Shockwave therapy for tendinopathy: useful in some tendons, not in patellar tendinopathy

Design

Systematic review and network meta-analysis of randomised trials with GRADE assessment

Population

65 publications, 3,921 participants with five types of tendinopathy

Primary outcome

Pain and function with extracorporeal shockwave therapy versus placebo and other conservative treatments

Effect

Pain versus placebo: lateral epicondylitis SMD -0.53 (-0.76 to -0.30); patellar tendinopathy -0.15 (-0.42 to 0.12)

A network meta-analysis pooled 65 publications from 2002 to 2024 with 3,921 participants across five tendinopathies: lateral epicondylitis, rotator cuff tendinopathy, Achilles tendinopathy, greater trochanteric pain syndrome and patellar tendinopathy. It compared extracorporeal shockwave therapy with placebo and other conservative treatments.

Against placebo, shockwave reduced pain in lateral epicondylitis (standardised mean difference -0.53, 95% CI -0.76 to -0.30), Achilles tendinopathy (-0.49, -0.83 to -0.16) and rotator cuff tendinopathy (-1.25, -1.61 to -0.89, though with I-squared of 89%). In patellar tendinopathy it did not clearly differ from placebo (-0.15, -0.42 to 0.12).

In rankings against other conservative options, shockwave placed second in several comparisons without significant differences from the leading treatment. The authors describe the evidence as limited, and heterogeneity was high for some comparisons. Exercise-based care remains the foundation for most tendinopathies.

• Shockwave beat placebo for pain in lateral epicondylitis, Achilles and rotator cuff tendinopathy.
• It showed no significant advantage over placebo in patellar tendinopathy.
• Rotator cuff results were highly heterogeneous (I-squared 89%).
• It often ranked second among conservative options, not clearly first.
• Use it alongside, not instead of, loading and exercise programmes.

Why it matters

It sorts a treatment often offered for all tendons into where it appears to help and where it does not.

Don't overread it

The authors describe the evidence as limited, trials varied in protocol and quality, and rankings among treatments were mostly not significantly different.

The statistics, in plain English

A standardised mean difference of -0.5 is a moderate effect on pain; -0.15 with an interval crossing zero is no clear effect. I-squared of 89% means the trials disagreed a lot, so the pooled rotator cuff number is shaky. A network meta-analysis ranks treatments indirectly, and rankings can mislead when differences are not significant.

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