EPAT, also called Shockwave Therapy, was developed in Europe by the company CuraMedix, but is now being used by doctors world wide. EPAT is an FDA approved emerging technology that delivers non-invasive low frequency (8-11 Hz) acoustic sound waves into a localized area. The sound waves act as pressure, and penetrate deep through your soft tissue. The energy emitted causes the cells in your soft tissue to release certain biochemicals that intensify the body’s natural healing process. These biochemicals allow for the building of an array of new microscopic blood vessels in your soft tissue. Overall, EPAT increases the nutrient flow to the chronically injured tissue, stimulating your cell metabolic rate, and giving hope for those who are considering surgery as their only option.

EPAT studies promise that, with EPAT treatments, you will have your cake and eat it too: first off, you can continue the activities that you love through treatment. Secondly you will not need surgery. Finally, you will still reap positive results – many times, more positive results than any other available treatment. In fact, the results of other treatments such cortisteroidal injections, orthoses, e-stim, and even surgery, seem to be significantly less effective in research studies than EPAT.  Moreover, more than 80% of patients who have failed to respond to anything other treatment are relieved of their pain after being treated with EPAT. Furthermore, While studies on ultrasound methods have been conflicting (Alexander, L.D. et al 2009), EPAT therapy studies, even when conducted by skeptics of EPAT, have seen resounding success in EPAT effectiveness to cure soft tissue maladies (Saxena 2011; Gerdesmeyer, L. 2008; Ibrahim, I. M. in press; Rompe, J.D. 2009; Rompe, J. D. 2008; Rompe, J. D. 2007; Rompe, J. D. 2009; Rompe, J. D.  2009; Furia, J. P. 2009).   These studies, with high standards of wellness and success rates, show between 75% – 95% success with EPAT.

After trying other types of treatment (cortisone injections, stretching, anti-inflammatories, night splints, physical therapy, and orthotic devices), you might be disheartened to start considering surgery for your injury. However, consult Dr. Murray and Dr. Chang about EPAT, since it might be a viable option instead of invasive surgery. EPAT is a small machine with a trigger end that looks like an ultrasound. It is administered once a week for a series of three weeks (up to five weeks), each taking approximately fifteen minutes (depending on the area of injury). Dr. Murray and Dr. Chang will apply coupling gel and use the EPAT on the area, in essence, breaking the soft tissue down and providing an opportunity for your cell responses to quickly get rid of dead cells and regenerate new ones. In essence, this is the most rapid stimulation of cell generation, known to have the most rapid healing rate of any technology out there.

EPAT can be used for acute and chronic musculo-skeletal pain – even knots, dysfunction, plantar fasciitis, Achilles Tendonitis and tendonosis, chronic heel pain, tendonal insertional pain, acute and chronic muscle pain, myofascial trigger points, and the list goes on. There have been very few side effects reported – in few cases, skin bruising may occur, and patients may feel sore afterward, as though they have worked out. Patients who choose EPAT treatment should not take NSAIDs (including ibuprofen, Motrin, Advil, Naproxen, Aleve, and Aspirin) for two weeks prior to and one month after the administration of EPAT, as they interfere with the hormones that regenerate your cells.

EPAT is available for a wide range of patients. Research suggests to postpone EPAT treatment for pregnant women, for deep venous thrombosis or malignancy cases, or if you are taking blood thinners. These studies suggest that women should wait until four months after pregnancy to receive EPAT treatment, waiting for regular swelling in the feet to go down, and for the hormones that act as muscle relaxants during pregnancy to level out.

While the initial fees for EPAT are expensive, you can rest assured that they are cost-effective in the long run. EPAT is not covered by insurance. You can expect to pay $500 for a series of three treatments, not including the fee of a co-pay for your initial office visit and evaluation charge, (after which there will be no co-pay). Inquire with your qualified health savings account or your employer’s flexible payment medical savings account, as these can usually be used to pay for the treatment. If a 4^th and 5^th treatment is necessary, you can expect to pay $150 per treatment. Despite these initial costs, remember that surgery is much pricier, and that EPAT is proven to be much more effective than other treatments. Additionally, patients treated with EPAT are immediately fully weight bearing, have no incision, no risk of infection or scar tissue, experience very few (if any) side effects, and do not need to be put under anesthesia. Overall, EPAT is sure to save money and time, and to accelerate your road back to having healthy feet!

So inquire with Dr. Murray and Dr. Chang to see if EPAT is the right treatment for you. Blue Ridge Foot and Ankle is excited to bring such an effective and preeminent technology to the office, in order to serve you with top quality and cutting edge medical care!

Comment on this post to share your sesamoid injury story or contact Blue Ridge Foot and Ankle Clinic. We’d love to hear from you!

Blue Ridge Foot and Ankle Clinic

Charlottesville Podiatrist Location: 887 A Rio E Ct., Charlottesville VA, 22911 (434) 979-8116

Waynesboro Podiatrist Location: 417 S. Magnolia Waynesboro,VA 22980 540-949-5150

Blue Ridge Foot and Ankle Clinic has been a part of the Waynesboro and Charlottesville communities for over 20 years. Podiatrists Dr. Kevin Murray and Dr. Stewart Chang offer services in sports podiatry, foot and ankle problems and diabetic foot care. Our friendly, accommodating team of Certified Podiatric Medical Assistants look forward to welcoming you to our practice.

Mark is riding in the following races:
March 18
Ohill, Charlottesville

June 9
Massanutten Hoo-Ha

July 29
Chimney Chase at Walnut Creek Park

October 20
Paranormal in Earlysville

He is riding on a really “sweet” ride-  The Cannondale Flash Alloy 29′ER 1.  Check out more details on his bike HERE.

If distinguishing between all of these possible injuries to the heel isn’t perplexing enough, consider Baxter’s Nerve Entrapment. This tricky injury affects the outside part of the posterior tibial nerve as the nerve snakes around the bottom of the foot. When this nerve is compressed or pinched, the heel will be in pain and the bottom of the foot will be numb. Feet with Baxter’s Nerve Entrapment will become increasingly painful throughout the day, and can be aggravated by pronation.

Part of the reason why Baxter’s Nerve Entrapment is so difficult to diagnose is because of the complexity of the foot’s structure; Baxter’s Nerve Entrapment occurs in an intersection for multiple nerves, not to mention other surrounding tissues. It also occurs in a specific part of the posterior tibial nerve, after this nerve divides into two branches on the inside of the ankle. On top of that, this part of the foot is close to the bottom of the calcaneus where heel spurs may form, providing further opportunity to aggravate the nerve.

There are limited treatments for Baxter’s nerve entrapments. Over the counter or custom orthotics can be helpful in controlling pronation, flatfeet and other biomechanical issues. If surgery is a viable option, a procedure to surgically release the nerve, called external neurolysis, will often be conducted. Neurolysis identifies the physical irritation of the nerve, releases the strictures and allows the nerve to return to normal function. Dr. Murray and Dr. Chang have found success through conducting cryosurgical neurolysis, which is an out patient method using cold to ablate the Baxter’s nerve. Be sure to discuss the pros and cons of your this procedure with your podiatrist.

Haglund’s Deformity is a bony enlargement in the back of the heel. When this enlargement rubs against the Achilles tendon’s surrounding tissues, it can lead to painful bursitis. This is especially painful when wearing a shoe that is tight or rigid along the heel.

Heredity can cause Haglund’s Deformity in one or both feet. High-arched feet, a tight Achilles tendon and supination (the outward rotation of the foot and ankle while walking) can all aggravate the swollen bursae. Your podiatrist will be able to detect this because your heel will have a noticeable bump, and will be swollen and red near the inflamed tissue. Your podiatrist may also take an X-ray while conducting a diagnosis to understand the structure of the heel bone, and thereby find the best treatment options for you.

The first step to treating Haglund’s Deformity should be diagnosing the root cause behind its development. Until you identify the root cause it will be difficult to prevent the pain from Haglund’s Deformity in the long term.

The immediate treatment for Haglund’s deformity include the good-old home remedies of rest (but not completely, just enough to take the stress off of the affected area), ice two times per day for twenty minutes at a time, and ask your podiatrist about methods for compression to reduce the swelling. Your podiatrist will recommend that you take non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the swelling and to relieve pain. In extreme cases, cortisone injections may help relieve pain. However, be wary of using these injections long-term, as they are not curative, the only relieve pain and inflammation.

Additionally, your doctor will recommend appropriate footwear and inserts for your shoes: these include heel grip pads, heel lifts and heel pads. Backless or soft backed shoes can help minimize the irritation, and over the counter and custom orthotics can help support the arches of the foot to control the foot’s motion.

Finally, consult your podiatrist for exercises and stretches that will increase muscle strength and relieve tension from the Achilles tendon. Physical therapy can be a productive option, in which exercises can help prevent the pain long-term and ultrasound methods can reduce immediate inflammation.

In extreme cases, complete immobilization or surgery may be necessary. Surgery for Haglund’s deformity reduces the prominence on the back of the heel so that the pressure from the shoe does not occur. In this procedure, Achilles is retracted to reveal the calcaneus, and then some bone is removed, the calcaneus is shaped and rounded so that pressure does not occur. Another method is to take out a wedge of bone from the calcaneus, shortening it, a method called “wedge osteotomy”.

In order to prevent Haglund’s deformity, avoid wearing shoes with rigid heel backs. Use arch supports or orthotics to control the motion of your foot, avoid running excessively on hard surfaces or excessively uphill with pounding strides, and engage in strengthening and stretching exercises for the Achilles tendon and surrounding muscles in order to prevent the Achilles from tightening up and aggravating Haglund’s deformity symptoms.

The foot only contains one naturally occurring bursal sac between the Achilles tendon and the heel bone, which protects the Achilles from the pressure against the heel bone during ambulation. However, shoes may put pressure on this bursa. The bursa might also incur trauma from walking on hard ground. And, though they are not naturally occurring, bursa sacs can also form, and become inflamed, in other parts of the foot, including the bottom of the heel, and the metatarsal plate, the outside of the foot below the fifth toe, and so on.

There are a variety of treatments for bursitis of the heel. Bursitis on the bottom of your heel (which is called infracalcaneal bursitis) is common in heels with thinning fat pads. Gel heel cushions or custom made orthotics (that have a horse-shoe cut and extra foam in the heel) can be lifesavers in reducing the pain. For bursitis of the posterior heel (retrocalcaneal bursitis), try to avoid going barefoot and to reduce the stress on the Achilles tendon by not over flexing your heel – the tighter your Achilles becomes, the more you compress the bursa sacs of the posterior heel. Heel lifts can help this, or wearing shoes with elevated heels (note that this method is not sanctioning high heels, as high heels can provide little comfort or support and usually are tight in the areas where your bursitis is most inflamed). Products such as AirHeel made by Aircast can help massage the bottom and back of the heel, helping to decrease pain.

In addition to being aware of foot-wear and inserts, be sure to modify your activity level to reduce the pain initially. Taking non-steroidal anti-inflammatory drugs (NSAIDs) and icing twice a day for 20 minute periods can help reduce the swell that leads to heel pain. Cortisone injections (more powerful anti-inflammatory medications) can be considered if your symptoms are persistent. After the swelling and pain has receded, ask your podiatrist about working with a physical therapist to strengthen the affected area in order to avoid bursitis by using your muscles in a more safe and efficient manner.

If all these treatment methods fail, surgery may be the best option to excise a painful bursa (note that this is in rare cases). Consult Dr. Murray and Dr. Chang for the best treatment method for your individual needs.

Injuries to the Achilles tendon, the tissue that connects the calf muscle to the heel bone, can cause considerable heel pain. The most common Achilles injuries are Achilles tendonitis and tendonosis, the former being inflammation of the Achilles tendon and the latter being degeneration of Achilles tendonitis. The inflammation from Achilles Tendonitis is usually short-lived. Over time, if tendonitis is not treated, it can degenerate into a worse condition called tendonosis, marked by tears in the tendon. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.

The most common risks to the Achilles, similar to the prognosis for stress fractures, are sudden increases of repetitive activity without giving the Achilles tendon the proper time to repair itself from the micro-injuries to the tendon fibers caused by intense activity. Additionally, Achilles injuries may be due to physiological reasons such as flat feet, which put extra pressure on the tendon while walking or running.

Achilles tendonitis and tendonosis will result in pain, aching and tenderness along the tendon’s path, increasing when the sides of the tendon are squeezed but with less pain in the back of the tendon. To diagnose Achilles injuries, your podiatrist will examine the foot, its range of motion, and may conduct further assessment with imagining techniques such as X-rays.

Fractures can be another cause of heel pain. Your heel bone, called the calcaneus, can incur fractures like any other bone. Calcaneal fractures, however, are dangerous because of the physiology of the calcaneus and the bones with which it forms a joint. The breaking of the calcaneus’s thin, yet hard outer shell reveals a softer bone inside that shell. Once the outer shell is broken, the entire bone is prone to collapse and fragmentation. Breaking the calcaneus can have negative effects on the joint it creates with the talus and cuboid bones, bones further of the foot. A fracture that disturbs the joint (inter-articular fractures) can cause damage to multiple bones and the cartilage between, and could have long-term effects including arthritis and chronic pain.

Calcaneal fractures are usually caused by traumatic events: big falls, car accidents and the like. Like other stress fractures, calcaneal fractures can also be caused by overuse or repetitive stress on the heel. Pain can vary, depending on whether the fracture is traumatic or not. Some patients with calcaneal fractures report not being able to put any weight on their foot, and others report pain and symptoms similar to that of plantar fasciitis (general pain growing progressively worse over a number of days or weeks). Calcaneal fractures, however, will produce pinpoint pain after pressing down on the middle or sides of the heel bone, which does not usually occur with plantar fasciitis. Additionally, in your primary assessment and to reach a correct diagnosis, your podiatrist will inquire into your recent activities (since, often, abrupt increases in exercise or sudden weight gain can cause calcaneal stress fractures), and may take an X-ray to examine the bone.

The most important thing to consider when treating calcaneal stress fracturesis the time they take to heal. Do not wait to treat stress fractures, or to visit your podiatrist for a diagnosis. If treated improperly or ignored, stress fractures will only worsen with time or reoccur, even leading to deformities that restrict motion and activity, cause arthritis and make shoes incredibly uncomfortable.

Your podiatrist and you can work together to find the proper treatment plan for your injury, which will likely include a combination of rest, immobilization with a caste or rigid shoe, avoiding the aggravating activity, ice, NSAIDs, physical therapy for rehabilitation, and surgery in extreme cases. Non-operative treatment of calcaneus fractures will range from limiting weight bearing activities and the use of crutches, limiting motion through casting, splinting or bracing for a short period of time, and range-of-motion exercises so that your muscles don’t atrophy and the blood keeps circulating to the healing area that needs it most. Be patient with your injury, as it takes time, usually around three months, to heal stress fractures. In extreme cases, or in the case that you have poor circulation or diabetes, surgical approaches for calcaneus fractures may be a good option for your injury. Be sure to discuss the benefits of surgical treatment with your podiatrist.