Another shockwave review that can't say which machine was used, and draws conclusions anyway

A team from the Department of Sports Medicine at Peking University Third Hospital ran a systematic review and network meta-analysis of randomised controlled trials of extracorporeal shockwave therapy for tendinopathy. It was published in Orthopaedic Surgery on 13 September 2026.

They pooled 65 publications from 2002 to 2024 covering 3,921 patients across five tendinopathies: lateral epicondylitis, rotator cuff tendinopathy, greater trochanteric pain syndrome, Achilles tendinopathy and patellar tendinopathy. Shockwave was compared against placebo and against 14 other conservative treatments, including laser therapy, corticosteroid injection, exercise, therapeutic ultrasound, kinesiotaping and platelet-rich plasma. The network used random-effects models and the evidence was graded with GRADE.

A network meta-analysis compares treatments that were never tested head to head, by linking them through the comparisons that were. That matters here, because most shockwave trials compare it against placebo or a single alternative.

Achilles tendinopathy. Shockwave beat placebo on pain: standardised mean difference -0.49, 95% CI -0.83 to -0.16, with an I² of 0.

Patellar tendinopathy. Against placebo on the VISA-P, the standardised mean difference was -0.15, 95% CI -0.42 to 0.12, also with an I² of 0. The authors conclude that shockwave shows no significant therapeutic effect over placebo for patellar tendinopathy.

Greater trochanteric pain syndrome. Shockwave beat exercise: standardised mean difference -0.41, 95% CI -0.70 to -0.11, I² 10.2%.

A quick guide to those numbers. The standardised mean difference puts results measured on different scales onto a common one. As a rule of thumb, 0.2 is a small effect, 0.5 moderate and 0.8 large; ignore the minus sign, which only reflects the direction the scale runs. I² measures how much the trials disagreed with each other, where 0% means they agreed. So the Achilles result is a moderate effect the trials agreed on, the hip result is small to moderate, and the patellar result is close to nothing, with a confidence interval that crosses zero.

Laser ranked ahead of shockwave for Achilles pain. In the Achilles network, laser therapy ranked first for pain and was significantly better than shockwave, which ranked second (mean difference 2.55, 95% CI 1.86 to 3.24). That network contained six studies, and the laser result came from a single trial.

For context on the upper limb, shockwave also beat placebo in lateral epicondylitis (SMD -0.53) and rotator cuff tendinopathy (SMD -1.25, though with an I² of 89.1%).

Device and dose were not analysed. The authors could not run subgroup analyses comparing focused and radial shockwave or different energy levels, because too many included trials failed to report energy flux density, modality or full treatment protocols. They identify that parameter variation as a main source of heterogeneity.

The work was funded by a Peking University Third Hospital clinical subject talent project and the National Natural Science Foundation of China. The authors declare no conflicts of interest.

The review could not say which machine or dose any of this applies to. Too many of the included trials failed to report energy flux density, device type or full treatment protocols for the authors to compare focused and radial shockwave or different energy levels. The authors acknowledge that focused and radial shockwave differ substantially in wave propagation depth, mechanical stress distribution and biological effect on tendon, and that energy level is a well-established determinant of clinical efficacy.

That is the biggest limitation in the paper. A low-energy radial device and a high-energy focused device are close to being different treatments, and this analysis pools them together. Every result here, positive and negative, is an average across machines and settings that mostly went unrecorded. The Achilles and hip findings show shockwave can work at those sites, and the patellar result shows no sign of it working there, but none of it can be tied to a particular device, energy level or number of sessions. Until trials report their protocols properly, that question stays open.

Efficacy varied by tendon. The authors conclude that shockwave's effect differs across tendinopathy types. The paper supports placebo-controlled evidence for the Achilles and comparative evidence at the lateral hip. It does not support a general claim that shockwave works for tendinopathy.

For patellar tendinopathy, shockwave has not beaten placebo. The patellar comparison had zero heterogeneity, so the included trials agreed: there was no effect to find. The authors also cite a trial in which adding shockwave to eccentric exercise did not improve outcomes, and note that eccentric exercise is the recognised effective treatment for patellar tendinopathy. If you do offer shockwave for a patellar tendon, the patient should know it has not outperformed a sham.

At the lateral hip, shockwave outperformed exercise. That is a comparison against an active treatment, which makes it more useful clinically than most shockwave findings. It is one pooled comparison, and it supports shockwave as an option for greater trochanteric pain syndrome alongside load management.

The laser result rests on one trial. Laser outranking shockwave for Achilles pain is statistically significant, but a single study inside a six-study network is a thin basis for changing equipment. It does mean shockwave was not the top-ranked Achilles option in this analysis.

Shockwave has consistent placebo-controlled evidence in Achilles tendinopathy and beat exercise in greater trochanteric pain syndrome. In patellar tendinopathy it did no better than placebo. Because most trials did not record which device or energy level they used, none of these results can be tied to a particular machine or protocol. The evidence supports tendon-specific claims, with shockwave as an adjunct to loading.

For how shockwave compares with injections and other machines in plantar heel pain, see which treatment actually works for stubborn plantar fasciitis.