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. 2025 Feb 8;7(2):100432. doi: 10.1016/j.arrct.2025.100432

Comparing Dry Needle Therapy and Extracorporeal Shockwave Therapy for Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Zonglin Li a,b,*, Yubin Chen a,b,*, Lili Chen a, Jinshen He a,1
PMCID: PMC12265909  PMID: 40678292

Abstract

Objective

To conduct a systematic review and meta-analysis to assess the effects of extracorporeal shockwave therapy (ESWT) and needling therapy in the treatment of tendinopathy.

Data sources

PubMed (Medline), the Cochrane Library, and Web of Science were searched from August 5, 2024, to August 25, 2024, for comparative studies of needling therapy and ESWT for the treatment of tendinopathy published between January 1, 2000, and August 5, 2024.

Study Selection

Two reviewers independently reviewed randomized controlled trials (RCTs) that reported a comparison of needling therapy and ESWT for tendinopathy for inclusion eligibility.

Data Extraction

Outcomes of interest were the visual analog scale (VAS) score and pressure pain threshold (PPT) score. Two reviewers independently assessed the quality of the included RCTs with the Cochrane risk of bias tool. Effect sizes were estimated using mean differences (MDs), and the significance level was estimated using the P value of the overall effect.

Data Synthesis

Nine RCTs involving 528 patients were deemed suitable for inclusion. Six RCTs involving 318 patients revealed that VAS scores showed no significant difference between ESWT and dry needling in either the immediate (MD, 0.06; 95% CI, −0.30 to 0.43; P=.73) or delayed effects (MD, −0.46; 95% CI, −2.10 to 1.18; P=.59). Two RCTs involving 132 patients revealed that PPT scores showed no significant difference between ESWT and dry needling in delayed effects (MD, −0.08; 95% CI, −0.30 to 0.14; P=.49). Three studies that enrolled 161 subjects concluded that ESWT combined with dry needling therapy was statistically more effective in reducing VAS scores in patients with tendinopathy than pure ESWT for delayed effects (MD, −1.79; 95% CI, −2.60 to −0.97; P<.0001).

Conclusions

This meta-analysis shows that the combination of ESWT with needling therapy is more effective in reducing pain indices in patients with enthesopathy than using ESWT or needling therapy alone. ESWT, combined with needling therapy, should be prioritized for conservative treatment in patients with tendinopathy.

KEYWORDS: Extracorporeal shockwave therapy, Meta-analysis, Needling therapy, Randomized controlled trial, Rehabilitation, Tendinopathy

Highlights

  • •

    We assessed extracorporeal shock wave therapy (ESWT) and needling for tendinopathy.

  • •

    There was no difference in pain relief between ESWT and needling.

  • •

    ESWT with needling had better delayed effects than ESWT alone for pain.

  • •

    ESWT plus needling is advised for conservative tendinopathy care.

Due to the intensifying competitive nature of sports, the burgeoning popularity of physical activities, and the joint influence of many factors, the incidence of an overuse/reprtitive injuries, tendinopathy, is gradually escalating all over the world.1,2 Being a prevalent musculoskeletal disease affecting human beings,3 tendinopathy is typically caused by strain degeneration of tendons attached to the distal area of bone under high load.4 Conditions such as patellar, Achilles, and rotator cuff tendinopathies are frequently observed.4 While surgical and nonsurgical interventions are available, nonsurgical treatments are often prioritized for their minimally invasive nature and potential for superior clinical outcomes.5,6 Treatment options for tendinopathy encompass a variety of approaches, including injection therapies such as platelet-rich plasma injections and the use of nonsteroidal anti-inflammatory drugs, as well as corticosteroids. Additionally, noninjection treatments like rehabilitation, sclerotherapy, and extracorporeal shockwave therapy (ESWT) are also used.7, 8, 9 More recently, there has been a shift toward noninjection treatments, with a particular focus on ESWT and dry needling therapies.10,11

ESWT, initially employed for the treatment of renal, salivary, and urinary calculi, was introduced to orthopedics in the 1990s for orthopedic pathologies such as tendinopathy.12 The therapeutic mechanism of ESWT is multifaceted, encompassing pain alleviation, tissue regeneration, and calcification dissolution.13 It is worth noting that this noninvasive modality offers rapid treatment with minimal disruption to patient activities, contrasting with the variable recovery periods of other nonoperative interventions, which can extend up to 12 weeks of limitations of activities.12,14, 15, 16

Concurrently, needling therapy has gained traction as a treatment for tendinopathy, with proposed mechanisms including enhanced tendon blood flow, fibroblastic activity, and modulation of cellular functions pivotal for tissue repair, such as neurotransmitter transmission and neurotrophic factor expression.17, 18, 19 What is more, some studies have shown that, in terms of immediate effects, needling therapy can get better results than other nonoperative treatments.20 However, no comparative reviews, as far as we know, have been conducted to evaluate the effectiveness of ESWT and dry needling.

The purpose of this study was to conduct a systematic literature review to assess the efficacy of various tendinopathy treatments, including ESWT and needling therapy, and to additionally provide insights that may guide clinical decision-making and patient management strategies. Specifically, the comparative analysis was based on 2 primary clinical metrics: the visual analog scale (VAS) for pain assessment and the pressure pain threshold (PPT) as an indicator of tissue sensitivity and healing.

Methods

Search strategy

A thorough search of published literature in PubMed, Web of Science, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines21 on August 5, 2024. References from primary and review articles were cross-referenced to identify any additional articles meeting the inclusion criteria that were not initially identified in the initial search. The following search terms were used: (“tendinopathy” OR “enthesis” OR “tendinitis”) AND (“ESWT” OR “extracorporeal shockwave therapy” OR “shock wave”) AND (“acupuncture” OR “needling”).

Study selection

This study followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two authors (Z.L. and Y.C.) independently conducted database searches and screened the retrieved articles. In cases of uncertainty, the full text of the article was further reviewed. If the 2 authors could not reach an agreement, the article was referred to by a third author (J.H.) for evaluation regarding its inclusion. The reviewers then compiled a list of studies that met all inclusion criteria and integrated the studies, removing any duplicates.

Inclusion and exclusion criteria

This study included original articles reporting on (1) randomized controlled trials (RCTs) with or without blinding and without language restrictions, (2) studies involving both ESWT and needle-based treatments, either alone or in combination during treatment, (3) studies with no age limit on patients, and (4) clear expression and obtainment of explicit grouping information.

Irrelevant articles and studies were excluded based on the following criteria: (1) non-RCT studies or quasi-randomized articles, (2) animal experiments, (3) duplicate studies, (4) literature lacking original data or full text, (5) studies of ESWT or needling therapy combined with any other additional treatments (such as steroid injections) during treatment, and (6) studies that included neither VAS nor PPT for the outcome measures.

Quality assessment

The Cochrane risk of bias tool was employed by 2 reviewers (Z.L. and Y.C.) to evaluate the methodological quality of the included RCTs. Five risks of bias were assessed according to the Cochrane Handbook for Systematic Reviews of Interventions,22 namely generation of random sequence, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting.

Data extraction and analysis

The 2 authors (Z.L. and Y.C.) extracted data independently, followed by a joint review to produce accurate and consistent data. Differences were resolved through consultation with the senior author. The extracted data included sample size, study design, interventions, age, sex, the location of tendinopathy, follow-up time, and results parameter data. Efficacy was divided into 2 stages in accordance with evaluation times after treatment: 1) immediate effects: the first follow-up after treatment (≤1 week), and 2) delayed effects: the last follow-up after treatment (>1 week).23 Parameters analyzed in this study included VAS and PPT. VAS adopted the data for the first and final follow-up times, and PPT adopted the data for the final follow-up time. Meta-analysis was applied for those parameters compared between (1) ESWT and needling therapy and (2) needle therapy combined with ESWT and ESWT alone.

Statistical analysis

We present all continuous variables as mean with SD or range. Review Manager 5.3 software was used (Cochrane Collaboration) to analyze the data. Two authors synthesized the results, and the results were presented in the form of forest plots. We assessed statistical heterogeneity between studies by visual inspection of the forest plots and by the I2 and chi-square test statistics for heterogeneity. Random (I2>50%) or fixed models (I2<50%) were used to synthesize the results, presenting weighted mean differences (MDs) and a 95% confidence interval (CI) for each subgroup. We used the P value of the overall effect to determine the significance level of treatment effects and defined the significance level for treatment effects and differences across the subgroups as a P value below .05. We designed needle therapy alone versus ESWT alone and a combination of the 2 versus ESWT alone. The primary outcome of this meta-analysis was the VAS score, and the secondary outcome was the PPT score. The VAS and PPT scores were both used to evaluate the pain of patients during the treatments.

Results

Studies selection and characters

Initially, 1219 records were retrieved from the database (fig 1). After the removal of duplicates, 945 unique records remained. Subsequently, 867 records were excluded based on predefined selection criteria, leaving 78 full-text articles for eligibility assessment. Ultimately, 9 RCTs24, 25, 26, 27, 28, 29, 30, 31, 32 were deemed suitable for inclusion (table 1), involving a total of 528 patients across 5 distinct tendinopathies: calcific tendonitis of the shoulder (2 articles), lateral upper malleoli (1 article), plantar fasciitis (3 articles), patellar tendonitis (1 article), and superior trapezius myofasciitis (2 articles). Among the subgroups that analyzed VAS indexes, 4 articles23,27,29,30 included immediate and delayed effects, while 5 articles24, 25, 26, 27,31 included only delayed effects. The subgroup that analyzed the PPT index included 2 articles27,28 on delayed effects. The principal treatment modalities encompassed needling therapy, ESWT, and ESWT combined with needling therapy. The primary focus of this study was to compare the efficacy of ESWT, needling therapy, and combination therapy.

Fig 1.

Fig 1

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Preferred Reporting Items for Systematic Meta-Analyses flow diagram.

Table 1.

Characteristics of included studies

First Author Year Journal Research Type Sample Size* Dropout Rate (%) Mean Age (y) (mean±SD) Last Follow-Up (wk) Outcomes VAS (mean±SD)(Last Follow-Up)
Dede et al24 2024 JFAS RCT 55 (29:26) 5.17 N: 48.1±12.1
E: 50.9±10.1		 4 VAS; FFI;
MAX PfST; MAX PfWD		 N: 1.0±1.7
E: 1.3±1.5
Kuo et al25 2021 JBMR RCT 61 (20:20:21) 2.38 N: 58.2±7.9
E: 57.6±9.4		 12 VAS; SF-36;
Constant Score		 N: 1.55±2.31
E: 0.95±1.40
Bagcier and Yilmaz26 2020 JFAS RCT 40 (20:20) 0 N+E: 40.1±11.9
E: 47.2±10.8		 4 VAS; PPT;
Standing time; FFI;
Walking distance		 N/A
Cheng et al27 2019 JSMPF RCT 51 (25:26) 0 N: 21.9±4.6
E: 22.7±5.3		 16 VAS;
Isokinetic Muscle Strength Test		 N: 5.9±1.0
E: 2.2±1.1
Luan et al28 2019 AJPMR RCT 65 (33:32) 0.46 N: 33.1±12.8
E: 32.5±10.6		 12 PPT; NDI;
SWE; VAS		 N: 1.69±1.03
E: 1.50±0.82
Manafnezhad et al29 2019 JBMR RCT 70 (35:35) 2.78 N: 39.2±7.2
E: 37.0±9.1		 12 NPRS;
PPT; NDI		 N/A
Rahbar et al30 2018 IRCMJ RCT 72 (36:36) 0 44.1 (23.0-65.0)
(Total mean)		 8 VAS; FFI N: 1.7±1.7
E: 2.9±1.9
Wong et al31 2016 APJSMART RCT 34 (17:17) 0 N/A 2 VAS;Maximum grip strength
; DASH		 E: 3.18±2.13
N: 4.06±2.41
Krasny et al32 2005 JBJS RCT 80 (40:40) 0 48.4 (32.5-6.3)
(Total mean)		 16.4
(Mean)		 VAS;
100-point shoulder score of Constant and Murley		 E: 8.3±1.7
E+N: 5.8±1.5
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AJPMR, American Journal of Physical Medicine & Rehabilitation; APJSMART, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology; DASH, Shoulder and Hand Questionnaire; E, extracorporeal shock wave therapy; FFI, Foot Function Index; IRCMJ, Iranian Red Crescent Medical Journal; JBJSB: Journal of Bone and Joint Surgery; JBMR, Journal of Back and Musculoskeletal Rehabilitation; JFAS, Journal of Foot & Ankle Surgery; JSMPF, Journal of Sports Medicine and Physical Fitness; Max PfST, maximum pain-free standing time; Max PfWD, maximum pain-free walking distance; N, needling; N/A, not applicable; NDI, Neck Disability Index; NPRS, Numeric Pain Rating Scale; PPT, pressure pain threshold; RCT, randomized controlled trial; SF-36: 36-Item Short-Form Health Survey; SWE, shear wave elastography; VAS, visual analog scale.

⁎

Sample size: the data of 6 articles24,27, 28, 29, 30, 31 are arranged in the order of “Total (N:E),” while 2 articles26,32 are arranged in the order of “Total (N+E:E),” and 1 article25 is arranged in the order of “Total (N+E:N:E).”

Risk of bias

This meta-analysis employed Review Manager version 5.3 (Cochrane Collaboration) to assess the risk of bias (fig 2). The summary reveals that among the 9 RCTs, the most prevalent risk of bias was performance bias, observed in 6 studies, likely attributed to the challenge of blinding subjects in this type of trial. Additionally, 3 RCTs did not specify blinding of assessors (fig 2B). However, apart from these instances, all other aspects of the articles demonstrated a low risk of bias. Consequently, the overall risk of bias across these 10 RCTs was deemed low.

Fig 2.

Fig 2

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Risk of bias graph and summary. (A) The risk of bias is presented as a percentage across all included studies. (B) Authors' judgments about each risk of bias item of each included studies.

ESWT versus needling therapy

This comparison incorporated 6 articles, comprising a total of 318 patients. The patients in these articles received either needling therapy or ESWT treatments. Initially, we analyzed the VAS scores at the first follow-up posttreatment, revealing no significant difference between ESWT and needling therapy (MD, 0.06; 95% CI, −0.30 to 0.43; P=.73) (fig 3A). Subsequently, we compared the VAS scores at the last follow-up between ESWT treatment and needling therapy, again finding no significant difference between the 2 therapies (MD, −0.46; 95% CI, −2.10 to 1.18; P=.59) (fig 3B). Taken together, these findings suggest that there is no significant disparity between ESWT alone and needling therapy alone in ameliorating pain indices in patients with tendinoterminal disease.

Fig 3.

Fig 3

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Forest plots showing the mean difference in ESWT and needling therapy. (A) Forest plot showing the mean difference in VAS scores between the ESWT group and the needling group at first follow-up. (B) Forest plot showing the mean difference in VAS scores between the ESWT group and the needling group at the last follow-up. (C) Forest plot showing the mean difference in PPT score between the ESWT group and the needling group at the last follow-up.

Furthermore, we examined 2 additional articles comprising a total of 135 patients, specifically targeting the PPT score at the final follow-up (fig 3C). The findings revealed no significant difference (MD, −0.08; 95% CI, −0.30 to 0.14; P=.49) (fig 3C) between ESWT and needling therapy in enhancing patients' PPT values, aligning with the previously mentioned outcomes (fig 3A and B).

Needling therapy combined with ESWT versus ESWT alone

We then assessed the comparative efficacy between 2 treatment regimens (needling therapy combined with ESWT versus ESWT alone) in alleviating pain at the final follow-up visit, encompassing 3 articles involving 161 patients (fig 4). The findings demonstrated that needling therapy combined with ESWT was notably more effective than ESWT alone in mitigating pain among patients with tendinoterminal disease in terms of delayed effects (MD, −1.79; 95% CI, −2.60 to −0.97; P<.0001).

Fig 4.

Fig 4

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Forest plot showing the mean difference in VAS scores between the combined ESWT and needling groups and ESWT alone group at the last follow-up.

Discussion

Tendinopathy, a general term used to describe conditions characterized by pain and swelling in the tendons, refers to the complex and multidimensional pathological state of tendons. It is typically manifested by pain, decline in function, and reduction in exercise endurance. The most common tendinopathies, caused by overuse, often occur in areas such as the rotator cuff tendons, the medial and lateral epicondyles of the elbow, the patellar tendon, the gluteal tendons, and the Achilles tendon.1 Current treatments mainly include self-care, physical therapy, medication, and surgical treatment, with no universally agreed-upon optimal therapy.1 This study focuses on conservative treatments, specifically comparing the effectiveness of ESWT and needle-based therapy, both used individually and in combination, in relieving pain for patients with tendinopathy.

This study conducted a meta-analysis and concluded that there is no significant difference in VAS scores in terms of immediate (P=.73) and delayed effects (P=.59) between solely needle-based treatments and ESWT for alleviating pain in patients with tendinopathy. However, combined treatment with ESWT and needle-based therapy shows significantly better delayed effects compared with ESWT alone on VAS scores (P<.0001). This suggests that needle-based treatments may play an important role in the delayed effects of patients, and they may need to be supplemented with ESWT to achieve better therapeutic effects.

First, needle-based therapy involves inserting needles into the painful area of the muscle or tendon to release pain. Many previous RCTs have demonstrated that needle-based therapy has significant efficacy compared with a placebo in treating tendon pain.33, 34, 35 When damaged muscle or tendon tissue is repeatedly punctured by dry needling, one perspective suggests that the puncturing disrupts the chronic degenerative process and promotes fibroblast proliferation.10 Another perspective suggests that dry needling stimulates trigger points, causing local twitch responses, which may induce rapid depolarization of the affected muscle fibers, resulting in local twitching. After the muscle completes the twitching, spontaneous electrical activity subsides, significantly reducing pain and dysfunction.36 However, needle-based therapy has also been observed to have some side effects, such as fainting, tissue damage, systemic reactions, infections, etc.37 We believe that repeated puncturing in needle-based therapy might also induce a chronic inflammatory response in the already inflamed affected area,38 preventing needling therapy from achieving optimal efficacy.

As previously mentioned, there is no significant difference in efficacy between using ESWT alone and needling therapy alone. First, ESWT is believed to increase pain threshold through overstimulation13 while activating cytoskeletal attachments, leading to enhanced specific messenger RNA transcription and nuclear translocation. This is followed by the activation of cellular organelles such as mitochondria and the endoplasmic reticulum, as well as cellular vesicles, which release specific proteins that aid in tissue repair and induce osteoblast differentiation.39,40 In addition, a study has shown that ESWT can reduce inflammation in joints by modulating inflammatory factors.41 When ESWT and needling therapy are used together, on the one hand, needling therapy may reduce pain by affecting intrinsic electrical activity, while ESWT raises the pain threshold, thereby better alleviating the patient's pain. On the other hand, ESWT may reduce the inflammatory response caused by needling therapy, leading to improved effectiveness of the needling therapy. This could be a reasonable explanation for why the combination of ESWT and needling therapy is more effective in reducing pain in patients with enthesopathy than using either treatment alone.

Existing studies also suggested that steroid medications have immediate anti-inflammatory and analgesic effects,42,43 and their combination with needling therapy has also shown good delayed outcomes in reducing pain in patients.44 This may suggest that combining needling therapy with certain drugs that have anti-inflammatory and tissue-healing properties could yield better results. However, steroid treatment is associated with certain side effects,45 such as localized pain after injection, skin atrophy, and pigmentation loss.46

In summary, the results show that the effects of ESWT and needling therapy alone for alleviating tendinopathy are comparable both in terms of immediate effects and delayed effects; therefore, the combination of ESWT with needling therapy is more effective in reducing pain indices in patients with tendinopathy than using ESWT or needling therapy alone. This may be because ESWT helps alleviate the minor inflammatory reactions caused by needling therapy. Given the possible synergistic effects between ESWT and needling therapy, it is recommended that conservative clinical treatment prioritize the combined use of ESWT and needling therapy.

Study limitations

The primary outcomes observed in this article are focused on pain, with no inclusion of indicators related to physical function. Additionally, this study mainly explores the efficacy of ESWT and needling therapies, as well as their combined use, without comparing them with other physical therapies. Furthermore, due to the limited number of suitable studies available, the number of articles included in this meta-analysis is restricted, which may introduce a risk of bias. Future research should incorporate more RCTs for a comprehensive investigation and should focus on the combination of more different therapies to mutually inhibit the negative effects and promote the positive effects to have a better effect in reducing pain in patients with terminal tendinopathy.

Conclusions

This meta-analysis of 9 included RCTs found that the combined use of ESWT and needling therapy demonstrated significant and statistically better results in delayed effects of reducing VAS scores in patients with tendinopathy compared with the use of either therapy alone. When ESWT and needling therapy were used individually, there was no statistically significant difference in reducing VAS or PPT scores, whether in terms of immediate or delayed effects.

Disclosures

The authors declare that there is no conflict of interest.

Acknowledgments

Acknowledgment

We thank Topola Boko Damaris for the correction of wording and grammar in this article.

Authorship contributions/CRediT statements

Zonglin Li: conceptualization; data curation; writing—original draft; writing— review and editing. Yubin Chen: conceptualization; data curation; validation; writing—review and editing. Lili Chen: conceptualization; data curation; validation; writing—review and editing. Jinshen He: conceptualization; data curation; funding acquisition; supervision; writing—original draft; writing—review and editing.

Data statements

All the data obtained were from articles selected from PubMed, Web of Science, and Cochrane Library.

Footnotes

Systematic review registration number: CRD42024580866.

Supported by the Foundation of Health Commission of Hunan Province (no. 202204074821) and the Natural Science Foundation of Changsha (no. kq2202434).

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