First used to smash kidney stones, acoustic waves (called shock waves) are having a moment— healing everything from sports injuries to Alzheimer’s disease. Cate Montana investigates
It sounds, well . . . shocking. Invasive. Even traumatic. But it’s none of that. Extracorporeal shock wave therapy (ESWT), as it’s formally known, is a noninvasive therapy first employed in the 1980s to dissolve kidney stones.
At that point it was called shock wave lithotripsy. After that, for many years ESWT was used only in orthopedics to treat musculoskeletal issues like frozen shoulder, bone fractures and plantar fasciitis.
But since the early 1990s, its uses have expanded. Today it’s found to be effective in an ever-growing number of areas, including sports medicine, pain management and rehabilitation, urology, aesthetic medicine, neurology, cardiology, wound healing and veterinary medicine.
Despite its name, a shock wave is a sound wave created by a pressure wave traveling through a medium like air or water. Sound waves are measured in hertz (Hz), the number of full cycles of amplitude (the height of their peaking waves) of each wave each second, and those in the range of 20–20,000 Hz are within our capacity to hear.
The sound waves used in shock wave therapy have high frequencies, 150,000–100 million Hz (150 kHz to 100 MHz). But the equipment creating these acoustic waves uses high-energy pulses of either electromagnetic energy or compressed air at low frequencies per second that nevertheless propel the sound waves as far as 5 inches into the body.
The result is brief and rapid acoustic (sound) waves that carry energy through bone and tissue, experienced as a rapid and rhythmic tapping and providing mechanical and biochemical stimulation.
The acoustic pressure waves created by shock wave therapy devices stimulate the transmission and absorption of energy in the cells and promote microcirculation and cell wall permeability. They fire up the production of biochemicals like adenosine triphosphate (ATP), the body’s energy storage and transport molecule. As well, they kick-start vascular growth, mitigate inflammation, and assist in bone and soft tissue healing.1
There are two major kinds of shock wave therapy: focused shock wave therapy (FSWT) and radial shock wave therapy (RSWT). Both are sound waves administered using handheld devices with applicator tips that are applied to the skin. A “coupling gel” specially formulated for shock wave therapy treatments is also used to help transmit the sound energy from the applicator to the body tissue.
Focused shock wave therapy is generated in water, and its sound waves are created in three different ways:
The advantage of focused shock wave therapy is that it can generate a pressure field focused in a tight location, penetrating nearly 5 in. (12 cm) into bone and tissues.
Radial shock wave therapy does not use waves generated in water, however. Instead it uses compressed air to accelerate a projectile at 80–90 kph (50–56 mph) through a guiding tube until it hits an applicator. The pressure wave generated by this forceful movement is then directed into the body in an effect similar to that of Newton’s cradle, the famous physics device consisting of a series of metal balls suspended on strings.
A radial pressure wave has a longer pulse length and is technically not a shock wave, which is why it can’t be focused. But it’s still referred to as a type of shock wave therapy.
Unlike focused shock waves, radial pressure waves generate most of their energy at the applicator point and radiate outward with diminishing energy. As a result, they affect a greater area while penetrating tissue to a much shallower average depth of 1–2 in. (3–5 cm).
All the physicians I interviewed say the most effective healing approach is to use both focused and radial therapies for many, if not most, conditions. However, there are obvious applications better suited to each method.
“Radial shock waves are more effective for more superficial conditions, such as muscle strains, shin splints, tennis elbow, Achilles tendinitis, adhesions and trigger points,” says Dr Amol Saxena, a sports medicine and foot and ankle surgical specialist in Palo Alto, California (amolsaxena.com). “It’s also excellent for augmenting other types of shock wave treatments.”
On the other hand, focused shock wave treatments go deep, increasing blood supply to non-healing bones and treating stress fractures, joint and knee arthritis, tendinopathies, groin pain and chronic pelvic pain.
“It took shock wave for me to appreciate true sports medicine,” says Dr Brice Blatz, a family and sports medicine specialist in Lake Oswego, Oregon (maplemedicalpdx.com). “That’s because true sports medicine has to do with the entire kinetic chain, from the top of your head all the way down to your big toe, and how that alters the way athletes can perform or people can recover from injury.
“For example, I haven’t met a person with knee arthritis who doesn’t have dysfunctional quads. So, sure, I can give a shot of platelet-rich plasma (PRP) into your knee, and that gets up to 70 percent of people feeling better for about a year.
“But to actually fix the issue, I need to address the whole kinetic chain, including the joints above and below. There needs to be a mechanical change at the cellular and extracellular matrix level to make them communicate and to make the tissue change. And the only thing that can do that is shock wave.”
Although thousands of studies have been conducted on ESWT over the past three decades, resulting in extensive insight into its physiological actions, its overall mechanics are still far from completely understood.
Blatz, who founded the American Society for Medical Shockwave Treatment, speculates that the effectiveness of ESWT is largely due to improved cellular communication and cellular changes it creates in the myofascial chain, particularly in the tissue surrounding joints and muscles.
“What we think is happening is mechano-transduction,” Blatz says. “We believe the waves are actually moving the extracellular matrix in which the cells swim. That opens up different channels on the cellular surfaces, which makes cells communicate differently, stimulating cell differentiation and proliferation.
“It’s also stimulating degenerative cells to essentially clear them out. Then it gets those local cells to communicate differently and facilitate regrowth and repair.”
Bones. Clinical studies show ESWT is associated with improvements in bone mineral density and bone microarchitecture.2 As a result, it can help treat osteoporosis, especially in postmenopausal women.3 As well, it aids healing of acute and even delayed non-union fractures.4
Joints. ESWT positively affects cartilage and bone alterations in patients suffering from knee arthritis while reducing chronic pain and limited range of motion.5 Patients with knee osteoarthritis who receive more or higher-energy shock waves experience “significantly greater” improvement than those receiving fewer and lower-energy treatments.
These patients are also getting better results than they do with physiotherapy or with PRP, corticosteroid or hyaluronic acid injections.6
Radial shock wave therapy improves grip strength, lessens pain and increases mobility in people suffering from tennis elbow (lateral epicondylitis)7 and relieves the pain of meniscus (knee cartilage) tears.8 Not surprisingly, ESWT can treat frozen shoulder,9 chronic low back pain10 and carpal tunnel syndrome.11
And that’s not all. Shock wave therapy is spreading its wings and being found effective in a surprising number of conditions that aren’t musculoskeletal in nature.
Teeth and gums. Dental applications range from increased antimicrobial function to better and more rapid bone regeneration for dental implants.12 Shock wave therapy has even been clinically proven to cure chronic gum disease in a “humanized rat model.”13
Wound healing. ESWT matches or exceeds the standard of care for treating wounds.14 It’s especially effective for diabetic foot ulcers. Even if the ulcer hasn’t healed in years, the therapy improves microcirculation, aiding its healing.15
Brain conditions. Between 2010 and 2013, 18 patients with Parkinson’s disease were treated with focused shock wave therapy six times in two weeks. Assessment using the Unified Parkinson’s Disease Rating Scale found their symptoms improved by over 50 percent.16
Clinical investigation using ESWT to treat Alzheimer’s patients also started in 2010, as did brain treatment of patients with “unresponsive wakefulness,” aka a vegetative state. Patients with Alzheimer’s treated with shock wave therapy—relabeled transcranial pulse stimulation (TPS)—experienced improvements in memory, speech and mood.17
Those in a vegetative state treated over several years with TPS improved by 135.9 percent on the German Coma Remission Scale and by 43.6 percent on the Glasgow Coma Scale.18 General “disorders of consciousness” resulting from brain injuries also respond well to TPS.19
Shock wave therapy, aka TPS, lifts depressive symptoms, especially in patients with more severe depression.20 As well, it is effective for reducing autism and ADHD symptoms.21
It also reduces pain and muscle hypertonia in multiple sclerosis patients with no side effects.22
Heart function. Cardiac function and coronary artery disease both improve with ESWT.23 It helps patients with ischemic heart disease to functionally improve by stimulating the regeneration of injured heart tissue and may relieve angina.24
Cancer. Clinical tests also show that ESWT reduces proliferation and promotes the death of colorectal cancer cells.25
One of the more novel uses of shock wave therapy is reducing pain and mobility issues in breast cancer survivors who have implants that get encapsulated. “Say you had a mastectomy and then the doctor used implants for reconstruction,” says Dr Brian Nathanson, a chiropractor in Norwalk, Connecticut (briannathansondc.com). “One or both implants sometimes get stuck to the chest wall.
“Also, the original breast skin used in reconstruction sometimes gets encapsulated around the base of the implant. It gets recalcified. When this happens, the reconstructed breast doesn’t feel normal and can even become disfigured.
“For example, I had one woman come in whose implant on one side was noticeably higher than the other. I used focused shock waves to trace around the encapsulations and loosen calcified tissue and scars impeding movement of the implant.”
Scar tissue. Speaking of scars, Nathanson says he had a 33-year-old woman with a chubby six-month-old baby boy come to his office complaining about “swimmer’s shoulder.” A competitive swimmer in college, she hadn’t been swimming in at least 12 years. But the pain and inflammation from that repetitive shoulder movement was back and worse than it had ever been, even in college.
During the exam, Nathanson says, it was obvious she had a severe shoulder impingement. But testing seemed to indicate it wasn’t the shoulder itself that was the issue.
“At that point she lifted up her shirt and showed me a huge scar running from her low back around to the front, between the ribs. Turns out she’d had a kidney removed when she was 21. Talk about a fascial insult!
“Suddenly it became obvious that constantly lifting and carrying around a baby of ever-increasing weight had irritated the massive amount of scar tissue on her back and ribs, affecting her shoulder. So I worked on that scar, and in about three treatments, her shoulder was fine. The scar remains to this day, but it’s no longer an issue.”
Who shouldn’t use shock wave therapy?
According to the International Society for Medical Shockwave Treatment, contraindications for the therapy are few. Basically, avoid use of either focused or radial shock wave treatments in these areas:
Potential side effects include redness, mild bruising and pain at the application site and nerve irritation.
The protocols for ESWT vary since every body and its symptoms are different. But most people respond positively after the first or second treatment and complete their treatment course within six sessions. The interval between treatments should be no less than four days.
Dr Amol Saxena takes a more minimalist approach, limiting treatment to three sessions, sometimes using two modalities at the same time. Then he pauses to allow the healing effects to continue and reassesses the patient at 12 weeks.
If the patient is not significantly better, Saxena may recommend another three treatments, but rarely more. “I reassess again after five treatments total,” he says. “Some people won’t respond to shock wave. It’s a pretty small number—perhaps 5–10 percent of the people I’ve treated. But it does happen.”
As you can tell from the many clinical studies cited in the main text of this article, shock wave therapy has a wide variety of applications, from shifting mood disorders to increasing cardiovascular health. But, in general, any of the following conditions can make you a good candidate:
The two case studies below feature young people, but practitioners insist that shock wave therapy works for people of all ages—especially older patients dealing with a lifetime’s accumulation of bumps, breaks, falls and sports injuries.
Dr Brian Nathanson recalls one woman, age 72, who had been an avid semi-pro athlete. She came to him, not surprisingly, with chronic knee and ankle pain as well as limited range of motion in both ankles and hips.
Over the years she’d had numerous ankle surgeries. She’d also had a thoracotomy, opening her chest cavity.
“There was a lot of atrophy and fibrosis around the ankles and knees,” he says. “And she needed to work on strength, mobility and balance. But after three shock wave treatments, her chief complaints had all been satisfactorily addressed.”
A competitive college rower, Addie struggled with a common rower’s complaint: rib pain.
It started as an occasional flare-up, but over the spring rowing season, the pain became constant. “I was in so much pain, just from even moving,” she says. “I couldn’t twist or bend or anything without getting shooting pains in my ribs.”
She came home for summer vacation and began seeing Dr Brian Nathanson, who started radial shock wave treatment. “At first I was confused by the technology and stuff,” she says. “But basically he told me it breaks down bad tissue, then helps your body create new healthy tissue. And I thought that was great.”
After two treatments, she was able to work longer sessions on the “erg,” the rowing machine at the gym. She felt noticeable improvement after each treatment and was completely out of pain after the sixth one. She went back to school and started training again. Well into the season, she noticed something else that was really important.
“A group of us got injured last year, and a lot of those girls got injured again this next season,” she says. “But I didn’t. I was fine. So, I thought it was interesting that the treatment is definitely more long-term.”
When “Cal” was a freshman in high school, he made the varsity baseball team as a pitcher. His team had a successful year, and scouts started calling, asking him to try out for Team USA, a US organization that builds national sports teams to compete internationally.
After some tryouts and tournaments, he was selected to play on the 15U, or age 15 youth team, that was scheduled to compete in the Pan American Games that summer in Mexico.
“Unfortunately, by the time he finished tryouts and was told he’d made the team, he came back home from his last game experiencing pain in his chest and arm and having trouble breathing,” says his mom. “It was a scary situation for a while.”
Eventually Cal’s doctor diagnosed him with costochondritis, aka chest wall pain syndrome or costosternal syndrome. For this benign inflammation of the upper sternocostal joints involving several ribs, traditional treatment is NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief and sometimes corticosteroid shots.
And yet the Pan Am Games were just five weeks away. The “rest, take aspirin and see how it goes” approach wasn’t going to hack it.
For a while, it looked like Cal wouldn’t be able to play, and his mom took him to see Dr Brian Nathanson. “I told him, ‘We got to get this kid ready to pitch. He’s going to Mexico in four weeks, and he’s got to be ready,'” she says.
Nathanson treated him with shock wave therapy every four days or so, tapering down to one treatment a week. By the end of week four, Cal was totally out of pain and was able to go to Mexico.
Cal pitched in the final game against the Mexican team and won the gold. He’s been fine ever since and is currently getting ready to pitch for his school’s 2026 spring season.
Shock wave therapy is delivered by a range of clinicians—from physiotherapists and sports medicine specialists to orthopedic surgeons and musculoskeletal practitioners. You can search for a practitioner anywhere in the world at these websites.
International Society for Medical Shockwave Treatment
shockwavetherapy.org/member-rooster
(Roster misspelling in this URL is required to access the page)
Shockwave Experts
shockwaveexperts.com
(This site is still under development)
Alternatively, you should be able to find a shock wave therapy practitioner near you by searching online for shock wave therapy + your city/town. You can also search via private healthcare providers or specialized sports injury centers.
In the UK, shock wave therapy is sometimes available on the NHS.
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