Healing or Hurting: Rethinking Equine Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) has become a prevalent trend in equine rehabilitation. It's widely featured in veterinary reports, social media posts, and treatment plans, often celebrated as a breakthrough for various orthopedic conditions.

But beneath the surface of this so-called innovation lies a more troubling reality: ESWT is a tissue-disruptive therapy that is frequently applied without adequate consideration for the physiology of healing—or the silent, non-verbal pain experienced by horses.

What Does Shockwave Actually Do?

ESWT works by delivering high-energy acoustic waves into tissues, designed to disintegrate calcifications, break down fibrotic adhesions, and induce microtrauma to stimulate a healing response (Wang, 2012).

In human medicine, ESWT is typically reserved for chronic conditions that have not responded to conservative treatment—such as calcific tendonitis, plantar fasciitis, lateral epicondylitis, and patellar tendinopathies (Wang, 2012). It is never applied casually and carries strict contraindications, particularly in acute injuries or when vulnerable structures like torn ligaments are involved (Auersperg & Trieb, 2020).

But in Equine Care?

ESWT is often used liberally—on fresh injuries, over unstable joints, and even on delicate suspensory ligaments that serve as the primary support for the lower limb. It’s applied to horses with kissing spine, where already compromised tissues are bombarded with high-energy pulses, despite the urgent need for controlled healing and spinal stability.

In fact, applying shockwave to the spine and surrounding nerves is contraindicated in human medicine (Tenforde et al., 2022). Yet in equine practice, it's not only tolerated—it’s commonplace, even recommended pre- and post-surgically.

To make matters worse, these devices are increasingly being marketed and sold directly to the general public. This is the equivalent of handing a child a grenade. Shockwave therapy should only be administered by licensed professionals with a deep understanding of both its indications and its contraindications.

How do I know this? Because I witness it weekly—locally in my own community, internationally online, and plastered across social media. Still skeptical? A quick Google search for “shockwave for horses” will reveal an abundance of images showcasing contraindicated use, just like the one below.

Image of kissing spine horse receiving shockwave directly over spinal nerve exit points

Ignoring Pain Because Horses Can’t Speak

In human medicine, ESWT is known to be intensely painful, often requiring local anesthesia. Patients can verbalize their discomfort and modify treatment accordingly.

Horses don’t have this luxury. Their pain is often misread—either as stoic cooperation or “bad behavior". Many horses receiving shockwave are in acute stages of injury. Applying additional trauma to already inflamed tissue not only delays healing—it can actively make things worse.

In human healthcare, this approach would be considered malpractice.

So why is it tolerated in equine care?

Destabilizing an Already Unstable System

Take, for example, a horse with poor hoof balance and chronic stifle dysfunction, now diagnosed with suspensory desmitis. Rather than addressing root causes—hoof pathology, compensatory movement patterns, or uneven load distribution—shockwave is applied directly to the overburdened suspensory ligament.

This already strained structure is subjected to high-energy pulses intended to break it down. The result? Further destabilization. Healing requires structure, balance, and time—not trauma dressed up as therapy.

Image of shockwave on the suspensory ligament on an horse with eggbar shoe indicative of pathology

When "Maintenance" Becomes Malpractice

In human medicine, shockwave therapy is applied with precision and restraint. It’s not an ongoing intervention like massage or strength training. Instead, it’s delivered in a limited series—typically three to five sessions—to break down stubborn adhesions or chronic scar tissue. Once this is achieved, treatment stops. Why? Because it’s inherently aggressive and often painful.

And yet, in equine care, it’s not unusual to see shockwave prescribed as part of a “maintenance plan,” administered every 2–4 weeks, indefinitely, with no re-evaluation. That’s not just misguided—it’s dangerous.

If scar tissue is forming repeatedly in a particular region, the logical clinical question should be: Why? What’s causing the re-injury? Instead, we continue to hammer the same structure, destabilizing it further, causing pain, and forcing the body to keep rebuilding under duress.

Recently, a U.S. veterinary clinic proudly posted about administering shockwave every few weeks—on “necks, backs, and SI joints”—regions where it’s explicitly contraindicated in human practice. Which raises a critical question: are we abandoning basic principles of tissue healing and rehabilitation in equine medicine?

Image taken from a veterinary website promoting bi-monthly shockwave. Demonstration picture shows a horse with less than optimal hoof balance receiving shockwave to the flexor tendons.

What We Can’t See Can Still Hurt Them

One of the most immediate and important clinical indicators following shockwave therapy in humans is the skin response—redness, subcutaneous bruising, and localized inflammation. These reactions help guide the practitioner in dosing and adjusting future treatments. If the area appears overly inflamed or bruised, it signals that the dose was likely too high.

Image of human calf post shockwave treatment showing the level of subcuatneous injury imposed

In horses, we don’t get this visual feedback. Their fur masks the very signs we rely on to assess intensity. This means we can’t see whether we’ve overstimulated the tissue. We’re flying blind—no cues, no inflammation markers, no visible evidence of harm. And if we can't see the damage, how can we possibly monitor or mitigate it?

Ethical Questions That Demand Answers

Why is there such a glaring disconnect between human and equine application of ESWT?

If it's contraindicated on ligaments in humans, why is it acceptable for the suspensory ligament in a horse?

If it’s unsuitable for acute injuries in people, why are we applying it to fresh soft tissue damage in equines?

If it’s not safe for the human spine, why is it used on the equine one?

Are we not all mammals with similar tissue architecture and cellular responses?

And most importantly—if no human would undergo a procedure this intense without informed consent, why are we inflicting it on animals who have no say?

So When Is Shockwave Indicated?

As already noted, in human medicine, shockwave is a last-resort therapy for chronic, treatment-resistant issues like tendinopathies and non-union fractures (Wang, 2012). Its use is carefully considered, and it is never applied as a routine modality.

A comprehensive assessment is essential before ESWT is considered. Without identifying the root cause and contributing factors, we’re just treating symptoms—and often creating new problems in the process.

In my own practice, I’ve seen human patients who worsened after shockwave therapy due to poor application or inappropriate timing. That may sound anecdotal, but after more than 20 years in the field, consistent patterns warrant consideration.

Yes, when shockwave is used correctly—under professional supervision, with clear clinical indications, and followed by appropriate aftercare—it can be effective. But it must always follow a regimented progression that respects tissue healing timelines. In human medicine, this includes a structured rehabilitation plan to restore function—not a “back to the gym tomorrow” approach.

In contrast, in equine sport, I’ve seen horses receive shockwave therapy and return to work the same day—or the very next. Again, ask me how I know. This casual disregard for healing biology is not just misguided. It's unethical.

An Urgent Need For Reform

It’s time to stop glorifying shockwave therapy and start applying it responsibly. This isn’t about rejecting science—it’s about using it wisely. Shockwave should never be a default treatment or a lazy replacement for proper diagnosis and rehabilitation.

The responsibility lies with all of us—therapists, veterinarians, trainers, bodyworkers, and owners. We must hold ourselves to a higher standard. Because if we continue to use shockwave indiscriminately, we’re not promoting healing. We’re causing harm. Silently. Systematically. And preventably.

References

Wang, C.-J. (2012). Extracorporeal shockwave therapy in musculoskeletal disorders. Journal of Orthopaedic Surgery and Research, 7, 11.

Auersperg, V., & Trieb, K. (2020). Extracorporeal shock wave therapy: an update. EFORT Open Reviews, 5(10), 584–592.

Tenforde, A. S., Borgstrom, H. E., DeLuca, S., McCormack, M., Singh, M., Hoo, J. S., & Yun, P. H. (2022). Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration. PM&R, 14(5), 611–619.