Shockwave and Magnetotransduction Therapy as Healing Accelerators in Athletes
Winning a trophy such as the European Soccer Championship in 2024 requires scoring at least one goal more than the opponent, and a team may be fortunate with a referee's decision, but in the end it also needs players who are available. Recent data from the Premier League show that between 75 and 89% of the members of a squad are available in a given season, which means that between 10 and 25% of the squad is affected by time-loss injuries. Muscle injuries are also much more frequent when the interval between two games is shorter than three days (Bengtsson, Ekstrand and Hägglund, 2013). In this article I describe how shockwave therapy and extracorporeal magnetotransduction therapy (EMTT) can be used to shorten healing time in athletes, drawing on published studies and on cases from my own practice.
Availability and the Value of Time
In the UEFA Champions League injury study, the majority of injuries were minor muscle injuries and contusions of the thigh, foot and knee, with an average time loss of four to six days (Ekstrand, Hägglund and Waldén, 2011). Concussions average around nine days, tendon injuries take somewhat longer, and structural muscle injuries and ligament injuries, above all of the anterior cruciate ligament, lead to much longer absences. An estimate from 2014 put one day off for a Champions League player at around 20,000 euro, so in high-level and professional athletes time has a clear monetary value.
The aim is therefore to bring healing forward by at least one or two steps compared with what is usual, and this depends on the techniques available in a regenerative toolbox.
Energy-Based Therapies in the Athlete
Shockwave and EMTT belong to the field of energy-based therapies, together with laser therapy and vibration therapy. Athletes in particular look for needle-free treatment options. Heinz Lohrer from Frankfurt was the first to treat athletes with a focused electromagnetic device during an Olympic Games, in Atlanta in 1996, and Adam Tenforde and Steve Sampson have shown that shockwave is a valid option to improve healing times in in-season athletes. EMTT was introduced in 2020. Several national teams were equipped with an EMTT device during the Soccer World Cup in 2026. In my practice in Hannover I focus on non-invasive ways to improve tendon, muscle and joint healing, based on ultrasound assessment, with radial, focused and EMTT devices.
Radial and Focused Shockwave
A shockwave is characterised by a rapid and steep rise of the pressure wave. We distinguish radial pressure waves, which act much like an air gun, from focused shockwaves, which in the devices I use are produced by an electromagnetic generator and can travel up to eight centimetres in tissue. For radial waves the energy is described in bar, together with the frequency and the number of shots, which is usually between 2,000 and 4,000 in the musculoskeletal field, whereas for focused devices the energy flux density is measured in millijoule per square millimetre. Radial waves act regionally, whereas focused waves are localised and can be aimed at the epicentre of the injury like a laser beam. Combining the two is already supported by some data.
The International Society for Medical Shockwave Treatment (ISMST) proposes indications at beginner, advanced, expert and experimental levels, based on the experience of providers, and updates them annually. Chronic tendinopathies and bone pathologies are standard indications, advanced indications include bone marrow oedema and Osgood-Schlatter disease, and experimental indications extend to Alzheimer's disease and chronic complex regional pain syndrome.
EMTT and the Bioelectric Concept
EMTT is a wireless, touch-free electromagnetic technique. When radial, focused and EMTT devices are used together, they offer a local, a focal and a regional option. Part of the rationale comes from the growing interest in bioelectricity: by shifting the membrane potential of a cell, its function may change. Cells can move from a non-proliferating to a proliferating state, and macrophages from an anti-inflammatory to a pro-inflammatory response, through a change in membrane potential alone.
We have shown that EMTT can increase vascular endothelial growth factor considerably. Colleagues from Italy have shown that tenocyte proliferation, migration and matrix production are enhanced with EMTT (Mancini et al., 2025), and Leonard Gerdesmeyer has shown that EMTT improves osteogenesis at every stage (Gerdesmeyer et al., 2024). Pulsed electromagnetic field devices have no clinical effect on bone, whereas EMTT acts on tendons, muscles and bones.
My early experience with EMTT, nearly ten years ago, included a young track and field athlete with bone oedema of the navicular. I gave focused shockwave for bone stimulation and EMTT with the coil. An early MRI six weeks after three treatments showed that the bone oedema had resolved. With focused shockwave alone I would expect to see changes on MRI after three or six months, so healing was clearly accelerated.
Muscle
In muscle, the response can be marked. Thomas is a 14-year-old soccer player who suffered a blunt trauma to the anterior thigh, with a significant haematoma in the vastus intermedius, deep and close to the femur. He could not run because of pain. Two days after treatment the haematoma was smaller on ultrasound, and four days after that it was barely visible. Over six days the haematoma size fell by 83%, and he was back in competition on day 18.
A tennis player with a tear of the rectus abdominis illustrates the combination of shockwave and EMTT. By shear wave elastography the injured muscle had a stiffness of 53 kilopascal against 25 kilopascal in the uninjured muscle. Ten to twenty minutes after a treatment combining radial, focused and EMTT, stiffness had fallen by 33%, and a week later by 47%, so the elasticity improved quite rapidly.
Tendons
Tendons heal faster with the help of shockwave and EMTT. This applies to patellar tendinopathies, including those of some soccer players from the German Bundesliga. In Osgood-Schlatter disease, which affects not only the apophysis but also the tendon, I combine radial and focused waves, class 3B low-level laser and EMTT, and neovascularisation can be followed on ultrasound. In epicondylitis I also try to act on neovascularisation, and in one case the combination of radial and focused shockwave, EMTT and polidocanol sclerosing reduced it from 28% to 12% after one week and to 0% after two weeks.
The strongest evidence comes from a randomised controlled trial in 86 patients with rotator cuff tendinopathy, who received either three sessions of focused, high-energy shockwave or focused shockwave plus EMTT (Klüter et al., 2018). Focused shockwave alone reduced pain significantly, by up to 42% after half a year. Combining three sessions of focused shockwave with EMTT more than doubled the clinical efficacy, to 88% pain reduction after 24 weeks. For this reason I promote the combination in tendinopathies, since it can at least double the effect of shockwave alone.
Bone
For bone I begin with case reports. A young consultant had a non-union of the scaphoid for 19 years after two operations with non-vascularised bone grafts. I offered three sessions of focused shockwave and EMTT with high-energy parameters, 4,000 focused shots and 6,000 EMTT shots, placing the coil as close as possible to the scaphoid. Five weeks after the first treatment the cone-beam CT showed a significant bone stock and no non-union any more. The same held for a non-union of the fifth metacarpal after two failed surgeries, where six weeks later the bone stock of the graft had improved significantly (Knobloch, 2021).
Kienböck's disease, or lunate necrosis, is a progressive disease that affects males twice as often as females, mostly between 20 and 40 years of age. Cristina D'Agostino from Milan showed as early as 2011, in 22 patients, that three high-energy sessions of focused electromagnetic shockwave with 4,000 shots plus splinting reduced pain significantly, from 8 to 4 at two months and to 5 after one year, with improvement of bone oedema on follow-up MRI (D'Agostino et al., 2011). A 22-year-old professional tennis player with lunate necrosis received five sessions of focused shockwave and EMTT in six days, since he had little time. I increased the energy flux density from day one to day six, keeping the visual analogue scale below five out of ten, and by the end I applied more than six times the initial total energy. He could play again.
Stress fractures are a very good indication for the combination. An Ironman triathlete with a plated collarbone fracture four weeks before his most important competition received focused shockwave and EMTT and could compete (Gerdesmeyer, Burgkart and Saxena, 2024). A German national swimmer with a great toe fracture three or four weeks before the Olympic qualifying competition could swim without pain after ten days of treatment with focused shockwave and EMTT, and consolidation was confirmed within a month. Arnold Saxena and colleagues have shown that adding EMTT and shockwave after foot surgical procedures significantly improves return to activity time, from 22 to 13 weeks (Saxena et al., 2025).
A 15-year-old boy had pain for three months in the anterior inferior iliac spine, with no diagnosis. MRI and ultrasound showed the inflammatory process of an apophysiolysis, and he received radial pressure waves, focused shockwave and EMTT. After one week the inflammation at the tendon insertion was 50% lower, six weeks later the apophysis had consolidated with no inflammation, and he could return to play (Knobloch, 2026). In osteitis pubis with bone oedema, a pilot trial of only four sessions of EMTT reduced pain from eight to less than one within a month. In the adolescent spine, lumbar bone marrow oedema responds to focused shockwave, and even better to focused shockwave with EMTT. Addressing the bone oedema may help prevent a pedicle fracture and subsequent spondylolisthesis, which is why early MRI matters in adolescents. EMTT also has a good perspective in paediatric orthopaedics, for example in a four-year-old with Perthes disease of the hip who walked with a limp and improved (Welter and Knobloch, 2026).
Knee and Ligaments
Experimentally, focused shockwave may help meniscal healing, even in the avascular region. A randomised controlled trial from Japan applied focused electromagnetic shockwave at 0.25 millijoule and 2,500 shots to degenerative menisci in patients around 65 years of age. It improved T2 relaxation time, a parameter of meniscal health, and, more importantly in my view, reduced pain compared with the control group (Hashimoto et al., 2024). In a 41-year-old with a degenerative medial meniscal tear, three sessions of focused shockwave and EMTT were followed by a scar that appeared stable on ultrasound after three months and was hardly visible after six months, and he ran three times 10 kilometres in a week without pain.
Patrick Weninger from Vienna has shown, in patients operated for anterior cruciate ligament rupture, that focused shockwave applied in weeks four, five and six after reconstruction with hamstring tendons significantly improved pain and the EQ-5D and Lysholm scores (Weninger et al., 2023). For the medial collateral ligament there are case reports at present showing that electromagnetic focused shockwave can improve pain and reduce healing times.
Nerves and Brain
The most prevalent neuropathy is carpal tunnel syndrome, in which a compressive neuropathy is often combined with tendinopathy of the nine flexor tendons entering the carpal tunnel. Applying shockwave to the nerve is considered beneficial for the surrounding tendons and for the nerve itself, since both axon and neurite are influenced beneficially by focused shockwave. In a network meta-analysis of 49 randomised trials of conservative treatments for carpal tunnel syndrome, shockwave therapy showed a significant benefit compared with control groups (Chen et al., 2025). I now combine radial, focused and EMTT in carpal tunnel syndrome before moving to ultrasound-guided hydrodissection or open repair, and at an early stage three to five sessions can change the course of the condition in a non-invasive way.
Concussions play a major role in collision sports and can lead to vestibular and ocular problems, post-traumatic migraine, anxiety and mood changes, and post-concussion syndrome can bring headaches, sleep problems and brain fog. Scottish former soccer players have a five-fold higher risk of Alzheimer's disease and a two-fold higher risk of Parkinson's disease (Mackay et al., 2019). In the post-concussive phase of four to six weeks, patients also have twice the odds of sustaining any musculoskeletal injury.
This is where shockwave may come into play. Transcranial pulse stimulation (TPS), marketed as NEUROLITH, is an MRI-navigated focused electromagnetic shockwave device. We usually apply between 0.2 and 0.25 millijoule through the skull, with about 6,000 shots in the entire brain, and 3D navigation shows where the shockwave is applied. In Alzheimer's disease the technique is CE-approved for mild to moderate disease (Beisteiner et al., 2020), and it is currently being studied in Parkinson's disease, with a significant reduction in tremor, and in depression. In sport, I studied six soccer players with football-related concussion, on average two days after the injury, using the SCAT-6. All six tolerated TPS very well without adverse effects, and symptoms and severity improved significantly within a week, with all items improving in this pilot trial. I see a promising future for the NEUROLITH in concussion and return to play, with a return after nine days.
Conclusion
The examples above cover muscle, tendon, bone, ligament, nerve and brain, and in each of them radial and focused shockwave, combined with EMTT, were used with the aim of shortening the time to recovery. The randomised trial in rotator cuff tendinopathy and the controlled studies on the meniscus, the anterior cruciate ligament and foot surgery are complemented by case reports and pilot studies, particularly for bone and for concussion. In my view, shockwaves and EMTT are superior healing accelerators, and their combination offers a non-invasive option for athletes who cannot afford long periods of absence.
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Frequently Asked Questions
Q: What is the difference between radial and focused shockwave?
Radial pressure waves act much like an air gun and are used in a regional way, with energy described in bar. Focused shockwaves are produced by an electromagnetic generator, can travel up to eight centimetres in tissue, and are localised on the epicentre of the injury like a laser beam, with energy described as energy flux density in millijoule per square millimetre. Both are usually applied with 2,000 to 4,000 shots, and combining them is supported by some data.
Q: What is extracorporeal magnetotransduction therapy (EMTT)?
EMTT is a wireless, touch-free electromagnetic technique that was introduced in 2020. Laboratory work shows enhanced tenocyte proliferation, migration and matrix production (Mancini et al., 2025) and improved osteogenesis at every stage (Gerdesmeyer et al., 2024).
Q: Does adding EMTT to shockwave improve results in tendinopathy?
In a randomised controlled trial of 86 patients with rotator cuff tendinopathy, three sessions of focused shockwave reduced pain by up to 42% after half a year, whereas the same sessions combined with EMTT led to an 88% pain reduction after 24 weeks (Klüter et al., 2018).
Q: Which bone conditions have been treated with the combination?
Reported cases include non-unions of the scaphoid and of the fifth metacarpal (Knobloch, 2021), pelvic apophysitis in an adolescent (Knobloch, 2026) and Perthes disease (Welter and Knobloch, 2026). In foot surgery, adding EMTT and shockwave was associated with a shorter return to activity, from 22 to 13 weeks (Saxena et al., 2025). Much of this evidence consists of case reports and pilot studies.
Q: How can shockwave be used in concussion?
Transcranial pulse stimulation (NEUROLITH) is an MRI-navigated focused electromagnetic shockwave applied through the skull and is CE-approved for mild to moderate Alzheimer's disease (Beisteiner et al., 2020). In a pilot trial of six soccer players with concussion, symptoms improved significantly within a week.
References
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Hashimoto, S., Ohsawa, T., Omae, H., Oshima, A., Takase, R. and Chikuda, H. (2024) 'Extracorporeal shockwave therapy for degenerative meniscal tears results in a decreased T2 relaxation time and pain relief: an exploratory randomized clinical trial', Knee Surgery, Sports Traumatology, Arthroscopy, 32(12), pp. 3141-3150. doi:10.1002/ksa.12384.
Klüter, T., Krath, A., Stukenberg, M., Gollwitzer, H., Harrasser, N., Knobloch, K., Maffulli, N., Hausdorf, J. and Gerdesmeyer, L. (2018) 'Electromagnetic transduction therapy and shockwave therapy in 86 patients with rotator cuff tendinopathy: a prospective randomized controlled trial', Electromagnetic Biology and Medicine, 37(4), pp. 175-183. doi:10.1080/15368378.2018.1499030.
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Knobloch, K. (2026) 'Pelvic apophysitis and avulsion fracture treated with a regenerative combination of extracorporeal shockwave therapy and extracorporeal magnetotransduction therapy in an adolescent soccer player', Wiener Medizinische Wochenschrift. doi:10.1007/s10354-026-01175-2.
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Saxena, A., Bondi, E., Gerdesmeyer, L., Leal, C., Knobloch, K., Maffulli, N., Gerdesmeyer, L. and Tenforde, A.S. (2025) 'Focused shock wave therapy (ESWT) and electromagnetic transduction therapy (EMTT) may improve post-operative bone healing in selective foot and ankle surgeries: a case-control pilot study', Journal of Orthopaedic Surgery and Research, 20(1), 1018. doi:10.1186/s13018-025-06420-9.
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Prof. Dr. Karsten Knobloch is a renowned expert in musculoskeletal medicine, with a special focus on ultrasound diagnostics and minimally invasive therapies. A Fellow of the American College of Surgeons (FACS), he is highly regarded for his innovative work in the assessment and treatment of tendinopathies and sports-related injuries. Prof. Knobloch has authored numerous publications in peer-reviewed journals and is a sought-after speaker at international conferences. His expertise spans advanced imaging techniques such as shear wave elastography and Power Doppler ultrasound, as well as cutting-edge therapeutic modalities including extracorporeal shockwave therapy (ESWT) and ultrasound-guided injection therapies.
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