Shock wave therapy after Achilles tendon operations: Benefits for insertional tendinopathy
What is insertional Achilles tendinopathy?
Insertional Achilles tendinopathy is a common cause of pain in the back of the heel and it affects both recreational and professional sportspeople. While conservative therapies are often the most recommended, an operation may be necessary in severe cases. However, the post-operative recovery stage is often protracted – lasting around seven months, on average, until the patient is able to fully bear weight again.
What therapy options are available after an Achilles tendon operation?
For patients with insertional Achilles tendinopathy, the post-operative stage is often associated with longer-term restrictions on everyday and sporting activities. In addition to standardised post-operative rehabilitation, additional therapy options are increasingly discussed in order to support regeneration and speed up the return to load-bearing. The following study illustrates the role that shock wave therapy can play in this.
Shock wave therapy after Achilles tendon operations
A current case-control pilot study by Saxena et al. is now indicating that the combination of focused shock wave therapy (ESWT) and radial shock wave therapy (RPW) can speed up the healing process following an operation. While the term radial shock wave therapy is familiar in practice, the physically correct term would be radial pressure wave therapy.
The theory: The effect of shock wave therapy (ESWT and RPW) on rehabilitation after Achilles tendon operations
Both ESWT and RPW have been proven to promote blood circulation, stimulate cellular activity and promote the release of growth factors. Focused ESWT also reaches deeper layers of tissue in a targeted way, while RPW mainly acts on superficial layers. If both procedures are used in an individual therapy plan, the effects of each are cumulative – with the aim of supporting regeneration processes, modulating inflammation and alleviating pain.
Study design and methodology
The study included all cases of insertional Achilles tendinopathy requiring surgery between January 2015 and November 2021, which was performed by the same surgeon. All patients underwent an identical standardised rehabilitation protocol with initial non-weight bearing, followed by gradual mobilisation and later physiotherapy, which was carried out exclusively post-operatively. A standardised medication-based treatment was not described.
The intervention group additionally received two to three sessions of ESWT and/or RPW peri-operatively with the following parameters:
- ESWT: 0.15 mJ/mm², 2500 pulses, 6 Hz
- RPW: 2.4 bar, 2500 pulses, 11 Hz
These treatments (ESWT/RPW) were given before, after, or both before and after the operation, depending on the case.
The primary endpoint was the time until return to activity (or RTA), defined as the time until sporting activity was resumed and based on the medical file at the last follow-up. No differentiation was made according to sport type or weight-bearing level. The secondary endpoint was the clinical status at the last follow-up examination, measured using the Roles and Maudsley score. The Roles and Maudsley score represents a patient’s own overall estimation, encompassing pain and functional load-bearing in categories ranging from excellent (no pain, full activity) to poor (pain even at rest, significant restriction).
Results: Significantly faster return to sporting activity
The analysis showed that participants who received shock wave therapy in addition to the operation returned to sporting activity around 1.3 months earlier on average than the control group that did not receive this additional treatment (5.5 versus 6.8 months). This difference was statistically significant (p = 0.02) and indicates a possible relationship between the additional therapy and faster return to sporting activity and weight-bearing.
With regard to a clinical assessment score on the Roles and Maudsley score (RM score), the ESWT/RPW group also tended to perform better. While this difference was not statistically significant (p = 0.07), the trend suggests potentially positive effects that should be investigated further in larger study populations.
Conclusion and outlook
The results suggest that peri-operative treatment with ESWT and RPW may reduce the time until return to activity after an operation for insertional Achilles tendinopathy. It was noted in the discussion that faster functional recovery could potentially have positive effects on general well-being during the healing stage, even though data on quality of life were not directly collected in this study.
Saxena A, et al. Extracorporeal shock wave therapy (ESWT) and radial pressure waves (RPW) may improve post-operative recovery following insertional Achilles tendon surgeries: a case-control pilot study. J Orthop Surg Res. 2025;20(1):751. doi:10.1186/s13018-025-06165-5
