Acoustic Wave Therapy: How It Works, What It Treats, and What Results to Expect

Electrohydraulic acoustic shockwaves are pressure waves made by a high-voltage spark that fires between two electrodes inside a water-filled treatment head: the spark vaporizes the water, the expanding bubble launches a shockwave, and a curved metal reflector focuses that wave on a target inside the body. Acoustic wave therapy, also called extracorporeal shockwave therapy (ESWT), uses this electrohydraulic source, or an electromagnetic, piezoelectric or pneumatic one, to treat chronic plantar fasciitis, calcific shoulder tendinopathy, tennis elbow and erectile dysfunction, with results that build over 8 to 12 weeks rather than right away.

The electrohydraulic method is the oldest way to make a therapeutic shockwave. It was first used to break up kidney stones without surgery in 1980, a procedure called extracorporeal shockwave lithotripsy (ESWL), according to Chaussy and colleagues (1980) [16]. Evidence today is strongest for plantar fasciitis, calcific tendinopathy and lateral epicondylitis. For erectile dysfunction it is more mixed, and the American Urological Association (2018) still classifies low-intensity shockwave therapy for ED as investigational [17].

Acoustic Wave Therapy and Shockwave Therapy Are the Same Thing

Acoustic wave therapy, shockwave therapy, and extracorporeal shockwave therapy (ESWT) all refer to the same category of treatment. “Acoustic wave therapy” became a popular marketing term, particularly in men’s health clinics offering treatment for erectile dysfunction (ED), but it is the same underlying technology that orthopedic surgeons and sports medicine physicians have used since the 1990s [1].

You will also see the abbreviations AWT (acoustic wave therapy), Li-ESWT or LiSWT (low-intensity shockwave therapy, the version used for ED), FSWT (focused shockwave therapy) and RPWT or rESWT (radial pressure wave or radial shockwave therapy). Our shockwave therapy treatment guide uses the clinical name, and every term in this list describes the same acoustic energy delivered through the skin.

The word “shockwave” can sound alarming, but these are not electrical shocks. They are acoustic pressure waves, essentially sound waves with specific energy characteristics that trigger biological responses in the tissues they pass through. Even in an electrohydraulic device, the electrical spark stays sealed inside the water-filled applicator; only the pressure wave reaches the skin.

How Acoustic Waves Work: The Physics

Focused Shockwave Therapy (FSWT)

Focused shockwaves are generated by electromagnetic, electrohydraulic, or piezoelectric sources within the treatment device. The waves are focused by a reflector or lens to converge at a specific depth in the tissue, creating a high-energy focal point [2].

Key characteristics:

• Penetration depth: Can reach tissues 4-12 cm below the skin surface
• Energy delivery: High peak pressure at the focal point (up to 100 MPa), with less energy at the skin surface
• Precision: The focal zone is small (a few millimeters), allowing targeted treatment of specific structures
• Applications: Deep tissue pathology, calcific tendinopathy, non-union bone fractures, ED

Radial Pressure Wave Therapy (RPWT)

Radial waves are generated pneumatically. A projectile inside the handpiece is accelerated by compressed air and strikes a metal applicator tip, which transmits the pressure wave into the tissue. The energy radiates outward from the skin surface, dispersing as it travels deeper [2].

Key characteristics:

• Penetration depth: Effective to approximately 3-4 cm below the skin surface
• Energy delivery: Highest pressure at the skin surface, decreasing with depth
• Treatment area: Broader dispersion pattern, covering a larger tissue area
• Applications: Superficial tendinopathies, trigger points, myofascial pain, plantar fasciitis

Physicists draw a line between the two. A true shockwave has a very steep pressure rise and a short pulse, which focused sources produce. Radial devices produce a slower pressure wave that is not a shockwave in the strict sense, which is why researchers such as Schmitz and colleagues (2015) call it radial pressure wave therapy [2].

Which Type Is Better?

Neither is universally superior. The choice depends on the condition being treated. Focused shockwaves are preferred for deep or precisely localized pathology (like a calcific deposit within the supraspinatus tendon). Radial waves work well for broader, more superficial conditions (like plantar fascia insertion pain or widespread trigger points). Many clinics use both types, sometimes in the same session, to optimize results [3].

What Are Electrohydraulic Acoustic Shockwaves?

Electrohydraulic acoustic shockwaves are focused shockwaves produced by an underwater spark. An electrode pair sits at one focal point of an ellipsoid reflector filled with water; each discharge creates a pressure pulse that the reflector concentrates at the second focal point, which the clinician places on the tendon, bone or tissue being treated [2]. The spark gap design is the first generation of shockwave technology, and it is still used in orthopedic ESWT and in some low-intensity ED devices.

How is an electrohydraulic shockwave generated?

1. A capacitor in the device charges to a high voltage.
2. The charge discharges across a small gap between two electrodes submerged in water inside the applicator.
3. The spark vaporizes a tiny volume of water, and the rapidly expanding gas and plasma bubble produces a spherical pressure pulse.
4. An ellipsoid metal reflector bounces that pulse toward a second focal point outside the applicator.
5. The pulse passes through a membrane and coupling gel into the skin and converges on the target tissue, where peak pressure is highest.

How do the shockwave sources compare?

Four types of generator power acoustic wave therapy devices. The table below summarizes how each one makes its wave, based on the technical reviews by Schmitz and colleagues (2015) and van der Worp and colleagues (2013) [2] [3].

Where are electrohydraulic devices used?

Electrohydraulic generators were built for urology first. Shockwave lithotripsy for kidney stones began with a spark gap machine in 1980 [16], and the first shockwave device the FDA approved for chronic plantar fasciitis, in 2000, also used an electrohydraulic source. In men’s health, the sham-controlled trial by Vardi and colleagues (2012) used a low-intensity electrohydraulic unit to treat vasculogenic ED [6].

Are electrohydraulic shockwaves better than other sources?

No head-to-head research shows that one focused source gives better clinical results than another. Electrohydraulic systems tend to produce a wider focal zone, while their electrodes wear with use and the energy of each pulse can vary more than with electromagnetic or piezoelectric systems. For a patient, the energy flux density chosen, the number of pulses, the accuracy of targeting and the clinician’s experience matter more than the generator inside the device.

The Biological Mechanisms

Mechanotransduction

When acoustic waves pass through tissue, they create mechanical stress at the cellular level. Cells respond to this mechanical force through mechanotransduction, the process of converting physical stimuli into biochemical signals. The key mechanotransduction pathways activated by shockwave therapy include [4]:

• Release of growth factors (VEGF, eNOS, PCNA, BMP)
• Activation of ERK1/2 and p38 MAPK signaling cascades
• Stimulation of toll-like receptor 3 (TLR3), triggering regenerative inflammation
• Upregulation of lubricin and other tissue-protective proteins

Neovascularization

Neovascularization is a central mechanism, particularly for ED treatment and chronic tendinopathy. Shockwaves stimulate the release of vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS), which together promote the formation of new blood vessels in the treated tissue [5].

In chronic tendinopathies, the affected tissue is often hypovascular, meaning it has an insufficient blood supply to support normal healing. By stimulating new vessel formation, shockwave therapy aims to restore the blood supply needed for tissue repair.

In ED, the same process occurs in the penile vasculature. Studies have demonstrated measurable increases in penile blood flow following low-intensity shockwave therapy (LiSWT), which correlates with improved erectile function [6].

Stem Cell Recruitment

Shockwaves appear to activate and recruit mesenchymal stem cells (MSCs) at the treatment site. Laboratory work by Schuh and colleagues (2014) found that shockwave exposure enhanced the stemness and preserved the multipotency of rat and human adipose-derived stem cells. This stem cell activity is thought to contribute to tissue remodeling and repair, particularly in tendon and bone pathology, although most of this evidence comes from cell and animal studies [7].

Pain Reduction

Acoustic waves reduce pain through several mechanisms: depletion of substance P (a pain neurotransmitter) from nerve endings, gate control theory activation through stimulation of large-diameter nerve fibers, and reduction of calcitonin gene-related peptide (CGRP) in the treated tissue [4].

Clinical Applications

Acoustic wave therapy is used by orthopedic surgeons, sports medicine physicians, podiatrists, physiatrists, physical therapists, chiropractors and urologists. The conditions below are ordered by how often they appear in the research, and the strength of evidence differs a lot between them.

Erectile Dysfunction (GAINSWave)

Low-intensity shockwave therapy for erectile dysfunction has become one of the most popular applications of acoustic wave technology. GAINSWave is the most widely recognized brand name, though many clinics offer the same treatment under different names.

The rationale is biological: vasculogenic ED (the most common form) results from inadequate blood flow to the penis due to endothelial dysfunction and atherosclerotic changes in the penile arteries. Shockwave therapy aims at this vascular cause by stimulating neovascularization and improving endothelial function [6].

A 2017 meta-analysis by Clavijo and colleagues pooled 7 sham-controlled trials (602 patients) and found that LiSWT improved International Index of Erectile Function (IIEF) scores more than sham treatment [9]. Man and Li (2018) reported a mean difference of 2.00 IIEF points over sham. Response rates ranged from 60-75% in men with mild to moderate vasculogenic ED [8].

Typical ED protocols:

• 6-12 sessions total
• 1-2 sessions per week
• Low-intensity focused or linear shockwaves
• Treatment applied to the penile shaft, crura, and perineum
• 3,000-5,000 pulses per session
• Results typically begin to appear 1-3 months after completing the protocol
• Effects can last 12-24 months based on available follow-up data

Important caveats: The strongest evidence supports LiSWT for mild to moderate vasculogenic ED. Men with severe ED, post-prostatectomy ED, or non-vasculogenic causes may see less benefit. This treatment is not FDA approved for ED (though shockwave devices are FDA approved or cleared for other musculoskeletal indications), and long-term durability data beyond 2 years is limited [9]. The American Urological Association guideline by Burnett and colleagues (2018) calls Li-ESWT for ED investigational, so many urologists still start with PDE5 inhibitors such as sildenafil or tadalafil [17]. Our ED treatment guide compares those options, and the directory of ED treatment clinics lists providers by state.

Plantar Fasciitis

Chronic plantar fasciitis that has not responded to conservative treatment (stretching, orthotics, physical therapy, corticosteroid injections) is one of the strongest evidence-based indications for ESWT. The FDA first approved a shockwave device for chronic plantar fasciitis in 2000, an electrohydraulic system, and later approvals added other focused and radial devices for this use.

A 2017 meta-analysis of 16 RCTs found that ESWT produced significantly greater pain reduction compared to placebo, with success rates of 50-75% at 12-week follow-up. Both focused and radial waves showed efficacy, though some analyses suggest focused ESWT may have a slight edge for recalcitrant cases [10]. The plantar fasciitis condition page covers the diagnosis and the first-line options to try before shockwaves.

Typical plantar fasciitis protocols:

• 3-5 sessions, spaced 1-2 weeks apart
• 2,000-3,000 pulses per session
• Treatment focused on the point of maximum tenderness (usually the medial calcaneal tubercle)
• Both radial and focused waves are used, depending on the clinic

Tennis Elbow (Lateral Epicondylitis)

Chronic lateral epicondylitis is another well-studied indication. A 2020 meta-analysis found that ESWT was superior to corticosteroid injections for pain reduction at 12-week and 26-week follow-up, with the advantage of avoiding the tendon-weakening effects of repeated steroid injections [11].

This finding is clinically significant because corticosteroid injections, while providing faster short-term relief, have been associated with higher recurrence rates and potential tendon degeneration with repeated use. Shockwave therapy targets the underlying tendon pathology rather than simply suppressing inflammation. Readers comparing options for tennis elbow can also review tennis elbow treatment options, including platelet-rich plasma (PRP injections).

Calcific Tendinopathy of the Shoulder

Calcific tendinopathy, where calcium deposits form within the rotator cuff tendons, is arguably the single strongest indication for focused ESWT. High-energy focused shockwaves can fragment and help resorb these calcium deposits while simultaneously stimulating tendon healing [12].

Success rates for calcium resorption range from 50-85% depending on the study and the energy level used, with corresponding improvements in pain and shoulder function. One sham-controlled randomized trial reported complete calcium resorption in 86% of treated patients compared to 8% in the sham group at 6-month follow-up [12].

Other Musculoskeletal Conditions

Emerging or established evidence also supports ESWT for:

• Achilles tendinopathy: Both insertional and midportion, with RCTs showing significant pain reduction
• Patellar tendinopathy (jumper’s knee): Moderate evidence, often used when physical therapy alone is insufficient
• Greater trochanteric pain syndrome: Radial shockwave therapy has shown efficacy comparable to corticosteroid injections with longer-lasting effects
• Myofascial trigger points: Radial pressure wave therapy has been reported to deactivate trigger points in the upper trapezius, infraspinatus, and other commonly affected muscles
• Non-union bone fractures: High-energy focused ESWT can stimulate bone healing in fractures that have failed to unite [13]

What a Treatment Session Feels Like

Most patients describe the sensation as a rapid tapping or pulsing against the skin, similar to a rubber band snapping. The intensity varies based on the energy level used:

Low-intensity (as used for ED): Generally painless or mildly uncomfortable. Most patients tolerate it easily without anesthesia.

Medium-intensity (as used for tendinopathies): Can be uncomfortable, particularly over tender areas. The discomfort is brief (each pulse lasts microseconds) and most patients describe it as tolerable. Clinicians typically start at a lower energy level and increase gradually during the session.

High-intensity (as used for calcific tendinopathy or non-union fractures): Can be quite painful. Local anesthesia or nerve blocks may be used for high-energy protocols, though some research suggests that anesthesia may reduce treatment efficacy by eliminating the neurogenic inflammatory response that contributes to healing [14].

Sessions typically last 15-30 minutes. You can usually return to normal activities immediately, though high-energy treatments may cause temporary soreness for 24-48 hours. Clinicians generally recommend avoiding anti-inflammatory medications (NSAIDs) for 24-48 hours after treatment, as the inflammatory response is part of the healing mechanism.

Electrohydraulic and other focused devices make a sharp clicking sound with each pulse, and the clinician applies coupling gel so the wave passes cleanly from the applicator into the skin. Some clinics use ultrasound to locate a calcific deposit or tendon before treating it.

Side Effects, Risks and Contraindications

Acoustic wave therapy is non-invasive, and published reviews such as Speed (2014) describe mostly mild, short-lived side effects [15]. The most common are redness, swelling, small skin bruises or pinpoint bleeding (petechiae), numbness or tingling, and soreness at the treated spot for a day or two. Higher energy settings make these more likely.

Who should not have shockwave therapy?

Device makers and clinical reviews commonly list these contraindications, and a clinician should ask about each one before the first session:

• Pregnancy, when the area being treated is near the abdomen or pelvis
• A known or suspected tumor at or near the treatment site
• Bleeding disorders, or anticoagulant medication that raises bruising risk
• Infection or an open wound at the treatment site
• Open growth plates in children and teenagers
• Treatment over the lungs or other air-filled tissue, or directly over major nerves and blood vessels
• A pacemaker or other implanted device, for some device types and treatment areas

Results Timeline

One of the most common misconceptions is expecting immediate results. Acoustic wave therapy works by initiating biological processes (neovascularization, tissue remodeling, stem cell recruitment) that take weeks to months to produce clinical improvements:

• Weeks 1-4 after completing treatment: Some patients notice initial improvements, particularly in pain levels
• Weeks 4-8: Neovascularization begins producing measurable changes in blood flow and tissue quality
• Weeks 8-12: The full effects of treatment typically become apparent. This is when most clinical trials measure primary outcomes
• 3-6 months: Continued tissue remodeling and maturation of new blood vessels. Some patients continue to improve during this period

Patience is required. If a clinic promises instant results from shockwave therapy, that should raise concerns. The biology simply does not work that way.

Is Acoustic Wave Therapy FDA Approved, and Does Insurance Cover It?

Shockwave devices are regulated by the US Food and Drug Administration (FDA) as medical devices. Specific focused and radial devices have FDA approval for chronic plantar fasciitis and lateral epicondylitis, and lithotripters are approved for kidney stones. No shockwave device is FDA approved specifically to treat erectile dysfunction, so ED treatment is off label.

Many US health insurers classify ESWT as investigational for most uses, and men’s health clinics generally sell ED courses as cash pay packages. Prices vary widely by clinic, device and number of sessions, so ask for the total course cost, the device type, the energy settings and the follow-up plan in writing. Cheaper options with stronger evidence, such as physical therapy for tendon pain or oral medication for ED, are often tried first.

Who Should Consider Acoustic Wave Therapy

Acoustic wave therapy is worth considering if you have:

• A chronic tendinopathy (3+ months) that has not responded to conservative management
• Calcific tendinopathy of the shoulder
• Chronic plantar fasciitis unresponsive to stretching, orthotics, and physical therapy
• Mild to moderate vasculogenic ED, especially if you prefer a non-pharmaceutical approach
• Myofascial pain with identifiable trigger points

When choosing a provider, look for clinics that use true shockwave devices (not ultrasound devices or vibration tools marketed as “acoustic wave” therapy), explain the difference between focused and radial approaches, and provide a clear protocol with a defined number of sessions and follow-up plan. A clinician who can explain the mechanism and set realistic expectations for the timeline of results is generally more trustworthy than one who leads with marketing promises [15].

How to Find an Acoustic Wave Therapy Clinic

The Regenerated.com shockwave therapy clinic directory lists providers across the United States, and each listing shows which treatments and conditions the clinic says it covers. Inclusion in the directory is not an endorsement, so use the questions in the section above when you call a clinic.

Listing order on Regenerated.com is not paid ranking. Featured slots are clearly labeled and capped, Verified means the clinic completed credential checks rather than paid for placement, and the directory is free for patients. Our guide to Featured, Verified and organic listings explains each label.

Frequently asked questions

What are electrohydraulic acoustic shockwaves?

Electrohydraulic acoustic shockwaves are pressure pulses created by a high-voltage spark between two electrodes in water. The spark vaporizes a small amount of water, the expanding bubble produces a shockwave, and an ellipsoid reflector focuses it on tissue inside the body. This is the oldest shockwave technology, first used to break kidney stones in 1980, and it is one of three sources, with electromagnetic and piezoelectric, used for focused acoustic wave therapy.

Is acoustic wave therapy the same as shockwave therapy?

Yes, acoustic wave therapy is the same treatment as shockwave therapy and extracorporeal shockwave therapy (ESWT). The name acoustic wave therapy is mostly used in marketing, especially by men’s health clinics offering low-intensity shockwave therapy (Li-ESWT) for erectile dysfunction. Orthopedic and sports medicine clinics usually say ESWT. All of these terms describe acoustic pressure waves delivered through the skin to stimulate blood flow and tissue repair, not electrical current.

Is electrohydraulic shockwave therapy better than electromagnetic or radial?

No source has been shown to be clearly better than another in head-to-head clinical trials. Electrohydraulic, electromagnetic and piezoelectric generators all produce focused shockwaves that reach deep tissue, while radial devices produce a weaker pressure wave that stays near the surface. The condition being treated, the energy level, the number of pulses and how precisely the clinician targets the tissue matter more than the generator inside the device.

Does acoustic wave therapy work for erectile dysfunction?

Acoustic wave therapy has shown modest benefit for mild to moderate vasculogenic erectile dysfunction in sham-controlled trials. Meta-analyses by Clavijo and colleagues (2017) and Man and Li (2018) found better erectile function scores than sham treatment. The American Urological Association (2018) still calls the treatment investigational, results for severe ED or ED after prostate surgery are weaker, and long-term data beyond two years are limited.

How many acoustic wave therapy sessions do you need?

The number of sessions depends on the condition. The studies cited in the clinical applications section commonly used 3 to 5 sessions spaced 1 to 2 weeks apart for plantar fasciitis and tendon problems, and 6 to 12 sessions over several weeks for erectile dysfunction. Improvement usually builds over 8 to 12 weeks after the last session, so most clinicians reassess at that point before recommending more treatment.

Is acoustic wave therapy FDA approved?

Specific shockwave devices are FDA approved for chronic plantar fasciitis and tennis elbow, and lithotripters are approved for kidney stones. No shockwave device is FDA approved specifically for erectile dysfunction, so using acoustic wave therapy for ED is off label and generally cash pay. Many US insurers also consider ESWT investigational for other uses, so check coverage and ask the clinic for the total course cost before booking.

Related Reading

• Shockwave Therapy: Complete Guide
• ED Treatment Options
• Plantar Fasciitis Treatment
• ESWT Therapy: How Extracorporeal Shockwave Works
• Penile Shockwave Therapy for ED: Evidence and Results

Sources

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