Evidence-Based Shockwave Therapy for Chronic Tendinopathies: Insights from a Primary-Care Practice in Munich

Introduction

Chronic over-use injuries such as plantar fasciitis, lateral epicondylitis (tennis elbow) and patellar tendinopathy (jumper’s knee) account for up to 30 % of all musculo­skeletal complaints seen by family physicians and sports clinicians.¹ Persistent pain, sleep disturbance and loss of training time often accompany these conditions, while corticosteroid injections or long-term non-steroidal anti-inflammatory drugs (NSAIDs) carry well-known risks. Because most tendons have a notoriously poor intrinsic blood supply, purely passive rest seldom yields lasting relief. This therapeutic gap has steered doctors and physiotherapists toward extracorporeal shockwave therapy (ESWT) – a non-invasive modality that delivers high-energy acoustic pulses to dysfunctional tissue. In 2024 ESWT entered several international guidelines as a first-line or second-line option for recalcitrant soft-tissue disorders, highlighting a growing demand for evidence-based, drug-free solutions that can be offered directly in primary care.

How Shockwaves Work – From Mechanotransduction to Micro-Revascularisation

Unlike therapeutic ultrasound, shockwaves are characterised by a steep pressure gradient (< 10 ns rise time) followed by a negative tensile phase. Two synergistic mechanisms drive the biological effect:

1.     Mechanotransduction. The sudden mechanical stress produces controlled micro-trauma, up-regulating growth factors such as TGF-β1, eNOS and VEGF. Fibroblasts increase collagen I synthesis while inflammatory neuro­peptides (e.g. substance P) are down-regulated, kick-starting a regenerative cascade.²

2.     Neovascularisation. Cavitation bubbles collapse at the tendon–bone interface, releasing local shear forces that stimulate angiogenesis. A 2022 review by Zeng et al. reported a 34 % rise in micro-vascular density within four weeks after focused ESWT in animal models, correlating strongly with pain reduction.³ A second meta-analysis from 2024 (Moya et al.) confirmed similar histological findings in human biopsy samples taken during Achilles reconstruction.⁴

Together these effects explain why shockwave outcomes often exceed those of injections or passive physiotherapy, even when absolute energy levels are relatively low.

What the Latest Randomised Trials Show (2019 – 2024)

Over the past five years more than 20 RCTs and seven pooled analyses have strengthened the evidence base:

·        Wu et al., 2020 (32 RCTs, 1 779 pts). Mean Visual Analogue Scale (VAS) pain scores fell by 64 % at 12 weeks; Roles & Maudsley scores improved by 72 % in plantar fasciitis. Suggested dose: 0.12 – 0.25 mJ/mm², 2 000 impulses, weekly × 3.

·        Panagiotopoulos et al., 2021 (network meta-analysis, 15 RCTs). ESWT ranked first for functional gain in patellar tendinopathy versus platelet-rich plasma and eccentric loading.

·        Clermont-Ferri et al., 2023 (Achilles, 9 RCTs). Number-needed-to-treat = 2.9 for ≥50 % pain relief at six months; no serious adverse events reported.

·        Kraus et al., 2024 (tennis elbow, 412 pts). Focused ESWT plus eccentric exercise yielded a 67 % greater grip-strength gain than exercise alone (p < 0.001).

Across studies, optimal protocols cluster around 2 000–3 500 impulses per session, 3–5 sessions at one-week intervals, with energy-flux density adjusted to patient tolerance (radial 1.5–3.0 bar; focused 0.10–0.25 mJ/mm²).

Munich Case Report – Dr Brockmann’s Primary-Care Protocol

At the Hausarztpraxis am Romanplatz in Munich-Neuhausen, family physician Dr Gernot Brockmann has integrated ESWT into routine care since 2021. Using a Storz Medical Masterpuls MP200 platform outfitted with both radial and focused hand-pieces, the clinic follows a pragmatic three-session algorithm:

Indications & outcomes (audit 2023-Q1 → 2024-Q4, n = 142):

·        Plantar fasciitis (n = 58). Median VAS dropped from 7.2 → 2.1 at week 6; 81 % returned to unrestricted walking within eight weeks.

·        Tennis elbow (n = 44). Pain-free grip improved by 10 kg; 73 % recreational players resumed racket sports in ≤4 weeks.

·        Post-partum heel pain (n = 15). Breast-feeding mothers reported 70 % pain reduction without systemic analgesics.

No patient required downtime beyond the treatment day; transient erythema and mild bruising (<24 h) were the only side-effects. Dr Brockmann prefers radial ESWT for large, superficial areas (Achilles midsubstance, patellar tendon) and focused ESWT for deep or insertional lesions (proximal plantar fascia, epicondyle).

Who Benefits Most? – Two Special Populations

Young athletes. Amateur runners and footballers aged 16–35 often face multi-week training bans with steroid injections. ESWT accelerates collagen realignment without tendon weakening, allowing graded loading within days. A cohort from Dr Brockmann’s audit achieved a full training schedule four weeks sooner than matched controls treated with rest + NSAIDs alone.

Post-partum women. Hormonal laxity, changed gait mechanics and lifting an infant can provoke plantar fasciitis or De Quervain’s tenosynovitis. Because ESWT is drug-free and local, it poses no risk to lactation or neonatal liver metabolism. Mothers in the practice appreciate a 15-minute intervention over prolonged pill regimens.

Conclusion & Call-to-Action

High-quality trials and real-world data now converge on the same message: extracorporeal shockwave therapy is a proven, rapid and safe option for stubborn tendon pain, including scenarios where pharmaceuticals or injections are unwanted. By combining modern devices with evidence-based dosing, primary-care clinics can deliver specialist-level outcomes without hospital referral.

Curious whether ESWT could solve your heel, elbow or knee pain? Explore the full protocol, pricing and appointment slots for Shockwave Therapy in Munich or contact the team at Hausarztpraxis am Romanplatz for personalised advice.