Can shockwave therapy and laser therapy be used together?

Some providers use both modalities in a combined protocol -- for example, ESWT to stimulate deep tissue healing followed by LLLT for surface-level pain modulation. However, there is limited research on combination protocols, and the added benefit over ESWT alone has not been established. If your provider recommends both, ask about the evidence supporting the combination for your specific condition.

Is laser therapy safer than shockwave therapy?

Both treatments have favorable safety profiles. Low-level laser therapy is generally painless and has very few reported side effects. Shockwave therapy produces temporary soreness and occasional bruising but is also considered safe when performed by a qualified provider. Neither modality carries significant risk for serious adverse events in appropriate candidates.

Why do some clinics offer laser therapy instead of shockwave therapy?

Several factors influence which modalities a clinic offers: equipment cost (LLLT devices can be less expensive than focused ESWT units), provider training background, patient preferences, and clinical philosophy. Some clinics offer both and select the modality based on the condition being treated. The modality available at a specific clinic does not necessarily indicate which is more effective.

Shockwave Therapy vs. Laser Therapy (LLLT)

Your provider recommends a non-invasive treatment for your tendon pain, and now you’re comparing options. Two names keep appearing: shockwave therapy and laser therapy. Both are described as non-invasive, both claim to promote healing, and both involve a provider applying a device to your skin. But the similarities largely end there.

Low-level laser therapy (LLLT) – also called photobiomodulation or cold laser therapy – and extracorporeal shockwave therapy (ESWT) use fundamentally different energy sources, work through different biological mechanisms, and have meaningfully different evidence bases. Here is an objective comparison to help you understand where each modality stands.

How the Technologies Differ

Shockwave therapy uses acoustic pressure waves – mechanical energy delivered through a handpiece pressed against the skin. These waves create physical force within tissue, triggering mechanotransduction (the biological process by which cells convert mechanical stimulus into healing signals). ESWT exists in two forms: focused devices that concentrate energy at a specific tissue depth, and radial devices that disperse energy from the skin surface. For a deeper explanation, see our guide on focused vs. radial shockwave therapy.

Low-level laser therapy uses photons – light energy at specific wavelengths (typically 600-1,000 nanometers) applied to tissue. The proposed mechanism involves photon absorption by mitochondrial chromophores (particularly cytochrome c oxidase), which may enhance cellular energy production (ATP synthesis) and trigger downstream biological effects including reduced inflammation and improved tissue repair.

The key distinction: ESWT delivers mechanical energy that physically stresses tissue. LLLT delivers light energy that interacts with cells at the molecular level. These are fundamentally different stimuli, and they produce different tissue responses.

Comparing the Evidence Base

For most musculoskeletal conditions where both modalities have been studied, ESWT has a larger and more consistent evidence base:

Calcific shoulder tendinitis. ESWT has strong evidence for calcium deposit resorption and pain reduction. Multiple RCTs and systematic reviews support its use. LLLT has minimal evidence for this condition. ESWT is clearly preferred for calcific shoulder tendinitis.

Plantar fasciitis. ESWT has extensive RCT support, FDA clearance, and consistent systematic review findings supporting its effectiveness for chronic plantar fasciitis. LLLT has some studies showing pain reduction, but the evidence is less consistent and effect sizes tend to be smaller (Cotchett et al., 2010).

Lateral epicondylitis (tennis elbow). Both modalities have been studied. ESWT has more and larger RCTs showing meaningful clinical improvement. LLLT has some positive studies, but a Cochrane review found the evidence for LLLT in lateral epicondylitis to be inconsistent due to high variability in laser parameters across studies (Bjordal et al., 2008).

Achilles tendinopathy. ESWT has moderate-to-strong evidence from multiple RCTs. LLLT evidence for Achilles conditions is limited.

Where LLLT may have a niche: TMJ disorders, carpal tunnel syndrome (some positive studies), neck pain, and post-surgical wound healing. These are areas where LLLT evidence is emerging, though not yet robust enough for strong clinical recommendations.

The Dosing Standardization Problem

One reason LLLT evidence is inconsistent is a fundamental problem with dosing standardization. LLLT protocols vary across multiple parameters:

Wavelength (630 nm vs. 810 nm vs. 980 nm – different wavelengths penetrate to different depths)
Power output (5 mW to 500 mW for low-level; up to 15 W for Class IV lasers)
Treatment duration (30 seconds to 30 minutes per point)
Continuous vs. pulsed delivery
Number of treatment points per session

This variability makes it difficult to compare studies. Two LLLT trials testing “laser therapy for tennis elbow” might use completely different wavelengths, power levels, and treatment times – producing contradictory results that have little to do with whether the modality itself works.

ESWT protocols also vary (energy flux density, number of pulses, frequency), but the parameter ranges are narrower and more standardized, which makes cross-study comparisons more reliable.

Class IV Laser vs. Low-Level Laser: An Important Distinction

The term “laser therapy” covers a wide range. Low-level laser therapy (LLLT) uses low-power lasers (typically Class IIIb) that produce no thermal effect in tissue. Class IV laser therapy uses higher-power lasers (up to 15 watts) that produce both photobiomodulation and thermal effects.

Class IV lasers are increasingly marketed for musculoskeletal conditions. They may produce stronger tissue effects than LLLT, but they also carry higher risks (thermal burns, eye damage) and require more careful application. The evidence base for Class IV laser therapy in tendinopathy is still developing and should not be conflated with LLLT evidence.

Practical Comparison

Factor	Shockwave Therapy (ESWT)	Low-Level Laser Therapy (LLLT)
Energy type	Acoustic (mechanical)	Photonic (light)
Sensation during treatment	Moderate discomfort (3-7/10)	Painless or mild warmth
Session duration	10-20 minutes	5-30 minutes
Sessions needed	3-6 (most conditions)	8-15 (typical)
Evidence strength (tendinopathy)	Strong (multiple RCTs, systematic reviews)	Moderate-weak (inconsistent findings)
FDA status	Cleared for plantar fasciitis, lateral epicondylitis	Cleared for various pain indications
Typical cost per session	$150-$500	$50-$200
Post-treatment soreness	Common (24-72 hours)	Rare

Understanding these differences helps when evaluating what clinics offer and why.

The Bottom Line

For most chronic tendinopathies – plantar fasciitis, tennis elbow, Achilles tendinopathy, and calcific shoulder tendinitis – ESWT has a meaningfully stronger evidence base than LLLT. LLLT is painless and very low-risk, but its evidence for musculoskeletal conditions remains inconsistent, partly due to the dosing standardization challenge. Neither modality is a clear winner for every condition, but patients making evidence-based decisions should weigh the significantly larger body of controlled research supporting ESWT for tendon-related pain.

Explore our condition guides to learn which treatment modality the evidence supports for your condition.

References

Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. 2010;3:18. PubMed
Bjordal JM, Lopes-Martins RA, Joensen J, et al. A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. 2008;9:75. PubMed
Chung H, Dai T, Sharma SK, Huang YY, Carroll JD, Hamblin MR. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng. 2012;40(2):516-533. PubMed

Medical Disclaimer: This content is for informational purposes only and does not constitute medical advice. Shockwave therapy outcomes vary by individual and condition. Consult a qualified healthcare provider to determine if shockwave therapy is appropriate for your situation.