In physics, shockwaves are high fluctuations of acoustical energy. When applied to a tissue shockwaves may stimulate an anabolic cellular response, increased blood perfusion and neo-angiogenesis. Shockwaves may furthermore promote anti-inflammatory effects and pain regulation. On a molecular scale upregulation of TGF-beta1, VEGF, FGF-2 signaling together with increased levels of NO and substance P in the tissue is seen following ESWT. During wound healing NO has been shown to induce IGF release through NF-kappaB pathway. Regarding to anti-inflammatory effects, ESWT reduces the cellular expression of metalloproteases and interleukins.