Treatments and gadgets. 11 minute read.
Shockwave therapy for plantar fasciitis: does it work, and where it fits
By the PocketPhysio editorial team. Published 2026-10-01.
What shockwave therapy actually is
The clinician presses a head against your heel through gel, and it fires pressure waves into the tissue underneath. There are two kinds, and clinics do not always say which they have. A focused machine aims its peak energy at a depth, so the strongest part of the wave lands on the sore tissue and not on the skin. A radial machine produces its peak at the surface and spreads from there. Both are called shockwave therapy and both appear in the trials, which is one reason the results scatter.
What it is doing is less settled than how it is done. The usual explanation involves irritating the tissue enough to restart a healing response in a fascia that has stopped responding, and that is a reasonable description of a plausible mechanism. Nobody has measured it in a human heel, and nobody should sell you certainty about the biology. The question worth answering is narrower: does the heel feel better afterward, and better than it would have done anyway?
Does shockwave therapy for plantar fasciitis work?
Against a placebo, the pooled trials point one way. How firmly is where the two newest syntheses part company.
A 2023 systematic review looked at shockwave across patellar tendinopathy, Achilles tendinopathy and plantar fasciitis, taking in 63 studies in total, of which 40 were on plantar fasciitis. Pooling the 13 that compared shockwave with a placebo, the authors concluded that it had a large effect on pain in the short, mid and long term and on function in the short term. They rated the certainty of that evidence moderate to high (Charles and colleagues, 2023).
Hold three things alongside that. Of its 63 studies, 39 were at high risk of bias for missing outcome data. No analysis group reached 10 studies, which is the threshold the authors had set for testing publication bias, so that test was never done; those 13 studies were split across separate pain and function analyses at each follow-up point. And most of the included studies did not report which type of machine was used.
A network meta-analysis published in 2025 is more cautious. Across 22 randomized trials and 2,299 people with plantar heel pain, every intensity of shockwave beat placebo on success rate, with odds ratios from 2.29 (95% confidence interval 1.39 to 3.76) for medium intensity to 5.50 (1.00 to 30.29) for low intensity, where that second interval only just clears no effect. Only medium and high intensity beat placebo on pain scores (standardized mean differences of minus 0.60, 95% confidence interval minus 0.94 to minus 0.26, and minus 0.28, minus 0.44 to minus 0.11). On function, no intensity beat placebo at all. Seven of the 22 trials were at high risk of bias and the rest unclear, and the authors graded the certainty of the whole body of evidence low to very low (Zhao and colleagues, 2025).
Then the comparison that decides whether this is worth doing. In the same 2023 review, shockwave was measured against other treatments: corticosteroid injection, prolotherapy, low level laser and ordinary conservative care. The difference in pain and function in the short term was small and inconclusive, at what the authors graded low to moderate certainty. Its own comparison against a corticosteroid injection, pooled from six studies, came out at very low certainty. Beating a sham is not the same as beating the alternatives, and on that second question the answer is that nobody knows.
The 2021 best practice guide for plantar heel pain is more specific about what kind of benefit to expect. It found moderate evidence for focused shockwave on overall pain, with a standardized mean difference of 0.36 and a confidence interval from 0.11 to 0.61, and what it labeled strong evidence for first step pain in the short term, an odds ratio of 1.89 (1.18 to 3.04). For radial shockwave it reported first step pain odds ratios of 1.66 (1.00 to 2.76) in the short term and 1.78 (1.07 to 2.96) in the long term (Morrissey and colleagues, 2021). Its labels are its own and not GRADE ratings: strong there means more than one adequately powered high-quality trial found an effect, moderate means one did. First step pain is the symptom most people came for, so that is the useful part of the finding.
What NICE says, and why the date matters
NICE has guidance on this exact question, and it is blunter than anything above. Extracorporeal shockwave therapy for refractory plantar fasciitis is HealthTech guidance HTG200, migrated from interventional procedures guidance IPG311 with the recommendations unchanged. Its first recommendation reads: "The evidence on extracorporeal shockwave therapy (ESWT) for refractory plantar fasciitis raises no major safety concerns; however, current evidence on its efficacy is inconsistent. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research." It then tells clinicians to inform the clinical governance leads in their trusts, to "Ensure that patients understand the uncertainty about the procedure's efficacy and provide them with clear written information", and to audit the outcomes of every patient they treat with it. NICE also encourages further research, and asks for trials with clearly described patient selection and protocols and at least a year of follow-up.
Now the date, because it changes how you read it. HTG200 was published on 26 August 2009 and has not been reappraised; NICE says it will be reviewed if there is new evidence likely to change the recommendations.
So this is not a current assessment of the 2021 guide or the two reviews above, and nobody should present it as one. It is still the formal status of the treatment, and the part that matters to you as a patient has not been withdrawn: the guidance tells the clinician to make sure you understand that the evidence on how well it works is uncertain, and to give you that in writing. In the UK, if that conversation does not happen, the clinic is not following the guidance that covers what it is doing. NICE does not apply outside the UK, but the reason for the written information travels.
Note also the word NICE uses, refractory. Even in 2009 this was a treatment for heels that had not settled with the basics.
Where it belongs in the order of treatment
Not first. One honest caveat before the reason: the authors of the 2023 review read their own result as meaning shockwave can be given as a primary treatment for plantar fasciitis. This page does not follow them there. A systematic review is not a care pathway, and the two documents that were written as pathways, the 2021 guide and NICE, both put shockwave later.
The 2021 guide builds its pathway around a core approach used for everyone: plantar fascia stretching, low dye taping and education matched to the individual, all running together. It asks for about 4 to 6 weeks of that before any adjunct is considered, and then names shockwave, radial or focused, as the adjunct for people who are not getting far enough on the core work, with custom orthoses after it (Morrissey and colleagues, 2021).
The NHS takes the same shape from the other end. It gives the self-care list first, says to see a GP if foot pain has not improved after treating it yourself for 2 weeks, then sends you to a physiotherapist or podiatrist for exercises, insoles, footwear advice or night splints, and only after that mentions steroid injections or a machine delivering high energy sound waves to the foot as treatments you may be offered.
That order is not an accident. If nobody has yet shown you how to load a calf, there is a cheaper and better supported step in front of this one, and it is set out in our plantar fasciitis program. If you want to know why the first steps of the morning are the worst part, heel pain in the morning answers that question on its own. If the sore spot sits higher up at the back of the ankle instead of underneath the heel, it may be Achilles tendinopathy, which has a different program.
One reason the order matters: these heels are slow. In the studies behind the 2021 guide, the average person had been putting up with the pain for 13 months before they entered a trial, with a range from under a month to over five years. A treatment that is offered at week 3 of a problem is being judged against a condition that improves on its own timetable.
What a course looks like, and what to do afterward
Expect a short course rather than a block of weekly appointments stretching into the distance. Across the plantar fasciitis trials in the 2023 review, courses ran from 2 to 6 sessions, most often 3, generally about a week apart over 3 to 6 weeks. The pulses per session ran from a few hundred to several thousand, and the frequency varied as well. That spread is not a detail: it means no clinic can tell you its protocol is the proven one, because the trials did not agree on a protocol.
Afterward, the loading work continues. That is the single most useful sentence on this page, and it follows directly from shockwave being an adjunct in every pathway that recommends it. On what it feels like on the day, the 2021 guide reported no or minimal side effects in each of its studies while describing the procedure itself as unpleasant for patients, and the 2023 review stated that studies of the potential adverse events of this treatment are still needed, so the reassurance only goes so far. Judge the whole thing on how the first steps of the morning feel across several weeks, which is the measure that moves slowly enough to be honest.
Who should not have it, and who should check first
The contraindications for this treatment are about what sits in the path of the wave rather than about the condition being treated. The professional society for the technique, the International Society for Medical Shockwave Treatment, lists plantar fasciitis with or without a heel spur as an approved standard indication, and gives three contraindications for radial and low energy focused devices: a malignant tumor in the shockwave field, which is not the same as having had cancer; a fetus in the shockwave field, which is not the same as being pregnant; and a pacemaker or defibrillator in the shockwave field. For high energy focused devices it adds brain and spinal cord tissue, the vertebral bodies, the skull, the ribs, lung tissue, plus a significant coagulation disorder. That is an industry-linked society and not an independent guideline body, so read the list as the practitioners' own consensus.
Read the words "in the shockwave field" carefully, because they do most of the work. For a heel, the entries about a tumor or a fetus, and the one about a cardiac device, are about where the head is pointed, not about whether you have the condition, which is why that list matters far more for treatment near the chest, the spine or the abdomen. Tell the clinician about a pacemaker or defibrillator anyway, so they can confirm it is nowhere near the treated area.
Three groups should have a conversation before they book. Anyone taking a medicine that thins the blood, or with a bleeding or clotting condition. Be clear on what the society's list does and does not say there: a significant coagulation disorder is a contraindication only for the high energy focused machines, and blood-thinning medicines are not on the list at all. Bruising is the obvious thing to think about with a device that drives pressure waves into tissue, and that is reasoning rather than a published finding, so put it to your prescriber and the clinician as a question and not as a rule. Never stop or change a prescribed medicine on your own.
Anyone with diabetes or reduced feeling in the feet comes next, and that caution is not a shockwave one either: it comes from standard diabetic foot care, where a numb foot cannot report a problem and any new foot pain needs checking by your own doctor or foot team first. Our plantar fasciitis program says the same thing before its exercises. Last, anyone whose heel pain has not actually been diagnosed, since a calcaneal stress fracture, a nerve problem and an inflammatory arthritis can all sit under the same heel and none of them is a reason for shockwave.
What it costs, and who pays
No prices here. They differ from country to country and from clinic to clinic, and a per-session figure means little without the number of sessions and the follow-up.
How payers class the treatment says something about how settled the evidence is. Aetna's clinical policy bulletin on plantar fasciitis treatments lists extracorporeal shock wave therapy among the approaches it considers experimental, investigational or unproven, and its stated reason is a lack of reliable published literature on safety and efficacy for this condition. Policies differ between insurers and between countries, so check your own cover: one insurer's position does not tell you what yours says. A treatment that performs well against a sham, inconclusively against its alternatives, and that NICE filed in 2009 as one to use only with special arrangements for consent and audit, is exactly the kind of treatment payers argue about.
When to see a physio (physical therapist)
Before the machine, not after it. An assessment gets you two things shockwave cannot: confirmation that this is actually plantar heel pain and not one of the problems in the warning list below, and a loading program you can run at home for nothing. If you have already had a course of shockwave and the heel is no better, the first question is whether the loading work ever happened properly alongside it.
Book sooner if you have diabetes or numb feet and any new foot pain, if the heel hurts at rest and at night, if both heels hurt, or if you felt something tear. The warning list sets out how fast each of those needs dealing with, and a physio is not the right first call for several of them.
See a doctor promptly if
- Emergency: part of your foot or a toe turns cold, pale, blue or black. Call emergency services or go to an emergency department straight away, and do not drive yourself, as the blood supply to the foot may be blocked.
- Same day: the heel or foot is hot, red and swollen, or you have a fever or feel unwell. Get medical help the same day, and go to an emergency department if you feel very unwell. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- Same day: the heel pain started with a fall or a landing from height, or you cannot put weight on the foot. Get it checked the same day.
- Same day: you felt a sudden pop or tearing under the foot, followed by bruising and difficulty walking. Get it checked the same day.
- Same day: you have diabetes or numb feet, and one foot becomes hot, swollen or red, or changes color or shape, with or without pain. Take your weight off that foot straight away and get advice the same day from your doctor or your diabetes foot team. This can be Charcot foot, where the bones and joints of the foot are damaged and the foot can collapse. Do not exercise that foot until it has been checked. If you also have a fever or feel very unwell, or redness is spreading up your foot or leg, go to an emergency department.
- Same day: you have diabetes or numb feet and find a new blister, cut or sore on your foot, especially one you did not feel, a wound that smells or is leaking, or new pain in your foot that you cannot explain. Get it seen by your doctor or foot team the same day. If you also have a fever or feel very unwell, redness is spreading up your foot or leg, or part of your foot or a toe turns black, go to an emergency department.
- Within a few days: the whole heel hurts when you squeeze it from both sides, especially after a sudden increase in running or walking, or if you have thin bones (osteoporosis). Stop running and jumping, cut down on walking and standing, and see a doctor within a few days, as this can be a stress fracture of the heel bone rather than plantar fasciitis. An X-ray can look normal for the first 2 to 3 weeks, so a normal early X-ray does not rule it out.
- Within a few days: the pain is there at night or at rest as well as when you stand and walk, and it is getting worse. See your doctor within a few days. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse. If you are being treated for cancer now, contact your cancer team the same day.
- Within a week or two: you have numbness, tingling, burning or loss of feeling in the foot. Book an assessment with a doctor or physio in the next week or two.
- Within a week or two: both heels hurt and you also have swelling or morning stiffness in other joints or your lower back. This is not an emergency, but see your doctor in the next week or two, as it can be a sign of an inflammatory arthritis.
Common questions
Does shockwave therapy work for plantar fasciitis?
Against a placebo, the pooled trials point that way, and the two newest syntheses disagree about how firmly. A 2023 systematic review of shockwave for three tendon and fascia problems included 40 plantar fasciitis studies and pooled 13 of them against placebo, concluding that shockwave had a large effect on reducing pain in the short, mid and long term and on improving function in the short term, at moderate to high certainty (Charles and colleagues, 2023). A 2025 network meta-analysis of 22 randomized trials in 2,299 people with plantar heel pain found every intensity more effective than placebo on success rate, but no intensity better than placebo on function, and graded the certainty of the evidence low to very low, with 7 of the 22 trials at high risk of bias and the rest unclear (Zhao and colleagues, 2025). Two weaker findings matter for choosing: compared with other treatments such as a corticosteroid injection, laser or standard conservative care, the 2023 review found only a small and inconclusive difference in the short term, at low to moderate certainty. And NICE guidance HTG200 states that the evidence on efficacy is inconsistent, that the procedure should only be used with special arrangements for clinical governance, consent and audit or research, and that patients should be given clear written information about that uncertainty; that guidance was published on 26 August 2009 and has not been reappraised since.
How many shockwave sessions do you need for plantar fasciitis?
There is no standard course, and the honest answer is that it depends on the clinic's protocol rather than on evidence about the best number. Across the plantar fasciitis trials in the 2023 review, courses ran from 2 to 6 sessions, most commonly 3, usually spaced about a week apart over 3 to 6 weeks, with the number of pulses per session varying from a few hundred to several thousand (Charles and colleagues, 2023). No trial has compared 3 sessions with 6 in a way that settles it. Before you start, ask how many sessions are planned, what the review point is, and what happens if the heel has not changed by then.
What should you do after shockwave therapy for plantar fasciitis?
Keep doing the loading work, because that is what shockwave is added to rather than a replacement for. The 2021 best practice guide for plantar heel pain positions shockwave as an adjunct used when stretching the plantar fascia, low dye taping and education matched to the person are not getting far enough, and the core treatment continues underneath it (Morrissey and colleagues, 2021). Our plantar fasciitis program sets out the staged version of that work: calf and plantar fascia stretches through to heavier heel raises, with the numbers on each exercise page and your physio adjusting them to your heel. Judge progress by how the first steps of the morning feel over weeks, not by how the foot feels on the walk back to the car.
Is shockwave therapy for plantar fasciitis painful?
Uncomfortable is the usual description, and an honest clinician will say so in advance. The 2021 best practice guide reports no or minimal side effects in each of its included studies while noting that the procedure was described as unpleasant for patients, both in the study reports and in the interviews the authors carried out (Morrissey and colleagues, 2021). The network meta-analysis of 22 trials found no significant difference between any shockwave intensity and placebo in acceptability, which is a measure of how many people dropped out, so the discomfort did not drive people away (Zhao and colleagues, 2025). Set against that, the 2023 review stated that studies of the potential adverse events of this treatment are still needed, so treat that reassurance as limited, not settled.
How much does shockwave therapy for plantar fasciitis cost?
We do not publish prices, because they differ by country and by clinic, and a single session price tells you nothing without the number of sessions. What is more informative is how payers class the treatment. Aetna's clinical policy bulletin on plantar fasciitis treatments lists extracorporeal shock-wave therapy among the approaches it considers experimental, investigational or unproven, citing a lack of reliable published literature on safety and efficacy for this condition. Policies differ between insurers and between countries, so that one example is a reason to check your own cover, not a prediction of what it says. NICE guidance HTG200, published in 2009 and not reappraised since, takes a similar view of the evidence: efficacy inconsistent, use only with special arrangements for clinical governance, consent and audit or research, and clear written information for the patient about the uncertainty.
Can you do shockwave therapy at home?
The trials behind this page all used clinic machines applied by a clinician, with pulse counts and energy settings recorded for each study. A handheld percussion or massage device bought for home use is a different thing doing a different job, and nothing here is evidence for one. If you want something to do at home for a sore heel, it is the stretching and loading work that has the research behind it, and our plantar fasciitis program is where it lives.
References
- Charles R, Fang L, Zhu R, Wang J. The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Frontiers in Immunology. 2023;14:1193835. doi:10.3389/fimmu.2023.1193835
- Morrissey D, Cotchett M, Said J'Bari A, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine. 2021;55(19):1106-1118. doi:10.1136/bjsports-2019-101970
- Zhao P, He Y, Li M, et al. Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy in adults with plantar heel pain: a systematic review and network meta-analysis. PM&R. 2025;17(12):1481-1493. doi:10.1002/pmrj.13417
- International Society for Medical Shockwave Treatment. Indications and contraindications for shockwave therapy. Accessed 1 October 2026. https://shockwavetherapy.org/indications/
- National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for refractory plantar fasciitis. HealthTech guidance HTG200, migrated from interventional procedures guidance IPG311. Published 26 August 2009. Read 1 October 2026. https://www.nice.org.uk/guidance/htg200
- NHS. Plantar fasciitis. Page last reviewed 14 February 2025. https://www.nhs.uk/conditions/plantar-fasciitis/
- Aetna. Plantar fasciitis treatments. Clinical Policy Bulletin 0235. Accessed 1 October 2026. https://www.aetna.com/cpb/medical/data/200_299/0235.html
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-01.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.