Focused and Radial Shockwave Therapy

Precise mechanical impulses for pain therapy, tissue regeneration and functional rehabilitation

Extracorporeal shockwave therapy, or ESWT, is a non-invasive procedure in which mechanical pressure impulses are delivered into the tissue from outside the body. In modern musculoskeletal medicine, two main forms are distinguished: focused shockwaves and radial shockwaves. Focused shockwaves concentrate energy at a defined depth, while radial shockwaves deliver their highest energy close to the surface and spread more broadly from the application site (STORZ MEDICAL, Tenforde et al. 2022).

At RECURIO, shockwave therapy is not used as a generic standalone treatment, but is integrated into a structured treatment concept after medical indication. The choice between focused and radial shockwave therapy depends on the condition, target structure, tissue depth, irritability, previous treatments and therapeutic goal. The aim is not only short-term pain reduction, but a meaningful combination of pain modulation, tissue stimulation, load management and active rehabilitation.

What is shockwave therapy?

Shockwaves are short, high-energy mechanical waves with a rapid pressure rise followed by a negative pressure phase. In musculoskeletal applications, they are intended to stimulate biological processes in the tissue, including mechanotransduction, meaning the conversion of mechanical stimuli into cellular signalling processes (Vázquez-Sasot et al. 2023). Analgesic, circulation-promoting, tissue-repairing and osteogenic effects have been described, although the exact mechanisms are not yet fully understood and vary depending on tissue and indication (Vázquez-Sasot et al. 2023).

Clinically, ESWT is mainly used for chronic tendon insertion disorders, fasciopathies, myofascial pain, selected bone healing disorders and certain degenerative or overload-related musculoskeletal conditions. Best-practice recommendations emphasise that shockwave therapy should generally be combined with active rehabilitation, progressive loading and clear follow-up monitoring (Tenforde et al. 2022).

Focused shockwave: precise energy at a defined depth

Focused shockwave therapy bundles mechanical energy into a therapeutic focus. This allows deeper target structures to be reached more precisely than with radial pressure waves. Best-practice recommendations describe focused shockwave therapy as particularly relevant for deeper structures, bony indications, calcific tendinopathies and joint or subchondral target regions (Tenforde et al. 2022).

At RECURIO, focused shockwave therapy may be considered when a clearly localisable, deeper pain or tissue structure needs to be treated. Examples include persistent tendinopathies, calcifications, bone stress reactions, delayed bone healing, bone marrow oedema-related conditions or deeper tendon insertion zones, provided the medical assessment supports this approach.

BTL focused shockwave

According to the manufacturer, the BTL Focused Shockwave System uses patented electroacoustic technology and a frequency range of up to 25 Hz (BTL). BTL describes focused shockwave therapy as a procedure for deeper chronic pain conditions such as tendinopathies, calcifications and bone healing disorders. According to the manufacturer, treatment typically lasts up to 10 minutes, and around 3 to 5 sessions are often mentioned, depending on indication and therapeutic goal (BTL).

The BTL-6000 FSWT manual describes adjustable parameters of 5–100% intensity, 1–20 Hz frequency, or up to 25 Hz in some device references, and 0–9999 shock impulses per treatment (BTL-6000 FSWT User Manual). Depending on the coupling pad, different focus depths can be selected according to the manual: approximately 15 mm, 30 mm or 45 mm focal point depth, with a stated focal zone of up to 65 mm depth when using the S pad (BTL-6000 FSWT User Manual).

The medically relevant advantage of BTL focused shockwave therapy lies in the ability to deliver energy precisely into defined tissue depths. At RECURIO, this precision is particularly relevant when not only a superficial pain region, but a deeper tendon insertion, bone or joint region needs to be therapeutically addressed.

STORZ focused shockwave

With the DUOLITH SD1 ultra, STORZ MEDICAL offers a modular system for focused and radial shockwave therapy with optional diagnostic ultrasound imaging (STORZ MEDICAL DUOLITH). For the focused SEPIA handpiece, STORZ specifies an energy flux density of 0.01–0.55 mJ/mm², a focal zone depth of 0–65 mm and a penetration depth of up to 125 mm (STORZ MEDICAL DUOLITH).

A particular advantage of the STORZ system is the option to link diagnostics and therapy more closely. For the DUOLITH SD1 ultra, STORZ describes optional ultrasound imaging with colour Doppler, which can be used to localise target structures and document findings within the integrated patient management system (STORZ MEDICAL DUOLITH). This is clinically relevant because exact diagnosis, localisation and indication are crucial for treatment success.

At RECURIO, focused STORZ shockwave therapy is particularly useful when precise deep target structures need to be treated, or when a combination of medical examination, imaging-based assessment and focused application is required. This may include selected tendon insertion disorders, calcific tendinopathies, deep myofascial pain areas, bony irritation states and more complex musculoskeletal conditions.

Radial shockwave: broad treatment of superficial tissue

Radial shockwave therapy differs physically from focused shockwave therapy. STORZ explains the difference in a patient-friendly way: radial shockwaves are generated through a handpiece placed on the affected area and spread radially, meaning in several directions, through the tissue. Focused shockwaves, by contrast, are concentrated on a defined target area and can penetrate more deeply (STORZ MEDICAL).

Best-practice recommendations describe radial shockwaves as particularly suitable for superficial soft tissues, tendinopathies, fasciopathies, myofascial trigger points and spastic or muscular indications using low- to medium-energy protocols (Tenforde et al. 2022). Radial shockwave therapy usually treats a larger area and is therefore particularly suitable for tissues where the focus is not a single deep point, but a superficial pain or functional zone.

STORZ radial shockwave

With the MASTERPULS ultra line, STORZ offers radial pressure wave therapy for orthopaedic and musculoskeletal applications (STORZ MEDICAL MASTERPULS). The MASTERPULS ultra systems use the FALCON handpiece, which according to STORZ offers an extended energy range from 0.3 bar and can optionally be supplemented with V-ACTOR vibration therapy and, in the MP200 ultra, with VACU-ACTOR vacuum therapy (STORZ MEDICAL MASTERPULS).

At RECURIO, STORZ radial shockwave therapy can be used primarily for superficial tendon and muscle complaints, myofascial pain areas, trigger points, fascial complaints and broader soft tissue problems. It can complement focused shockwave therapy when both a deep target point and surrounding superficial muscle and fascial structures need to be treated.

BTL radial context and distinction

BTL describes radial shockwave therapy as a procedure in which maximum intensity is concentrated close to the surface, making it particularly suitable for superficial soft tissues (BTL Radial Shockwave). For its radial system, BTL states manufacturer parameters of up to 6 bar pressure and up to 22 Hz frequency, as well as typical treatment series of 5 to 10 sessions, depending on indication and tissue response (BTL Radial Shockwave).

This distinction is important: radial shockwave therapy is not simply a “weaker” version of focused shockwave therapy, but a different application form with different strengths. It is particularly suitable for superficial and broader tissue targets, while focused shockwave therapy has advantages for deeper, more precisely localisable target structures (BTL Radial Shockwave, STORZ MEDICAL).

Mechanisms of action

The biological effect of shockwave therapy is mainly explained through mechanical stimuli that can influence cellular signalling pathways. Reviews describe effects such as pain modulation, reduced activity of pain-related neuropeptides, promotion of local blood flow, neovascularisation, stimulation of tenocytes, collagen synthesis and osteogenic signalling pathways (Vázquez-Sasot et al. 2023).

These mechanisms should be interpreted seriously and cautiously. Shockwave therapy does not mechanically “repair” tissue immediately, but provides stimuli that may support biological remodelling and healing processes. This is why combination with load management, progressive exercise therapy, functional training and medical follow-up is essential.

For which conditions can shockwave therapy be useful?

At RECURIO, focused or radial shockwave therapy can be used for selected musculoskeletal conditions. Whether focused, radial or combined treatment is used depends on the depth and type of the target structure.

Possible areas of application include:

Tendinopathies and enthesopathies: for example Achilles tendon, patellar tendon, rotator cuff, epicondylitis, gluteal tendons or plantar fascia.
Calcific tendinopathies: especially in the shoulder, when calcifications and irritation need to be therapeutically addressed.
Plantar fasciopathy and heel pain: in chronic complaints, especially after insufficient response to standard conservative measures.
Myofascial pain and trigger points: primarily with radial shockwave or combined treatment.
Chronic tendon insertion pain: when load management and active therapy alone are not sufficient.
Selected bone healing disorders: for example delayed fracture healing or pseudarthrosis, although particularly careful medical indication and imaging-based localisation are required.
Sports and overload-related complaints: when pain, function and return to activity need to be managed in a structured way.
Selected joint and subchondral irritation states: for example osteoarthritis-related pain or bone marrow oedema-related complaints, depending on findings and therapeutic goal.

Clinical evidence: what is well supported, and what must be interpreted cautiously?

The evidence for ESWT varies depending on the indication. A narrative review on musculoskeletal pain describes good evidence for several established indications, including calcific tendinopathy of the shoulder, lateral epicondylitis, plantar fasciitis and delayed bone healing. For other indications such as patellar tendon, Achilles tendon or myofascial complaints, the evidence is promising but more heterogeneous (Vázquez-Sasot et al. 2023).

Best-practice recommendations emphasise that differences in device type, energy flux density, number of impulses, session frequency, application site, analgesia and accompanying rehabilitation make the study landscape difficult to compare (Tenforde et al. 2022). For this reason, RECURIO should not communicate shockwave therapy as a standardised one-size-fits-all treatment, but as a precisely dosed component within a physician-led plan.

For sports and tendon complaints, reviews show that ESWT can be used safely for various musculoskeletal injuries and tendinopathies, ideally in combination with physiotherapy and progressive load management (Schroeder et al. 2021). A systematic review of orthopaedic indications describes ESWT overall as an effective and safe non-invasive option for tendon and other musculoskeletal pathologies, while also highlighting the importance of appropriate protocols (Schmitz et al. 2015).

The serious and balanced assessment is therefore: shockwave therapy is an established, non-invasive procedure with good clinical plausibility and relevant evidence for several musculoskeletal indications. However, it is not an isolated “instant cure”; its benefit is most likely to unfold when diagnosis, device selection, precise dosing and accompanying rehabilitation are appropriate.

Focused, radial or combined?

Question	Focused shockwave	Radial shockwave	Combined application
Tissue depth	Precise focus at a defined depth	Superficial, broader	Deep target plus surrounding soft tissue
Typical target structures	Bone, calcification, deep tendon insertions, subchondral regions	Muscles, fascia, superficial tendons, trigger points	Complex tendinopathies, multiple pain generators
Energy character	Energy concentrated at the focus	Maximum energy near the applicator	Combination of different stimulus profiles
Diagnostic requirement	Often particularly dependent on localisation	Often more clinically broad-area	Requires clear prioritisation of target structures
RECURIO logic	Precision for deep target structures	Broad neuromuscular and myofascial complement	When deep and superficial components interact

Best-practice recommendations consider combined shockwave therapy a useful approach in tendinopathies, fasciopathies and complex joint anatomy, because different tissue layers and pain sources can be addressed (Tenforde et al. 2022).

Treatment process at RECURIO

Before shockwave therapy, a medical assessment is carried out. This includes evaluating which structure is affected, whether the complaints are more superficial or deep, whether imaging is required and whether contraindications are present. At RECURIO, we also assess what role shockwave therapy should play in the overall plan: pain reduction, tissue stimulation, mobilisation, preparation for active therapy or support of a rehabilitation process.

During treatment, the target region is localised and treated with an applicator. Depending on the device and target structure, focused, radial or combined treatment is used. A session often lasts only a few minutes to around 10–15 minutes. Many protocols use several sessions at intervals of approximately one week, often in the range of 3 to 5 sessions, although the indication, tissue response and therapeutic goal are decisive (Tenforde et al. 2022, BTL).

During treatment, a pressure, tapping or pain stimulus may occur. The intensity is adjusted so that a therapeutic stimulus is produced while the treatment remains tolerable. Best-practice recommendations generally do not recommend local anaesthesia, because clinical pain localisation and tissue response can be therapeutically relevant (Tenforde et al. 2022).

Safety and contraindications

When correctly indicated and professionally applied, ESWT is generally considered well tolerated. Possible side effects include local pain during or after treatment, redness, swelling, bruising, haematoma, skin irritation or temporary tingling or nerve irritation (Tenforde et al. 2022, BTL-6000 FSWT User Manual).

A medical assessment is particularly required in cases of pregnancy, acute infection, tumour disease in the treatment area, relevant coagulation disorders, anticoagulation, thrombosis, sensory deficits, recent corticosteroid injection in the target area, complete tendon rupture, growth plates in children, implanted electronic devices or treatment near the lungs, major nerves and blood vessels or sensitive organs (Tenforde et al. 2022, BTL-6000 FSWT User Manual).

After treatment, loading should be managed in a medically appropriate way. Best-practice recommendations advise combining shockwave therapy with rehabilitation and critically assessing anti-inflammatory medication, ice, corticosteroids or other factors that may interfere with the intervention in the immediate treatment context (Tenforde et al. 2022).

Why RECURIO for shockwave therapy?

At RECURIO, the focus is not on the device itself, but on the medical decision about which structure should be treated and why. The ability to use BTL focused shockwave as well as STORZ focused and STORZ radial shockwave in a differentiated way allows the treatment to be adapted more precisely to the condition.

This differentiation is particularly important in complex pain, chronic tendinopathies, persistent insertional problems, bone stress reactions or mixed myofascial and deep pain sources. Focused shockwave therapy can precisely address deep target structures, radial shockwave therapy can complement treatment of superficial and broader soft tissue components, and the combination can be useful when several tissue layers contribute to the condition.

If you would like to know whether focused or radial shockwave therapy is suitable for your condition, arrange a medical consultation with Dr. Gruther at RECURIO. Together, we will assess which method is medically appropriate, how it can be integrated into a therapy programme and which accompanying steps are necessary to sustainably improve pain reduction, resilience and function.