Shockwave Therapy and PRP: Should We Stop Thinking of Them as Competing Treatments?

When treating chronic tendinopathy, shockwave therapy and platelet-rich plasma (PRP) are often presented as competing options.

Try shockwave. Or get a PRP injection.

But that comparison may miss something important.

Shockwave provides a mechanical stimulus to the tissue. PRP attempts to influence the biological environment around that tissue. And progressive loading provides the repeated mechanical input necessary for a tendon to adapt and regain capacity.

Those aren't necessarily competing ideas.

They may represent different pieces of the same rehabilitation problem.

Why Do Chronic Tendon Problems Become So Stubborn?

A tendon problem that has persisted for months is different from a fresh injury.

Chronic tendinopathy isn't simply an injury that hasn't finished healing. Changes can occur in tendon structure, cellular behavior, pain sensitivity, and the tendon’s ability to tolerate load.

That helps explain why simply resting a tendon often doesn't solve the problem.

Eventually, the tendon usually needs an appropriate stimulus.

In rehabilitation, that stimulus frequently comes from progressive loading. Isometric, eccentric, heavy slow resistance, and other loading strategies can all be used depending on the tendon, stage of rehabilitation, and individual patient.

The goal isn't simply to irritate the tendon.

The goal is to provide enough mechanical input to stimulate adaptation without repeatedly exceeding the tissue's capacity.

This is where shockwave becomes particularly interesting.

Think of Shockwave as a Mechanical Stimulus

Patients sometimes hear that shockwave therapy “breaks up scar tissue” or deliberately damages the tendon so that the body has to heal it again.

That's probably too simplistic.

Shockwave delivers mechanical energy into tissue. That mechanical stimulus can produce biological responses involving cellular signaling, pain processing, vascular responses, and tissue remodeling.

So rather than thinking of shockwave as physically beating up a tendon, we prefer to think of it as providing a new mechanical stimulus to tissue that may have become stuck in a persistent state.

In simple terms, sometimes a stubborn tendon may need a different signal.

Shockwave may provide one.

Where Does PRP Fit Into This?

PRP approaches the problem differently.

A patient's blood is drawn and processed to concentrate platelets. The resulting platelet-rich plasma is then injected into or around the targeted tissue.

Platelets contain growth factors and numerous signaling molecules involved in inflammation and tissue repair.

That's why we think of PRP primarily as a biologic intervention.

But this raises an interesting question.

If you inject PRP around a chronically abnormal tendon, is simply placing those biological factors near the tendon enough?

Maybe not.

The Problem With Thinking of PRP as a “Bath”

One simple way patients sometimes conceptualize PRP is as bathing an injured area in healing factors.

That description makes intuitive sense, but tendon adaptation doesn't happen through biology alone.

Tendons respond to mechanical load.

If a tendon has lost its ability to tolerate the demands being placed upon it, adding biological signaling without restoring appropriate mechanical loading doesn't necessarily restore that capacity.

This may help explain why PRP research for tendinopathy has produced mixed results.

For example, PRP has not consistently demonstrated superiority over placebo for chronic midportion Achilles tendinopathy when patients are also participating in loading-based rehabilitation.

That doesn't necessarily mean PRP has no biological effect.

It may mean that biology is only one part of the problem.

What About Needling the Tendon During PRP?

This makes PRP procedures themselves particularly interesting.

In some tendon procedures, the clinician doesn't simply place PRP near the painful area.

The tendon may also be repeatedly penetrated with a needle—a technique often described as tendon fenestration, dry needling, or percutaneous needle tenotomy depending on exactly what is being performed.

That needle manipulation itself creates a mechanical stimulus.

So now we're potentially doing two things:

Creating a mechanical stimulus to the tendon.

And introducing PRP into that environment.

That begins to look conceptually different from simply injecting PRP around a tendon and hoping the biologic material solves the problem.

Could Shockwave Provide the Mechanical Stimulus Instead?

This is where the relationship between shockwave and PRP becomes interesting.

Shockwave provides a mechanical stimulus without inserting a needle into the tendon.

PRP provides a concentrated biologic intervention.

Progressive exercise then provides repeated mechanical loading over the following weeks and months.

Conceptually, that gives us three different tools:

Shockwave: mechanical stimulus.

PRP: biological signaling.

Progressive loading: repeated stimulus that rebuilds the tendon’s capacity.

Rather than asking which one is the “best” treatment, it may be more useful to ask what role each could play.

Does That Mean Shockwave Should Always Be Done Before PRP?

No.

This is where we need to separate an interesting clinical model from something that has been definitively proven.

There is biological plausibility for combining mechanical stimulation with PRP, and laboratory research supports interactions between mechanical loading and platelet-derived signaling.

But we don't yet have enough high-quality human research to say that performing shockwave before or around PRP reliably produces better outcomes than either treatment alone.

We also don't know the ideal timing.

Should shockwave occur before PRP?

How long before?

Should shockwave continue afterward?

When should heavier loading resume?

Does the answer change between the Achilles tendon, patellar tendon, plantar fascia, or common extensor tendon at the elbow?

Those are legitimate questions that research has not completely answered.

Loading May Be the Most Important Piece

Regardless of whether shockwave or PRP is used, progressive rehabilitation remains difficult to ignore.

A tendon ultimately has a job.

An Achilles tendon needs to tolerate walking, running, jumping, and eventually much larger forces during sport. The common extensor tendon at the elbow needs to tolerate gripping and repeated upper-extremity loading.

Neither shockwave nor PRP teaches a tendon to tolerate those forces.

Loading does.

Shockwave or PRP may potentially change the environment in which that adaptation occurs, but rehabilitation still has to progressively expose the tissue to the demands it needs to handle.

That's why we generally don't think of either treatment as a replacement for physical therapy.

A Different Way to Think About Shockwave and PRP

Instead of:

Shockwave vs PRP

we think the more interesting framework may be:

Mechanical stimulus + biological environment + progressive loading.

Shockwave may provide an additional mechanical stimulus.

PRP may provide biological signaling.

Exercise progressively exposes the tendon to load and builds its capacity.

Whether combining those approaches actually produces superior outcomes remains an open question, and the answer may ultimately be different for different tendons and different patients.

But it changes the conversation.

Rather than asking which treatment wins, we can ask a more useful question:

What does this tendon need to start adapting again—and what combination of mechanical stimulus, biology, and progressive loading gives it the best opportunity to do that?

That is where we think the future of treating stubborn tendinopathy becomes particularly interesting.

Disclaimer: This article is for educational purposes only and is not medical advice. It discusses both established research and evolving clinical concepts surrounding tendinopathy, shockwave therapy, and PRP. Individual treatment decisions should be based on an appropriate evaluation with a qualified healthcare professional.