Why We Need to Move On From Shockwave Therapy for Tendons

Why We Need to Move On From Shockwave Therapy for Tendons

By Physio Daniel O’Grady

Let’s talk about shockwave therapy for tendon pain.

It’s been around for a while, but is it really worth your time, money, and effort?

A new, high-quality study shows the answer is clear:

No, it’s not.

This research is a game-changer.

It shows us that it’s time to leave shockwave therapy behind and focus on better, more effective ways to recover from tendon pain.

Let me explain why this study matters and why it’s time for us to move forward.

A Study You Can Trust

This wasn’t just another small, poorly done study.

This was a randomized controlled trial—the gold standard of clinical research.

The researchers wanted to find out if shockwave therapy actually helps people with insertional Achilles tendinopathy, a common type of tendon pain.

Here’s what made this study so reliable:

• Participants were randomly split into two groups: one got shockwave therapy, and the other got a fake, sham treatment.

• Both groups received the same high-quality exercise program and education about their condition. The only difference was the shockwave therapy.

• Participants and assessors were blinded—they didn’t know who got the real treatment. This helped eliminate bias and ensured the results were fair.

What Did the Study Find?

After 6 weeks and 12 weeks, the results were in: there was no difference between the group that received shockwave therapy and the group that got the sham treatment.

That’s right—shockwave therapy didn’t improve pain, function, or any other outcome.

Even with a solid exercise program alongside it, shockwave therapy offered no extra benefit.

This finding is consistent with previous research, which has also failed to show that shockwave therapy is effective for tendon pain.

Why Does This Matter?

Shockwave therapy is expensive, time-consuming, and often uncomfortable.

If it doesn’t work any better than a fake treatment, why are we still using it?

This study tells us it’s time to stop chasing ineffective solutions and focus on what actually helps.

The good news? We already have effective tools for tendon recovery: exercise and education.

Why This Study Stands Out

This research wasn’t just any study—it was done right. Here’s why it’s so trustworthy:

1. It included 76 participants, enough to ensure the results were reliable.

2. It measured real-world outcomes, like pain, function, and quality of life. These are the things that actually matter to patients.

3. It followed modern clinical guidelines, allowing participants to keep walking, running, and staying active as long as their pain was manageable. This makes the results much more applicable to everyday life.

Meet the Expert: Professor Peter Malliaras

One of the lead researchers on this study was Professor Peter Malliaras, a world-renowned expert in tendon rehabilitation.

He’s spent decades helping people recover from tendon pain and is a leader in evidence-based approaches to treatment.

Professor Malliaras has published numerous scientific papers on tendon pain and regularly trains physiotherapists around the world.

His work emphasizes what really works—like load management and exercise—and steers us away from outdated or ineffective treatments.

If he’s saying shockwave therapy doesn’t help, you can trust that it’s based on solid evidence.

A Better Way Forward

So, what should you do if you’re dealing with tendon pain?

The answer is simple: Focus on exercise and education.

Exercise, when done right, strengthens your tendon and helps it handle the demands of your life—whether that’s walking, running, or sports.

Education helps you understand your pain and manage it with confidence.

These approaches are backed by strong evidence and don’t rely on expensive, unproven add-ons like shockwave therapy.

The Takeaway

Let’s be bold: It’s time to move on from shockwave therapy.

The evidence is clear—it doesn’t work better than a placebo.

Instead, we should focus on the bigger picture: building resilience, managing load, and using proven strategies to recover from tendon pain.

Your recovery doesn’t need gimmicks or quick fixes.

It needs patience, the right exercises, and a focus on what really matters.

It’s just about to tick over to 2025—let’s leave ineffective treatments behind and embrace what works.

If you’re ready to take control of your tendon pain start with a comprehensive evaluation with expert Physio Daniel O’Grady.

Research link:

Does shockwave therapy lead to better pain and function than sham over 12 weeks in people with insertional Achilles tendinopathy? A randomised controlled trial

Moseley’s Red/Blue Light Study: Why It’s Time to Move On

Moseley’s Red/Blue Light Study: Why It’s Time to Move On

Let’s talk about Moseley’s infamous red/blue light study—a research piece from nearly 20 years ago that somehow still gets rolled out as a cornerstone of pain science education.

It’s a clever experiment, sure, but it’s wildly overused to justify his unwavering commitment to the neuromatrix model.

Here’s the thing - it’s an extremely superficial look at pain that doesn’t hold up when you dig deeper.

Worse, its oversimplified conclusions have caused real-world harm to patients and clinicians alike.

I think it’s to time we moved on.

What Does the Study Actually Show?

In the study, a noxious cold probe was paired with either a red light (associated with danger, tissue damage) or a blue light (associated with cold, less dangerous).

Participants rated the pain unpleasantness as higher with the red light, but pain intensity—how physically strong the pain felt—didn’t change.

This means that context (the visual cue) affected the emotional evaluation of pain (unpleasantness) but not the raw sensory experience (intensity).

This is an interesting finding—but very narrow.

It’s about exteroception (external cues like vision) influencing pain perception.

That’s fine for a lab-controlled experiment on acute pain, but it tells us nothing about interoception, chronic pain, or the real-world complexity of pain.

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In a recent 2023 podcast, Moseley doubled down on his study with this quote:

“There were some people for whom, with the blue light they reported no pain and with the red light they reported pain eight out of ten. And that’s a very severe pain. There are other people who reported the same level of pain in each situation. And in scientific terms we describe those people as idiots (laugh) because their brains are not picking up on these cues that everyone else is picking up on.”

This is deeply problematic for several reasons:

• Dismissive attitude: Referring to participants as "idiots" because they didn’t conform to the expected pattern is disrespectful and ignores the complexity of individual pain responses and the fact that they can trust their bodies experience without being contaminated with external distractions (a rare and amazing skill to be honest)

• Moseley uses phrases like "pain eight out of ten" without distinguishing whether he means intensity (strength) or unpleasantness (emotional impact). However, based on the study results, the only dimension that showed such variability in response to the cues was pain unpleasantness, not intensity. This lack of clarity can be misleading

• Pain intensity and pain unpleasantness are distinct dimensions, and conflating them obscures the actual findings of the study. It risks overstating the impact of visual cues, as they DIDN’T alter the sensory intensity of the pain but only its EMOTIONAL interpretation.

• Failure to update his model: Instead of recognizing that his study barely scratches the surface of pain complexity, Moseley doubles down on his original findings, refusing to appreciate their limited scope.

• Ignores interoception and chronic pain: His study is about acute nociceptive pain modulated by visual cues. Chronic pain, which involves interoceptive processes (e.g., inflammation, fatigue, homeostatic dysregulation), isn’t even in the same ballpark.

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Moseley’s study isn’t a bad experiment—it’s just wildly overgeneralized. Here’s why:

• It only applies to exteroceptive pain: The study is about surface-level pain influenced by external cues (red/blue light). It says nothing about deeper, interoceptive pain (e.g., from muscles or organs), which involves different brain regions like the insular cortex.

• It separates pain intensity from unpleasantness: The findings show that context changes unpleasantness (salience), NOT intensity.

• But in real-world chronic pain, those dimensions are deeply intertwined and modulated by systemic factors like inflammation and central sensitization.

• It ignores chronic pain altogether: Chronic pain is a much messier phenomenon involving altered interoception, disrupted homeostasis, and central sensitization. This study doesn’t even begin to address that complexity.

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Unintended Harmful Consequences

By clinging to this superficial study, Moseley’s work has contributed to serious downstream problems:

• Gaslighting patients: Patients with chronic pain are often told their pain is just a "brain output," implying it’s all in their head. This dismisses the real interoceptive and structural factors driving their pain, leaving them feeling invalidated and alienated.

• Oversimplified treatments: The idea that context alone can “rewire” pain has spawned treatments that focus on changing the brain’s interpretation of pain while ignoring physical contributors like mitochondrial dysfunction, inflammation, and recovery deficits.

• Therapist confusion: Clinicians trying to reconcile this brain-centric model with their patients’ real-world experiences often find it doesn’t work. Chronic pain doesn’t behave like the tidy pain in Moseley’s lab study, and therapists are left frustrated and unsure how to help.

Bud Craig’s Interoceptive Model: A Better Framework

Bud Craig’s work on interoception offers a much more realistic and applicable model for understanding pain:

• Pain as a homeostatic emotion: Pain reflects disruptions in the body’s internal state, integrating interoceptive signals with emotional and cognitive processes.

• Role of the insular cortex: Unlike the neuromatrix model, Craig’s framework emphasizes the insular cortex as a hub for processing interoceptive inputs (e.g., inflammation, fatigue) and driving adaptive responses.

• Chronic pain as a prediction mismatch: Craig’s model explains chronic pain as a mismatch between the brain’s predictions and the body’s actual internal signals, a more accurate representation of what patients experience.

This framework doesn’t just make more sense scientifically—it aligns better with what patients and therapists see in the real world.

The unpleasantness of tonic pain is encoded by the insular cortex

While Moseley’s red/blue light study has been widely cited, its focus on acute skin-based sensations (exteroception) offers little relevance to the kind of pain most patients bring to a physiotherapist.

In stark contrast, Schreckenberger’s study, The unpleasantness of tonic pain is encoded by the insular cortex, dives into the mechanisms of interoceptive pain, the deep, internal discomfort often experienced in muscles and other tissues.

Schreckenberger’s research highlights how muscle pain—the type of pain patients commonly report—activates the insular cortex, which encodes the unpleasantness of pain tied to homeostatic dysregulation and internal states.

Unlike superficial findings from Moseley’s study, which rely on external cues like light, Schreckenberger’s work reflects real-world pain mechanisms and offers a far more valid framework for understanding and treating the persistent pain that drives patients to seek care.

This critical distinction underlines why Moseley’s study, despite its fame lacks practical relevance.

Time to Retire the Red/Blue Light Study

Moseley needs to stop using this study as the cornerstone of his arguments.

It’s outdated, oversimplified, and irrelevant to the complexity of chronic pain.

Pain science has moved on, and so should Moseley. His refusal to update his model—despite the clear limitations of this study—shows a troubling lack of humility.

The future of pain science lies in embracing complexity, not reducing pain to a “brain output” but understanding it as a dynamic interplay of interoception, homeostasis, and real-world biology.

Bud Craig’s interoceptive model offers a path forward.

Let’s stop relying on superficial lab studies and start focusing on what truly helps patients.

If Lorimer Mosely was open to question - this is what I would love to know…

"How do you see your red/blue light study, which focuses on external skin pain, applying to the deeper, internal pain that most patients experience in muscles or joints? And do you think its widespread interpretation might have unintentionally led to oversimplified treatments or left some patients feeling dismissed?"

POTS: A Trauma-Sensitive Approach

Recovering from POTS can feel like a mountain to climb, and for many, it’s made even harder by past trauma.

Trauma could be emotional, physical, or even the result of repeated experiences of not being believed by medical professionals.

Unfortunately, traditional “do this plan, stick to it” rehab approaches can unintentionally make things worse for someone dealing with both POTS and trauma.

Why Trauma Matters in Recovery

Trauma changes how we feel safe in the world—and in our own bodies.

David Emerson, in his book Trauma-Sensitive Yoga, explains that trauma survivors often feel unsafe when being told what to do, especially by an authority figure like a doctor or trainer.

For someone with POTS, being handed a rigid exercise plan with no say in the process can feel overwhelming or even triggering.

Instead of building confidence, it can ramp up stress and worsen symptoms.

The key is to give control back to you, the person doing the work.

A Smarter Way Forward: Patient-Led Experimentation

Exercise for POTS doesn’t have to follow a one-size-fits-all model. Here’s how a trauma-sensitive, patient-first approach works:

1. You’re in the Driver’s Seat

• Every choice starts with you. You decide what feels safe to try, whether it’s gentle stretching, seated yoga, or just focusing on your breath.

• The role of a guide or physiotherapist isn’t to tell you what to do—it’s to provide options and support while you explore what works.

2. Plenty of Options, No Pressure

• Movement doesn’t have to look like “traditional” exercise. It can be as simple as lying-down cycling, a slow walk, or even sitting quietly and engaging your core.

• If something doesn’t feel right today, that’s okay. Try something else. The goal is flexibility, not perfection.

3. Adjust in Real Time

• Instead of sticking to a strict plan, give yourself permission to adapt. If something feels like too much, scale it back. If something feels good, lean into it a bit more.

• This moment-by-moment approach builds trust in your body and helps you reconnect with what it can do, without overwhelming your system.

Recovery is Personal, Not Perfect

Getting better from POTS isn’t about sticking to someone else’s plan—it’s about rediscovering what your body is capable of, one small, safe step at a time.

This isn’t linear, and it isn’t always easy.

But with a trauma-sensitive approach that puts you in control, recovery can feel less like a battle and more like a partnership between you and your body.

Your journey is yours to lead. Start where you are.

Move at your pace.

And remember, every small step forward is progress.

Reference

Trauma-Sensitive Yoga in Therapy: Bringing the Body into Treatment

Pain and POTS

Why Even Small Exercises Can Feel Overwhelming: The Science Behind Your Pain

If anyone’s ever dismissed the pain or fatigue you feel after the tiniest bit of exercise as “all in your head,” let’s stop right there.

Science is on your side, and Bud Craig’s homeostatic model of pain explains exactly why this happens.

It’s not about muscle damage or injury—it’s about how your body manages (or struggles to manage) balance.

Why Does Exercise Feel So Hard?

Craig’s research flips the old ideas about pain on their head. Pain isn’t just caused by visible damage like tears or injuries—it’s your body’s way of saying something is out of balance. When you push beyond what your body can handle, even slightly, here’s what can happen:

1. Inflammation
   Your body might react to exercise by kicking off an inflammatory response if it’s not ready to handle the stress.

2. Metabolic Waste Buildup
   Exercise creates byproducts like lactic acid, which lowers the pH in your muscles. If your body isn’t conditioned to clear this waste efficiently, it can trigger pain and discomfort.

Why This Doesn’t Show Up on Scans

Here’s the frustrating part: modern medical technology isn’t designed to “see” this kind of pain.

There’s no visible injury or damage to point to on an MRI or X-ray.

Because of this, many people are unfairly dismissed by doctors, told their symptoms are psychological, or simply not believed.

This creates a vicious cycle:

• Frustration and Emotional Burnout: Not being taken seriously is exhausting.

• Stress Response Overload: Emotional distress ramps up your body’s stress system (the sympathetic nervous system, or SNS), worsening inflammation and pain sensitivity.

A New Way to Understand Pain: Nociplastic Pain

The kind of pain many people with POTS experience, especially after exercise, fits into a groundbreaking new category called nociplastic pain.

Unlike pain caused by injury (nociceptive pain) or nerve damage (neuropathic pain), nociplastic pain is driven by how the nervous system processes pain signals, even when there’s no visible tissue damage or structural issue.

This revolutionary definition validates the experiences of people with persistent pain, showing that their pain is real and rooted in biological changes—not in their imagination.

For people with POTS, this recognition can be a game-changer, offering hope and paving the way for better understanding and treatment.

Finding Your “Exercise Tolerance Window”

For people with POTS, exercise tolerance is like walking a tightrope.

Your body has a narrow window of what it can handle, and stepping outside of it—even a little—can trigger a cascade of symptoms.

When you exceed your threshold:

1. The Fight-or-Flight System Kicks In
   Your SNS goes into overdrive, increasing your heart rate, inflammation, and stress hormones.

2. Tracking Can Help
   Using tools like the ELITE HRV app, you can monitor your heart rate variability (HRV). A lower HRV means your body is in a stressed, inflamed state. Recognizing these signs early can help you adjust before things spiral.

This Isn’t Your Fault

Feeling this way after exercise isn’t a sign of failure—it’s your body telling you it needs to start smaller and slower.

Recovery isn’t about pushing harder; it’s about finding your unique window of tolerance and working within it.

Over time, with patience and the right approach, your body can learn to handle more without pushing back.

Trust the process, respect your limits, and know that your experience is valid—even if the medical world doesn’t always make you feel that way.

Resources:

A new view of pain as a homeostatic emotion

Nociplastic Pain

POTS & Exercise

Exercise, POTS, and the Art of Doing Hard Things: A No-B.S. Guide to Moving Forward

Let’s get real for a minute: if you’re living with Postural Orthostatic Tachycardia Syndrome (POTS), exercise can feel like the cruelest joke.

It’s supposed to help you feel better, right?

So why does it sometimes make you feel like you’ve been hit by a truck?

And why does every rehab plan out there seem like it was designed for someone with a completely different body?

This isn’t just frustrating—it’s one of the greatest challenges of your recovery journey.

The problem?

Most exercise protocols for POTS are rigid, cookie-cutter, and completely out of touch with the messy, unpredictable reality of how your body responds.

But here’s the thing: you’re not broken.

Your body isn’t a failure.

It’s just stuck in a loop it hasn’t yet learned how to break.

And today, we’re talking about how to change that—without toxic positivity, fluff, or empty promises.

Let’s dive into the real science, the struggles, and why hope isn’t just a cliché when it comes to your recovery.

Why Exercise Can Feel Like Your Worst Enemy

First, let’s validate what you’ve been through. If you’ve tried to follow a traditional exercise program and felt worse, it’s not because you didn’t try hard enough. It’s because most rehab plans don’t account for what’s really happening in a body with POTS.

The Science of “Why Do I Feel Worse After Exercise?”

When your body is “unconditioned”—which is common if you’ve had to limit activity due to POTS—exercise can actually cause inflammation.

Here’s why:

• Inflammatory Storm: Your muscles release chemicals (cytokines) that irritate nerves and trigger pain. It’s like your body’s alarm system is on overdrive​

• Hyperactive Pain Signals: Your nervous system hasn’t learned how to regulate itself yet, so it amplifies every signal—making soreness, fatigue, and dizziness feel 10 times worse​

• Emotional Fallout: Let’s not ignore this. When exercise leaves you bedridden or flaring, it’s not just physical—it’s emotionally crushing. You start to wonder, “What’s wrong with me? Am I ever going to feel normal again?”

But here’s the thing: this isn’t permanent.

Your body can learn to respond to exercise differently.

You just need a smarter, more compassionate approach.

Moving Beyond Rigid Rehab: A Smarter, Science-Backed Way Forward

The old way of exercising for POTS goes something like this: start slow, progress in fixed stages, and hope for the best.

Sounds harmless, right?

Wrong.

For many people, these programs feel like a one-way ticket to symptom flare-ups.

It’s time to move on from one-size-fits-all.

Here’s how we make exercise work for you, not against you:

1. Start Horizontal—Seriously

Forget about jumping straight into standing exercises. Your body needs to build tolerance without gravity messing things up. Supine or recumbent exercises, like cycling or leg lifts, are the best place to start.

“Programs should begin with horizontal exercises to minimize orthostatic stress while building tolerance.” (Ziaks et al., 2024)

2. Understand the Transition to Anti-Inflammatory Exercise

When you stick with gentle, regular movement, something magical happens: your body adapts.

Over time:

• Your muscles start producing anti-inflammatory chemicals that calm pain sensors.

• Your nervous system learns to stop amplifying pain signals and starts calming down instead.

• Your immune system shifts from a “fight” mode (inflammatory cytokines) to a “heal” mode (anti-inflammatory cytokines).

This is why exercise feels hard at first but gets easier the more conditioned you become.

Reference: Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation

This diagram shows how your muscles, immune cells (called macrophages), and pain sensors (nociceptors) interact.

When your body is under stress or inactive for long periods, more macrophages take on the “M1” role.

These M1 macrophages release chemicals that cause inflammation, which makes your pain sensors more active and leads to pain.

However, when you do regular, gentle exercise, your immune system starts shifting.

More macrophages become “M2” instead, which release anti-inflammatory chemicals.

These chemicals calm down your pain sensors, reducing pain and helping your body feel better.

The takeaway?

Over time, consistent movement can teach your body to create more M2 macrophages, reducing inflammation and improving how your body handles stress and pain.

3. Go at Your Own Pace—No Timelines

Progression isn’t about rigid timelines. It’s about listening to your body. You’re ready to move to seated or standing exercises when you can handle 20 minutes of horizontal movement without flaring up. Not before.

4. Use Interval Training for Recovery

If steady-state exercise feels overwhelming, try intervals: short bursts of effort followed by rest. For example, 30 seconds of light movement and 1–2 minutes of rest. It’s a gentle way to build endurance without overloading your system​.

The Philosophical Side of Doing Hard Things

Here’s the tough truth: recovery is hard.

Exercise with POTS forces you to face both physical and emotional challenges head-on.

It’s uncomfortable, messy, and often feels like two steps forward, one step back.

But what if the struggle is the point?

Every time you listen to your body and adjust instead of pushing through, you’re practicing self-compassion. Every time you show up, even when you’re scared of flaring, you’re building resilience. And resilience isn’t just physical—it’s emotional, too.

By focusing on small, consistent actions instead of fearing the big picture, you’re taking back control.

Hope, Without the Fluff

Let’s get one thing straight: this isn’t about toxic positivity. Hope doesn’t mean pretending everything is fine when it’s not. Hope is understanding that your body isn’t your enemy—it’s just trying to protect you in ways that aren’t helpful right now.

With the right approach, exercise can go from being a trigger to being a tool. It can become something that strengthens you—physically, emotionally, and even spiritually.

So, start small. Stay consistent. And remember: every step forward, no matter how tiny, is progress.

You’ve got this. One rep, one breath, one day at a time.

References:

Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation

Adaptive Approaches to Exercise Rehabilitation for Postural Tachycardia Syndrome and Related Autonomic Disorders