Achilles Tendinopathy Treatment with a Focus on Extracorporeal

Shock Wave Therapy

Nanxi Pan

OT (Occupational Therapy), Guangzhou Medical University, Guangzhou, Guangdong, China

Keywords: Achilles Tendinopathy, Extracorporeal Shock Wave Therapy (ESWT), Non-invasive Treatment.

Abstract: Achilles tendinopathy has been an extremely common problem especially among active people and athletes.

A multitude of previous and latest treatments have been studied and applied in clinical treatments, including

the ESWT (Extracorporeal Shock Wave Therapy). While there is still a lack of systematic summary or review

of the efficacy of ESWT. Therefore, this research will use a systematic review approach to review the existing

effective non-surgical treatments for Achilles tendinopathy, with a focus on shock wave therapy. And the

analysis and summary, in conclusion, suggest that ESWT has an excellent therapeutic effect on Achilles

tendon diseases. At the same time, it can be widely used in medical practice as a non-invasive treatment alone

or in combination with other therapies.

1 INTRODUCTION

Achilles tendinopathy is one of the most common

lower limb motor function diseases in contemporary

times. According to the available data, there are

relatively limited studies on the incidence and

epidemiology of Achilles tendinopathy in

authoritative journals. However, existing studies

have shown that it is a common condition. The

Achilles tendon is a core structural component of the

disease. This tendon is extremely strong and it is

essential for walking, running, and jumping, as it

helps push the foot off the ground. Despite its

strength, it is prone to being in a damaged state,

particularly in athletes and active individuals.

Types of Achilles tendinopathy encompass

Achilles Tendinitis, Achilles Tendon Tear/Rupture,

Insertional Achilles Tendinopathy and so on. It

causes great discomfort to patients and seriously

affects their lower limb functions such as walking and

even standing. Despite of the manifold associative

factors of the problem, it is commonly agreed the

causes and mechanisms of Achilles tendinopathy

remain not clear enough. However, what is currently

known is that Achilles Tendinopathy usually

develops from overuse, with healthcare professionals

frequently identifying repetitive tendon overloading

as a primary precipitating factor (Traweger et

al.,2025). This can occur with excessive jumping and

landing type activities. It can also occur as a

consequence of trauma such as a direct blow to the

tendon. Shoes that do not fit properly may also cause

irritation of the tendon due to the repetitive rubbing

forces on the tendon. Tendon vascularity, lifestyle,

age, gender, body weight and height are firmly

believed associated as well. For example, it is

suggested that the peak incidence of ankle injuries

occurs between 15 and 19 years old, with a rate of 7.2

per 1,000 person-years (Delahunt et al.,2019). In

addition, there are a variety of options for diagnosing

and evaluating Achilles tendon disorders.

Professional palpation and testing are considered to

be extremely effective in the diagnosis and

assessment of Achilles tendinopathy. Modern

imaging examinations are also crucially required to

confirm the diagnosis and precisely locate the site of

injury. In terms of the non-invasive treatments, as

with general treatments for Achilles tendinopathy,

plenty of common treatment options can also

demonstrate efficacy in Achilles tendinopathy. Ice,

adequate rest, lifting the injured foot above heart are

widely considered beneficial, along with specific

stretching and strengthening exercises and

nonsteroidal anti-inflammatory drugs. While with the

rapid advancement of modern technology, multitudes

of new treatment methods have emerged including

ESWT that will be focused on in this article.

Extracorporeal shock wave therapy is a widely used

medical therapy. It was first used for lithotripsy of

kidney stones in 1980. Later, due to its characteristics

of no side effects, simple operation, short treatment

Pan, N.

Achilles Tendinopathy Treatment with a Focus on Extracorporeal Shock Wave Therapy.

DOI: 10.5220/0014494800004933

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Biomedical Engineering and Food Science (BEFS 2025), pages 435-438

ISBN: 978-989-758-789-4

435

course, and ability to cure, the medical community in

various countries began to conduct research and

application in various aspects. At present, there are

literatures discussing and promoting its application in

orthopedics, rehabilitation, cardiology, urology, etc.

According to the generation and treatment principles

of shock waves, extracorporeal shock waves can be

divided into focused and diffuse types. Focused

Shock Wave is the main type of shock wave currently

used in the medical community, which is essentially

equivalent to ESWT. Radial Shock Wave was widely

used in the massage shock wave type of rehabilitation

in the past, usually as part of the pain relief course,

but it has gradually been replaced by focused shock

wave. ESWT is used in physical therapy to relieve

pain, promote cell metabolism, blood vessel

reconstruction, and restore normal muscle tension

after various diseases. ESWT is considered as an

extremely efficient non-invasive treatment option for

managing Achilles tendinopathy, manifesting

substantial effectiveness in relieving pain and

improving functional outcomes(Fan et al.,2020).The

increasing amount of evidence from clinical studies

and trials corroborates ESWT’s efficacy,

demestrating that it can rival or even surpass other

conservative treatments, including physical

rehibilitation therapy and corticosteroid injections in

certain curcumstances (Perwez et al.,2024).However,

at present, there is still a lack of systematic summary

or review of it. In addition, evaluation and

comparison of the treatment (ESWT) effect of

Achilles tendinopathy with other therapies are not

very comprehensive and well-rounded. Thus, it is of

great value to study and summarize the current

application and research progress of non-surgical

treatments especially the shockwave therapy

mentioned above.

This study adopts a systematic review approach to

evaluate the therapeutic effects of shockwave therapy

on Achilles tendinopathy. The literature selection

process was guided by the aim of including the most

recent and high-quality studies; therefore, only

publications from 2020 onward were considered,

except for very few special cases. A key inclusion

criterion was the presence of strong empirical

evidence, particularly studies reporting persuasive

experimental or clinical results. This served as the

primary benchmark for assessing the quality and

credibility of each study.

To ensure comprehensive coverage, literature was

retrieved primarily through Google Scholar, allowing

access to a broader range of publications beyond

conventional databases and high-impact journals.

The search strategy included combinations of

keywords such as "shockwave therapy," "Achilles

tendinopathy," "treatment outcomes," and "clinical

trial."

The included studies were categorized and

analyzed based on the specific therapeutic outcomes

they reported. This outcome-based classification

enabled a more nuanced synthesis of the effectiveness

of shockwave therapy across different dimensions of

patient recovery, such as pain reduction, functional

improvement, and recurrence rates.

2 THERAPEUTIC OUTCOMES

2.1 Pain Alleviation

Pain is often the primary reason why patients seek

medical treatment. It also causes great physical and

mental damage to patients. Especially psychological

damage, it may even hinder the patient's recovery.

Therefore, any treatment to relieve pain is extremely

important, including shock wave therapy. Shockwave

therapy has a complex mechanism for pain regulation

of pain. Shockwaves are able to modulate the release

of painmediating substances such as prostaglandins

and cytokines, and affect neural mechanisms

involved in pain modulation. Additionally, ESWT

may activate endogenous pain control systems,

including the release of endorphins and activation of

descending inhibitory pathways. In a general

controlled trial, 28 participants were assigned into an

experimental (n=9) and control group (n=9). And the

result demonstrates that the ESWT could improve the

pain in patients with CAI (Chronic Ankle Instability)

(Lee et al.2022). In addition, in another

systematically completed randomized controlled trial

，by six weeks following the completion of therapy,

there was a notable reduction in Achilles tendon pain

associated with physical activity (Stania et al.,2022).

According to loads of multiple randomized controlled

clinical trials, extracorporeal shock wave therapy

(ESWT) has demonstrated significant efficacy in

alleviating pain and discomfort associated with

various Achilles tendon disorders. Thus, ESWT holds

considerable potential for clinical application in pain

management.

2.2 Restoration of Achilles Tendon

Function

The function of the Achilles tendon is extremely

important in daily life and lower limb movement. Its

core function is plantar flexion of the foot, which is

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derived from maintaining balance, stabilizing the

body, absorbing and releasing energy, achieving

force transmission and tiptoeing. In daily life, it is

specifically reflected in running, jumping, walking

and all other activities that require the body to move

forward or upward.

One of the best standards for measuring Achilles

tendon and ankle function is the VISA-A. The VISA-

A(Victorian Institute of Sport Assessment–Achilles)

is a validated questionnaire designed to assess the

severity of Achilles tendinopathy. It consists of 8

items covering pain, function in daily living, and

sporting activity. Scores range from 0 to 100, with

higher scores indicating better function and fewer

symptoms. A score of ≥90 is commonly used to

indicate readiness to return to sport (Silbernagel and

Crossley,2015).

In a retrospective cohort study, after treatment

with radial shockwave therapy (n = 58) or combined

radial and focused shockwave therapy (n = 29) for

patients with Achilles tendinopathy refractory to

exercise therapy, it was demonstrated overall

functional improvement for both groups. Besides, it

is suggested that combined radial and focused

shockwave therapy may provide more predictable

functional gains for treatment of Achilles

tendinopathy compared to radial shockwave therapy

(Robinson et al.,2022).

2.3 Anti-inflammatory Effect

Inflammation is often present to varying degrees in

Achilles tendinopathy, commonly referred to as

Achilles tendonitis. Many symptoms, including

discomfort, swelling, warmth, and pain, are

attributable to inflammatory processes. Therefore, for

any therapeutic intervention to be effective in treating

Achilles tendon disorders, anti-inflammatory effects

are essential. However, there are very few clinical

studies and literatures, especially after 2020, to study

the anti-inflammatory effects of the shock wave

therapy of Achilles tendon disease. However, many

articles have discussed the anti-inflammatory effect

of shock wave therapy and explained its mechanism.

Therefore, at the same time, the materials cited in this

chapter are relatively special and are not entirely

literature after 2020 and clinical practice. As

highlighted in this concise review, a potential

molecular mechanism underlying the anti-

inflammatory effects of extracorporeal shock waves

(ESWs) appears to involve the maintenance of local

nitric oxide (NO) concentrations within physiological

ranges during the early phase of the inflammatory

response. This effect may be mediated through the

facilitation of both enzymatic and non-enzymatic

pathways of NO molecule production (Mariotto et

al.,2009). ESWT, therefore, has great potential to be

applied in an increasing number of inflammatory

diseases in the future.

No matter how effective a treatment may be, the

emergence of adverse side effects warrants serious

attention from both researchers and healthcare

professionals. Over the past five years, few clinical

studies and corresponding publications have

specifically focused on the adverse effects of

shockwave therapy. Nonetheless, a considerable

number of clinical reports have included discussions

on treatment-related side effects. Most of these

studies reported no observable adverse reactions

attributable to shockwave therapy throughout the

research period. However, some accounts have noted

the occurrence of typical side effects associated with

extracorporeal shockwave therapy (ESWT), which

were generally limited to localized skin erythema,

mild bruising, swelling, pain, numbness, or tingling

sensations within or around the treatment area during

or within 24 hours post-treatment (Crevenna et

al.,2021). Other types of adverse reactions were

rarely documented. The most effective approach to

mostly avoiding side effects remains the strict

adherence to contraindication guidelines.

Extracorporeal shock wave therapy should be

contraindicated or used with caution under the

following conditions: pregnancy (particularly when

the treatment area is near the abdomen or pelvic

region); the presence of bleeding disorders or

ongoing use of anticoagulant medications; localized

infections or malignancies at the treatment site; and

patients with implanted cardiac pacemakers

(depending on the type of device).Overall, shock

wave therapy is a treatment with relatively few side

effects and can be regarded as a safe method.

3 LIMITATIONS

The analysis and synthesis presented in this study are

reasonably systematic. However, aside from the

illustrative references explicitly discussed, the

number of underlying studies identified and reviewed

is fewer than ten. This limited scope of literature

somewhat undermines the robustness of clinical

evidence supporting each specific shockwave therapy

system. Additionally, the study does not provide a

comprehensive exploration of the underlying

mechanisms through which various types of

shockwave therapy exert their therapeutic effects;

Achilles Tendinopathy Treatment with a Focus on Extracorporeal Shock Wave Therapy

437

instead, these mechanisms are only briefly

mentioned.

Furthermore, a comparative evaluation between

shockwave therapy and conventional treatment

modalities is warranted. Such comparisons are

crucial to better elucidate the unique advantages—

and potential limitations—of shockwave therapy

within clinical practice. Overall, a more extensive and

in-depth synthesis of the available evidence will be

necessary in future studies to strengthen the

conclusions and broaden the applicability of the

findings.

4 CONCLUSIONS

Achilles tendinopathy remains a prevalent condition,

particularly among athletes and physically active

individuals, with multiple factors contributing to its

occurrence. Traditional management strategies,

including rest, physical therapy have shown efficacy,

but emerging evidence suggests that extracorporeal

shock wave therapy (ESWT) offers significant

therapeutic benefits, particularly in improving pain,

Achilles tendon function recovery anti-inflammatory

effect，and physical stability. Its mechanisms—such

as promoting local blood flow, stimulating cellular

activity, and accelerating tissue regeneration—make

it a compelling therapeutic option. Despite ESWT

showcases a promising non-invasive treatment

option, more and further research is needed to

optimize its protocols and long-term effectiveness.

Besides, it is worth noting that while ESWT is

generally well-tolerated, some studies have reported

mild and transient side effects, such as localized pain,

skin reddening, or soft tissue swelling following

treatment. These effects are typically self-limiting

and do not compromise the overall safety profile of

the therapy. Nevertheless, clinicians should remain

cautious, particularly when determining treatment

intensity and frequency.

Overall, ESWT can be considered a safe and

effective option for the management of Achilles

tendinopathy. Further standardized clinical trials and

long-term outcome studies are recommended to

better define its optimal application and to validate its

role in evidence-based treatment protocols.

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