Can Shockwave Therapy Make Plantar Fasciitis Worse?

Shockwave therapy rarely makes plantar fasciitis permanently worse, but it can temporarily increase heel pain in the days following a session. A systematic review covering nearly 2,500 patients found only two actual complications across thousands of treatment sessions, though transient side effects like pain, redness, and swelling were more common.¹ The distinction between a short-lived flare and genuine worsening matters, because the two look similar to the person limping around the morning after treatment.

The Post-Treatment Pain Flare

The most common complaint after shockwave therapy is a temporary spike in heel pain, and it catches many people off guard. In one study of patients treated with extracorporeal shockwave therapy (ESWT), about 38% experienced a noticeable increase in heel pain within 72 hours of their session, usually starting within hours of treatment.² That is a significant minority of patients, and if nobody warned you about it, it is easy to assume the treatment backfired.

This early flare is considered a self-limited reaction. The pain resolves on its own, typically within a few days, without requiring any change to the treatment plan. In clinical studies where patients experienced this flare, it did not cause them to drop out of treatment.³ Some patients did, however, need extra analgesics to get through those first 24 hours.

An interesting question is whether the flare means the treatment is working better. The answer, at least in the short term, appears to be no. The study that tracked early flares found that patients who experienced them did not have superior clinical outcomes compared to patients who felt no spike in pain.² So if your clinician tells you that the post-treatment soreness means the shockwaves are doing their job, the evidence does not clearly support that reassurance. The flare is common and harmless, but it is not a signal of anything in particular.

What “Side Effects” Actually Show Up

Beyond the pain flare, the side-effect profile of shockwave therapy is dominated by minor and temporary issues. The systematic review that pooled data from 39 studies cataloged what patients reported across more than 6,400 treatment sessions. Roughly 225 patients reported pain during the treatment itself, and about 247 had transient redness of the skin afterward. Other reported effects included swelling, bruising, small broken blood vessels under the skin, brief numbness or tingling, and a throbbing sensation at the treatment site.¹

Most of these resolve within hours to days. In comparative trials, the redness and throbbing affected about 11% of people in the shockwave group, while those getting corticosteroid injections did not experience those specific symptoms.⁴ A small number of patients in those trials also reported severe headache or migraine, which is unusual enough to be worth knowing about. In one trial, four participants in the shockwave group experienced this.⁴

As for serious complications, the picture is remarkably clean. Across those 2,493 patients tracked in the systematic review, only two actual complications were recorded: one case of chest pain and one superficial skin infection that happened after regional anesthesia, not from the shockwaves themselves.¹ A separate long-term follow-up study found zero systemic complications, zero local complications, and zero device-related problems.⁵ No study in the plantar fasciitis literature has reported shockwave therapy causing a rupture of the plantar fascia, which is a complication that does show up with other treatments.

When the Treatment Simply Does Not Work

There is a scenario that functionally feels like the treatment making things worse, even if it technically didn’t: you go through multiple sessions, your plantar fasciitis doesn’t improve, and you’ve now lost weeks or months of time you could have spent on something else. This is a real risk, and the evidence for shockwave therapy is not as overwhelming as some clinic marketing suggests.

One large multicenter randomized trial compared shockwave therapy to a placebo procedure and found success rates of 34% in the treatment group versus 30% in the placebo group, a difference that was not statistically meaningful.⁶ That result has been debated in the literature, particularly because the energy levels used and patient selection criteria can vary widely across studies. Other trials have reported better outcomes, and the therapy is generally considered safe and effective for chronic cases that have resisted other conservative treatment.⁷

The inconsistency in results is partly why shockwave therapy is generally recommended after conservative approaches like stretching, orthotics, and activity modification have been tried for at least six months without success.⁸ If you try it earlier in the course of your condition, you may be no better off than if you had continued with simpler treatments, which is not the same as being made worse but can feel that way.

Focused Versus Radial Shockwaves

Two main types of shockwave devices are used clinically, and they deliver energy differently. Focused shockwave therapy concentrates pressure waves to a precise depth, while radial shockwave therapy sends pressure waves outward from the applicator tip and disperses them more broadly. Both are used for plantar fasciitis, and both have been found to be safe and effective for chronic cases.⁷

From a side-effect standpoint, the distinction matters mostly in terms of how much energy hits the tissue. The systematic review tracked treatments delivered across a wide range of energy levels, from 0.01 to 0.64 millijoules per square millimeter, with anywhere from 1,000 to 3,800 shockwave pulses per session.¹ Higher energy tends to be more uncomfortable during the procedure and more likely to produce the redness, bruising, and post-treatment soreness described earlier. But even at the higher end of that energy range, serious adverse events were essentially absent. If your provider uses high-energy focused shockwaves, expect more discomfort during and after treatment, but not a fundamentally different risk profile.

Who Should Not Get Shockwave Therapy

There are specific situations where shockwave therapy is genuinely contraindicated, meaning it could cause harm beyond the temporary flare. The established contraindications for high-energy shockwave therapy include severe blood clotting disorders, application over a fetus or embryo, and use over areas of severe infection.⁹ People on blood thinners should discuss this with their provider, since the therapy can cause small bleeds under the skin even in people with normal clotting.

Beyond the formal contraindications, there are practical situations where shockwave therapy is a poor choice. If your heel pain has not been confirmed as plantar fasciitis, applying shockwaves to the wrong diagnosis won’t help and could delay appropriate treatment. Conditions that mimic plantar fasciitis include nerve entrapment, stress fractures of the calcaneus, and fat pad atrophy. Each of these has a different treatment path, and shockwave therapy aimed at a plantar fascia that isn’t the problem is wasted effort at best.

How It Compares to Corticosteroid Injections on Safety

Many people considering shockwave therapy are weighing it against corticosteroid injections, which are one of the most commonly used treatments for plantar fasciitis. On the safety front, the two have very different risk profiles. Corticosteroid injections carry a known risk of plantar fascia rupture, a serious complication that can take months to recover from and may permanently alter foot mechanics.⁸ No such risk has been documented with shockwave therapy. In studies that tracked both treatments, no infections and no fascia ruptures occurred in either group.⁴

The trade-off is in the type of short-term discomfort. Shockwave therapy tends to produce more minor, visible side effects like redness and throbbing in the treated area, while corticosteroid injections are more likely to require post-procedure pain relief. In pooled data from comparative trials, none of the patients in the shockwave group required analgesics afterward, compared to about 12% of those who received injections.⁴ That said, other comparative studies found the opposite pattern, with shockwave patients needing more analgesics due to post-treatment pain spikes.³ The overall picture is that both treatments have minor short-term downsides, but shockwave therapy avoids the structural risk that comes with repeated steroid injections.

Changes in How You Walk After Treatment

One aspect of shockwave therapy that doesn’t get much attention is what it does to your gait. When plantar fasciitis hurts, you naturally adjust how you walk to avoid loading the painful heel. You might shift weight to the outside of your foot, shorten your stride, or spend less time on the affected leg during each step. These compensations can create secondary problems in your knees, hips, and lower back over time.

Research tracking patients after radial shockwave therapy found that as pain decreased, gait patterns changed measurably. Patients reported pain reductions of about 43% at the first follow-up, growing to roughly 67% by six weeks after treatment. Alongside that, they put significantly more force through both the rearfoot and forefoot during walking, their step length increased by about 3 to 4 centimeters, and the stance phase on the affected foot lasted longer.¹⁰ These are signs that people were trusting the foot more and walking in a more balanced, normal pattern.

This matters because the question of whether shockwave therapy makes things worse should account for what happens to the rest of the body, not just the heel. If the treatment reduces pain enough to let you walk normally again, that has knock-on benefits for your whole kinetic chain. Conversely, if you are a non-responder and the treatment doesn’t reduce your pain, your compensatory gait patterns continue, and the lost treatment time could mean your secondary issues progress.

Why Pairing It with Rehab Matters

Shockwave therapy is not designed to be a standalone cure. The clinical consensus is that it should be combined with physical therapy to produce lasting improvements in function and to support the healing process.¹¹ People who receive shockwave therapy alone, without addressing the underlying biomechanical factors that caused the fasciitis in the first place, are more likely to see their pain return.

The rehabilitation side typically includes calf stretching, eccentric strengthening of the foot and ankle muscles, and sometimes changes to footwear or the addition of orthotic inserts. These interventions address the mechanical stresses that overload the plantar fascia. Shockwave therapy may help kick-start the healing response and reduce pain enough to make those exercises tolerable, but it does not change the structural or movement patterns that caused the problem. If you skip the rehab and just show up for shockwave sessions, you’re addressing the symptom without fixing the cause, and the fasciitis is more likely to come back.

The Role of Expectations

An underappreciated factor in how patients experience shockwave therapy is what they expect going in. One randomized trial tested whether the appearance of the shockwave device influenced outcomes. Three groups of patients received the same radial shockwave treatment, but the devices looked different. All three groups improved significantly from baseline at every follow-up point through 14 months, and there were no meaningful differences between groups.¹²

This tells us a couple of things. First, the placebo component of shockwave therapy, while real for many medical treatments, does not appear to be driven by the impressiveness of the equipment. Second, when patients report that shockwave therapy made their condition worse, it is worth considering whether the worsening is the temporary flare described earlier, an unrelated progression of the underlying condition, or a mismatch between expectations and the reality of a treatment that takes weeks to show full benefits. None of the clinical evidence points to shockwave therapy causing structural damage to the plantar fascia or creating new pathology. The “worse before better” experience, when it happens, appears to reflect the tissue’s acute response to mechanical stimulation rather than any lasting harm.