Extracorporeal shockwave therapy and low-level laser therapy

Both ESWT and LLLT physical modalities resulted in reduced pain, greater mobility and an improvement in function of the tissues that they were used to treat.

Extracorporeal shockwave therapy (ESWT), commonly referred to as shockwave therapy, and low-level laser therapy (LLLT) are two noninvasive treatment options that in the recent past have gained a lot of traction and popularity.

ESWT uses acoustic energy via high-pressure air which travels through tissues in waves. These waves of energy cause micro-changes to structures and functions of the different tissues they pass through. This effect has been seen to promote angiogenesis and tissue regeneration, break up calcification, decrease inflammation and pain and improve function and mobility of the affected tissue.

LLLT uses the effect of photochemical energy instead of acoustic energy. This energy causes biostimulation of the penetrated cells by delivering energy to the cell and increasing cellular metabolism. It is thought to specifically affect Cytochrome C oxidase in the electron transport chain of mitochondria. This stimulation helps increase adenosine triphosphate (ATP) production of the cell, which then leads to increased cellular metabolism.

LLLT has been seen to promote revascularization and tissue regeneration, decrease pain and inflammation, and improve function and mobility of the affected tissue. Because of this mechanism, LLLT has been used to treat tendinous and ligamentous pathologies specifically because of the increase in cellular metabolism it can cause. Tendons and ligaments receive less blood supply than skeletal muscle, so healing and regeneration is harder and takes more time. By increasing cellular metabolism via LLLT, healing and regeneration may occur more quickly than without intervention.^1,2

When comparing both ESWT and LLLT, they have two distinct mechanisms of action (MOA) but seem to provide a very similar effect. Because of this difference in MOA, this summary aims to see if there is a difference in general treatment effectiveness as well as if there is a difference in effectiveness based on tissue type when treated by both methods. The two articles selected included two random-controlled trials (RCT) comparing the effectiveness of ESWT and LLLC in treating myofascial pain syndrome (MPS) and another using the same modalities but treating chronic lateral epicondylitis (LE).

Király, et al., compared the effect ESWT and LLLT had on pain, functionality of the neck and quality of life of 61 patients with MPS of the trapezius.³ In this study, the ESWT group was treated once a week for three weeks, while the LLLT group was treated every day for three weeks for a total of 15 treatments. Measurements were taken before the initial treatment, after three weeks of treatment, then again 15 weeks after the last treatment. Both groups experienced significant improvements in perceived pain, neck function and quality of life, but the ESWT group saw significantly better improvement for all three parameters. At the 15-week follow-up, the LLLT group showed significantly better reduction in resting pain compared to the ESWT group. It was concluded both treatments were effective in treating MPS, with ESWT being slightly more clinically relevant and effective.

Turgay, et al., tested the effectiveness of using ESWT and LLLT in treating chronic LE.⁴ In this study, the ESWT group was treated once a week for five weeks, while the LLLT group was treated once a day for 15 consecutive days. The patients were evaluated using two upper extremity specific questionnaires and a quality of life questionnaire both before and after the treatments. This study found both treatment modalities were effective in treating chronic LE. When comparing the treatments, ESWT performed significantly better in many of the parameters than did LLLT. This study concluded both treatments are safe and effective in treating chronic LE, but clinically, ESWT may be more effective in treating pain and restoring functionality of the arm.

Both studies concluded ESWT and LLLT both proved effective in treating and reducing symptoms of both MPS and LE. Both studies followed similar treatment protocols and used similar diagnostic testing to gauge treatment effectiveness. Both studies concluded the two modalities were effective in treating their respective pathology and agreeing ESWT was more effective than LLLT. At this point, the reason why ESWT was more effective in treating both musculoskeletal and tendinous pathologies isn’t known. While the MOA of each is known, the full extent that each one has and the cascade of events that might occur is still not fully understood.

Final thoughts

After reviewing both studies, it is clear both ESWT and LLLT have a time and a place in treating many different conditions. Based on the two articles, ESWT may be more effective in the long run than LLLT. One of the notable differences is that in both studies, the patients were treated less with ESWT than they were with LLLT. This may be one benefit to using ESWT even if both modalities have the same general effect. If ESWT can be used in a clinical setting over LLLT, more people might be able to be treated because the total number of treatments needed seems to be much less. In both studies, patients received 15 LLLT treatments, while ESWT was used three and five times, respectively, in the first and second studies reviewed.

In conclusion, ESWT and LLLT are both great options for treating musculoskeletal and tendinous conditions. They both resulted in reduced pain, greater mobility and an improvement in function of the tissues that they were used to treat. More comparative studies need to be done to further understand if there exists a more definitive distinction of when ESWT or LLLT should be used to maximize patient healing and recovery.

Brennon Bressler is a chiropractic student currently in his seventh trimester of the National University of Health Sciences’ (NUHS, FL) program. He tutors anatomy, is a teacher’s assistant (TA) for thoracic manipulation and is chair of the Florida functional neurology student club. He is a second-generation chiropractor; his father attended NUHS (IL) and was his inspiration for pursuing a career in chiropractic.

Acknowledgment

This research article represents successful implementation of student learning objectives from Dr. Gantzer’s National University of Health Sciences (FL) biomedical literature fourth trimester course, addressing the role of research, efficient medical literature searches, identification of study designs and their critical analysis, thereby preparing students to identify research findings that will assist them in being more effective practitioners.

References

1. Lyu K, et al. The functions and mechanisms of low-level laser therapy in tendon repair (review). Front Physiol. 2022;13:808374. https://www.frontiersin.org/journals/physiology/articles/10.3389/fphys.2022.808374/full. Accessed May 6, 2026.
2. Simplicio CL, et al. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. J Clin Orthop Trauma. 2020;11(Suppl 3):S309-S318. https://www.sciencedirect.com/science/article/abs/pii/S0976566220300631. Accessed May 6, 2026.
3. Király M, et al. Comparative study of shockwave therapy and low-level laser therapy effects in patients with myofascial pain syndrome of the trapezius. Rheumatol Int. 2018;38(11):2045-2052. https://link.springer.com/article/10.1007/s00296-018-4134-x. Accessed May 6, 2026.
4. Turgay T, et al. Comparison of low-level laser therapy and extracorporeal shockwave in treatment of chronic lateral epicondylitis. Acta Orthop Traumatol Turc. 2020;54(6):591-595. https://pmc.ncbi.nlm.nih.gov/articles/PMC7815222/. Accessed May 6, 2026.