Shockwave Therapy for Knee Pain — Patellar Tendinopathy, Osteoarthritis, and More

Shockwave Therapy for Knee Pain: Patellar Tendinopathy, Osteoarthritis, IT Band, and More

By Dr. Matthew Wilson, DC, FIACA  |  Ashworth Chiropractic, Physical Therapy & Acupuncture  |  West Des Moines, Iowa

The knee is one of the most mechanically loaded joints in the body. It takes the impact of every step, every squat, every landing. It bears the accumulated stress of sport, work, and simply moving through a day. And when it breaks down — whether through overuse, degeneration, or injury — it has a way of limiting everything.

Knee pain is also one of the most common reasons people end up in our office after trying other things. Cortisone injections that helped for a few weeks. Physical therapy that made progress but plateaued. A diagnosis of ‘wear and tear’ with a recommendation to come back when it’s bad enough for surgery.

Shockwave therapy fills a specific and meaningful gap in that landscape. It’s not appropriate for every knee problem — we’ll be honest about that throughout this post — but for the conditions where it works, it produces results that change the clinical picture in ways that other non-invasive treatments can’t.

Why Shockwave Works for Knee Conditions

The knee is surrounded by tendons, ligaments, bursa, and connective tissue — all structures that respond to the biological stimulus focused shockwave delivers. The core mechanisms are the same as for other musculoskeletal applications:

• Neovascularization — new blood vessel formation in tissue that has become chronically ischemic and degenerative
• Collagen synthesis and tendon remodeling — replacing disorganized degenerated tissue with structurally organized repair
• Stem cell recruitment and activation — triggering the body’s own regenerative repair process in the surrounding connective tissue
• Substance P reduction — lowering the primary pain-signaling neuropeptide driving chronic tendon and joint pain
• Chondrocyte stimulation — in osteoarthritic conditions, focused shockwave has been shown to stimulate cartilage cell activity and reduce local inflammatory mediators

The Storz Medical Duolith SD1 Ultra with Sepia focused handpiece delivers this energy precisely — to the tendon insertion, the joint line, the fascial attachment — not diffusely through surface tissue. That precision matters particularly around the knee, where the structures that need treatment are often millimeters apart.

Patellar Tendinopathy — Jumper’s Knee

Shockwave has been shown to help knee pain, range of motion and function for all kinds of knee injuries.

Patellar tendinopathy — commonly called jumper’s knee — is degeneration and pain at the patellar tendon, usually at the inferior pole of the patella where the tendon originates. It’s common in athletes who jump, sprint, or load the knee repeatedly: basketball players, volleyball players, runners, weightlifters, and CrossFit athletes.

Like other tendinopathies, it transitions from an acute inflammatory phase to a chronic degenerative phase. In the chronic phase, the tendon tissue has structurally broken down and the body has largely stopped trying to repair it. Rest helps temporarily. The pain returns when activity resumes.

What the Research Shows for Patellar Tendinopathy

Based on articles retrieved from PubMed, a 2023 systematic review and meta-analysis published in Frontiers in Immunology (Charles et al.) evaluated shockwave therapy specifically for patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis. For patellar tendinopathy, the review found that ESWT significantly affects pain compared to conservative treatment — though the evidence for function was less consistent. The review assigned low-moderate GRADE evidence for patellar tendinopathy, compared to high-quality evidence for plantar fasciitis.

We want to be honest about what that means: the evidence for shockwave in patellar tendinopathy is real but not as strong as for some other conditions. What the research consistently supports is that ESWT plus eccentric exercise loading produces better outcomes than either alone — and that for athletes who have plateaued with physical therapy or who can’t tolerate sufficient loading due to pain, shockwave therapy changes the tissue environment and makes further rehabilitation possible.

Charles R, et al. The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Front Immunol. 2023;14:1193835. DOI: https://doi.org/10.3389/fimmu.2023.1193835

A randomized controlled trial published in the Clinical Journal of Sport Medicine (Lee et al., 2020) enrolled 34 male in-season athletes with patellar tendinopathy and compared eccentric exercise alone against eccentric exercise combined with ESWT. Both groups showed significant reduction in pain and dysfunction, and significant changes in tendon stiffness on ultrasound — confirming that the combination produces measurable structural tendon changes, not just reported pain improvement.

Lee WC, et al. Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise. Clin J Sport Med. 2020;30(1):25-32. DOI: https://doi.org/10.1097/JSM.0000000000000562

Knee Osteoarthritis — Meaningful Relief Without Surgery

Knee osteoarthritis is one of the most common chronic musculoskeletal conditions in adults over 50 — and one of the most common reasons people are told to come back when it’s bad enough for a knee replacement. What often gets lost in that conversation is how much can still be done conservatively.

Shockwave therapy for knee OA doesn’t reverse cartilage degeneration — we won’t claim that. What it does is address the periarticular soft tissue, the subchondral bone, and the inflammatory environment around the joint in ways that produce meaningful pain relief and functional improvement — often at all follow-up timepoints, not just short term.

Umbrella Review of 8 Meta-Analyses — Effective for Pain and Function

Based on articles retrieved from PubMed, a 2024 umbrella review published in the International Journal of Surgery (Tang et al.) analyzed 8 separate meta-analyses on ESWT for knee osteoarthritis. The pooled conclusion: ESWT significantly outperformed sham treatment on the WOMAC arthritis index (MD = -2.94), Visual Analog Scale pain (MD = -2.0), range of motion (MD = 17.55 degrees improvement), and the Lequesne index of functional disability. The authors concluded that ESWT is now an effective therapy for improving pain and function in patients with knee OA.

Tang P, et al. The efficacy of extracorporeal shock wave therapy for knee osteoarthritis: an umbrella review. Int J Surg. 2024;110(4):2389-2395. DOI: https://doi.org/10.1097/JS9.0000000000001116

A 2022 meta-analysis published in Clinical Rehabilitation (Silva et al.) analyzed 12 RCTs covering 734 participants and found that shockwave therapy was favored over sham for pain at short, medium, AND long-term follow-up — a finding that matters because many non-surgical interventions produce short-term relief that fades. For knee OA, the pain benefit from shockwave appears to persist.

Silva AC, et al. Effect of extracorporeal shock wave therapy on pain and function in patients with knee osteoarthritis: a systematic review with meta-analysis and grade recommendations. Clin Rehabil. 2023;37(6):760-773. DOI: https://doi.org/10.1177/02692155221146086

For patients who have been told their only option is a knee replacement: that is often not accurate. ESWT is an evidence-supported non-surgical option that produces lasting pain relief and functional improvement. We’d encourage a conversation with us before committing to surgery.

IT Band Syndrome — Lateral Knee Pain in Runners and Cyclists

Iliotibial band syndrome is the most common cause of lateral knee pain in runners and cyclists — a sharp, burning pain at the outside of the knee that typically comes on at a predictable distance into a run and forces a stop. It’s caused by repetitive friction of the IT band over the lateral femoral condyle, leading to local tissue thickening, inflammation, and eventually fibrotic change in the underlying periosteum and peritendinous tissue.

The IT band itself is not the primary treatment target — it’s a thick fascial structure with limited blood supply and limited capacity to remodel. What shockwave therapy addresses effectively is the compressed tissue and periosteal reaction at the lateral femoral condyle insertion zone, and the chronic soft tissue thickening and adhesion that develops with repeated friction.

The evidence base for ESWT specifically in IT band syndrome is smaller than for patellar or Achilles tendinopathy, but the biological rationale is strong — the same mechanisms that address calcific deposits and fascial restriction elsewhere are applicable here. At Ashworth, we use shockwave for IT band presentations that have not responded to activity modification and targeted hip abductor strengthening — specifically for the periosteal and fascial component at the lateral condyle.

Combined with physical therapy from Kelly Brown Gross, PT, MPT, WCS to address the hip mechanics and running gait that drive IT band loading, the results are consistently better than either alone.

Pes Anserine Bursitis and Tendinopathy — The Overlooked Medial Knee

Pes anserine bursitis and tendinopathy is one of the most frequently missed sources of medial knee pain — particularly in middle-aged and older patients, women, patients with knee OA, and those who are overweight or have diabetes. The pes anserine is the conjoined insertion of the sartorius, gracilis, and semitendinosus tendons on the medial tibial plateau, just below the knee joint line.

Pain here is often mistaken for knee OA progression or medial meniscal pathology. It is characteristically present with stair climbing, rising from a chair, and medial knee pain that aches at rest. It frequently coexists with OA but is a distinct, independently treatable condition.

Shockwave therapy to the pes anserine insertion addresses the same chronic degenerative tendon changes present at other tendon insertions throughout the body — fibrotic tissue, reduced blood supply, pain signaling. In patients with medial knee pain who have not responded to standard OA management, identifying and treating the pes anserine component frequently produces substantial improvement. We see this regularly and it often surprises patients who have been managing what they thought was just ‘arthritis.’

Quadriceps Tendinopathy — The Upper Pole of the Patella

Quadriceps tendinopathy is degeneration of the quadriceps tendon at its insertion on the superior pole of the patella — the upper kneecap. It is distinct from patellar tendinopathy (which involves the inferior pole and patellar tendon) and is more common in older athletes, weightlifters, and recreational exercisers who maintain high-load knee extension activity.

The presentation is anterior knee pain above the kneecap — worsened by loaded knee extension, squatting, stair climbing, and activities that require eccentric quadriceps control. It is frequently under-diagnosed because its location above the patella is less recognized than patellar tendinopathy below it.

The evidence base for ESWT specifically in quadriceps tendinopathy is less extensive than for patellar tendinopathy, but the mechanism is identical — the same degenerative tendon pathology at an insertion site that responds to the same biological stimulus. At Ashworth, we treat quadriceps tendinopathy presentations with shockwave using the same protocol principles as patellar tendinopathy, combined with progressive eccentric loading through physical therapy.

Chronic Meniscus-Related Pain — Where Shockwave Fits and Where It Doesn’t

This one deserves an honest explanation because it’s more nuanced than the other conditions in this post.

Shockwave therapy does not repair a torn meniscus. The meniscus is fibrocartilage — it has limited blood supply and limited regenerative capacity, particularly in the inner two-thirds where most tears occur. If you have a mechanically significant meniscal tear — one that is causing locking, catching, or significant instability — that is a structural problem that requires structural evaluation and possibly surgical treatment.

That said, a large proportion of people with ‘meniscus issues’ on imaging are actually dealing with a more complex picture than a simple meniscal tear. Degenerative meniscal changes often coexist with:

• Perimeniscal soft tissue inflammation — the synovium, joint capsule, and surrounding tissue that become chronically irritated and contribute significantly to pain
• Pes anserine tendinopathy — medial knee pain that mimics meniscal symptoms but is at a different location and responds to different treatment
• Knee OA — the degenerative joint changes that accompany meniscal degeneration and are often the primary pain driver
• Popliteal and posterior capsular restriction — the posterior knee soft tissue that becomes restricted and painful in chronic knee conditions

For all of these surrounding tissue contributors, shockwave therapy is clinically relevant and produces meaningful improvement. When we see patients with chronic ‘meniscus pain’ who have not responded to other treatment, a thorough clinical examination often identifies specific soft tissue targets — the pes anserine insertion, the joint line soft tissue, the popliteal region — where shockwave produces excellent results.

The meniscal cartilage itself is not the target. The suffering around it often is.

If you have been told you have a meniscal tear and you are not experiencing locking or significant instability, a trial of targeted conservative care — including shockwave to the perimeniscal soft tissue and any concurrent tendinopathic contributions — is reasonable before surgical consultation. We will be direct with you at evaluation about what we think the shockwave can address and what it can’t.

When Knee Surgery Didn’t Fully Work — and What Comes Next

A significant portion of the knee patients we see at Ashworth have already had surgery. Arthroscopy that improved things for a year and then the pain returned. A meniscal repair or partial meniscectomy that helped with mechanical symptoms but left persistent aching. A total knee replacement that resolved the grinding and instability but introduced new pain — anterior knee pain, patellar tendon irritation, or soft tissue tightness around the joint line that didn’t respond to standard post-surgical rehabilitation.

Surgery fixes the structural problem it was designed to address. What it doesn’t fix is the periarticular soft tissue — the tendons, the capsule, the surrounding connective tissue — that has been guarded, restricted, or mechanically altered by the surgical process and recovery period. That tissue is exactly what focused shockwave therapy addresses.

For patients whose pain returned after arthroscopy — the underlying tendinopathy, soft tissue degeneration, or OA component that drove the problem in the first place was still present. Shockwave addresses exactly those periarticular tissue targets and produces meaningful improvement even in previously operated knees.

On Hardware — What You Should Know

One of the most common questions we hear from post-surgical patients is whether shockwave therapy is safe around orthopedic hardware — screws, plates, rods, knee replacement components. The answer is important: metallic orthopedic implants are not a contraindication to focused shockwave therapy.

The reason is straightforward. The known contraindications for ESWT involve electronic implanted devices — pacemakers and defibrillators — because acoustic energy can interfere with electronics. Orthopedic hardware is passive metal. It has no electronics. The acoustic waves produced by focused shockwave pass through and around the surrounding soft tissue without interacting with the implant in a harmful way. This is well established in ESWT clinical practice guidelines and recognized by international shockwave therapy consensus panels.

In practical terms: if you have a total knee replacement and are dealing with persistent patellar tendon pain, pes anserine irritation, or lateral soft tissue restriction around the prosthesis — all of which are common and often undertreated in post-TKA patients — focused shockwave to the specific soft tissue target is a viable and clinically appropriate option. We treat around hardware regularly. We are precise with the treatment location and conservative with energy parameters in post-surgical tissue.

If you had knee surgery and you’re still dealing with pain — whether it never fully resolved or it came back — you have not run out of options. The soft tissue around your knee can still be treated effectively. Call us and let’s figure out specifically what’s driving it.

Every knee patient starts with a thorough evaluation. The knee is a joint where multiple things can be happening simultaneously — patellar tendinopathy and IT band syndrome in the same runner, knee OA and pes anserine bursitis in the same older patient. Getting the diagnosis right before treating is how we get the results we do.

If shockwave therapy is appropriate:

• 6 focused shockwave sessions, spaced 1 to 2 weeks apart
• 5 to 15 minutes per session — no anesthesia, no recovery time, walk right out
• Storz Medical Duolith SD1 Ultra with Sepia focused handpiece — precise delivery to the specific structure, not surface-level radial waves
• Coordinated with physical therapy from Kelly Brown Gross, PT, MPT, WCS for the movement and loading component — because tissue repair without addressing the mechanics that caused the problem leads to recurrence.

Common Questions

I have a knee replacement / screws / plates from previous surgery. Can I still have shockwave?

Yes — metallic orthopedic hardware is not a contraindication to focused shockwave therapy. The contraindication for ESWT applies to electronic implanted devices like pacemakers and defibrillators, because acoustic energy can interfere with electronics. Passive metal hardware — screws, plates, rods, prosthetic knee components — does not carry that risk. We treat around hardware regularly and are precise about treatment location and energy parameters in post-surgical tissue. If you have persistent soft tissue pain around a previous knee surgery, that tissue can still be evaluated and treated effectively.

I have knee arthritis. Am I too far gone for shockwave to help?

Probably not. The 2024 umbrella review covering 8 meta-analyses found significant improvements in pain and function even in established knee OA. Cartilage doesn’t regenerate, but the periarticular tissue, the inflammatory environment, and the bone remodeling that occurs around an arthritic joint all respond to shockwave. Many patients with significant arthritis on imaging get meaningful relief.

I’ve been told I need a knee replacement. Should I try shockwave first?

For many patients, yes — especially if the surgical recommendation is based primarily on pain and functional limitation rather than structural instability or severe deformity. The evidence supports shockwave as a meaningful non-surgical option for knee OA. A conversation with us before committing to surgery costs nothing and may significantly change the picture.

I’m a runner with IT band syndrome. How many sessions before I can run again?

That depends on how long you’ve had it and how significant the soft tissue changes are. Most IT band patients see meaningful improvement within 3 to 4 sessions. Return to running is typically done progressively and in coordination with the hip strengthening work that addresses the underlying mechanical driver. Kelly can build a return-to-run program that uses the shockwave progress as the foundation.

If you’re ready to find out whether you’re a candidate, visit our shockwave therapy service page for full details

Clinical References

The following peer-reviewed studies were retrieved from PubMed and cited in this article.

1. Charles R, et al. The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Front Immunol. 2023;14:1193835. DOI: https://doi.org/10.3389/fimmu.2023.1193835
2. Lee WC, et al. Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise. Clin J Sport Med. 2020;30(1):25-32. DOI: https://doi.org/10.1097/JSM.0000000000000562
3. Tang P, et al. The efficacy of extracorporeal shock wave therapy for knee osteoarthritis: an umbrella review. Int J Surg. 2024;110(4):2389-2395. DOI: https://doi.org/10.1097/JS9.0000000000001116
4. Silva AC, et al. Effect of extracorporeal shock wave therapy on pain and function in patients with knee osteoarthritis: systematic review with meta-analysis and grade recommendations. Clin Rehabil. 2023;37(6):760-773. DOI: https://doi.org/10.1177/02692155221146086

About the Author

Dr. Matthew Wilson, DC, FIACA, CCWP is the owner and lead clinician at Ashworth Chiropractic, Physical Therapy & Acupuncture in West Des Moines, Iowa. He is a Palmer College of Chiropractic honors graduate with advanced training in Postural Restoration (PRI), Graston Technique, acupuncture, dry needling, laser therapy, and functional medicine. He works alongside Kelly Brown Gross, PT, MPT, WCS to provide coordinated care for knee pain patients across the full spectrum of presentations and diagnoses.