The study
Midportion Achilles tendinopathy is the stubborn one, the presentation that drags on for months and responds slowly to treatment. This was a randomised clinical trial in 41 patients with chronic midportion Achilles tendinopathy, with everyone followed for 26 weeks.
Both groups did the same 12-week progressive resistance training program, the slow, heavy calf and tendon loading that is the standard of care for this problem. The only difference was that one group also received four sessions of focused extracorporeal shockwave therapy. This was focused shockwave, which concentrates acoustic energy at a set depth in the tendon, rather than radial shockwave, which spreads its energy more superficially. The paper does not name a device brand or model. So the trial was really asking a practical question: when you add focused shockwave on top of good loading, do you get anything extra for it?
They tracked pain on a numeric rating scale and function with the VISA-A questionnaire, the Victorian Institute of Sport Assessment for the Achilles, a standard score for tendon pain and function where a higher number is better. They also imaged the tendon with ultrasound at baseline and at weeks 6, 12 and 26, using a technique called spatial frequency analysis to look at how well the collagen fibres inside the tendon were organised.
What they found
Both groups got better, and meaningfully so. Pain came down and VISA-A function went up in the loading-only group and in the loading-plus-shockwave group alike. On its own that is a useful reminder that progressive loading does the job for most of these tendons.
The difference showed up inside the tendon. On ultrasound, the collagen became better organised and the tissue more uniform over time in both groups, but this remodelling was more pronounced in the group that added focused shockwave. The authors went as far as describing shockwave as a physiological catalyst for tendon remodelling, not just something that dampens symptoms. In plain terms, the loading drove the recovery and the shockwave appeared to help the fibres reassemble in better order.
What it means for your practice
Keep progressive loading as the foundation for every midportion Achilles case. It has the strongest evidence behind it, it is the part of treatment the patient does for themselves, and this study gives you no reason to move it off centre stage.
Think of focused shockwave as an add-on for selected cases rather than a replacement for the work. It makes the most sense in chronic, stubborn presentations where you want some extra help with tendon remodelling while the patient keeps loading. It does not make sense as a passive treatment that lets the patient skip the loading, because the loading is still what is driving the result. Note that this evidence is for focused shockwave specifically, so it speaks to the focused devices rather than radial ones.
This also matters for how you talk about shockwave and, if you offer it, how you charge for it. When it is a paid add-on, be straight with patients: it can support a loading program in the right case, but it does not fix the tendon on its own. Patients tend to respect that, and it keeps you from overselling a device.
The way we explain it to patients is that the heavy loading is doing the real work, while the shockwave helps the fibres reassemble in the right alignment. If you have an ultrasound in the clinic, it can be a powerful way to show patients that remodelling happening in real time, which makes the plan far easier to understand and buy into.
Bottom line
For midportion Achilles tendinopathy, progressive loading remains the treatment that does the work. Focused shockwave, given as four sessions alongside the loading in this trial, is a reasonable extra in chronic cases where you want a little more help with tendon healing, as long as it sits alongside the loading rather than replacing it.