Shockwave Therapy vs Cortisone Injections: What the 12-Month Evidence Actually Shows

Jonathan Hall
2 days ago
10 min read

Short answer: corticosteroid injection usually produces faster pain relief than shockwave therapy in the first four to six weeks, but from six to twelve months the position reverses shockwave therapy shows better pain and function outcomes with substantially lower recurrence. Because a recent corticosteroid injection is a contraindication to shockwave therapy for 6–12 weeks, choosing the injection first delays your access to the treatment with the stronger long-term evidence. Choosing shockwave first closes no doors.

That’s the headline. The detail matters more, because “shockwave versus cortisone” is not one question it changes depending on your diagnosis, how long you’ve had it, and what you need your body to do over the next twelve months. This article walks through what each treatment does at tissue level, what the randomised evidence shows condition by condition, when an injection is genuinely the better call, and how to sequence the decision so you don’t accidentally rule out your best option.

I’m an ACC-registered osteopath in Browns Bay and the EMS DolorClast® Key Opinion Leader for Aotearoa. I have no financial interest in you avoiding injections several of my patients have them, and some should. What I do have is a strong interest in patients making this decision with the twelve-month picture in front of them, not just the six-week one.

Alternative to steroid injection for pain

Why this decision is usually framed wrongly

Most patients arrive having been told something like: “We can try an injection, and if that doesn’t work we can look at other options.” That framing has a hidden assumption that the treatments are independent, and that trying one costs nothing but time.

They aren’t independent. Corticosteroids suppress the inflammatory and cellular healing cascade. Shockwave therapy works by provoking a healing cascade. Running them close together isn’t just unhelpful, it’s counterproductive, which is why our own shockwave therapy safety guidance recommends waiting 6–12 weeks after a steroid injection before beginning shockwave.

So the real question isn’t “which one?” It’s “which one first, and what does the other cost me?”

What cortisone does to tendon tissue

Corticosteroid injection delivers a potent anti-inflammatory directly into or around the painful structure. Where there is genuine active inflammation an inflamed bursa, an acutely inflamed joint capsule this can work impressively and quickly.

The complication is that most persistent tendon pain is not primarily inflammatory. Since the 1990s, histological studies of chronic painful tendons have consistently shown a degenerative picture rather than an inflammatory one: disorganised collagen, increased ground substance, neovascularisation (new blood vessel ingrowth), and accompanying nerve ingrowth that helps explain the pain. This is why the terminology shifted from “tendinitis” to tendinopathy the “-itis” was describing something that largely wasn’t there.

Cortisone does not reverse degeneration. It reduces pain by damping nociceptive and neurogenic signalling, which is a real and sometimes valuable effect. But the tendon you had before the injection is the tendon you have after it often with a few weeks of pain-free use that encourages loading the tissue harder than its actual capacity allows.

There is a second, better-documented problem: long-term outcomes. The landmark trial here is Coombes and colleagues, published in JAMA in 2013. In 165 patients with chronic tennis elbow randomised to corticosteroid injection or placebo injection, with or without physiotherapy:

Corticosteroid produced better pain outcomes at 4 weeks
At one year, the corticosteroid group had a 54% recurrence rate versus 12% in the placebo injection group
Complete recovery at one year was 83% in the corticosteroid group versus 96% with placebo injection
Adding physiotherapy did not rescue the corticosteroid group’s outcomes

In other words, for this condition, patients who received the injection were several times more likely to be worse off a year later than patients who received a saline injection. That is a difficult finding, and it should be part of every informed-consent conversation about cortisone for tendinopathy.

A meta-analysis of randomised trials comparing shockwave therapy against corticosteroid injection in plantar fasciitis found the same shape of result: corticosteroid ahead in the short term, shockwave superior at longer follow-up, with better durability of effect.

Where cortisone is genuinely useful

Balance matters. Corticosteroid injection remains a reasonable option when:

Pain is so severe that sleep, work or any rehabilitation is impossible sometimes you must lower the volume before anything else can be heard
The problem is genuinely inflammatory or capsular (some bursitis presentations, early-phase frozen shoulder)
There is a fixed deadline an event, a flight, a surgical date where short-term relief is the goal and the trade-off is understood
Diagnostic clarification is needed (a targeted injection that abolishes pain tells you something)

If you’re in one of those categories, we’ll say so, and we’ll plan your rehabilitation and any subsequent shockwave course around the injection window rather than pretending the injection didn’t happen.

What shockwave therapy does instead

Extracorporeal shockwave therapy (ESWT) delivers acoustic energy into tissue. Rather than suppressing a healing response, it provokes one. The mechanisms documented in laboratory and clinical research include:

Mechanotransduction - converting mechanical stimulus into cellular signalling that drives tendon cell activity and collagen synthesis
Neovascularisation - stimulating new blood vessel formation, improving perfusion in chronically hypovascular tendon
Modulation of neurogenic inflammation - reducing substance P and CGRP-mediated signalling, which is central to why shockwave reduces pain without blocking healing
Reduction of pain sensitisation at the peripheral nerve level
Stimulation of bone healing responses, which underpins its use in bone stress injuries and delayed unions

That last point is worth sitting with, because it is the cleanest illustration of the difference between the two treatments. Shockwave is used to heal bone. Cortisone is contraindicated near tendon precisely because of what it does to tissue integrity. These are opposite interventions at the biological level.

This is our clinical philosophy in a sentence: movement restores biology, and biology restores movement. Shockwave is how we restart stalled biology so that loading the actual long-term cure for tendinopathy becomes tolerable and productive.

The evidence for shockwave, by condition

Not all shockwave evidence is equal, and not all shockwave devices are equal (a point covered in detail in our post on why we use EMS DolorClast® devices). What follows are trials conducted with the device family we use.

Plantar fasciitis

Gerdesmeyer et al., American Journal of Sports Medicine, 2008. A multicentre, double-blind, placebo-controlled randomised trial of radial shockwave therapy in 245 patients with chronic recalcitrant plantar fasciitis meaning symptoms of at least six months and failed conservative treatment. Radial ESWT produced significantly greater improvements in heel pain, function and quality of life than sham at 12 weeks, with benefits maintained at 12 months. This trial was conducted using the Swiss DolorClast® and formed the basis of that device’s FDA approval for chronic proximal plantar fasciitis.

This is the single most relevant plantar fasciitis trial for our clinic, because it studied the specific device and the specific patient group we treat: people who have already failed the standard advice.

Achilles tendinopathy

Rompe et al., American Journal of Sports Medicine, 2009. Sixty-eight patients with chronic (>6 months) midportion Achilles tendinopathy randomised to eccentric loading alone versus eccentric loading plus radial shockwave. The combined group did significantly better at four months (approximately 82% versus 56% reporting satisfactory outcomes). The shockwave protocol used the DolorClast® radial device at three weekly sessions, 2,000 impulses, 0.1 mJ/mm², 8 Hz.

Rompe et al., Journal of Bone and Joint Surgery (Am), 2008, found radial shockwave superior to eccentric loading alone at four months for insertional Achilles tendinopathy a group notoriously resistant to standard heel-drop protocols.

The pattern across this literature is important and often misrepresented: shockwave is not a replacement for loading it is what makes loading work. We cover Achilles specifically in our Achilles tendinopathy treatment guide and on our Achilles tendinopathy page.

Tennis elbow

Radial shockwave for lateral epicondylalgia has been studied in multiple randomised trials, with systematic reviews and meta-analyses generally favouring ESWT over corticosteroid injection for long-term pain and function outcomes, while corticosteroid wins short-term. Given the Coombes recurrence data above, tennis elbow is arguably the condition where the sequencing argument is strongest. See our tennis elbow treatment page.

Calcific tendinopathy of the shoulder

A special case, because shockwave can act on the calcium deposit itself rather than just the surrounding tendon. Gerdesmeyer et al., JAMA, 2003 randomised 144 patients with chronic calcifying rotator cuff tendonitis to high-energy focused ESWT, low-energy focused ESWT, or sham. Both active groups beat sham; high-energy beat low-energy for both symptoms and radiographic resolution of the deposit. This is why international guidance specifies focused, high-energy shockwave for calcifications covered in full in our calcific shoulder tendinopathy article.

The device question, briefly

Shockwave is dose-dependent, and devices differ measurably in the energy they actually deliver. Independent bench testing (Reinhardt, Wegenaer & de la Fuente, Scientific Reports, 2022) found significant differences in acoustic output between ballistic devices at higher frequency settings. EMS DolorClast® systems also account for a substantial share of the high-quality randomised trials indexed in the Physiotherapy Evidence Database (PEDro). Two clinics can both advertise “shockwave” and deliver materially different treatments we’ve written about why in detail.

Not sure which option is right for your tendon?

Book a consultation with Jonathan Hall (M.Ost) ACC-registered osteopath and EMS DolorClast® Key Opinion Leader for Aotearoa. You’ll get a clear recommendation, including when an injection genuinely is the better choice. Book an appointment → · Browns Bay, Monday–Saturday · No referral needed

Head to head, summarised

	Corticosteroid injection	EMS DolorClast® shockwave therapy
Onset of relief	Days to 2 weeks	Gradual; peak results typically ~12 weeks after starting
Short-term (4–6 wks)	Usually superior	Building
6–12 months	Effect commonly fades; high recurrence (54% at 1 yr in tennis elbow, Coombes 2013)	Superior outcomes and durability in comparative trials
Mechanism	Suppresses inflammatory signalling — and healing activity	Stimulates repair: mechanotransduction, neovascularisation, collagen remodelling
Effect on the underlying tissue	None (deposit or degeneration unchanged)	Directly targets tissue state; can resorb calcific deposits with focused ESWT
Invasiveness	Needle, drug, small infection risk	Non-invasive, no drug, no injection
Repeatability	Limited — cumulative tendon and local tissue risk	Course of 3–6 sessions; can be repeated if clinically indicated
Effect on your other options	Blocks shockwave for 6–12 weeks	Blocks nothing
Typical cost pathway	Consult + injection fees; often repeated	$130 per single-site session; typically 4–6 sessions (fees)

How to sequence the decision

If you take one thing from this article, take this framework:

Get the diagnosis right first. Shockwave for a misdiagnosed problem fails as reliably as cortisone does. Our assessment includes orthopaedic testing, and imaging referral (ultrasound or X-ray) where warranted.
Ask what phase the tissue is in. Acutely inflamed and highly irritable? High-power laser therapy is often the better opener, because it can be applied when mechanical loading isn’t yet tolerated. Chronic and degenerative? Shockwave.
Start with what preserves options. Shockwave first preserves the injection option. Injection first removes shockwave for up to three months.
Insist on a loading plan either way. No passive treatmentneedle or acoustic wave resolves tendinopathy without progressive loading. If nobody has given you a loading programme, that’s the gap.
Set review points. We reassess at defined milestones. If you aren’t tracking, we change the plan or refer you on including for injection or surgical opinion where that’s genuinely indicated.

Frequently asked questions

Can I have shockwave therapy if I’ve already had a cortisone injection?

Yes, but not immediately. We recommend waiting 6–12 weeks after a corticosteroid injection before beginning shockwave, because the steroid suppresses the healing response shockwave is designed to trigger. Tell us the date of your injection at assessment and we’ll plan the timing.

Does shockwave therapy hurt?

Most patients describe it as uncomfortable rather than painful. Each site takes roughly 3–5 minutes, intensity is adjusted to your tolerance, and there’s no downtime. The most common side effects are temporary local soreness and occasionally minor bruising.

How many sessions will I need?

Most tendon conditions are treated over 4–8 sessions at weekly intervals. Some patients notice change quickly; the best results typically appear around 12 weeks after starting, because tissue remodelling takes time.

Is shockwave therapy better than cortisone for everyone?

No. For severe inflammatory flares, some capsular conditions, or when short-term relief is the explicit goal, injection may be the better choice. The evidence favours shockwave for chronic, degenerative tendinopathy which is the majority of persistent tendon pain, but not all of it.

Can I take anti-inflammatories during a course of shockwave?

We advise avoiding NSAIDs (ibuprofen, diclofenac) around treatment sessions, and avoiding icing the treated area, because both blunt the healing response you’re paying to stimulate. Paracetamol is generally fine. Full guidance is in our safety article.

Are there people who shouldn’t have shockwave therapy?

Yes. Contraindications include pregnancy, blood clotting disorders, anticoagulant therapy (requires GP coordination), local malignancy or active infection, and corticosteroid use within the preceding six weeks. Under-18s are treated only in specific circumstances such as Osgood-Schlatter disease. See our FAQs.

Does ACC or Southern Cross cover this?

Where an injury-related claim applies, we can lodge an ACC claim for you ACC osteopathy information here. We’re also Southern Cross Easy-claim providers.

Do I need a referral or a diagnosis first?

No referral is needed. If you don’t yet have a clear diagnosis, book a standard consultation assessment comes first, and treatment recommendations follow from it. We also accept referrals from GPs, physiotherapists, podiatrists and specialists.

The bottom line

Cortisone changes how your tendon feels. Shockwave changes how your tendon heals. For a genuinely inflamed structure, or when pain has made everything else impossible, an injection may be the right first move and we’ll tell you when we think it is. But for chronic tendinopathy, the twelve-month evidence and the sequencing logic both point the same way: start with the treatment that rebuilds tissue, because it costs you nothing to try first.

That’s the reason we invested in this technology in the first place to be able to offer patients a genuine non-invasive alternative to injections and surgery, delivered on the devices the research was actually done with.

Get a straight answer about your tendon

Book with Jonathan Hall → Browns Bay, Auckland. Same-week appointments, Monday to Saturday. Or call our reception on 09 884 0935.

Jonathan Hall M.Ost, BAppSci (Human Biology), PGCertHSc (Acupuncture), GradDipHeal, FIFA Diploma in Football Medicine

References

Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461–469.
Gerdesmeyer L, Frey C, Vester J, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36(11):2100–2109.
Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37(3):463–470.
Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomized, controlled trial. J Bone Joint Surg Am. 2008;90(1):52–61.
Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003;290(19):2573–2580.
Xu D, Jiang W, Huang D, et al. Comparison of efficacy of shock wave therapy versus corticosteroids in plantar fasciitis: a meta-analysis of randomized controlled trials. Med Sci Monit. 2019.
Reinhardt N, Wegenaer J, de la Fuente M. Influence of the pulse repetition rate on the acoustic output of ballistic pressure wave devices. Sci Rep. 2022;12(1):18060.

Disclaimer: This article is general information, not individual clinical advice. Treatment recommendations require assessment.