Is Shockwave Therapy Safe If You’re on Blood Thinners or After Cortisone?

Short answer: sometimes—but it depends on the drug, dose, timing, and your clinical picture. Below, I outline how shockwave therapy works, why anticoagulants and recent steroid injections alter the risk–benefit balance, and what we typically advise at our Auckland clinic (we utilise EMS Swiss DolorClast radial and focused devices).

Why shockwave works

Extracorporeal shockwave therapy (ESWT) sends short, high-pressure acoustic pulses into sore tissue. When we reach the target tissue with the right energy, several helpful things happen:

• Pain modulation & neurogenic inflammation: ESWT can deplete pain-carrying neuropeptides (notably substance P and CGRP) in sensory nerves and dorsal-root ganglia, which helps “turn down” pain and neurogenic inflammation. That’s one reason people often feel easier loading afterwards. 

• Angiogenesis: it stimulates new microvessels and upregulates VEGF and eNOS, improving local blood flow for repair over the following weeks. 

• Matrix & tendon cell effects: in lab and animal models, ESWT increases tenocyte proliferation (PCNA), boosts type-I collagen synthesis and normalises dysregulated MMPs/IL-6; importantly, it also nudges tendon-lineage signalling (including scleraxis) and restores collagen architecture over time. 

• Lubrication: ESWT can increase lubricin (the tendon “Teflon™”), improving gliding where tissues stick and snag. 

Those benefits rely on a controlled, pro-healing cascade. That’s precisely why blood thinners and recent steroids matter.

Blood Thinners: When Are They a Problem?

Why they matter: Shockwaves create tiny mechanical stresses and microvascular changes. On normal clotting, that’s fine (you may see mild redness or pinpoint petechiae). With significant anticoagulation, the risk of excess bruising or hematoma rises. International guidance and manufacturer labelling list anticoagulation/coagulation disorders as a contraindication for ESWT, particularly with higher energies. 

1. Classic anticoagulants (e.g., warfarin)

Warfarin has a long, variable effect (INR-dependent). EMS Swiss DolorClast® labelling cautions against treatment in patients taking anticoagulants; in our clinic, we do not treat while actively therapeutic on warfarin unless the prescribing physician specifically manages an interruption/bridging plan for a low-bleed-risk session. 

2. DOACs/NOACs (e.g., apixaban, rivaroxaban, dabigatran)

These have shorter half-lives, which is why—with your prescriber’s approval—timing can sometimes be adjusted for a safer window:

• Apixaban: ~12 h apparent half-life. 

• Rivaroxaban: 5–9 h in younger adults (often 11–13 h in older adults). 

• Dabigatran: 12–17 h (longer if kidneys are impaired). 

General peri-procedural guidance for low-bleeding-risk interventions is to hold a single dose (~24 hours); for moderate to high risk, 48 hours—then restart once hemostasis is secure. ESWT sessions are usually of low to moderate risk (we choose the energy/dose accordingly), but you and your prescriber must agree on whether to skip/shift a dose. Never change anticoagulants without medical sign-off. 

3. Antiplatelets (e.g., clopidogrel, dual therapy)

These also raise skin-bleeding/bruise risk. Whether to pause depends on why you’re on them. For anyone with stents or undergoing secondary prevention, we aim to avoid interruption and either lower energy or defer ESWT, always making this decision in consultation with your cardiology/GP team. (Device labelling treats antithrombotics broadly as a caution/contraindication.) 

Expected side-effects even off blood thinners: transient soreness, petechiae, minor bruises; hematoma is uncommon at therapeutic settings but is a known adverse effect, hence the caution in anticoagulated patients.

What about a recent cortisone (steroid) injection?

The clash: ESWT leans on controlled inflammation → regeneration; corticosteroids suppress that cascade (they reduce tenocyte proliferation and collagen synthesis, can promote tenocyte apoptosis, and are linked to worse long-term outcomes for several tendinopathies despite good short-term pain relief). 

• Basic and clinical science consistently show short-term pain gains but poorer mid- to long-term outcomes/recurrence after steroid injections for common tendinopathies. 

• Because steroids can block the very processes ESWT tries to stimulate, many centres avoid ESWT for 6–12 weeks after a steroid injection for the same region. (Several UK hospital leaflets and private centres advise 12 weeks.) We follow that conservative window locally. 

“Why can’t I just take ibuprofen?” — NSAIDs & ESWT

We usually ask patients to avoid oral/topical NSAIDs during a shockwave block (and for a short period before/after). Rationale: NSAIDs blunt prostaglandin and related inflammatory signalling that appears to be part of the shockwave’s therapeutic effect; expert reviews and multiple hospital protocols advise against them around ESWT. If you need something, paracetamol (also known as acetaminophen) is OK.

Safety summary (how we decide in clinic)

• On warfarin or therapeutic anticoagulation? ESWT is contraindicated during treatment, as per device labelling; we’ll coordinate with your prescriber if there’s a compelling reason to proceed with a managed pause/alternative. 

• On a DOAC (apixaban/rivaroxaban/dabigatran)? Short half-lives can allow a prescriber-approved timing strategy (often holding a dose for ~24 h for low-risk sessions).

• After a steroid injection to the same area? We prefer to wait 6–12 weeks so that the regenerative cascade ESWT triggers aren’t blocked and to reduce the risk of rupture in load-bearing tendons. 

• During treatment blocks, no NSAIDs; keep loading graded. We target ~2000 impulses per session (more can be okay), and select radial versus focused EMS handpieces to match tissue depth, ensuring the target tissue is actually reached.

Why we use EMS Swiss DolorClast® devices

For musculoskeletal work, the key is delivering sufficient energy to the target (deep rotator cuff vs. superficial plantar fascia) reliably and repeatably. EMS devices have clear contraindications and an extensive evidence base; they’re also characterised and benchmarked across frequencies/pressures in independent acoustic work, which is crucial for consistent biological effects.

FAQs

Can I stay on low-dose aspirin?

It increases bruise risk. Whether to continue depends on why you’re on it. For secondary prevention, we typically do not stop treatment and recommend that you speak to your GP/cardiologist about NOACs. Please bring your medication list; however, your GP/cardiologist must ultimately decide on the appropriate medication and whether it can be modified.

Why not combine steroid + shockwave?

They pull in opposite directions: steroids suppress tenocyte activity/collagen; shockwave tries to up-regulate them. Combining tends to cancel out the upside and may increase the risk of tendon failure.

What if I can’t pause my blood thinner?

We can discuss DolorClast® high-power laser for acute pain control (it reduces PGE2 without systemic NSAIDs) and plan ESWT later if/when safe.

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Jonathan Hall M.Ost, BAppSci (Human Biology), PGCertHSc (Acupuncture), GradDipHeal

Jonathan Hall is the founder and principal Osteopath at Movement Mechanics Osteopathy. Jonathan specialises in Shockwave Therapy and Western medical acupuncture. A fully qualified Osteopath registered with OCNZ, PNZ, PAANZ and ACC, Jonathan also founded Auckland Shockwave Therapy to help bring evidence-based Shockwave treatment to New Zealand using the industry-leading EMS Radial Shock Wave device.

Contact Us: hello@movementmechanics.nz

References

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International Society for Medical Shockwave Treatment (ISMST). (2023). ISMST Guidelines for ESWT/RSWT in musculoskeletal disorders. Retrieved from https://shockwavetherapy.org

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Disclaimer: This content is for educational purposes and is not a substitute for professional medical advice. Changes to anticoagulants or steroid plans must be cleared by your prescribing clinician.

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