Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis Page 1 of 62 and Other Musculoskeletal Conditions Medical Policy An Independent licensee of the Blue Cross Blue Shield Association Title: Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions Professional Institutional Original Effective Date: July 11, 2001 Original Effective Date: July 1, 2005 Revision Date(s): November 5, 2001; Revision Date(s): December 15, 2005; June 14, 2002; June 13, 2003; October 26, 2012; May 7, 2013; January 28, 2004; June 10, 2004; April 15, 2014; April 14, 2015; April 21, 2005; December 15, 2005; August 4, 2016; January 1, 2017; October 26, 2012; May 7, 2013; August 10, 2017; August 1, 2018; April 15, 2014; April 14, 2015; July 17, 2019, March 11, 2021 August 4, 2016; January 1, 2017; August 10, 2017; August 1, 2018; July 17, 2019, March 11, 2021 Current Effective Date: August 10, 2017 Current Effective Date: August 10, 2017 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. Populations Interventions Comparators Outcomes Individuals: Interventions of Comparators of interest Relevant outcomes • With plantar interest are: are: include: fasciitis • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy stretching, heel supports) • Functional outcomes • Quality of life Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis Page 2 of 62 and Other Musculoskeletal Conditions Populations Interventions Comparators Outcomes • Nonsteroidal anti- • Medication use inflammatory therapy • Treatment-related • Local corticosteroid morbidity injection Individuals: Interventions of Comparators of interest Relevant outcomes • With lateral interest are: are: include: epicondylitis • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy physical therapy, rest) • Functional outcomes • Nonsteroidal anti- • Quality of life inflammatory therapy • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With shoulder interest are: are: include: tendinopathy • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy physical therapy, rest) • Functional outcomes • Nonsteroidal anti- • Quality of life inflammatory therapy • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With Achilles interest are: are: include: tendinopathy • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy heel lift, rest) • Functional outcomes • Nonsteroidal anti- • Quality of life inflammatory therapy • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With patellar interest are: are: include: tendinopathy • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy icing, support) • Functional outcomes • Nonsteroidal anti- • Quality of life inflammatory therapy • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With medial tibial interest are: are: include: stress syndrome • Extracorporeal shock • Conservative therapy (eg, • Symptoms wave therapy icing, support) • Functional outcomes • Quality of life • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With interest are: are: include: osteonecrosis of • Extracorporeal shock • Medication therapy (eg, • Symptoms the femoral head wave therapy alendronate) • Functional outcomes • Hip arthroplasty • Quality of life • Medication use • Treatment-related morbidity Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis Page 3 of 62 and Other Musculoskeletal Conditions Populations Interventions Comparators Outcomes Individuals: Interventions of Comparators of interest Relevant outcomes • Acute fracture interest are: are: include: nonunion or • Extracorporeal shock • Surgical therapy • Symptoms delayed union wave therapy • Functional outcomes • Quality of life • Medication use • Treatment-related morbidity Individuals: Interventions of Comparators of interest Relevant outcomes • With spasticity interest are: are: include: • Extracorporeal shock • Medication therapy • Symptoms wave therapy • Intrathecal medication • Functional outcomes therapy • Quality of life • Medication use • Treatment-related morbidity DESCRIPTION Extracorporeal shock wave therapy (ESWT) is a noninvasive method used to treat pain with shock or sound waves directed from outside the body onto the area to be treated, (eg, the heel in the case of plantar fasciitis). Shock waves are generated at high- or low-energy intensity, and treatment protocols can include more than 1 treatment. ESWT has been investigated for use in a variety of musculoskeletal conditions. OBJECTIVE The objective of this evidence review is to examine whether the use of extracorporeal shock wave treatment for plantar fasciitis, lateral epicondylitis, tendinopathy (shoulder, Achilles, and patellar), medial tibial stress syndrome, osteonecrosis of the femoral head, acute fracture nonunion or delayed union, or spasticity improves the net health outcome BACKGROUND Chronic Musculoskeletal Conditions Chronic musculoskeletal conditions (eg, 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 calcific deposits by shock waves may loosen adjacent structures and promote resorption of calcium, thereby decreasing pain and improving function. Plantar Fasciitis Plantar fasciitis is a common ailment characterized by deep pain in the plantar aspect of the heel, particularly on arising from bed. While the pain may subside with activity, in some patients the pain persists, interrupting activities of daily living. On physical examination, firm pressure will elicit a tender spot over the medial tubercle of the calcaneus. The exact etiology of plantar fasciitis is unclear, although repetitive injury is suspected. Heel spurs are a common associated finding, although it is unproven that heel spurs cause the pain. Asymptomatic heel spurs can be found in up to 10% of the population. Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis Page 4 of 62 and Other Musculoskeletal Conditions Tendinitis and Tendinopathies Common tendinitis and tendinopathy syndromes are summarized in Table 1. Many tendinitis and tendinopathy syndromes are related to overuse injury. Table 1. Tendinitis and Tendinopathy Syndromes Disorder Location Symptoms Conservative Other Therapy Therapies Lateral Lateral elbow Tenderness over lateral • Rest Corticosteroid epicondylitis (insertion of epicondyle and proximal wrist • Activity injections; ("tennis wrist extensor muscle mass; pain modification joint elbow") extensors) with resisted wrist extension • NSAIDs debridement with elbow in full extension; • Physical (open or pain with passive terminal therapy laparoscopic) wrist flexion with elbow in full • Orthotic extension devices Shoulder Rotator cuff Pain with overhead activity • Rest Corticosteroid tendinopathy muscle • Ice injections tendons, • NSAIDs most • Physical commonly therapy supraspinatus Achilles Achilles Pain or stiffness 2-6 cm • Avoidance of Surgical repair tendinopathy tendon above the posterior calcaneus aggravating for tendon activities rupture • Ice when symptomatic • NSAIDs • Heel lift Patellar Proximal Pain over anterior knee and • Ice • tendinopathy tendon at patellar tendon; may • Supportive ("jumper's lower pole of progress to tendon taping knee") patella calcification and/or tear • Patellar tendon straps • NSAIDs NSAIDs: nonsteroidal anti-inflammatory drugs. Fracture Nonunion and Delayed Union The definition of a fracture nonunion remains controversial, particularly the duration necessary to define nonunion. One proposed definition is a failure of progression of fracture healing for at least 3 consecutive months (and at least 6 months after the fracture) accompanied by clinical symptoms of delayed/nonunion (pain, difficulty weight bearing).