Extracorporeal shockwave therapy (ESWT) causes some discomfort during the procedure, but most people tolerate it well. The sensation is typically described as small pulses against the skin, and practitioners start at low energy levels, gradually increasing based on what you can handle. Pain during treatment is real but manageable, and it varies depending on the type of shockwave device, the energy setting, and the body part being treated.
What It Actually Feels Like
Most patients compare the sensation to rapid tapping or pulsing against the skin. It’s not sharp or burning. The discomfort comes from the pressure waves penetrating into deeper tissue, and it tends to be more noticeable over bony areas or inflamed tendons where the tissue is already sensitive.
Pain intensity scales directly with the energy level used. A study on healthy volunteers confirmed that increasing the energy flux density of shockwaves led to a statistically significant increase in pain. This is why every session begins at a low setting. Your practitioner will ramp up the intensity gradually, checking in with you as they go, and they won’t push beyond what you can tolerate. Current international guidelines published in the British Journal of Sports Medicine recommend keeping your pain below a 6 out of 10 for tendon conditions and below 7 out of 10 for bone-related conditions during treatment.
Radial vs. Focused Shockwave Devices
There are two main types of shockwave therapy, and they feel somewhat different. Radial shockwave therapy uses compressed air to fire a projectile inside a handheld device, creating pressure waves that spread outward from the skin surface. Focused shockwave therapy generates waves inside the applicator and concentrates them into a specific point deeper in the tissue.
In a clinical trial comparing both types for rotator cuff tendon problems, five patients in the focused group reported moderate pain compared to three in the radial group. One patient in the focused group fainted during treatment. These numbers were small, and neither type caused severe or lasting harm, but focused shockwave therapy does tend to feel more intense because the energy is concentrated into a smaller area rather than dispersed across a wider zone.
How Energy Levels Affect Discomfort
The energy setting your practitioner selects has the biggest influence on how much discomfort you feel. Shockwave energy is measured in millijoules per square millimeter (mJ/mm²), and treatments generally fall into low, medium, and high categories. A study on plantar fasciitis compared low-energy treatments (0.08 mJ/mm²) with medium-energy treatments (0.16 mJ/mm²) and found that both produced significant pain relief and tissue improvement. The medium-energy group got the same results in three sessions that the low-energy group needed six sessions to achieve.
Higher energy delivers faster results but comes with more discomfort during the procedure. Research has shown that high-intensity energy applied quickly leads to more pain, local swelling, and tenderness at the treatment site. This is why many clinicians prefer medium-energy protocols. They offer an efficient balance: fewer total sessions, meaningful pain reduction, and no reported adverse effects in the study. If you’re particularly sensitive, your practitioner can use a lower energy setting and simply add more sessions to reach the same total dose.
Why Numbing Isn’t Recommended
You might wonder why practitioners don’t just numb the area first. It turns out local anesthesia can actually undermine the treatment. A study applying shockwaves to forearm skin with and without lidocaine found that the anesthetic blocked the activation of pain-sensing nerve fibers, which are part of how shockwave therapy triggers its healing response. The biological changes that ESWT relies on, including increased local blood flow through a nerve reflex, were significantly inhibited when anesthesia was used.
This finding aligns with broader clinical observations: studies using local anesthesia before shockwave therapy have produced weaker outcomes. International expert recommendations now explicitly advise against using local anesthesia during ESWT. The discomfort you feel during treatment is, to some extent, a sign that the therapy is working as intended.
Soreness After Treatment
Some soreness in the treated area after a session is normal. A systematic review found that about 20.7% of patients developed temporary side effects including pain, swelling, and small red spots (petechiae) on the skin. These reactions were more common with higher-dose protocols and radial shockwave therapy.
When practitioners use a gradual approach, starting low and increasing energy based on your feedback, side effects drop significantly. One clinical trial using this careful titration method reported zero adverse events across the entire study period, with follow-up checks at one, four, and twelve weeks. The post-treatment soreness that does occur typically feels like a mild ache, similar to what you might experience after deep tissue massage, and resolves within a day or two.
What to Expect During a Typical Session
A standard course of ESWT involves three to five sessions spaced one to two weeks apart. Each session lasts roughly 10 to 15 minutes of active treatment. Your practitioner will apply gel to the skin, place the applicator over the target area, and begin delivering pulses at a low intensity. Over the first few hundred pulses, they’ll gradually increase the energy while asking you to report your comfort level. If you hit your tolerance threshold, they hold steady or back off.
The first session is often the most uncomfortable because the tissue hasn’t been exposed to shockwaves before and the practitioner is still calibrating the right intensity for you. Many people find subsequent sessions easier to tolerate, partly because they know what to expect and partly because the treated area may already be responding to therapy. You can return to normal activities immediately after treatment, though your practitioner may suggest avoiding high-impact exercise on the treated area for 24 to 48 hours while any residual soreness settles.