Medical Review - Experimental/Investigational
Extracorporeal Shock Wave Therapy (ESWT) for Tennis Elbow and Musculoskeletal Conditions
Description
Extracorporeal shock wave treatment (ESWT), also known as orthotripsy, has been available since the early 1980s for the treatment of renal stones, and has been widely investigated for the treatment of biliary stones. Shock waves create a transient pressure disturbance, which disrupts solid structures, breaking them into smaller fragments, allowing spontaneous passage and/or removal of stones. The mechanism by which ESWT might have an effect on musculoskeletal conditions is not well defined. Chronic musculoskeletal conditions, such as tendinitis, can be associated with a substantial degree of scarring and calcium deposition. Calcium deposits may restrict motion and encroach on other structures such as nerves and blood vessels, causing pain and decreased function. One hypothesis is that disruption of these calcific deposits by shock waves may loosen adjacent structures and promote resorption of calcium, thereby decreasing pain and improving function.
Other functions are also thought to be involved. Physical stimuli are known to activate endogenous pain control systems, and activation by shock waves may "reset" the endogenous pain receptors. Damage to endothelial tissue from ESWT may result in increased vessel wall permeability, causing increased diffusion of cytokines, which may in turn promote healing. Microtrauma induced by ESWT may promote angiogenesis and thus aid in healing. Finally, shock waves have been shown to stimulate osteogenesis and promote callous formation in animals, which is the rationale for ESWT in delayed union or non-union of bone fractures.
Both high-dose and low-dose protocols have been investigated. A high-dose protocol consists of a single treatment of high-energy shock waves (1300mJ/mm2). This painful procedure requires anesthesia. A low-dose protocol consists of multiple treatments, spaced one week to one month apart, in which a lower dose of shock waves is applied (1405mJ/ mm2 over three sessions). This protocol does not require anesthesia.
BCBSKS considers the low dose machine experimental. There are currently three ESWT devices approved by the U.S. Food and Drug Administration (FDA).
Device Name |
Type |
FDA Approved Indication(s) |
OssaTron® device (HealthTronics, Marietta, GA) |
High-dose - Electrohydraulic delivery system |
Chronic proximal plantar fasciitis that has failed to respond to conservative management. |
Epos™ Ultra (Dornier, Germering, Germany) |
High-dose - Electromagnetic delivery system |
Treatment of chronic plantar fasciitis for patients with symptoms of plantar fasciitis for 6 months or more and a history of unsuccessful conservative therapy. |
SONOCUR® Basic (Seimens, Erlangen, Germany) |
Low-dose - Electromagnetic delivery system |
Treatment of chronic lateral epicondylitis (commonly referred to as tennis elbow) for patients with symptoms of chronic lateral epicondylitis for 6 months or more and a history of unsuccessful conservative treatments. |
Policy
ESWT is considered experimental/investigational for lateral epicondylitis and musculoskeletal conditions due to the lack of long-term studies.
CPT Code
0019T
0101T
0102T
C9720
Determined by the Orthopedic Liaison committee at the 01-07-04 meeting and approved by the Medical Advisory Committee in April 2004. On August 9, 2005, the Guide Team/Medical Director added the statement on musculoskeletal conditions to the title and policy and new category III codes.
(Web updated 11/2005)
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