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think about getting eswt

Posted by tyshea on 10/12/04 at 22:55 (161379)

My doctor said that I woul be a good candidate for eswt i was just wondering if there is going to be any pain afterwards from the procedure or is it going to be painless.

Re: think about getting eswt

Dr. Z on 10/12/04 at 23:48 (161382)


ESWT in most cases will have very little pain. There are patients that can have pain for a few days after the procedure. Some patients will receive immediate reduction in pain, some will be gradual, some will be delayed for weeks- months. Some will have ups and downs. So that's alot of variation. I do find that most will have improvement with little pain but there are a certain group that will experience all that I have laid out for you

Re: think about getting eswt

Lori S. on 10/13/04 at 01:30 (161384)


I had ESTW on 9/29. I have had bad days and good days. I was in miserable pain before ESTW, now I have had some painful days, BUT, nothing like before. Before ESTW i was living on pain meds, now I take one every now and then. When my doc asked how the pain is now, compared to before, I told him I am doing much better.
Hope you feel better,

Re: think about getting eswt

Elizabeth Y. on 10/13/04 at 12:15 (161422)

I think your pain factor will depend upon how chronic your PF is and how long you have suffered. Don't expect the procedure or the period following treatment to be painfree. It is not. However, I am 12 days out of treatment and the bad days and good days are about evenly split.

I don't know how the ESWT can be painfree if it is directed at the area of extreme affliction. Just bear through the shockwave treatments knowing it might provide relief you obviously haven't enjoyed through any other modality.

It is the HOPE for relief that keeps us all going!

Best of luck and hang tough!


Re: think about getting eswt

Lynn F. on 10/13/04 at 17:44 (161446)

I had ESTW 11 days ago. I was in pain the first week (about the same as before the procedure). The pain subsided for a day and two but it's quite sore again. I have good days and bad and it's probably too soon to weigh in. As someone else mentionted, your pain level will largely depend on how severe your PF is. Mine was chronic and extremely inflamed. I had it done as an outpatient with local anesthesia in heel and ankle to numb the foot (that was the worst part) I felt some pain during the procedure where shockwaves exited the outside of foot but nothing intolerable. Without anethesia (either local or sedation) you would likely be unable to tolerate the level of shockwaves necessary to be effective.

Good luck with your decision.

Re: think about getting eswt

Elizabeth Y. on 10/14/04 at 11:59 (161499)

Tyshea and Lynn:

I endured ESTW (at a level 3) three times during my week of treatments without an aspirin, let alone anesthesia. Was it a picnic? NO. Did I get through it--YES. Was it beneficial--that remains to be seen. However, I was able to assist in focusing the waves on the area most afflicted. If you are given a local, I feel that diminishes your ability to pinpoint treatment the most inflamed area.

Were there times on that table that I wondered what I must be thinking-- going it alone without medication---darn right. But the advantages to me outweighed my need for numbness. And even with the benefit of a sonogram, we adjusted once or twice for accuracy upon beginning the shocks. I only had so many 'shots' (2100 each treatment, to be exact) at getting the waves to turn my life around---and in retrospect, I'd do it the same way again.

Either way, I believe you will realize improvement. But know that the moderately better days will alternate with bad days so hang in there. IT TAKES TIME AS WE ALL ARE LEARNING. When you consider the alternative---a life of pain with every step and your life constantly put on hold--ESWT provides hope for any improvement.

Keep us in the loop as you go forward, Tyshea---you are not alone! I get more useful time (not necessarily painfree) each day. But I am hopeful that the pain relief will accompany the healing gradually. Other 'veterans' who take the time to post give us post-ESWT troopers encouragement that it does get better.


Re: think about getting eswt

Tina H on 10/14/04 at 12:31 (161502)

I agree with Elizabeth, I have much, much more 'useful' time each day, although it's not pain-free. I am about 11 weeks post ESWT and slowly continue to improve. I still have very bad days, but more are good now. The only thing that frustrates me is that often bad days occur randomly, with no reason, and sometimes when I am really on my feet too much and expect a lot of pain it happily doesn't happen. The reason for painful days now are not as clear-cut as it used to be. Think I will start noting what I've done on those days where I've had a lot of pain and see if I find a common denominator. However on painful days, if I do my 'homework' stretching, ice, and antiinflam.before bed, I'm usually fine the next morning and most days generally have just a little pain until late afternoon, a huge improvement to pre ESWT. Hang in there, yes we should all continue to keep each other posted! I am waiting for the magic 12 weeks next week! :)

Re: think about getting eswt

Dr. Z on 10/14/04 at 15:06 (161512)

Hi Gang,
I hate to start this conversation again but I must. It is my opinion that level three CAN'T cause a cavitational effect, which must be obtained in order to repair a plantar fasciosis. A plantar fasciosis is where this in degeneration of the tissue and not just inflamation. High energy is the only method whereby a cavitational effect can take place and is necessary to cause a direct biological interaction between sound waves and degenerative tissue. Low energy which is what you are talking about will only cause a neurogenic response which will indeed increase blood flow to the tissue and help to reduce inflamation and stop the pain cycle. Now if you could go into higher low energy that is something different.
I welcome and appreciate Dr. Jan Rompe comments regarding what I have stated. Any additional information and research is welcomed for my own learning.

Re: think about getting eswt

Lynn F. on 10/14/04 at 17:45 (161531)

Tyshea - I sought the opinions of 3 different podiatrists before getting ESTW. I was told by 2 of them (as well as the ESTW technician) that the level of shockwaves (3800) delivered by the Dornier Epos Ultra could NOT be tolerated without some form of anesthesia. I also asked if repeat treatments were necessary and was told, in rare instances, yes. My fascia is extremely inflamed, measuring 7 (the norm is 2) so I imagine it's going to be awhile before I know how effective the procedure was for me. Some notice improvement right away (lucky them!)

Re: think about getting eswt

Judy L. on 10/15/04 at 09:57 (161576)

My 17 year old daughter has had surgery for her PF. Although she is relieved of some of the pain, she is not painfree. It has been suggested by her podiatrist that she consider eswt. She has had to stop her dancing classes and change her lifestyle to accomodate the pain that she experiences. As a parent, I feel so bad for her having to endure this pain as a teenager. This has been a chronic problem for years. Would you recommend the treatment for a teen?? She was told that she would need to reduce her activities for 4 weeks following the treatment, does that sound accurate?

Re: think about getting eswt

Elizabeth Y. on 10/15/04 at 11:13 (161581)

Hello Judy L.:

You have mentioned that your daughter's PF has been chronic for years. I am not sure reducing her activities for only 4 weeks will enable the healing she obviously needs to accomplish. I remember how quickly as teenagers my sons (and even I) healed--from broken bones to 'strawberries' on the knees from gym floor encounters. However, PF is a horse of a different color.

She should reduce her activities until her foot tells her otherwise, which could be weeks, months or more. Well worth the wait if the desired results are achieved.

What a horrible affliction for a teen to endure. I am sure her lifestyle has been dramatically altered and her life put on hold. I am not sure any of us---surgically treated or through ESWT--will ever be painfree. It is a matter of levels of tolerance and managing the pain through stretching, icing, proper foot support, etc.

Please be aware of depression in your daughter, as this disorder is not only extremely painful but limits the desire to get out and socialize---especially during the self-concious teen years when she has to limp (or even crawl on bad days) around her friends. It is maddening...possibly encouraging her to participate on this board and read the posts would be highly theraputic...she is not alone! We wish her well and Godspeed in this healing process!!! We've all been there, done that.


Re: think about getting eswt

J. P. (Sunny) Jacob on 10/15/04 at 18:18 (161612)

Hello Dr. Z.,
Several times during the past months and again on October 14th, you have made statements about the cavitational effect from ESWT. You suggest that this effect can only be produced by 'high energy' ESWT in order to repair Plantar fasciosis. You are also implying that low energy treatment does not produce any cavitational effect.
Although it may not be your intention, I believe that you may be confusing some patients, without providing sufficient scientific back-up for such claims. Low energy ESWT (without local anesthesia) also produces cavitational effect for healing of PF within the recommended treatment level from 0.08 to 0.26 mJ/mm2.
There are several published papers on the subject. If you wish to refer to a publication by Prof. Rompe, I can suggest the following: Electromedica 65 (1997) No.1, page 20-25.
When Dr. Ed talks about the treatment and success rate of ESWT in Europe and Canada it is worthwhile to note that a great majority of those patients are being treated using low energy, multi-session (usually 3) ESWT treatments, without anesthesia.
I have been involved with low energy ESWT treatment since 1995 and have rarely seen a below expected treatment outcome. I am familiar with most of the countries where ESWT is used and the majority of them provide low energy, multiple sessions. Using anesthesia and single session treatment is a U.S. phenomenon. From my standpoint as a provider, choosing a single treatment or multiple session protocol is mainly a business decision.

Re: think about getting eswt

Dr. Z on 10/15/04 at 18:30 (161614)

It was an e-mail with Dr. Rompe that he confirmed my idea that you need high energy to produce a cavitional effect. I asked him directly this question.
I would like to read the article that you have mentioned. Would you direct me to the site so that I can read this. I am very familiar with Dr. Rompe's work with ESWT and this is the reason why I asked him this question about cavitional effect and energy levels.
I am using 0.28mj/mm2 as the starting point for high energy.
I would be interesed in knowing wny you think that it is a business decision with low vs high energy ?

Re: think about getting eswt

Vince on 10/15/04 at 19:12 (161618)

Make sure her growth plates are closed before you consider ESWT

Re: think about getting eswt for Judy

Tina H on 10/15/04 at 20:35 (161622)

Judy, I'm so sorry about your daughter. Something my physical therapist said once made a lot of sense at least it seemed logical, so for what it's worth I'll pass it on. He said when someone gets PF later in life, mid 40's for example, and they've not had it before it's usually due to a number of lifestyle issues, like weight gain, inflexibility, and working on those things often will bring a cure. However when someone young gets PF it's often due to some biomechanical issue, like one leg longer than the other, misaligned pelvis, gate issues etc. So just wondering since your daughter is so young has she had a thorough evaluation for these types of things. If not you might want to get another opinion. Hope she can find an answer soon! Good Luck, Tina

Re: think about getting eswt

Ed Davis, DPM on 10/16/04 at 15:06 (161650)


I used to send patients to Canada before ESWT was available in the US. They got great results. Low energy is affordable to most folks. Granted, no company or group has gone out and opted to spend the tens of millions of dollars it takes to get through the FDA hoops. But people have to remember that NO surgical procedure is FDA approved and, aggregately, a tiny portion of the treatment armementarium in a typical office from orhtotics to physical therapy modalities has not gone through the FDA process.

Sorry, but no one will convince me that US citizens are any safer in an American physician's office than in a Canadian one. The Canadian system has its imperfections as all systems do but I feel that the Canadian authorities have struck a reasonable balance between protecting their citizens and allowing effective modalities. If anything, people in the US are less safe as they are more apt to be subject to surgical treatment.


Re: think about getting eswt

Ed Davis, DPM on 10/16/04 at 15:19 (161652)

Dr. Z:
The 'business decision' is are we going to invest the tens of millions of dollars to try to get low enery officially approved by the FDA for treatment of PF which will effectively make it non-affordable to many Americans. The burden of 'proof' set by the FDA is absurd relative to the amount of harm (or lack of) that can occur via low energy ESWT. The amount of patients cured in Canada and Europe and the lack of side effects among thousands of such patients should be enough to have the FDA approve low energy ESWT. Every person getting surgery is potentially one person too many when a modality hundreds of times safer than surgery exists, not to mention the fact that no one, including the FDA regulates the safety of surgical procedures. I really don't want the FDA telling me and my patients what to do. I want them, only, to let us know if and when dangers are involved. As far as efficacy, the FDA is clueless as they cannot compare low to high energy and that to ART, cross fiber massage, chiropractic manipulation. Americans have spent billions of dollars on chiropractic treatment annually. Much of it is very safe. As far as efficacy, I feel that some of the treatments are efficacious and some treamtents may not be. Where is the FDA doing its efficacy research in that area? Are they going to keep ignoring the billions per year spent by our citizens, auto insurers and third parties because they feel it is oaky to thumb their noses at the 'unclean masses.' Sorry, but it is the 'masses' that pay the salaries of the FDA bureaucrats.

Re: think about getting eswt

Dr. Z on 10/16/04 at 15:23 (161655)

I agree with what you are saying, but Sonocur already spent lots money for an FDA approval process for Tennis elbow tendinois. They came this far so why not finish the process with PF. There is much more plantar fasciitis then elbow tendinosis in the USA. I believe that once you have the process set up the cost for FDA approval should be cheaper.

Re: think about getting eswt

Ed Davis, DPM on 10/16/04 at 15:29 (161657)

Dr. Z:
I agree that they should 'finish' the process. Of course, what is really meant by 'finish.' The achilles tendon is next and then the patellar tendon and so on. At some point, one safety is proven beyond any questionable doubt and there are thousands of success stories in our patient database, the FDA needs a body-wide indication to go through.

Re: think about getting eswt

J. P. (Sunny) Jacob on 10/16/04 at 19:22 (161661)

Hello Dr. Z.,
As you are already communicating with Prof. Rompe, may I suggest that you request the Electromedica paper directly from him. I don't have the website for this publication. At the same time you might want to discuss with him if he has any recent published papers that suggest that cavitation can be produced only at or above 0.28 mJ/mm2. I would be quite interested to see such a research paper.
Regarding ESWT equipment selection (high or low energy) and the treatment modalities one wishes to provide in a clinic, yes this is a business decision.
There are 3 or 4 internationally known and established medical equipment manufacturers and most are European. They all manufacture equipment for urology and orthopedics, i.e. ESWL and ESWT.
If one wishes to treat only PF, one has to make the business decision to buy either low energy (approx. 12-15% lower equipment price), or a ‘variable energy' equipment with an energy level over 0.28 mJ/mm2, or a high energy equipment, example Ossatron. If one intends to treat only PF, Ossatron may not be the ideal equipment. However, if the orthopedic surgeon also wishes to treat non-union of fracture along with joint tendonitis and PF, then it is a good compromise that would justify the cost. I am not certain if variable energy equipment such as Dornier has an energy range that is sufficient to treat non-union.
Each equipment has its pros and cons. An important factor in the decision making regarding equipment is the experience of the operator and the operator's personal preference.
Another business decision point is the time that is required for the treatment sessions. Although the initial investment for low energy equipment is less, one requires 3 to 4 times more treatment time. Considering that, multiple session low energy treatment has a higher operating cost per patient when one compares it with the one session PF treatment in USA. Besides good treatment outcome, another advantage for the patient is the avoidance of any type of anesthetic with low energy.

Re: think about getting eswt

J. P. (Sunny) Jacob on 10/16/04 at 19:24 (161662)

Hi Ed,
You are absolutely right. There is no perfect health care system. We Canadians are quite proud of our health standards and safety. The Health Protection Branch of Health Canada is responsible for the approval of medical equipment and related clinical procedures. This approval takes into consideration the treatment outcome in other geographical areas, manufacturer's history, etc. The mission of HPB is safety for the patient - not charging exorbitant registration fees. HPB realizes that high approval fees and overkill of clinical studies will reflect on the retail cost of the equipment and in turn a higher cost for the tax payer.
With reference to ESWT, my discussion with certain manufacturers in Europe reveals that their interest in registering for additional modalities with FDA for U.S. sale is minimal due to the almost unjustifiable cost.
I do understand the frustrations many health care providers and consumers in USA are facing. Irrespective of US, Canada or Europe, unfortunately politics plays a major role in health care, - not always to the benefit of the patient

Re: think about getting eswt for Judy

Judy L. on 10/16/04 at 19:55 (161663)

Thanks for the info. You are right, my daughter's PF is caused by a biomechanical issue. I am considering trying a chiroprator. Physical therapy, a night-time brace and surgery has not rid her of this problem. Sounds like she is not alone in her misery. We are in the process of getting another opinion. Thanks for the advice.

Re: think about getting eswt

Judy L. on 10/16/04 at 19:59 (161664)

Thanks for the words of encouragement. I have invited her to participate on this board. You are so right, the pain of PF is restricting her from activities that she would like to participate in. As a parent you know the 'pain' a parent feels when a child in suffering. I am consantly seeking alternative treatments or new ideas for her. Thanks for the advice.

Re: think about getting eswt

Dr. Z on 10/17/04 at 14:30 (161683)

Hi Sunny,

ESWT and Ultrasound Imaging of the Musculoskeletal System written by C.E Brachmann, G. Gruber W. Konerman, A. Aronold, G. M Gurber and F. Ueberle states the following: Page 22. 4.1 Structural Damage
'The Application of High-energy is necessary for the development of CAVITATION PHENOMENA.
I have sent an e-mail sent ot DR. Rompe and will read his article with great interest.

Re: think about getting eswt

Dr. Z on 10/17/04 at 14:33 (161684)

The dornier has the ability to treat non-unions. It can deliver up to one joule of energy.. The typical range for pseudo-arthrosis is around 0.5mj/mm2

Re: think about getting eswt

J. P. (Sunny) Jacob on 10/19/04 at 06:57 (161769)

Cavitation and Low/High Energy:

Dr. Z.,
The equipment used at the PainFree clinic is low energy. To be specific, it is Siemens Sonocur Plus with inline ultrasound. The shock wave density level at the focal region is between 0.04 and 0.50 mJ/mm2. However, the maximum level we ever use is 0.33 mJ/mm2 for pain therapy (tendonitis and PF).
It is my understanding that:
1) cell membrane becomes permeable at around 0.12 mJ/mm2
2) cell parts fuse at around 0.2 mJ/mm2 and
3) Change in mitochondrial activity takes place at around 0.3 mJ/mm2.
According to various papers, including Dr. Rompe's, damage to cell nucleus happens at around 0.5 mJ/mm2.
The energy intensity level for lithotripsy equipment is between 0.08 and 1.2 mJ/mm2.
All the above are peer reviewed, published data and can be verified.

I would appreciate to know the following in mJ/mm2:
1. 'low energy' range: From …….. to ……… mJ/mm2
2. 'high energy' range: From ……. to ………. mJ/mm2
3. At what intensity does cavitation take place? ………. mJ/mm2

Re: Pseudo arthrosis
I am not clear about your statement regarding the Dornier energy intensity range.
1. 'It can deliver up to one joule of energy.' I am not familiar with the Dornier model you use. However it cannot be 1.0 joule/mm2 of energy. Perhaps you mean 1.0 mJ/mm2?
2. You are quoting a typical 'range' for pseudo arthrosis of 0.5 mJ/mm2. As there should be two figures in a range I assume that the 0.5 mJ/mm2 you are stating is the lowest level at the focus area for pseudo arthritis treatment.

Re: think about getting eswt

Dr. Z on 10/19/04 at 08:51 (161777)

The top range for the Dornier is 1mj/mm2 not 1 joule.
Cavitation ranges:

You question about ranges depends on who you talk to . I am using 0.28mj/mm2 as the beginnng of high energy. Dr. Rompe calls this medium energy. In the USA it is referred to as High energy.
By the way I spoke with Dr. Rompe regarding the article you mentioned. He doesn't have the article. Would you be so kind to send it to me if you have it. I did look on the web site for Electromedica but this issue isn't there.


Dr. Z
(email removed)

Re: think about getting eswt

J. P. (Sunny) Jacob on 10/19/04 at 13:23 (161794)

Dr. Z.,
I agree with Dr. Rompe regarding the separation of low, medium and high energy. It is based on energy level intensity and equipment use.

1. Pain therapy: 0.08 to 0.42 mJ/mm2
2. Lithotripsy: 0.08 to 0.6 mJ/mm2
3. Osteotherapy: 0.33 to 1.2 mJ/mm2

From what I understand, the above energy levels are based on studies of the physiological changes in cells as a result of the shockwave energy.
Therefore, deviating from a scientifically based and accepted norm and calling it 'what it is called in USA' is difficult for me to accept, unless there is new scientific evidence.

Regarding your previous statement that low energy does not produce a cavitational effect, could you please clarify at exactly which energy intensity level (mJ/mm2) cavitation occurs (regardless of what it is called, low or high).
Regarding the publication of Dr. Rompe I mentioned previously: This was a reprint of the electromedica article in a publication for Siemens 'Efficient Use of Extracorporeal Shock Waves in Tendopathies'. I do not have the original article of electromedica.
However, there is another paper in German by J. D. Rompe, P. Eysel, C. Hopf, O. Krischek , title 'Extrakorporeale Stosswellentherapie in der Orthopaedie' in the journal 'Fortschritte der Medizin'(1997), Nr.18. This paper explains the biological effect of ESWT, including the energy level at which damage to the cell nucleus occurs and the energy level ranges of low, medium and high energy and is very similar to the Electromedica paper.

Re: think about getting eswt

Dr. Z on 10/19/04 at 15:17 (161798)

Cavitation occurs at energy level 0.36mj/mm2 per dornier medtech. This is the energy level that we use for chronic plantar fasciosis.

Re: think about getting eswt

J. P. (Sunny) Jacob on 10/20/04 at 16:06 (161845)

Dr. Z.,
Finally we have it: It is according to Dornier Medtech that cavitation happens at 0.36 mj/mm2. This is like consulting a tiger about vegetarian diet.
All the low energy equipment I know work at an intensity energy level of max. of 0.5 mJ/mm2 or slightly above and thus should produce cavitation. That's why I found your statement of October 14, incorrect and misleading for the patients (saying 'high energy is the only method whereby cavitational effect can take place and is necessary to cause a direct biological interaction between sound waves and degeneration tissue').
After all, cavitation is one of the hypotheses, among others, believed to encourage the 'biological interaction between sound waves and degeneration tissue.'
I have not yet seen a convincing independent research paper about the cavitational effect stating that it takes place at 0.36 mJ/mm. I wish everything were so black and white.
It is beneficial for patients intending to undergo ESWT to read more about studies done by unbiased researchers like Dr. Rompe and others regarding the effects of local anesthesia, high and low energy, and their statistical and clinical significance (from time time some related research comments appear on this message board).

Re: think about getting eswt

Dr. Z on 10/20/04 at 18:59 (161859)

I do believe the equipment CAN go to that level however, I don't believe that you apply ANY energy at the intensity of 0.5 mj/mm2.with the low energy Sonocur ESWT equipment, without any anesthesia to a patient. That is a lot of pain for any patient to undergo. How come the energy levels that Dr. Rompe talks about ( 0.09mj/mm2) aren't even close to this level. The reason I quoted Dornier is because as stated before the Dornier Epos is an FDA high energy classified equipment by the FDA for Plantar Fascia treatment. Are you saying that 0.36 mj/mm2 isn't high energy? I already quoted the book that states the cavitations takes place ONLY at high energy so if 0.36.mjs/mm2 is considered high energy then the dornier epos produces the cavitational effect as I stated already. Wow I can't believe you feel so negative about Dornier why the attitude? I stand by my statement that cavition only takes place with high energy I quoted a textbook that written by outstanding ESWT physicians. I am always willing to read, learn and add to my understanding of ESWT, however stop with the 'consulting a tiger about vegetarian diet' So tell me about the patient that received 0.5mj/mm2 of energy on the bottom of the foot?

Re: think about getting eswt

Ed Davis, DPM on 10/20/04 at 19:02 (161860)

The discussion of the cavitation phenomenon is interesting but as Sunny Jacob aptly points out, a presumed beneficial biologic effect of cavitation is, indeed, a hypothesis. Perhaps one way to 'test' this hypothesis is to eventually compare RSWT (radial shockwave therapy) where there, presumably, is no cavitation to those ESWT machines known to cause the effect.

Re: think about getting eswt

Dr. Z on 10/20/04 at 19:14 (161863)

It is my understanding that it has been proven with ESWL. I have never heard of any literature or source that states that LOW energy can produce the cavitational effect except for Sunny's saying that it take place . I have a question for you, have you ever used the energy level 0.5mj/mm2 on a patient with the sonocur eswt equipment.? If so what kind of pain did the patient experience

Re: think about getting eswt

Ed Davis, DPM on 10/22/04 at 12:04 (161987)

Dr. Z:

Unfortunately, the energy levels on the various machines do not cross correlate with other machines so I cannot verify which Sonorex energy levels are most commonly applied.

Are you referring to pain during treatment or after treatment? If the question is 'during' treatment, my response would be that that varies greatly from patient to patient. Currently, due to third party demand, I use more high energy on PF but more low energy on achilles tendinosis.

We do use nitrous oxide in our office so treatment may be interrupted to provide that if needed. Additionally, the issue of finding the area of maximum tenderness as a trageting mechanism, I feel is subject to creative application of the technology. For example, one can find the area of maximun tenderness with lower energy levels but as energy is increased and discomfort encountered then treatent interupted and a medial calcaneal block applied. There may be some confusion between the term 'local' anesthesia and the type of blocks that we use which are actually a form of 'regional' anesthesia. 'Local' implies that the fluid of anesthesia is present that could potentially dampen the shock wave.