Shockwaves and Tendon healing.
Tendon injuries like strains, Tendonosis and Tendonitis are a huge source of pain, discomfort and disability in the patients we see at Mission Chiro. Historically, they have been difficult to treat, stubborn to resolve and have the propensity to recur. The introduction of shockwave therapy has had a tremendous impact on how we treat these injuries and dramatically improved our treatment outcomes in both time frames and resolution. Below is a short article on how Shockwave works in the remodeling phase of tendon healing.
How Shockwave Therapy Supports the Remodeling Phase of Tendon Healing
Tendon injuries often require a long and complex healing process, progressing through three overlapping phases: inflammation, proliferation, and remodeling. While shockwave therapy (extracorporeal shockwave therapy, or ESWT) is well-recognized for its pain-relieving effects, it also plays a crucial role in supporting tissue remodeling — the final phase of tendon repair. This is the stage where long-term function and durability of the tendon are restored.
What Happens During the Remodeling Phase?
The remodeling phase can last several months following a tendon injury. During this time, the initially disorganized scar tissue begins to transform:
Collagen transitions from type III to the stronger and more aligned type I.
Tensile strength increases, and fibers realign along the lines of stress.
The extracellular matrix (ECM) is remodeled to more closely resemble healthy tendon tissue.
However, chronic tendinopathies often involve incomplete or maladaptive remodeling. This is where shockwave therapy can make a significant difference.
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How Shockwave Therapy Enhances the Remodeling Process
1. Stimulates Tenocyte Activity and Collagen Synthesis
Shockwave therapy increases metabolic activity within tendon cells (tenocytes), promoting the production of high-quality type I collagen — the structural backbone of strong, healthy tendon tissue. This helps ensure that newly remodeled tissue has the mechanical integrity required for daily function and load-bearing.
2. Promotes Collagen Fiber Realignment
The mechanical energy delivered by ESWT can help reorganize disordered collagen fibers. This is critical, as chronic tendinopathy often results in tangled, weak fibers that are prone to re-injury. By promoting better alignment, shockwave therapy improves the tendon’s load-handling capabilities.
3. Enhances Blood Flow and Nutrient Delivery
Although vascularity decreases in the remodeling phase, the neovascularization stimulated by earlier shockwave treatments can persist and provide sustained blood flow. This improves oxygen and nutrient delivery, supporting ongoing cellular remodeling and tissue turnover.
4. Regulates Matrix Remodeling Enzymes (MMPs)
Shockwave therapy modulates the activity of matrix metalloproteinases (MMPs), enzymes that break down and rebuild the ECM. In chronic tendon injuries, abnormal ECM accumulation can persist. Shockwaves help normalize this process, clearing dysfunctional tissue and promoting a healthier matrix structure.
5. Reduces Pain and Restores Functional Movement
By reducing local concentrations of pain mediators like substance P, ESWT improves patient tolerance for therapeutic loading. This allows for more effective rehabilitation through movement — which is essential for functional tendon remodeling via mechanotransduction.
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Evidence-Based Outcomes
Multiple studies support ESWT’s role in remodeling:
Wang et al. (2003) demonstrated improved tendon strength and collagen organization in animal models.
Notarnicola & Moretti (2012) highlighted ESWT’s ability to stimulate long-term biological healing responses.
Clinical improvements in pain and function seen with ESWT may reflect these deeper histological and structural changes.
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Final Thoughts
Shockwave therapy is more than a pain-relief tool. When applied at the right stage of recovery, it can actively influence tendon remodeling — promoting better tissue quality, fiber alignment, and long-term functional outcomes. For patients dealing with chronic or recalcitrant tendinopathies, ESWT offers a safe and evidence-informed adjunct to rehabilitation strategies.
If you’d like to learn more about how shockwave therapy fits into your recovery plan, feel free to reach out to our clinic — we’re here to help guide your healing journey.
