Supraspinatus tendinopathy, a common cause of shoulder pain, often presents a challenge in clinical management. Conservative treatments range from physical therapy and corticosteroid injections to more advanced options like platelet-rich plasma (PRP) injections. But do we really understand how these therapies work at the tissue level? Shockwave therapy, particularly, remains somewhat of a 'black box' despite growing evidence supporting its efficacy.
This review attempts to unpack the underlying mechanisms of shockwave therapy, differentiating between radial and focused approaches, and exploring the biological processes they initiate. Clinicians need more than just outcome data- we need to understand the 'why' behind the treatment to optimize its application and better manage patient expectations.
lightbulb Clinical Key Takeaways
- The Pivot:Understanding the biophysics of shockwave therapy, rather than solely relying on clinical trial data, is key to appropriate application and optimized patient outcomes.
- The Data:Studies suggest shockwave therapy can significantly reduce pain scores (e.g., VAS) in supraspinatus tendinopathy patients, but reproducibility depends on specific protocols and patient selection.
- The Action:Before opting for invasive procedures, consider a course of shockwave therapy, adjusting parameters (frequency, intensity) based on patient response and the type of device available (radial vs. focused).
In this article
Pathogenesis of Supraspinatus Tendinopathy
Supraspinatus tendinopathy, a prevalent condition affecting the rotator cuff, is characterized by pain and dysfunction arising from the supraspinatus tendon. The exact etiology remains multifactorial, involving intrinsic factors like age-related degeneration and vascularity, as well as extrinsic factors such as repetitive overhead activities and impingement. Is it truly 'impingement' driving this, or a more complex interplay of cellular responses to microtrauma? What we do know is that the tendon undergoes a cascade of pathological changes, including collagen disorganization, increased vascularity (neovascularization), and altered matrix composition. These changes ultimately weaken the tendon, predisposing it to pain and potential rupture. Understanding this progression is crucial for selecting appropriate interventions, and while rest and activity modification are foundational, they often fall short in addressing the underlying biological derangement.
Shockwave Therapy- Mechanisms of Action
Shockwave therapy (SWT) involves the application of high-energy acoustic waves to the affected tissue. The precise mechanisms by which SWT exerts its therapeutic effects are still being elucidated, but several key processes are believed to be involved. Mechanotransduction, the conversion of mechanical stimuli into biochemical signals, plays a central role. SWT induces microtrauma in the targeted tissue, stimulating the release of growth factors such as vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-β). These factors promote angiogenesis (new blood vessel formation) and collagen synthesis, contributing to tendon regeneration and repair. SWT also modulates inflammation by reducing the levels of pro-inflammatory cytokines and increasing the production of anti-inflammatory mediators. This is not simply masking the pain, but an attempt at actual healing.
Radial vs. Focused Shockwave Therapy
Two primary types of SWT exist- radial and focused. Radial SWT (rSWT) generates shockwaves via a projectile striking an applicator head, which then transmits the energy outwards into the tissue. The energy dissipates rapidly with increasing distance from the applicator, making rSWT suitable for treating superficial tissues. Focused SWT (fSWT), on the other hand, uses an electromagnetic or electrohydraulic source to generate shockwaves that converge at a specific focal point within the tissue. This allows for targeted delivery of energy to deeper structures, such as the rotator cuff tendons. The choice between rSWT and fSWT depends on the depth and location of the targeted tissue, as well as the desired therapeutic effect. Are we choosing the right device for the right patient, or simply using what's available?
Clinical Evidence and Considerations
Numerous studies have investigated the efficacy of SWT for supraspinatus tendinopathy. Meta-analyses and randomized controlled trials (RCTs) have generally shown that SWT can significantly reduce pain and improve function compared to placebo or other conservative treatments. However, the results are not always consistent, and several factors may influence the outcomes. These include the type of SWT (radial vs. focused), the treatment parameters (frequency, intensity, number of pulses), and the patient population (chronicity of symptoms, presence of calcifications). Some studies suggest that SWT is more effective in patients with non-calcific tendinopathy, while others have reported positive results in both calcific and non-calcific cases. Clinicians should carefully consider these factors when deciding whether to use SWT and when tailoring the treatment protocol. Furthermore, it is crucial to set realistic patient expectations regarding the timeline for improvement and the potential need for adjunctive therapies. If we are not seeing results, what are the alternatives, and when do we consider surgical intervention?
Implementing shockwave therapy requires investment in equipment and staff training. CPT codes exist for shockwave therapy, but reimbursement rates can vary depending on the insurance provider and the specific code used. A streamlined workflow for patient selection, treatment delivery, and follow-up is essential. Patients should be informed about the potential benefits and risks of SWT, as well as the expected costs. Consider the impact on patient convenience- multiple sessions are typically required, potentially increasing the overall burden compared to a single corticosteroid injection. Finally, document objective measures of improvement (range of motion, pain scores) to justify continued treatment and track patient outcomes.
LSF-1667126878 | December 2025
Michael Trent
How to cite this article
Trent M. Shockwave therapy for supraspinatus tendinopathy-a technical overview. The Life Science Feed. Published December 3, 2025. Updated December 3, 2025. Accessed December 6, 2025. .
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References
- Alvarez-Salgado, D., Fernandez-Gonzalez, P., Albornoz-Cabello, M., Torres-Costoso, A., & Lucha-Lopez, M. O. (2018). Effectiveness of radial shock wave therapy in the treatment of shoulder pain- a systematic review. Journal of Rehabilitation Medicine, 50(3), 193-203.
- Cacchio, A., Paoloni, M., Rompe, J. D., Postacchini, F., Santilli, V., & Martino, C. (2006). Shockwave therapy for calcific tendinitis of the shoulder- a systematic review. BMC Musculoskeletal Disorders, 7, 66.
- Hsu, C. J., Wang, D. Y., Tseng, K. F., Chen, C. K., & Wang, F. S. (2008). Extracorporeal shock wave therapy for rotator cuff tendinopathy- a randomized controlled trial. Journal of Shoulder and Elbow Surgery, 17(1), 51-55.