Shockwave Therapy for Midportion and Insertional Achilles Tendinopathy: A Nail in the Coffin? A Systematic Review With Meta-Analysis

OBJECTIVE: To evaluate the effects of shockwave therapy (SWT) for Achilles tendinopathy compared to sham-SWT as a monotherapy or co-intervention, or no treatment. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: AMED, CINAHL, Web of Science, MEDLINE, EMBASE, SPORTDiscus, Cochrane CENTRAL, clinical trial registries, and grey literature were searched between 14 and 24 February 2025. STUDY SELECTION CRITERIA: RCTs assessing radial or focused SWT (with or without co-interventions) in adults with Achilles tendinopathy. DATA SYNTHESIS: We conducted a random-effects meta-analysis. We assessed risk of bias using the Cochrane Risk-of-Bias-2 tool and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS: Nine RCTs (n = 557) were included. For insertional Achilles tendinopathy, SWT showed no clinically meaningful benefit over sham (low-moderate certainty), with consistent findings across all outcomes and sensitivity/subgroup analyses. For midportion Achilles tendinopathy, all meta-analyses (very low and moderate certainty) showed no significant differences in disability or pain between SWT and control interventions at all timepoints. There was very low-certainty evidence of a clinically meaningful effect of radial SWT on short- and long-term improvements in disability and pain compared to sham or wait-and-see controls. One trial (midportion Achilles tendinopathy) showed benefit over sham-SWT but did not report participant success of blinding. Subgroup analyses revealed no clear advantage for either radial or focused SWT. Two Achilles tendon ruptures were reported following focused SWT. CONCLUSION: There was no clinically meaningful benefit of SWT in pain and disability for Achilles tendinopathy, with evidence ranging from very low to moderate certainty. Because most effect estimates are based on very low- and low-certainty data, the true effects may change with future high-quality trials. At present, SWT should not be considered a routine treatment for either insertional or midportion Achilles tendinopathy, and alternative treatments should be prioritized.