Shockwave Therapy for Stress Fractures
Shockwave Therapy for Stress Fractures: A Non-Surgical Option Backed by a Head-to-Head Trial Against Surgery
By Dr. Matthew Wilson, DC, FIACA | Ashworth Chiropractic, Physical Therapy & Acupuncture | West Des Moines, Iowa
A stress fracture that isn’t healing on the expected timeline puts athletes in a frustrating position. Rest hasn’t resolved it. Return to sport keeps getting pushed back. And for certain fracture locations — the proximal fifth metatarsal chief among them — surgery is often presented as the default next step, given how notoriously prone that bone is to poor healing and reinjury.
Shockwave therapy has real, direct evidence behind it as a non-surgical alternative for stress fractures, including a randomized trial comparing it head-to-head against surgery. We think that’s worth walking through in detail, because it’s a genuinely strong result.
What Makes Stress Fractures Different From Other Fractures
A stress fracture develops from repetitive loading rather than a single traumatic event — the bone fails gradually under cumulative stress that outpaces its capacity to remodel and adapt. This is why stress fractures are so common in runners and other endurance athletes, and why certain locations, particularly the proximal fifth metatarsal, are known for healing poorly even with appropriate rest and immobilization. That specific bone has a comparatively poor blood supply at the fracture zone, which is part of why it has a higher-than-average rate of delayed union, nonunion, and reinjury even when treated correctly.
That combination — a bone that’s biomechanically prone to slow healing, in athletes who want to return to sport as quickly as safely possible — is exactly the scenario where the choice between surgery and a non-invasive alternative matters most.
Surgery for a fifth metatarsal stress fracture typically means an intramedullary screw, hardware that stays in place, and a real (if generally low) risk of wound complications, nerve injury, or hardware intolerance. A genuinely equivalent non-surgical option is a significant thing to have.
How Shockwave Therapy Is Thought to Affect Bone Healing
- Stimulates osteoblast activity — the cells responsible for new bone formation
- Increases local blood flow to the fracture site, directly addressing the reduced vascularity that makes certain stress fracture locations prone to slow healing
- Triggers a localized biological response that can help restart or accelerate a healing process that has stalled under repetitive loading
What the Clinical Research Shows
Randomized Controlled Trial: Shockwave vs. Surgery
A 2023 pilot randomized controlled trial published in Foot & Ankle International (Ramon et al.) directly compared focused ESWT to surgical fixation for proximal fifth metatarsal stress fractures in soccer players. Eighteen players were randomized to either surgery with an intramedullary screw, or focused shockwave therapy once weekly for three weeks. At final follow-up, there was no statistically significant difference between the two groups in bone healing, pain relief, functional outcome scores (AOFAS and Tegner), or time to return to play. No complications were reported in either group.
Ramon S, Lucenteforte G, Alentorn-Geli E, et al. Foot Ankle Int. 2023;44(12):1256-1265. DOI: 10.1177/10711007231199094.
This is a small study — the authors themselves called for larger trials to confirm the finding, and we think that caveat is worth stating plainly. But a fracture location where surgery is often the default recommendation showing statistically equivalent outcomes to a non-invasive alternative, with zero complications in either study arm, is a genuinely meaningful result, not a marginal one.
Real-World Outcomes in Runners
A 2023 retrospective review of 40 runners with 41 bone stress injuries treated with focused ESWT found that every runner returned to pain-free running after treatment except one, who had a grade 4 navicular nonunion and chose surgery instead. No complications were observed with ESWT in the entire cohort. Runners treated earlier in their injury course (within 3 months of diagnosis) returned to running faster — an average of 12 weeks — than those with delayed or nonunion presentations (nearly 20 weeks), reinforcing that earlier treatment tends to produce better outcomes.
Beling A, Saxena A, Hollander K, Tenforde AS. Bioengineering (Basel). 2023;10(8):885. DOI: 10.3390/bioengineering10080885.
CuraMedix / Storz Medical Clinical Data
CuraMedix, the U.S. distributor for Storz Medical — whose Duolith SD1 Ultra we use at Ashworth Chiropractic — reports an over 80% patient satisfaction rate across treated musculoskeletal conditions, consistent with the outcomes shown in the stress fracture research above.
Why Shockwave Is Worth Discussing Before Surgery
We’re not going to tell you shockwave is right for every stress fracture — a lot depends on the specific bone, the grade of injury, and how it’s responding so far. But for the fracture location with the strongest direct evidence — the proximal fifth metatarsal — a real randomized trial found outcomes equivalent to surgery, without the surgical risks. If you’re being told surgery is the next step for a stress fracture, particularly at that location, we think it’s worth a conversation before committing to the operating room.
What to Expect at Ashworth Chiropractic
- Initial evaluation including imaging review to confirm the fracture, its grade, and its healing trajectory so far
- An honest assessment of whether shockwave is a good fit for your specific fracture — not every stress fracture presentation has the same evidence behind it, and we’ll tell you where yours falls
- A session count and treatment plan determined by your evaluation, not a preset protocol
- Coordination with your physician or surgeon when you’re already under care for the fracture, so treatment isn’t happening in isolation
Common Questions About Shockwave for Stress Fractures
Is shockwave really as effective as surgery for a stress fracture?
For the fracture location with the strongest evidence — the proximal fifth metatarsal — a randomized trial found no significant difference between shockwave and surgery in healing, pain, function, or return to play, with no complications in either group. It’s a small trial, and we’d encourage you to know that going in, but it’s a real head-to-head comparison, not just a favorable single-arm study.
Does this apply to all stress fractures, or just certain locations?
The strongest direct evidence is specific to the proximal fifth metatarsal. Other stress fracture locations have supportive but less direct evidence. We’ll be specific with you about what the research actually supports for your particular fracture at your evaluation.
How soon after diagnosis should shockwave therapy start?
Generally, once a fracture has been given a reasonable window to heal with standard conservative care and isn’t progressing as expected, or immediately if you and your care team are weighing shockwave against surgery as a first-line option. We’ll walk through your specific timeline at your evaluation.
Will my insurance cover this?
Most insurance carriers in the United States do not currently cover ESWT. We’re upfront about this. Pricing and session options are covered clearly at your evaluation.
Should I talk to my doctor or surgeon before starting shockwave therapy?
If you’re already under the care of a physician or surgeon for this fracture, yes. We coordinate with your existing care team rather than treating this in isolation.
Learn More about Shockwave Therapy and the many conditions it can treat.
Clinical References
The following peer-reviewed studies were retrieved from PubMed and cited in this article. All DOIs link to the original published research.
- Ramon S, Lucenteforte G, Alentorn-Geli E, Steinbacher G, Unzurrunzaga R, Álvarez-Díaz P, et al. Shockwave treatment vs surgery for proximal fifth metatarsal stress fractures in soccer players: A pilot study. Foot Ankle Int. 2023;44(12):1256-1265. DOI: 10.1177/10711007231199094
- Beling A, Saxena A, Hollander K, Tenforde AS. Outcomes Using Focused Shockwave for Treatment of Bone Stress Injury in Runners. Bioengineering (Basel). 2023;10(8):885. DOI: 10.3390/bioengineering10080885
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 certifications in Graston Technique, Postural Restoration, functional medicine, acupuncture, laser therapy, and dry needling. He selected the Storz Medical Duolith SD1 Ultra for Ashworth Chiropractic after extensive evaluation of the shockwave market.