Dev Joshi
November 27, 2007
Extracorporeal shock wave therapy (ESWT) is considered an innovative non-surgical procedure that provides a non-invasive healing option for patients with musculoskeletal conditions that have failed to respond to conservative treatment. ESWT is performed as an outpatient procedure to alleviate the pain caused by chronic plantar fasciitis. Plantar fasciitis is a common problem that causes pain in the heel and arch of the foot. ESWT also was developed for musculoskeletal conditions like lateral epicondylitis (tennis elbow) and tendonitis of the rotator cuff. For years ESWT was best known as an effective therapy for kidney stones, but research suggested the procedure would be helpful for patients with orthopedic conditions, and thus it received FDA approval for the treatment of plantar fasciitis in October 2000. MEDISPEC’s Orthospec™ ESWT System, which uses sound waves for treating chronic heel pain caused by proximal plantar fasciitis, was approved on April 1, 2005.
Extracorporeal shock wave therapy is still considered a relatively new procedure, and so far the experience has been sparse in the musculoskeletal field. ESWT’s exact mechanisms of action are still unknown. However, according to Dr. Hale from the Foot and Ankle Center of Washington, based in Seattle, the theory behind the ESWT is that the shock wave stimulates and reactivates healing to encourage revascularization and other elements necessary to advance normal tissue healing.
ESWT might not be a primary outpatient procedure in terms of medical necessity; however, doctors and surgeons believe it does provide distinct advantages over the traditional surgical treatments. According to Dr. William Donahue, foot surgeon at Lutheran Hospital in Cleveland, Ohio, “ESWT has become my first choice for the treatment of persistent heel pain. It offers patients whose condition has not responded to conservative care a non-invasive alternative with a return to daily activities the next day.” They have fewer potential complications and a faster return to normal activity than the traditional therapy, which is mostly injection (explained in detail later in the article). Also, using the PearlDiver database we see that ESWT is being used extensively to treat plantar fasciitis and other extremities disorders such as tennis elbow and pain in limb, as well as stiff shoulder and chronic tendon pain.
There are four different types of outpatient procedures that use extracorporeal shock wave therapies in musculoskeletal conditions like plantar fasciitis and epicondylitis. However, since these are newly developed innovative treatments, the counts are still low with the exception of plantar fasciitis. Table 1 shows four different ESWT outpatient procedure codes and descriptions, as well as the primary diagnoses used for treatment and the distinct patient counts residing in our PearlDiver database.<
Table 1: Extracorporeal Shock Wave Therapies
Source: PearlDiver Patient Records Database 2004-2006
According to the PearlDiver database, plantar fascial fibromatosis is one of the top five diagnoses in the foot and ankle region. This is a common clinical condition caused by overuse or injury of the plantar fascia, which is a band of connective tissue on the plantar surface of the heel. Table 2 from the PearlDiver database shows the demographics by gender for the years 2005 and 2006 for the patients diagnosed with plantar fascial fibromatosis. The data shows females being diagnosed at significantly higher rates than males.
Table 2: ICD-9 — 728.71 Plantar Fascial Fibromatosis
Note: The adjustment is made to the annual total in order to more accurately account for the number of distinct patients who received the diagnosis or procedure for that year. Source: PearlDiver Patient Records Database
Extracorporeal shock wave therapy involving plantar fascia is the most performed procedure among the four listed above in Table 1. CPT 28890, as described in Table 1, is the most used procedure and is most often employed to treat plantar fascial fibromatosis. Table 3 shows the distinct patient count broken down by gender that underwent ESWT involving plantar fascia during 2005 and 2006. Females underwent this procedure significantly more often than males for both 2005 and 2006. The last quarter of 2006 showed a steep decline in number of procedures. The reason for this decline is still not clear, but could be attributed to the relative newness of the procedure and the extremely high charges compared to older, conservative treatments.
Table 3: CPT 28890 — Extracorporeal Shockwave Therapy Involving Plantar Fascia
Note: The adjustment is made to the annual total in order to more accurately account for the number of distinct patients who received the diagnosis or procedure for that year. Source: PearlDiver Patient Records Database 2004-2006
The following chart shows the top six diagnoses treated with ESWT involving plantar fascia. Approximately 75% of the time, plantar fascial fibromatosis (ICD 728.71) is treated with the ESWT procedure. Plantar fibromatosis is a condition that presents with firm bumps, or nodules, that are found in the plantar fascia. They are non-cancerous tumors that enlarge slowly and cause pain when walking.
Chart 1: Common Associated Diagnoses Treated by ESWT Procedure
Source: PearlDiver Patient Records Database 2004-2006
Injection; single tendon sheath/ligament/aponeurosis (CPT 20550), is one of the common conservative treatments for plantar fascial fibromatosis. The physician injects a therapeutic agent into a single tendon sheath, ligament, or aponeurosis such as the plantar fascia and locates the injection site. The needle is then inserted and medicine is injected. Table 4 provides a demographic breakdown of gender for CPT 20550.
Table 4: CPT 20550 — Injection; Single Tendon Sheath/Ligament/Aponeurosis
Note: The adjustment is made to the annual total in order to more accurately account for the number of distinct patients who received the diagnosis or procedure for that year. Source: PearlDiver Patient Records Database 2004-2006
Clearly, ESWT is innovative and it has earned its share of physician champions. But one of the barriers to broad acceptance is its cost. As the PearlDiver data illustrates, the charges submitted to insurance companies for performing ESWT ranges from $5,432 to more than $8,000. By contrast, as we show in Table 5 below, conservative care is a fraction of the cost.
Table 5: Charges per Region for ESWT Including Plantar Fascia and Injection; Single Tendon Sheath/Ligament/Aponeurosis, 2006
Source: PearlDiver Patient Records Database 2004-2006
Using ESWT for plantar fascia has generated a lot of interest since its approval by the FDA. Dr. William Donahue from the Lutheran Hospital in Cleveland, speaks for many supporters when he says that it is an excellent treatment for heel pain. But the jury is still out for many physicians like Dr. Weil, Fellowship Director of the Weil Foot & Ankle Institute in Des Plaines, Illinois, and a fellow of the American College of Foot and Ankle Surgeons, who has been stating that more outcome studies are required before ESWT can be declared a routine treatment modality.
To be sure, ESWT has its own share of complications. The patients who have undergone ESWT have seen complications ranging from mild pain and tingling or numbness, to bruising and swelling, to reports of rupture of the plantar fascia and damage to the blood vessels or nerves.
Still, as we’ve seen in our PearlDiver data, ESWT is an emerging technology. Generating as much as $8,000 per treatment in a market that represents more than a quarter million patients annually (and that is ONLY in the PearlDiver data) this is clearly an attractive new technology and is worth paying close attention.