In this episode of Chewing It Over, Jack speaks with Nick Ilic about shockwave therapy, clinical uncertainty, and the problem with taking overly confident positions in MSK practice.

Nick argues that shockwave is only really “shocking” when clinicians either oversell it as a powerful long-term solution or dismiss it entirely without proper consideration. Much of the conversation sits deliberately in the middle ground: shockwave may have a role, but the evidence does not support grand claims across broad MSK conditions.

The discussion explores the tension between proposed mechanisms and clinical outcomes. Shockwave is often described as creating a pro-inflammatory or mechanotransductive stimulus, potentially “restarting” a repair process in chronic tissue. However, Nick is cautious about mechanistic certainty, noting that many MSK interventions have attractive theoretical explanations that become far less convincing when tested rigorously.

They also discuss how shockwave may simply act as another form of neuromodulation, particularly when outcomes appear similar between focused and radial approaches, or when benefits are mainly short term. Nick is especially critical of “condition creep,” where a modality gradually becomes marketed for more and more problems despite limited supporting evidence.

Importantly, he does not dismiss shockwave altogether. He acknowledges stronger evidence for indications such as calcific tendinopathy and non-union fractures, where the mechanism and evidence appear more plausible. But for common tendinopathies and broader pain presentations, he remains sceptical of inflated claims, especially when patients are paying privately.

Overall, this is a funny, sharp, and thoughtful conversation about evidence, uncertainty, informed consent, and why clinicians should be wary of both hype and lazy scepticism.

5 clinical/professional takeaways

• Avoid overconfidence in either direction. Shockwave should not be sold as a miracle treatment, but dismissing it completely may also be too simplistic.
• Mechanistic plausibility is not enough. Claims about pro-inflammatory effects, mechanotransduction, or tissue “restart” need to be matched by meaningful clinical outcomes.
• Context matters. Shockwave may be more defensible in areas like calcific tendinopathy or non-union fractures than in broad tendinopathy or general pain presentations.
• Short-term pain relief is not the same as recovery. Clinicians should be careful not to confuse temporary neuromodulation with long-term tissue change.
• Consent and expectation-setting are crucial. If patients are paying privately, they deserve a clear explanation of likely benefits, uncertainty, cost, and alternative options.