Table 4 Summary of the final analytical framework

1.1 Persistent symptoms

Most had chronic symptoms that were up to many years before rESWT was tried.

A mixture of emotions was expressed from some subjects with persistent symptoms – anger, hopelessness, and desperation.

“I was so desperate for anything to help my plantar fasciitis that I was prepared to try anything, I didn't actually care what the procedure involved” (P7).

“I was keen to investigate something that I hadn't tried before, purely because I almost ran out of options” (P9).

1.2 Previous failed treatments

Physiotherapy, home exercises, massages, acupuncture, oral medication, injection therapy, surgery. Combination of these treatments. Misdiagnosis and delayed diagnosis was also mentioned.

“I'd had quite a few invasive procedures, you know all the injections and things, umm and I'd also had like compartment pressure testing and everything, so to me, I was like, kind of, quite reasonably happy to go and have the ESWT” (P6).

1.3 Non-invasive treatment

rESWT generally acceptable and preferred over more invasive therapies such as injections and surgery.

“it seems very non invasive and if that was going to work then I'd be very happy with that” (P2).

“I think surgery was discussed, but they said they'd like to try shockwave therapy first because it was less intrusive and less risky than surgery” (P9).

1.4 Clinician factors

Reported success rates with rESWT, experience with athletes, research active, non-surgical approach.

“He [has a] background in sports medicine and he treated not only like, every day people” (P5).

“special to this sports medicine rather than, you know, being a general orthopod.......... I can have very much more precise conversations about training plans” (P7).

2.1 Initial knowledge about rESWT

Most had no prior knowledge about rESWT until it was introduced by a clinician and others had done their own research primarily online.

“I don't think there was maybe that much sort of like stuff on the internet about it really” (P4).

“I had a look on pubmed, and clinical evidence for it, which seemed to be equivocal” (P7).

2.2 Understanding of the mechanisms of ESWT

Inflammatory response, breakdown of calcium deposits, breakdown of “scar” tissue, remodelling, angiogenesis, and stimulate blood flow to the injured area were mentioned by some.

“shockwave was going to disperse any calcium deposits I had, and also sort of agitate the tendon so it heals better” (P2).

“stimulates more blood flow into a particular area.......... focuses more blood flow, which should improve healing” (P9).

2.3 Initial outcome expectations

Complete resolution of symptoms, pain free, short-term gains, and return to previous sporting activity were mentioned.

Those with more longstanding symptoms were less optimistic.

“I don't think I was expecting very much to be honest because I tried so many different things. So I wasn't really expecting that much” (P3).

“I was confident that it was going to address the problem” (P4).

3.1 Initial discussion about rESWT with the healthcare professional

Description about the rESWT procedure itself, the protocol of requiring a number of weekly sessions, and, in some cases, potential mechanisms, side-effects, post-procedural practical advice were discussed.

“avoid long walks immediately following the treatment for the next day” (P3).

“there's firing [of] this ball bearing at high frequency into the damaged area, and the whole idea about it, you're damaging the tendon, to basically get it to repair itself” (P4).

3.2 First experiences of rESWT

Generally considered an unfamiliar sensation.The initial experience of rESWT ranged from being comfortable to being significantly painful.

“it was really quite pleasant, and particularly after the treatment, it felt, my foot felt great” (P3).

“really, really painful, really uncomfortable” (P4).

“I'd describe it as less painful than deep tissue massage” (P9).

3.3 Subsequent experiences of rESWT

Increase intensity with subsequent sessions did not always reflect a more painful experience and tolerance maybe a factor as well as noticeable improvements in symptoms.

“I was use to quite sharp pain shooting through the tendon. The ESWT to me seemed kind of like, ok, in comparison because it was more like a kind of ache or pressure” (P6).

“you know if I can't walk to the shops or I can't take my children for a walk ..........frankly, two minutes of pain with a thing hammering at my foot was completely irrelevant” (P7).

3.4 Experiences of rESWT against expectations

Uncertainty as to what to expect.

Comparisons of rESWT experience with other previous treatments and attitudinal factors had an influence on expectations.

“I wasn't thinking it wasn't going to work at any one point.......I felt something was being done” (P2).

“it's not as frightening as other stuff because it's non-invasive, so it's not like someone's saying to you, right, I'm going to chop you open and I'm going to take this out, and I'm going to stitch that together” (P5).

“I expected it to be more painful or kind of hurt in a different way if that makes sense. I think also if you've had like lots of invasive treatments, you do expect it to kind of hurt in a kind of way like an injection would” (P6).

3.5 Aspects that were done well (Positive aspects)

Healthcare professional periodically checking to see if the patient was tolerating the rESWT, being able to feedback on progress, provision of pre-planned exercises, and other treatment options.

A friendly, knowledgeable and sensitive medical approach to the problem.

“I felt like I was getting answers to my questions and obviously, I had a good idea of how things were progressing” (P4).

“when you go to the physio, it was always really annoying that you had to wait 2 weeks before you know, you increase the exercises, whereas he [sports consultant] kind of pre-planned for, this is the easy, medium, hard version” (P6).

“he personalised the treatment, so the number of sessions and I expect also the impact of shockwave” (P7).

3.6 Aspects that were not done well (Negative aspects)

Procedure protocol, success rates, outcome timeframes, side-effects and activity modification measures were not always adequately covered for some patients.

Unable to understand or address the root cause of the tendinopathy.

“throughout the treatment it got tougher, and I don't remember that being explained to me” (P3).

“what about the cause?................ my only one little bit of frustration was that maybe we should have addressed this VMO stuff earlier” (P4).

“I wasn't allowed to dance whilst doing it I suppose. I suppose actually that's probably the only thing that I wasn't aware of until the first treatment............I had to suddenly make plans” (P6).

4.1 Personal views and level of improvement

Overall rESWT was found to have a positive effect on the different tendinopathy conditions to a varying degree but had not cured the problem for most.

Some considered other factors (e.g. rest, activity modification, appropriate exercises) to have improved symptoms rather than rESWT alone.

“I run the Brighton half marathon in an hour and 35.......without pain and probably quicker..........I'm convinced it's all of 80% shockwave and then with the strengthening and that, made it 100[%]” (P5).

“I had the second course [of ESWT] which improved it probably about 90% better, it didn't quite clear it, but I had a third course which cleared it on the right foot completely, and almost cleared it on the left foot” (P7).

“I guess the bit I don't know, is whether I would be in the same place having not had the procedure because of natural healing or not?” (P8).

4.2 Responsibility over own health

Awareness that physical activity modification and exercises were important alongside rESWT.

“I have now lost nearly 3 stone, so I'm thinking if I could lose more weight, I might be able to put off any other further problems” (P2).

“He got me to get like a trampette and to get like a wobble board and do quite dance specific, injury specific exercises” (P6).

4.3 Perceived outcomes

Remain asymptomatic and return to baseline health status in a minority.

For those that had not completed their course of rESWT they were not confident that the condition will be cured completely.

“I can walk at work without being in pain. So, to me, that's massive, so you know, I'm doing all of the same on-calls, the same duties, walking around buildings and it doesn't hurt anymore, so to me that's a massive positive even though I know, at the minute, I can't dance for hours on end” (P6).

“these issues I'd say they are quite resistant so far, for quite a long time, so if they completely disappear, that would be great, but I'm not sure if this is going to happen” (P10).