Cath Lab Digest

Yes. Lowell Weil Jr., DPM, MBA, FACFAS cites emerging research on low-energy ESWT and says it can be a cost-effective treatment for plantar fasciitis and other conditions.

   When musculoskeletal extracorporeal shockwave (ESWT) was introduced in the United States with its first FDA approval in 2000, there was a great deal of controversy and posturing among manufacturers of ESWT technologies. Each company was determined to create an exclusive market for itself at the expense of its competition.

   One of the most common targets for criticism was the level of energy of the technology. Based on industry biases, high-energy ESWT was considered the most effective for the musculoskeletal system and those devices that failed to reach high energy were considered inferior.

   Interestingly, there was no standard to measure energy levels. Each technology had a different gauge of energy level so comparisons were not valid. When physicists who were experts in ESWT were questioned as to which companies had high-energy devices and which companies had low-energy devices, they usually were unable to answer the question because of the lack of standardization.

   As the battle for differentiation continued, some of the companies claiming to have high-energy devices successfully differentiated themselves to the CPT coding committee. These companies received a standard CPT code (28890) that required “high energy performed under anesthesia other than local and using an ultrasonic targeting device for the treatment of plantar fasciitis.” At that time, research from outside of the U.S. tended to favor high-energy ESWT. While some insurance companies would not cover any ESWT, others would only cover “high-energy” ESWT based on the “flawed” research and an effective lobby by the then more powerful shockwave companies.¹

   High energy ESWT often differentiated itself by the need for anesthesia other than local (intravenous sedation, ankle block: CPT 28890). The high-energy shockwave devices do have the advantage of providing treatment through one session but are also extraordinarily expensive to the patient with the combination of technology expense, procedural expense and anesthesia expense. Few private practitioners could afford the investment of a high-energy device and private partnerships emerged to make devices available on a rental basis. Unfortunately, the cost of high-energy ESWT became prohibitive to the insurance companies as well as to many patients.

A Closer Look At The Merits Of Low-Energy ESWT

   However, during the last several years, more and more research has emerged and indicated that low-energy shockwave is as effective as high-energy ESWT at a better value to the podiatric physician, insurance company and, most importantly, to the patient.²

   After previously being a staunch believer in high-energy ESWT as being the “only ESWT for the musculoskeletal system,” I decided to take another look at low-energy ESWT due to some interesting papers published by Rompe and Gerdesmeyer.^3,4 Subsequently, based on my experience at international shockwave conferences and personal experience with FDA clinical trials with both high-energy and low-energy devices, I became a believer in low-energy ESWT.⁵

   Subsequently, a multicenter study examined the safety and efficacy of using radial extracorporeal shockwave therapy (rESWT) to treat chronic recalcitrant plantar fasciitis.³