Extracorporeal Shockwave Therapy as an Adjunct to Physiotherapy for Tendinopathies: A Scoping Review of Dosage, Modality, Clinical Outcomes, and Treatment Response

Abstract

Background: Tendinopathy is a common musculoskeletal disorder characterized by pain, reduced load tolerance, and functional limitation. Extracorporeal shockwave therapy (ESWT) is increasingly used as an adjunct to physiotherapy, but differences in treatment parameters and rehabilitation programs complicate interpretation of its effectiveness. Objective of this study: To map the available evidence on ESWT combined with physiotherapy for tendinopathies, focusing on treatment modality, dosage, rehabilitation co-interventions, clinical and structural outcomes, adverse events, and factors associated with treatment response. Methods: This scoping review follows the Arksey and O’Malley framework, Levac et al.’s methodological enhancements, Joanna Briggs Institute guidance, and PRISMA-ScR recommendations. The review examines adults with tendinopathy receiving ESWT alongside physiotherapy. Evidence is charted according to tendon site, ESWT modality, treatment parameters, co-interventions, outcome domains, follow-up, and treatment response. Results: The evidence demonstrates substantial clinical and methodological heterogeneity. Achilles and lateral elbow tendinopathies are prominent evidence clusters. Focused, point-focused, line-focused, and radial protocols differ considerably in physical dose. Some lateral elbow studies report favorable pain and functional responses, whereas sham-controlled Achilles trials do not consistently demonstrate additional benefit beyond exercise and education. Structural outcomes are less frequently reported and do not always parallel clinical improvement. Conclusion: ESWT may be a useful adjunct for selected patients, but current evidence does not support a universal protocol or universal superiority over high-quality rehabilitation. Future research should standardize dose reporting, physiotherapy co-interventions, clinically meaningful outcomes, structural measures, and long-term follow-up.