in sports. One treatment showing promise for accelerated healing of Achilles tendinopathy is extracorporeal shock wave therapy (ESWT).

What is ESWT?

Extracorporeal shock wave therapy was first invented in Germany as a tool for breaking up kidney stones. However, doctors soon discovered that ESWT could be an effective method for treating injured soft tissues like muscles and tendons. Shock wave therapy is a non-invasive and relatively painless method for treating tendinopathy, with extensive research to vouch for its efficacy. The procedure is quick and simple, with a track record of successful results.


ESWT is useful for treating the following conditions:

  • Pain stemming from myofascial trigger points
  • Hamstring injuries
  • Achilles tendon injuries
  • Plantar fasciitis
  • Tennis elbow
  • Shoulder tendinopathy

Two Types of Shock Waves


ESWT uses two types of shock waves. Radial shock waves are not true shock waves, but rather radial pressure waves that are generally too shallow and dispersed to penetrate deep tissues. Radial shock wave therapy is often not effective for treating tendon tissues that lie close to the bone (proximal tendinopathy).

Focused shock waves are able to penetrate up to 7 cm into the body, with focused energy that allows for precise soft tissue treatment. When used in conjunction with ultrasound guidance, focused shock waves can precisely target damaged tissues without impacting surrounding structures.

How ESWT Stimulates Tendon Healing


Tendon tissue has less blood supply than muscle, slowing the healing process for ruptured or damaged tendons. Shock wave therapy provides a wave of energy that penetrates tendons on the molecular, cellular, and tissue levels.

Focused ESWT evokes a reaction called neovascular regenesis, which is the growth of new blood vessels, in areas of the tendon that have little or no blood supply. Increased vascularity means that more oxygen and nutrients can be delivered to tendon cells, accelerating the healing process.

How ESWT Stimulates Tendon Healing


In addition to guiding the ESWT process, high resolution ultrasonography offers capabilities for superior microvascular imaging (SMI) and sonoelastography. SMI can reveal vascular activity in the target tissue that indicates where inflammatory activity exists, and where healing has begun. Elastography measures tissue density and elasticity, which helps gauge the effectiveness of EWST treatment.

Mechanisms of Focused ESWT

Despite evidence that focused shockwave therapy is effective for promoting tendon healing, its precise mechanisms of action remain a mystery. Scientists have proposed four possible phases of action:

  • Physical phase: In this phase, the shockwave causes positive pressure that transmits energy to tissues and cells.
  • Physiochemical phase: In this phase of ESWT, cells are stimulated to release biomolecules like adenosine triphosphate (ATP), which activates cell signaling pathways.
  • Chemical phase: During the chemical phase, shockwaves alter ion channels in the cell membrane and mobilize calcium within the cells.
  • Biological phase: In the final phase, ESWT modulates biological processes, including angiogenesis, vascular endothelial growth factor, nitric oxide synthase in the endothelia, and proliferating cell nuclear antigen (PCNA). It has anti-inflammatory effects that promote soft tissue and bone healing, and increase the production of insulin-like growth factor [IGF]-1.

ESWT stimulates new functional proteins that induce the following effects:

  • Chondroprotective effect (prevents joint space narrowing)
  • Neovascularization (stimulates new blood vessels)
  • Anti-inflammation (reduces local swelling)
  • Anti-apoptosis (prevents cell death)
  • Regeneration of nerves and tissue

Indications for ESWT

Shock wave therapy is often used in conjunction with other therapies, or as a last resort when other treatment measures have failed to promote healing. The International Society for Medical Shockwave Treatment has provided guidelines for ESWT use.

Clinical indications for ESWT include:

  • Calcifying and non-calcifying shoulder tendinopathy
  • Lateral epicondyle tendinopathy (tennis elbow)
  • Patellar tendinopathy
  • Greater trochanter pain syndrome
  • Achilles tendinopathy
  • Bone nonunion after a fracture

Shock wave therapy is not recommended for conditions that involve lung tissue, malignant tumors, epiphyseal (growth) plates, brain or spinal regions, or during pregnancy.

ESWT Achilles Tendon Treatment

Achilles tendinopathy can be subcategorized into insertional and non-insertional tendinopathy. Insertional tendinopathy occurs close to the bone, where the tendon attaches muscle to bone. Non-insertional tendinopathy affects tissues in the middle portion of the tendon.

Popular treatment methods for Achilles tendinopathy include:

  • Eccentric loading exercises
  • Physical therapy
  • Injections of steroids and platelet-rich plasma (PRP)
  • Pain medications
  • Heel lifts

Of those, eccentric loading and physical therapy are standard protocols for treating athletes with Achilles tendinopathy. Multiple studies have been conducted to gauge the efficacy of ESWT for treating Achilles tendinopathy. While results are varied, the general consensus is that ESWT is an effective treatment for both insertional and noninsertional Achilles tendinopathy when other conservative treatment options have failed, especially when combined with eccentric loading.


The clinical director at NYDNRehab, Dr. Lev Kalika, is an expert in ultrasound guided shock wave therapy. He has published multiple peer-reviewed papers on the subject and successfully treated hundreds of patients.

The NYDNRehab clinic in Manhattan features some of the most advanced medical technologies for tendinopathy treatment, rarely found in private clinics, including:

  • High resolution diagnostic ultrasonography
  • Superior microvascular imaging (SMI)
  • Sonoelastography
  • Radial and focused ESWT
  • Injection therapies
  • Kineo intelligent load system for eccentric loading
  • Proteus motion system for 3D training
  • DD Robotech for AI enhanced performance feedback
  • C.A.R.E.N. (computer assisted rehab environment) for enhanced analysis, training and feedback

For accelerated healing and successful return to sports, contact NYDNRehab today. We offer physical therapy and chiropractic care, along with TeleHealth services so you can receive treatment on the go. Get the best treatment available in NYC at NYDNRehab in Manhattan.


Moya, Daniel, et al. “The role of extracorporeal shockwave treatment in musculoskeletal disorders.” JBJS 100.3 (2018): 251-263.

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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