Shock wave therapy in sports medicine: international experts present new guidelines
According to the World Health Organization (WHO), musculoskeletal conditions affect more than 1.7 billion people worldwide.1 Extracorporeal Shock Wave Therapy (ESWT) can treat such conditions and has gained popularity in sports medicine, but experts remain divided on its optimal use, efficacy, and the types of injuries it can treat. To address these questions, sports medicine experts from Mass General Brigham (one of the United States' leading research medical centres) and collaborators around the world have established new clinical guidelines for the use of ESWT in musculoskeletal and sports medicine. The guidelines, which were recently published in the British Journal of Sports Medicine2, clarify key concepts behind ESWT’s efficacy and cover indications, standardised terminology, treatment procedures for tendon injuries and bone diseases, pre- and post-treatment protocols, and potential side effects.
Methods
The lead authors of the study first performed a systematic literature review on ESWT for musculoskeletal and sports injuries to select potential panellists and develop a questionnaire. They then created a three-part survey, distributing it to 41 international clinical and research experts across 13 countries. The panellists had the opportunity to suggest edits to existing statements on ESWT or recommend additional statements in Round 1. Consensus was defined as ≥75% agreement.
Results and conclusions
All 41 panellists completed Rounds 1, 2 and 3. Consensus was reached on 69/118 statements (58.5%). Of the 49 statements that did not reach consensus, 17/49 (34.7%) were related to procedural aspects of bone pathology.
The statements that reached consensus are intended to guide clinical decision-making for sports medicine clinicians in the treatment of tendon, fascia and bone pathologies. In the »What this study adds« section of the paper, the authors emphasise the following points:
- A distinction should be made between the use of focused shock wave and/or radial pressure waves with their corresponding energy levels (low, medium, high).
- Shock wave and/or pressure wave therapy is recommended as part of the treatment algorithm for various tendinopathies, plantar fasciopathy, bone stress injuries, delayed and non-union fractures, sesamoiditis and medial tibial stress syndrome.
- Procedural recommendations include the use of clinical focusing (defined as treatment over areas of maximal pain reported by the patient) without local anaesthesia, treatment intervals of 1–2 weeks with a total of 3–5 sessions, variable energy levels depending on the specific pathology and avoidance of Visual Analogue Scale pain scores greater than 6 and 7 for tendon and bone conditions, respectively.
- Non-steroidal anti-inflammatory drugs should be avoided throughout the duration of treatment as well as a period of time after treatment dependent on the specific clinical context.
- Following treatment, no range of motion restrictions or weight-bearing precautions are required for tendinopathies or fasciopathies, including for in-season athletes.
Future research will be needed to strengthen specific recommendations and to establish the best evidence-based clinical practices for ESWT in sports medicine.
1. https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions
2. Rhim H.C., et al. (2025). Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study. British Journal of Sports Medicine, 59(18), 1287-1301. https://doi.org/10.1136/bjsports-2024-109082
