The effects of shockwaves were first observed during the Second World War with human lungs cracking from waterbomb explosions without signs of external injuries. In 1966, Claude Dornier observed cavitations on the surface of aircrafts approaching the sound barrier, this subsequently led to the development of the first extracorporeal shockwave lithotripser used on kidney and gall bladder stones. Over the last 30 years, applications of extracorporeal shockwave therapy (ESWT) for musculoskeletal conditions pathologies have emerged. There is strong basic science research and clinical evidence for the use of ESWT for tendinopathies and bone pathologies. The capabilities of ultrasound in locating musculoskeletal pathology adds another dimension to the use of focused ESWT. Ultrasound allows the identification of specific areas of tendon pathology such as tendon swelling, fibre disarray, calcifications, micro-tears and neo-vascularisation as targets for shockwave treatment, in addition to palpation, skin markings and patient feedback. This non-invasive and low risk modality has proven to be highly effective with predictable outcomes and has high patient acceptance. As such, ultrasound guided focused ESWT has been the cornerstone in the management of recalcitrant tendon pathologies around the heel, knee, elbow and shoulder in my practice.