Medical Policy

Subject: Extracorporeal Shock Wave Therapy for Orthopedic Conditions
Document #: SURG.00045 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017


This document addresses the use of extracorporeal shock wave therapy (ESWT), including Extracorporeal Pulse Activation Therapy (EPAT® ), for the treatment of musculoskeletal conditions, including chronic plantar fasciitis, lateral epicondylitis (tennis elbow) and tendinitis of the supraspinatus muscle or rotator cuff.

Position Statement

Investigational and Not Medically Necessary:

Use of Extracorporeal Shock Wave Therapy (ESWT), including but not limited to the use of Extracorporeal Pulse Activation Therapy (EPAT® ), for the treatment of musculoskeletal conditions is considered investigational and not medically necessary. These conditions include, but are not limited to:


Plantar fasciitis

Evidence in the form of randomized controlled trials (RCT) regarding the efficacy of extracorporeal shock wave treatment (ESWT) for plantar fasciitis is conflicting. A trial by Buchbinder, published in 2002 in the Journal of the American Medical Association (JAMA), reported no significant difference between individuals with plantar fasciitis treated with low energy ESWT vs. placebo.  Concerns about the selection criteria used for this study have been raised, asserting that individuals who participated in the study failed to have long-standing conditions, nor did they fail any previous therapies.  A study, also of a low energy device, was in the form of unpublished data submitted to the U.S Food and Drug Administration (FDA) by Dornier Medical Systems Inc, a manufacturer of the EPOS UltraÒ ESWT device.  In that study, a small but statistically significant improvement was noted in subjective pain ratings and on a standardized foot scoring tool in the experimental group.  No other significant differences were noted between the experimental and placebo groups.  Of note, the study's blinding may have been ineffective in that 59% of the experimental group vs. 15% of participants in the placebo group correctly identified their treatment group; bias favoring treatment must be considered.

Additional peer-reviewed journal articles continue to produce conflicting results.  Randomized, placebo controlled, double-blinded studies by Haake (2003), Rompe (2003), and Speed (2003) all evaluated the efficacy of this therapy with low energy devices for the treatment of plantar fasciitis.  While the Rompe study found a significant benefit to these devices, the Haake and Speed studies found the devices to be ineffective when compared to placebo treatments.  The medical evidence remains unclear regarding the benefits of low energy ESWT for plantar fasciitis.

The currently available randomized, placebo controlled, double-blinded trial data addressing high energy devices is limited.  An RCT study reporting on the use of ESWT for plantar fasciitis was published in 2001 by Ogden and colleagues.  This study reported a significant benefit of high energy ESWT.  Two randomized placebo controlled, but non-blinded trials of high energy ESWT devices demonstrated a significant benefit of high energy ESWT for plantar fasciitis (Alvarez, 2003; Lee, 2003).  The lack of adequate participant blinding is an important source of bias and conclusions that these treatments are effective cannot be reasonably drawn. 

Gollwitzer and colleagues (2007) published the results of a prospective, double-blind, randomized, placebo controlled trial involving 40 individuals with plantar fasciitis.  Participants were randomly assigned to receive either extracorporeal shock wave therapy or sham shock wave therapy.  Treatments were given 1 week apart for 3 weeks and the final follow-up was 12 weeks after the last treatment.  The authors reported that there was a 73.2% reduction in composite heel pain in the experimental group, and that this was 32.7% greater than the results achieved in the placebo group.  However, the authors reported this difference was not statistically significant.

A double-blind RCT by Malay (2006) provided active ESWT to 115 participants and placebo to 57.  The authors report that both blinded observer and self-reported assessments of heel pain were significantly better in the treatment group.  A significant limitation of this study is that the researchers did not utilize formal standardized quality of life or foot scoring systems, nor did they collect data on participants past 3 months post-treatment. 

Two studies of low energy devices, both placebo controlled, double-blind clinical trials (Kudo, 2006; Porter, 2005) have conflicting conclusions, with the Kudo article supportive of ESWT when compared to placebo, and the Porter article finding that ESWT was not more efficacious than corticosteroid therapy.  Additionally, Rompe et al. published the findings of a single-blind RCT comparing low energy treatment to plantar fascia-specific stretching exercises in 82 subjects (2010).  The authors reported finding no significant differences between the two groups, at 15 months.

A systematic review and meta-analysis by Thompson (2005) reviewed six RCTs which included a total of 897 individuals.  Their analysis concluded that ESWT does provide some beneficial effects, but that the treatment effects are very small.

In 2012, Radwan and colleagues published their findings from a non-blinded RCT.  In this study, 65 subjects were randomized to undergo treatment with endoscopic plantar fasciotomy (n=31) vs. high energy ESWT (n=34) and followed for 12 months.  The authors reported no significant differences between treatment groups with the exception of the American Orthopedic Foot and Ankle-hindfoot Scale (AOFAS) maximum walking distance and gait sub-scores at 3 weeks.  This difference was not durable and disappeared at subsequent time points.  They also report that at 2- and 3-year follow-up times, subjects were contacted regarding perceived success of their interventions.  At 2 years, 50% (13/26) of the ESWT group and 80% (20/25) of the fasciotomy group felt their procedure was a success (p=0.026).  At 3 years, these numbers changed to 47% (11/23) vs. 80% (20/25) respectively (p=0.021).  To date, the published evidence regarding ESWT for plantar fasciitis continues to be contradictory. 

Two systematic reviews and meta-analyses of RCTs were published in 2013 (Aquil, 2013; Dizon, 2013).  Both reported that ESWT is better than or comparable to placebo in reducing pain and improving functional status in the short-term.  However, many limitations exist in interpreting these findings, including inconsistent results and heterogeneity in the studies that sometimes precluded meta-analysis of pooled data.  Additionally, significant variation between the included studies with regard to dose intensities, type of shockwaves used, and frequency of treatments limited the conclusions which could be drawn from these studies.  Finally, given plantar fasciitis often resolves within a 6 month time period, longer follow-up studies are needed to compare ESWT results to the natural resolution of the condition.  The clinical significance of results reported at shorter follow-up, such as 3 months, is uncertain.

In 2014, Yin and colleagues published a systematic review and meta-analysis of studies involving ESWT for plantar fasciitis.  The authors included a total of seven studies that were either RCTs or quasi-RCTs involving subjects with plantar fasciitis of at least 6 months duration.  The primary outcome was treatment success rate.  Among the five studies included in the pooled analysis for low energy devices, the result indicated that low energy ESWT was more likely to lead to treatment success than control treatment (p<0.001).  However, the authors noted significant heterogeneity in the definitions for treatment success across studies.  The pooled analysis for high energy ESWT devices involved two studies, and no difference between the ESWT and control treatments was reported.  This study is hampered by the heterogeneity of the definition of treatment success across studies, as well as the basic issues of the base studies themselves, which are addressed above.

Gollwitzer published the results of a double-blind RCT involving 250 subjects with plantar fasciitis randomized to ESWT or placebo intervention and followed for 12 weeks post-treatment.  The authors reported that the visual analog scale composite score showed a significant difference in the reduction of heel pain in the ESWT group vs. the placebo group (69.2% vs. 34.5%, p=0.0027, one-sided).  They also stated that the ESWT group demonstrated significantly superior results on the Roles and Maudsley score, a subjective 4-point patient assessment of pain and limitations of activity (p=0.0006, one-sided).  No test for the accuracy of the blinding was conducted.

Overall, there is conflicting evidence regarding the benefits of ESWT for plantar fasciitis.  Significant questions remain that warrant investigation in a large, well designed and conducted double-blind RCT.


ESWT has also been proposed as a treatment for lateral epicondylitis (tennis elbow).  Recent systematic reviews and meta-analyses (Bisset, 2005; Buchbinder, 2005 and 2006) conclude that ESWT for tennis elbow does not provide significant clinical benefit.  The Buchbinder studies go further, concluding that there is good evidence to demonstrate that corticosteroid injection may be more effective than ESWT treatment.

A systematic review of the available RCTs addressing the efficacy and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain was published in the Journal of Rheumatology (Buchbinder, 2006).  This study utilized Cochrane Collaboration methodology in evaluating nine placebo controlled trials and one steroid injection controlled trial.  The authors note that the nine placebo controlled trials reported conflicting results, although 11 of 13 pooled analyses found no significant benefit of ESWT over placebo.  Two of the included studies favored ESWT.  It was noted by the authors that the results of four other trials not included in the pooled results found no benefit to ESWT as well.  The result of the systematic review indicates that steroid injection was more effective than ESWT at 3 months after the end of treatment, and only minimal adverse effects of ESWT were reported.  The conclusion of the study was:

There is "platinum" level evidence that ESWT provides little or no benefit in terms of pain and function in lateral elbow pain. There is "silver" level evidence based upon one trial that steroid injection may be more effective than ESWT.

Radwan and colleagues (2008) presented the results of a small RCT of ESWT for epicondylitis (n=29) vs. percutaneous tenotomy (n=26).  The results reported at 12 month follow-up found no significant difference between groups in terms of success rate, as measured by score on the Thomsen test.  This is the first published report comparing ESWT to surgical intervention.  Further data from larger trials would be helpful in understanding these results.  An article describes the results of a double-blind randomized placebo controlled trial of ESWT for epicondylitis (Staples, 2008).  This study involved 68 individuals assigned to either ESWT or sham treatment.  The authors reported that at the 6-month follow-up visit, there were significant improvements in both groups, but no significant differences between groups even after adjusting for duration of symptoms.

In a 2013 systematic review and meta-analysis, Ioppolo et al. included six RCTs on ESWT compared to sham treatment or placebo for calcific shoulder tendinopathy.  Greater shoulder function and pain improvements were found at 6 months with ESWT over placebo.  However, most studies were considered to be low quality.

Tendinitis of the Shoulder

To date, the majority of studies on the use of ESWT for the treatment of shoulder tendinitis are limited by small sample size and flawed study design.  The study by Cosentino (2001), while demonstrating good clinical response to ESWT, is only single-blinded and includes only 70 participants.  Similarly, the Pan study (2003) includes 60 participants and does not specify the degree of blinding, which hampers the ability to fully weigh the benefits of the study objectively.  As with any study of a pain syndrome, large-scale, randomized double-blind, placebo controlled design is the most effective in isolating placebo effect and minimizing confounding factors.  One such study by Gerdesmeyer (2003) found significant benefits of both low- and high-powered ESWT devices in the treatment of shoulder tendinitis when compared to placebo treatment with a follow-up of 12 months.  While this evidence is promising, the authors comment that their findings need to be confirmed by further studies. 

In 2013, Kolk and colleagues published the results of an RCT in which 82 subjects with chronic tendinitis were assigned to receive treatment with either low-dose radial ESWT (n=44; 3 sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm2 , 8 Hz) or placebo (n=38).  The follow-up period was 6 months.  Both the subjects and the evaluating surgeon were blinded to the treatment assignment.  The authors reported that the visual analogue scale (VAS) score for pain, Constant-Murley score (CMS), and a Simple Shoulder Test (SST) were all significantly improved in both groups at 3 and 6 months compared with baseline (p≤0.012).  The mean VAS was similar in both groups at 3 (p=0.43) and 6 months (p=0.262).  They concluded that low-dose radial ESWT did not reduce pain or improve function in subjects with chronic rotator cuff tendinitis.

A small RCT by Kim et al. (2014) compared ultrasound guided corticosteroid injections to ESWT in a group of 62 subjects with shoulder tendinitis.  A total of 54 (87%) subjects completed an average 24 months in the follow-up period.  While the radiologic evaluations were blinded, it is not clear whether or not the clinical evaluations were blinded as well.  At the last follow-up, it was reported that the calcium deposits had decreased in size significantly more in the ESWT group (p=0.001).  However, at 1 year, functional outcomes were reported to be significantly better in the corticosteroid group on the American Shoulder and Elbow Surgeons assessment (p=0.001), SST (p=0.015), and visual analog scale (p=0.003).  The authors concluded that corticosteroid injections are more effective than ESWT.

Verstraelen and colleagues published a meta-analysis of studies comparing high energy vs. low energy ESWT for shoulder tendinitis (2014).  The analysis involved 5 studies totaling 359 subjects.  Three of the included trials were considered high quality.  The authors reported that high energy ESWT, when compared to low energy ESWT, provided significantly more improvements in functional outcomes (p<0.001).  They added that high energy ESWT was more likely to provide resolution of calcium deposits at 3 months (p=0.009).  These results are interesting, but are based on data from studies with significant flaws.  Further investigations are needed to fully understand the safety and efficacy of ESWT for shoulder tendinitis.

Other Indications

ESWT has been proposed for a wide range of other musculoskeletal conditions.  For most of these conditions, no RCTs have been published, but some limited evidence has been made available.  A study by Caccio and colleagues (2009) reports on the use of ESWT for the treatment of long bone non-unions.  In this study, 126 participants with long bone non-unions were randomized to receive either: (1) low energy ESWT; (2) high energy ESWT; or (3) surgical management.  The authors reported that at 3 and 6 months post-treatment the clinical outcomes in the 2 shock wave groups were significantly better than those in the surgical group (p<0.001).  However, at 24 months after treatment, there were no differences among the 3 groups.  

Lui presented the findings from a sham-controlled RCT of 90 subjects with bicipital tenosynovitis treated with radial ESWT (2012).  Of the 90 subjects starting the study, 79 (87%) completed the 12-month follow-up period (n=34 ESWT, n=18 Control).  At 1 month post-treatment, 32 ESWT subjects received evaluation with ultrasound (US) with 27 reverting to normal.  At the same time point, 18 control subjects received US evaluation with 15 reporting no changes.  The results of VAS pain scale indicated significant improvement for the ESWT group vs. controls at all time points.  Similar benefits were reported for the ESWT group vs. the control group with regard to the L'Insalata shoulder questionnaire.  No significant complications were reported.  This study is hampered by unequal numbers of subjects in each group, no blinding, and only subjective survey tool data from follow-up calls. 

An RCT was conducted by Seok (2013) comparing one session of ESWT (1000 shots at the maximal tolerable intensity) vs. one session of local corticosteroid injection in 36 subjects with carpal tunnel syndrome.  Follow-up was at 3 months post-treatment.  The results indicated that both groups showed a significant reduction in the visual analog scale measurements at 1 and 3 months compared with baseline.  For the symptom severity score, as measured by the Levine Self-assessment Questionnaire, the ESWT group showed a significant reduction at 1 and 3 months, whereas the injection group showed a significant reduction only at 3 months following treatment.  Nerve conduction parameters were not significantly improved in the ESWT group, whereas the sensory nerve conduction velocity, the sensory nerve action potential amplitude, and the distal sensory and motor latencies of the median nerve were significantly improved in the injection group.  The authors concluded that ESWT may be as useful as local corticosteroid injection for relieving symptoms of carpal tunnel syndrome.  However, the results of this small unblinded trial indicate that ESWT is not superior to corticosteroid injection therapy.

Zhao and others (2013) conducted a single-blind, placebo controlled RCT of ESWT for the treatment of osteoarthritis of the knee.  In this study, 70 subjects were assigned to receive ESWT (n=34) or placebo (n=36).  For ESWT, subjects received 4000 pulses of shockwave at 0.25 mJ/mm2 weekly for 4 weeks.  In the placebo group, subjects received shockwave at 0 mJ/mm2 in the same area.  No adverse events were reported.  Of the original 70 subjects, 61 (87.1%) subjects completed the study, with no significant difference between groups.  The authors state that ESWT was more effective than placebo in reducing pain on movement at each period as measured by visual analog scale (p<0.01).  The mean visual analog scale score with ESWT was 3.83 at 12 weeks versus 7.56 at baseline (p<0.01).  For the Lequesne index, at 12 weeks, the decrease in disability was almost -2.0 for the placebo group but -4.1 for the ESWT group (p<0.01).  Similarly, the mean change in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score after 12 weeks was -8.5 for the placebo group and -19.1 for the ESWT group (p<0.01).  The authors conclude that ESWT is effective in reducing pain and improving knee function, with better results than placebo during the 12-week treatment.  Although promising, the results of this small study need to be validated in larger, double-blind controlled trials with longer follow-up to establish a durable treatment effect over placebo.

Li and others (2016) reported on a prospective single-blind, placebo controlled RCT investigating the long-term effect of radial ESWT (rESWT) in subjects with poststroke spasticity.  The 60 participants were assigned to 1 of 3 groups: (1) treatment with one session of rESWT per week for 3 consecutive weeks; (2) a single session of rESWT; and (3) one session of sham rESWT per week for 3 consecutive weeks.  Evaluations were performed at baseline prior to treatment and 1, 4, 8, 12, and 16 weeks after treatment.  Compared to the control group, significant reduction in spasticity of hand and wrist lasted at least 16 and 8 weeks in group 1 and 2, respectively.  The authors noted that three sessions of rESWT had a longer-lasting effect than one session.  Furthermore, the reduction in spasticity after three sessions of rESWT was maintained for 16 and 12 weeks, respectively.  They concluded that "rESWT may be valuable in decreasing spasticity of the hand and wrist with accompanying enhancement of wrist control and hand function in chronic stroke patients."

Extracorporeal Pulse Activation Therapy (EPAT)

Recently a treatment method referred to as "extracorporeal pulse activation therapy" (also known as "EPAT" or extracorporeal acoustic wave therapy), has been proposed for a wide array of orthopedic maladies.  This approach uses low energy ESWT to areas of soft tissue inflammation, which has been proposed to promote tissue healing.  At this time, only one peer-reviewed study has been published addressing a musculoskeletal condition (Saxena, 2011).  This case series study of 60 subjects investigated the use of EPAT for Achilles tendinopathy.  The authors reported that 58 (78.38%) tendons improved by at least 1 year post-treatment, including 75% in the subjects with paratendinosis, 78.26% with proximal tendinosis, and 84.21% with insertional tendinosis.  No adverse effects were reported.  Further research is warranted to properly evaluate the safety and efficacy of this treatment methodology.


The plantar fascia is a wide ligament-like structure that covers the bottom of the foot, extending from the heel bone to the base of the toes.  This band of thick tissue protects the bottom of the heel bone and acts like a shock absorber for the bottom of the foot.  The plantar fascia may become irritated, possibly due to repetitive trauma, causing a condition called plantar fasciitis.  It is common in several sub-groups of people, including runners and other athletes, people who have jobs that require a fair amount of walking or standing (especially if it is done on a hard surface), and in some cases it is seen in people who have gained weight, including through pregnancy.  Once present, plantar fasciitis can take many months to resolve spontaneously with approximately 75% of individuals recovering after 6 months and up to 98% after 12 months.

Extracorporeal shock wave therapy (ESWT), also known as orthotripsy, uses sonic shock waves (high energy sound pulses) focused upon a target tissue associated with pain, discomfort, and functional orthopedic problems.  It is theorized that the shock waves disrupt the target tissue, break up scar tissue, reduce inflammation, and stimulate healing.

ESWT treatment involves a series of shock waves, up to several thousand, focused on a target area within the body.  When the shock waves are focused on the part of the body needing treatment, the waves impact on the target area with great power, similar to a strong hammer blow.  Local anesthesia is usually used to numb the area undergoing treatment.  The strength of the shock wave can be controlled to have maximum effect without disturbing surrounding normal tissues. 

Potential complications seen with ESWT have been temporary post-operative pain, nerve irritation and numbness.  ESWT has been proposed for the treatment of several conditions, including plantar fasciitis, tennis elbow and tendinitis of the shoulders.  These conditions have been associated with significant pain and functional limitations.  In many cases, these conditions are resistant to conservative treatments such as rest, anti-inflammatory medications and steroid injections, and thus surgical intervention is indicated.  ESWT has been proposed as an alternative to surgical treatment for individuals who have failed prior attempts of conservative therapies.


Bicipital tenosynovitis: Bicipital tendinitis is inflammation, irritation, and swelling of the biceps tendon, which is the fibrous structure that joins the biceps muscle to bone.

Calcified tendinitis of shoulder: A condition where the tendons connecting the shoulder muscles to the skeleton become hardened with calcium deposits, making shoulder movement difficult and painful.

Chronic lateral epicondylitis (tennis elbow): A form of elbow tendinitis where the tendon on the outside part of the elbow becomes inflamed and painful.

Elbow tendinitis: A condition that causes a tendon in the elbow to become inflamed and painful.

Non-union fracture: A condition where a bone fails to heal naturally, leaving a gap.

Orthopedic prosthesis: A device, such as a hip or knee replacement prosthesis, that has been surgically implanted in place of a deteriorating body part.

Plantar fasciitis: Inflammation of thick tissue on the bottom of the foot caused by chronic irritation resulting in pain while standing, walking, and running.


The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

20999 Unlisted procedure, musculoskeletal system, general [when specified as extracorporeal shock wave of musculoskeletal system any area, low energy]
28890 Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy
0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle
ICD-10 Procedure  
6A930ZZ Shock wave therapy, musculoskeletal, single
6A931ZZ Shock wave therapy, musculoskeletal, multiple
ICD-10 Diagnosis  
  All diagnoses

Peer Reviewed Publications:

  1. Alvarez R. Preliminary results on the safety and efficacy of the OssatronÒ for treatment of plantar fasciitis.  Foot Ankle Int. 2002; 23(3):197-203.
  2. Alvarez RG, Ogden JA, Jaakkola J, Cross GL. Symptom duration of plantar fasciitis and the effectiveness of Orthotripsy. Foot Ankle Int. 2003; 24(12):916-921.
  3. Aqil A, Siddiqui MR, Solan M et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013; 471(11):3645-3652.
  4. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005; 39(7):411-422.
  5. Buchbinder R, Green SE, Youd JM, et al. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheumatol. 2006; 33(7):1351-1363.
  6. Buchbinder R, Ptasznik R, Gordon J, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA. 2002; 288(11):1364-1372.
  7. Cacchio A, Giordano L, Colafarina O, et al. Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Joint Surg Am. 2009; 91(11):2589-2597.
  8. Cosentino R, Falsetti P, Manca S, et al. Efficacy of extracorporeal shock wave treatment in calcaneal enthesophytosis. Ann Rheum Dis. 2001; 60(11):1064-1067.
  9. Crowther MA, Bannister GC, Huma H, Rooker GD. A prospective, randomized study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow. J Bone Joint Surg Br. 2002; 84(5):678-679.
  10. Dizon JN, Gonzalez-Suarez C, Zamora MT et al. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil. 2013; 92(7):606-620.
  11. Engebretsen K, Grotle M, Bautz-Holter E, et al. Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study. BMJ. 2009; 339:b3360.
  12. Engebretsen K, Grotle M, Bautz-Holter E, et al. Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-year results of a single-blind randomized controlled trial. Phys Ther. 2011; 91(1):37-47.
  13. Furia JP. High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy. Am J Sports Med. 2008; 36(3):502-508.
  14. Gerdesmeyer L, Frey C, Vester J, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008; 36(11):2100-2109.
  15. Gerdesmeyer L, Wagenpfeil S, Haake M, et al.  Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003; 290(19):2573-2580.
  16. Gollwitzer H, Diehl P, von Korff A, et al. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007; 46(5):348-357.
  17. Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015; 97(9):701-708.
  18. Haake M, Boddeker IR, Decker T, et al.  Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow. Arch Orthop Trauma Surg. 2002; 122(4):222-228.
  19. Haake M, Buch M, Schoellner C, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003; 327(7406):75.
  20. Ho C. Extracorporeal shock wave treatment for chronic plantar fasciitis (heel pain). Issues Emerg Health Technol. 2007; 96(part 1):1-4.
  21. Ho C. Extracorporeal shock wave treatment for chronic lateral epicondylitis (tennis elbow). Issues Emerg Health Technol. 2007; 96(part 2):1-4.
  22. Ioppolo F, Tattoli M, Di Sante L et al. Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013; 94(9):1699-1706.
  23. Kim YS, Lee HJ, Kim YV, Kong CG. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg. 2014; 23(11):1640-1646.
  24. Kolk A, Yang KG, Tamminga R, van der Hoeven H. Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: a prospective randomised double-blind placebo-controlled multicentre trial. Bone Joint J. 2013; 95-B(11):1521-1526.
  25. Kudo P, Dainty K, Clarfield M, et al. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. J Orthop Res. 2006; 24(2):115-123.
  26. Lee GP, Ogden JA, Cross GL. Effect of extracorporeal shock waves on calcaneal bone spurs. Foot Ankle Int. 2003; 24(12):927-930.
  27. Li TY, Chang CY, Chou YC, et al. Effect of radial shock wave therapy on spasticity of the upper limb in patients with chronic stroke: a prospective, randomized, single blind, controlled trial. Medicine (Baltimore). 2016; 95(18):e3544.
  28. Liu S, Zhai L, Shi Z, et al. Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis a prospective randomized controlled study. Ultrasound Med Biol. 2012; 38(5):727-735.
  29. Malay DS, Pressman MM, Assili A, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006; 45(4):196-210.
  30. Ogden JA, Alvarez R, Levtii R, et al. Shockwave therapy for chronic proximal plantar fasciitis. Clin Orthoped. 2001; 387:47-59.
  31. Pan PJ, Chou CL, Chiou HJ, et al. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Arch Phys Med Rehabil. 2003; 84(7):988-993.
  32. Pettrone FA, McCall BR.  Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005; 87(6):1297-1304.
  33. Porter MD, Shadbolt B. Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med. 2005; 15(3):119-124.
  34. Radwan YA, El Sobhi G, Badawy WS, et al. Resistant tennis elbow: shock-wave therapy versus percutaneous tenotomy. Int Orthop. 2008; 32(5):671-677.
  35. Radwan YA, Mansour AM, Badawy WS. Resistant plantar fasciopathy: shock wave versus endoscopic plantar fascial release. 2012; 36(10):2147-2156.
  36. Rompe JD, Cacchio A, Weil L Jr, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010; 92(15):2514-2522.
  37. Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. 2003; 31(2):268-275.
  38. Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004; 32(3):734-743.
  39. Saxena A, Ramdath S Jr, O'Halloran P, et al. Extra-corporeal pulsed-activated therapy ("EPAT" sound wave) for achilles tendinopathy: a prospective study. J Foot Ankle Surg. 2011; 50(3):315-319.
  40. Schmitt J, Haake M, Tosch A, et al. Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus. A prospective randomized study. J Bone Joint Surg Br. 2001; 83(6):873-876.
  41. Seil R, Wilmes P, Nuhrenborger C. Extracorporeal shock wave therapy for tendinopathies. Expert Rev Med Devices. 2006; 3(4):463-470.
  42. Seok H, Kim SH. The effectiveness of extracorporeal shock wave therapy vs. local steroid injection for management of carpal tunnel syndrome: a randomized controlled trial. Am J Phys Med Rehabil. 2013; 92(4):327-334.
  43. Speed CA, Nichols D, Wies J, et al. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003; 21(5):937-940.
  44. Staples MP, Forbes A, Ptasznik R, et al. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol. 2008; 35(10):2038-2046.
  45. Stasinopoulos D, Johnson MI. Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med. 2005; 39(3):132-136.
  46. Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2005; 6(1):19.
  47. Verstraelen FU, In den Kleef NJ, Jansen L, Morrenhof JW. High-energy versus low-energy extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: which is superior? A meta-analysis. Clin Orthop Relat Res. 2014; 472(9):2816-2825.
  48. Wang CJ, Chen HS. Shock wave therapy for patients with lateral epicondylitis of the elbow: a one- to two-year follow-up study. Am J Sports Med. 2002; 30(3):422-425.
  49. Wang C, Chen H, Huang T. Shockwave therapy for patients with plantar fasciitis: a one-year follow-up study. Foot Ankle Int. 2002; 23(3):204-207.
  50. Wang CJ, Wang FS, Yang K, et al. Long-term results of extracorporeal shockwave treatment for plantar fasciitis. Am J Sports Med. 2006; 34(4):592-596.
  51. Yin MC, Ye J, Yao M, et al. Is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. Arch Phys Med Rehabil. 2014; 95(8):1585-1593.
  52. Zhao Z1, Jing R, Shi Z, et al. Efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a randomized controlled trial. J Surg Res. 2013; 185(2):661-666.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Buchbinder R, Green SE, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005;(4):CD003524.
  2. Blue Cross and Blue Shield Assoc. Technology Evaluation Center (TEC) assessments. Extracorporeal shock wave treatment for musculoskeletal conditions. Vol 16, No. 20. August 2002.
  3. Blue Cross and Blue Shield Assoc. Technology Evaluation Center (TEC) assessments. Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis. Vol 19, No. 19. March 2006.
  4. Blue Cross and Blue Shield Assoc. Technology Evaluation Center (TEC) assessments. Extracorporeal Shock Wave Treatment for chronic Tendinitis of the Elbow. Vol 19, No. 16. February 2006.
Websites for Additional Information
  1. American Academy of Orthopedic Surgeons. Tennis Elbow. Available at: Accessed on February 22, 2017.
  2. American Academy of Orthopedic Surgeons. Plantar Fasciitis and Bone Spurs. Available at: Accessed on February 22, 2017.
  3. National Library of Medicine. Medline Plus: Foot Injuries and Disorders. Available at: Accessed on February 22, 2017.

D-Actor® 200
Dornier Epos Ultra® Device
Duolith SD1®
Extracorporeal Acoustic Wave Therapy
Extracorporeal Pulse Activation Therapy (EPAT)
Extracorporeal Shock Wave Treatment
Ossatron® Orthotripsy Device
Plantar Fasciitis
Siemens Sonocur® Basic
Tennis Elbow

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. 

Document History
Status Date Action
Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale and References sections.
  01/01/2017 Updated Coding section with 01/01/2017 CPT changes; removed code 0019T deleted 12/31/2016.
Reviewed 05/05/2016 MPTAC review. Updated Rationale and Reference sections. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated Rationale and Reference sections.
Reviewed 05/15/2014 MPTAC review. Updated Rationale and Reference sections.
Reviewed 05/09/2013 MPTAC review. Updated Reference and Index sections.
  01/01/2013 Updated Coding section with 01/01/2013 CPT descriptor change.
Reviewed 05/10/2012 MPTAC review. Updated Reference and Index sections.
Revised 05/19/2011 MPTAC review. Added Extracorporeal Pulse Activation Therapy (EPAT® ) to the investigational and not medically necessary statement. Updated Rationale, Reference, and Index sections.
Reviewed 05/13/2010 MPTAC review. Updated Rationale and Reference sections.
Reviewed 05/21/2009 MPTAC review. Updated Rationale and Reference sections.
Reviewed 05/15/2008 MPTAC review. Updated Rationale and Reference sections.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 05/17/2007 MPTAC review. Updated Rationale and Reference sections. Coding updated; removed CPT 0020T and HCPCS G0279, G0280 deleted 12/31/2005.
Reviewed 06/08/2006 MPTAC review. Updated Rationale and Reference sections.
  01/01/2006 Updated Coding section with 01/01/2006 CPT/HCPCS changes
Revised 07/14/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organization Last Review Date Document Number Title
Anthem, Inc. 06/12/2001 SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
WellPoint Health Networks, Inc 12/02/2004 10.07.01 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions