The Shockwave Debate Continues: A Critical Review of the Latest Randomised Controlled Trial (RCT) | Find Your Stride | Edinburgh Podiatrist

Introduction

Plantar fasciopathy remains one of the most frustrating injuries faced by runners and one of the most common conditions treated by podiatrists. While extracorporeal shockwave therapy (ESWT) has become increasingly popular over the past decade, many patients and clinicians still ask the same question: Is shockwave actually better than good physiotherapy?

A recent randomised controlled trial published in BMC Musculoskeletal Disorders attempts to answer exactly that.

Is shockwave actually better than good physiotherapy?

What did the researchers do?

Researchers from Tunisia recruited 129 adults with chronic plantar fasciopathy lasting more than three months. Participants were randomised into two groups:

Group 1

• Six weekly sessions of radial extracorporeal shockwave therapy (rESWT)

Group 2

• Twelve sessions of physiotherapy including:

  • plantar fascia stretching

  • deep transverse friction massage

  • therapeutic ultrasound

Patients were followed for up to 12 months, although the paper reports complete outcomes only through six months because one-year follow-up was still ongoing at publication.

The Key Findings

Both groups improved substantially. Pain scores fell significantly over time regardless of treatment. Importantly: Shockwave therapy was not statistically superior to physiotherapy at any follow-up point. Morning pain improved in both groups, with almost identical reductions in Visual Analogue Scale (VAS) scores. At three months:

• Overall treatment success: 73%

• Shockwave success: 54%

• Physiotherapy success: 46%

Despite these numerical differences, they were not statistically significant.

What does this mean?

This is perhaps the paper’s biggest message. Many clinics market shockwave therapy as a premium treatment capable of producing superior outcomes. This study suggests something rather different. Good conservative rehabilitation appears to work just as well. That doesn’t mean shockwave is ineffective, quite the opposite. It simply means that when compared against an active, well-delivered physiotherapy programme (not placebo) it loses much of its apparent advantage.

This distinction is important. Many earlier studies compared shockwave with sham treatment or minimal care. Naturally, shockwave looked impressive. Comparing it against an effective rehabilitation programme is a much tougher test.

What did the study do well?

1. Randomised controlled design

RCTs remain one of the strongest methods for evaluating treatment effectiveness.

2. A relatively large sample

With 129 participants, this is larger than many previous plantar fasciopathy trials.

3. Clinically relevant comparison

Rather than comparing shockwave against placebo, investigators compared it against something clinicians actually use every day. That makes the findings much more applicable in clinical practice.

4. Six-month follow-up

Many shockwave studies stop after only six to twelve weeks. Following patients for six months provides a more meaningful assessment of durability.

5. Interesting biomechanical assessment

One novel aspect was the inclusion of baropodometric analysis (the computerised measurement and study of how body weight is distributed across the feet). Higher pain levels were associated with:

• greater plantar contact area

• increased rearfoot loading

• altered pressure distribution

  
  

This supports the idea that plantar fasciopathy isn’t simply a tissue problem but often reflects broader biomechanical loading patterns.

But there are important limitations

Although this is a valuable study, several methodological issues prevent it from changing clinical practice on its own:

1. It wasn’t a true comparison of shockwave versus physiotherapy

The physiotherapy group received:

• stretching

• massage

• ultrasound

  
  

This makes it impossible to know which component actually produced improvement.

Current international guidelines generally place little emphasis on therapeutic ultrasound compared with progressive loading and education.

2. No progressive strengthening programme

This is probably the study’s biggest weakness. Modern evidence increasingly supports:

• plantar fascia loading

• calf strengthening

• progressive resistance exercise

  
  

These were largely absent. The rehabilitation programme therefore doesn’t fully reflect contemporary best practice.

3. No participant blinding

Patients knew which treatment they received. With pain outcomes, expectation effects can be substantial. Although outcome assessors were blinded, participant expectations may still have influenced results.

4. Functional outcomes were limited

Pain improved but runners care about more than pain. The study tells us very little about:

• return to running

• training volume

• performance

• recurrence during sport

• patient-reported function beyond the Roles and Maudsley score

5. Cost-effectiveness wasn’t assessed

Shockwave is expensive.

The authors themselves acknowledge that no economic analysis was performed. If outcomes are similar, clinicians should ask: Is the additional financial cost justified? That question remains unanswered.

6. The one-year results are incomplete

Although described as a 12-month trial, final long-term outcomes were still being collected.

Therefore, conclusions should primarily be interpreted as six-month findings.

What does this mean for runners?

For runners hoping that shockwave provides a “quick fix,” this paper is a useful reality check.

The evidence increasingly suggests:

• loading matters

• biomechanics matter

• calf capacity matters

• plantar fascia capacity matters

• 
  

Shockwave may reduce symptoms. But it probably isn’t replacing good rehabilitation.

In many cases it should be viewed as an adjunct rather than the primary intervention.

What does this mean for podiatrists?

This paper reinforces an important clinical principle. Technology should not replace rehabilitation. Shockwave remains a useful tool, particularly in persistent cases, but clinicians should continue prioritising:

• education

• progressive loading

• footwear advice

• activity modification

• addressing biomechanical contributors

• long-term exercise adherence

  
  

The inclusion of baropodometric findings is also a welcome reminder that assessing foot function - not simply treating pain - may improve long-term outcomes.

The Verdict

This is a well-designed and clinically relevant study that asks a question many practitioners have wanted answered. Its conclusion is refreshingly balanced. Shockwave works. Physiotherapy works. Neither proved superior.

For clinicians, the study supports using shockwave selectively rather than routinely.

For patients, it provides reassurance that a structured rehabilitation programme remains one of the most effective and potentially most cost-effective ways to recover from plantar fasciopathy. As with most musculoskeletal conditions, there is still no substitute for careful diagnosis, progressive loading and patience.

Clinical Takeaways

• Both shockwave therapy and physiotherapy significantly reduce plantar heel pain.

• Shockwave was not superior to physiotherapy.

• Progressive rehabilitation should remain first-line treatment.

• Shockwave appears best used as an adjunct rather than a replacement for exercise.

• Addressing biomechanics may improve long-term outcomes.

• More high-quality trials comparing shockwave with modern loading programmes are still needed.

Find Your Stride!

Citation

Ines, L., Rihab, M., Sana, B., Saoussen, L., Mariem, G., Sinene, F., & Sonia, J. (2025). The effectiveness of radial extracorporeal shock wave therapy (rESWT) in plantar fasciitis: A 12 months randomised controlled trial in a Tunisian rehabilitation department. BMC Musculoskeletal Disorders, 26, 938. https://doi.org/10.1186/s12891-025-09103-y