Shockwave Therapy
What Is Shockwave Therapy?
Shockwave therapy, known clinically as extracorporeal shockwave therapy (ESWT), uses focused acoustic pressure waves delivered through the skin to jumpstart healing in tendons and soft tissue that have stopped healing on their own. It's not electrical stimulation, and it's not the same as ultrasound. The device generates a rapid series of high-energy pressure pulses that travel into the tissue and trigger a specific biological response most people have never heard of: controlled microtrauma that restarts the healing process in tissue that's become stuck.
That's the key distinction. Most soft tissue injuries heal in stages, inflammation, repair, remodeling, and move through them without much intervention. Chronic tendinopathy is different: the tissue gets stuck in a degenerative state and stops progressing through those stages on its own, sometimes for months or years. Rest doesn't fix it, because the tissue was never inflamed in the way an acute injury is. Stretching doesn't fix it, because the problem isn't tightness. Shockwave works because it mechanically disrupts that stalled state and reintroduces a healing signal the body stopped sending.
How It Works, in More Detail
At the tissue level, shockwave produces several effects that have been documented in the research:
Neovascularization — the formation of new blood vessels in and around the treated tissue, improving blood supply to an area that's often become under-vascularized in chronic tendinopathy.
Collagen resynthesis — stimulating the fibroblasts responsible for producing new, organized collagen, which is what damaged tendon tissue actually needs to remodel and strengthen.
Down-regulation of pain receptors — reducing the density and sensitivity of pain-signaling nerve fibers in the treated area, contributing to reduced pain both immediately and over the following weeks.
Breakdown of calcific deposits — in calcific tendinopathy specifically (most common in the rotator cuff), the mechanical energy can help fragment calcium buildup so the body can reabsorb it.
None of these effects happen instantly. That's why shockwave is delivered as a series over several weeks, not a single visit, and why results build progressively rather than showing up immediately after session one.
Who It's For
Shockwave isn't the right first step for everyone, and it isn't meant to be. It's specifically suited for:
Chronic tendinopathies — pain that's been present for at least 6-8 weeks (often much longer) and hasn't meaningfully improved with rest, activity modification, or a basic exercise program.
People who've plateaued in standard rehab — you're doing the right exercises, you're consistent, and progress has stalled. Shockwave is frequently used as the piece that gets stalled tissue responsive to loading again.
People trying to avoid injection or surgery — for many of the conditions below, shockwave has a comparable or better long-term evidence profile than corticosteroid injection, without the tissue-weakening downside injections can carry with repeated use.
Active people who don't want to fully stop training — unlike some interventions, shockwave doesn't typically require a period of complete rest, which matters if you're trying to stay active through treatment.
It is generally not the right tool for acute injuries (something that happened in the last few weeks), for pain that hasn't been properly diagnosed yet, or as a first-line treatment before a real trial of loading-based rehab has been attempted, shockwave works best alongside that rehab, not as a replacement for it.
Conditions We Treat
Plantar fasciitis (chronic heel pain) — one of the most researched applications, with strong evidence for reducing pain and improving function in cases that haven't responded to stretching, orthotics, or basic rehab.
Achilles tendinopathy (mid-portion and insertional) — particularly useful for the "stuck" chronic cases that plague runners and recreational athletes.
Patellar tendinopathy ("jumper's knee") — common in golfers and athletes with repetitive loading through the knee.
Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow) — two of the best-studied applications of shockwave, with outcomes research going back decades.
Rotator cuff tendinopathy, including calcific tendinitis — particularly effective where calcium deposits are contributing to pain and restricted motion.
Greater trochanteric pain / hip tendinopathy — evaluated case-by-case, since tissue depth affects how well energy reaches the target area.
What a Session Actually Looks Like
Sessions are quick, typically 5–10 minutes of active treatment time as part of a regular visit. A conductive gel is applied to the treatment area, and the device delivers a set number of pulses (typically 1,500–2,500) at an intensity calibrated to your tolerance and the tissue being treated. You'll feel a rhythmic tapping or pulsing sensation; most people describe the first session or two as uncomfortable but tolerable, since the treated area is often already sensitive. Intensity is adjusted in real time based on how you're responding.
No anesthesia or numbing is used, partly because the treatment doesn't require it, and partly because some degree of sensation actually helps confirm the device is reaching the right tissue. Most protocols run once a week for 3 to 6 sessions, though this varies by condition and how you're progressing. Mild soreness for a day or two afterward is common and expected, similar to how a deep tissue massage feels the next day.
Why It's Never Used Alone
Shockwave changes the biology of the tissue, it doesn't rebuild strength or capacity by itself. Every shockwave patient at Back Nine leaves with a loading and strengthening component built into their plan, because the research is clear: shockwave paired with progressive loading outperforms shockwave alone. Used in isolation, you may get short-term pain relief without the tissue ever building back the capacity to handle real demand again, which is exactly how these problems tend to come back.
What Makes This Different at Back Nine
Shockwave is delivered by a Doctor of Physical Therapy who is also doing your evaluation, your rehab, and your strength programming, not handed off to a technician running a device on a timer. That matters because dosing, targeting, and progression decisions are made by someone who understands the full picture of what's driving your specific case, and can adjust your rehab plan in the same visit based on how the tissue is responding.
Frequently Asked Questions
How is shockwave different from ultrasound therapy?
Therapeutic ultrasound uses sound waves to generate mild heat in tissue and has fairly weak evidence for meaningful, lasting change. Shockwave uses acoustic pressure pulses, mechanically different and far more energetic, and has a substantially stronger evidence base for actually changing tissue at the cellular level rather than just producing a temporary warming effect.
How is shockwave different from a cortisone injection?
Cortisone reduces inflammation and can provide fast pain relief, but repeated use has been associated with weakening tendon tissue over time, and the relief is often temporary since it doesn't address the underlying tissue quality. Shockwave works more slowly but targets the actual biological problem, stalled healing and poor tissue quality, and doesn't carry that same tissue-weakening risk.
Is shockwave the same as a massage gun or percussion device?
No, and this is a common mix-up given they look superficially similar. A massage gun/percussion device operates at a fraction of the force and depth of a true shockwave device and works on the muscle surface for temporary relief and warm-up. Shockwave delivers far more focused mechanical energy, deep enough to actually reach tendon tissue and produce a genuine biological healing response.
Does shockwave hurt?
It's uncomfortable more than painful. Most people describe a deep, rhythmic tapping sensation and some tenderness, especially in the first session or two, since the treated area is often already sensitive from chronic irritation. Discomfort typically decreases across the series as the tissue responds. Intensity is adjusted based on what you can tolerate, not a fixed setting.
How many sessions will I need?
Most conditions respond to a series of 3–6 sessions, spaced roughly a week apart. Some people notice improvement within the first couple of sessions; for others, especially more chronic cases, meaningful change takes the full series. We reassess along the way and adjust the plan if it's not tracking the way we'd expect.
How soon will I feel better?
This depends on the condition and how long you've had it. Chronic tendon issues present for months typically take several weeks of treatment before a real shift is noticeable, shockwave is stimulating a biological repair process, not providing instant relief the way an injection might. We'll set expectations specific to your case at your evaluation.
Is shockwave covered by insurance?
Back Nine is a cash-based practice, so we don't bill insurance directly for any service, including shockwave. Currently, shockwave is typically not covered by insurance.
Who is shockwave not a good fit for?
Shockwave isn't appropriate for acute injuries (recent fractures, active infections, or fresh tears), for anyone who is pregnant, or for use directly over certain implants or growth plates in younger athletes. It's also not the right tool for every type of pain, during your evaluation, we'll confirm whether your specific issue is a genuine match before recommending it rather than defaulting to it.
Will shockwave work if I've already tried everything else?
This is actually one of the more common scenarios shockwave is used for. If you've done a real course of rehab, tried rest, tried stretching, and you're still stuck, that's often exactly the profile of tissue that responds well to shockwave, tissue that's stalled and needs a mechanical push to get moving through the healing process again.
Do I need a referral or diagnosis first?
No referral is needed, Maine allows direct access to physical therapy. At your evaluation, we'll assess whether shockwave is appropriate for what you're dealing with, or whether a different approach makes more sense first.
Can I keep training or playing golf while getting shockwave treatment?
In most cases, yes, with some modification. Unlike treatments that require a full stop in activity, shockwave is generally compatible with continuing to train, though we'll guide you on what to scale back during the series so you're not working against the tissue's ability to respond.