Effect of Acetic Acid Shockwave Phonophoresis on Calcaneal Spur Patients: A Randomized Controlled Trial
Phase: NA
Conditions: Calcaneal Spur
Sponsor: Beni-Suef University

Effect of Acetic Acid Shockwave 
Phonophoresis on Calcaneal spur patients: A 
Randomized Controlled Trial 
 
 
 
 
 
 
By 
Mostafa Ali Abdellah Elwan 
 
 
 
 
 
Submitted for Partial Fulfillment for Requirements of Doctoral Degree in Physical 
Therapy department for Basic science department 
Faculty of Physical Therapy 
Cairo University 
9/5/2022 

1 
 
CHAPTER I 
INTRODUCTION 
 
Epidemiological data shows that 46 % of adults suffer from various 
foot conditions that result in abnormal mechanics of standing and walking. 
Chronic heal pain might impair walking and cause spinal pain. Plantar heel 
pain is one of the most common musculoskeletal disorders of the lower 
extremity that affects about 10% of the general population, associated with 
limitation on activity, depression, and reduced health related quality of life 
(Krukowska et al., 2016)(Cotchett et al., 2016). 
A calcaneal spur is an abnormal undesired calcium deposits on the 
heel bone, this process usually chronic process that continues for many 
months. The treatment of calcaneal spur is primarily conservative. However, 
Surgery and corticosteroid therapy is a line of treatment in severe 
cases. (Lizis et al., 2017). 
Conservative treatment includes non-steroidal anti-inflammatory 
drugs (NSAIDs), physiotherapy modalities such as electrotherapy 
(microwaves, 
extracorporeal 
Shockwave 
(ESWT), 
Ultrasounds, 
Transcutaneous electrical nerve stimulation (TENS), short waves, 
Iontophoresis, phonophoresis, interferential and pulsed electromagnetic 
therapy) (Cuadros, 2016). 
Extracorporeal shockwave therapy (ESWT) is  now extensively used 
in the treatment of musculoskeletal disrobes, For example, chronic 
diabetic and non-diabetic ulcers ,calcifying tendinitis of shoulder, planter 
fasciitis and lateral epicondylitis, from approximately 20 years with 

2 
 
successful rate ranged from 65% to 91% (Frairia & Berta, 2011) (Wang, 
2012). 
Many researchers investigated the effect of shockwave therapy in the 
management of proximal plantar fasciitis and conveyed a success rate 
ranging from 34% to 88%. (Wang, 2012). 
The interaction of shockwave with biological cells is a new area of 
research. For example, water purification, desalination, and bacterial 
decontamination. Shockwave also have great potential for biomedical use, 
since they can also permeabilize cell membranes thereby allowing for the 
transport of various macromolecules, drugs and genetic material into cells. 
in addition to that extracorporeal Shockwave lithotripsy (ESWL) used to 
treat kidney stones below 20 mm in size, or destruction of cancer cells (Hu 
et 
al., 
2019). 
 
Marcos et al., conducted a research about the effect of 5% Acetic Acid 
Iontophoresis and Ultrasound over calcified Achilles Tendon. The result 
showed that Iontophoresis with 5% Acetic Acid and Ultrasound is a safe, 
simple and inexpensive modality able to reduce significantly pain and size of 
calcification on the ankle (Marcos et al., 2019). 
 
Acetic acid is one of the most important substance used in physical 
therapy to treat abnormal calcification via introducing it by phonophoresis or 
iontophoresis because it promotes a chemical reaction capable of forming a 
compound more soluble, which facilitates the calcium absorption. Pamplona 
E et al., report a case study in which he apply (5% acetic acid) 
phonophoresis for calcified shoulder joint was effective in the treatment of 

3 
 
calcific tendinitis of supraspinatus muscles , improving the ROM, muscle 
strength and functional capacity, in addition to eliminating the pain of the 
affected shoulder (Pamplona et al., 2017). 
 
➢ Statement of the Problems:   
There is a gap in literature on the effect of Shockwave in combination with 
substance like acetic acid gel on treatment of calcaneal spur patients. So, this 
study conducted to answer the following question: 
- Dose the extracorporeal acetic acid shockwave phonophoresis has any 
effect on length of calcaneal spur, pain pressure threshold, pain level 
and physical function in patients with calcaneal spur?      
- Dose the extracorporeal shockwave has any effect on length of 
calcaneal spur, pain pressure threshold, pain level and physical 
function in patients with calcaneal spur?      
- Is there a statically significant difference between extracorporeal 
shockwave and extracorporeal acetic acid shockwave phonophoresis 
on length of calcaneal spur, pain pressure threshold, pain level and 
physical function in patients with calcaneal spur?   
➢ Purposes of study: 
The aims of this study is: 
- To investigate the effect of extracorporeal acetic acid shockwave 
phonophoresis on length of calcaneal spur, pain pressure threshold, 
pain level and physical function in patients with calcaneal spur. 

4 
 
- To investigate the effect of extracorporeal shockwave on length of 
calcaneal spur, pain pressure threshold, pain level and physical 
function in patients with calcaneal spur.  
- To investigate and compare the efficacy of extracorporeal shockwave 
versus extracorporeal shockwave acetic acid phonophoresis in patients 
with calcaneal spur. 
➢ Significance of the study: 
The painful heel is a common musculoskeletal problem that affects 
the general population in their lifetime especially runners (Perez et al., 
2003). Local application of the drug is faster, increased comfort of the 
patient, improve the effectiveness of the treatment, and decreases the 
hazards of systematic side effect of the Like gastrointestinal tract problems 
and decrease the efficacy of the treatment.  
Iontophoresis with 5%Acetic Acid and Ultrasound is a safe, simple 
and inexpensive technique and effective treatment capable to reduce pain 
and calcification on the shoulder, elbow, wrist, hip, knee and ankle 
(Cuadros, 2016). 
The biochemical theory of the process has been described in detail where 
the use of acetic acid iontophoresis converts insoluble calcium carbonate in 
chronically inflamed tissue to calcium acetate, which is soluble in blood. 
Pulsed ultrasound was used to reduce inflammation, improve local blood 
flow that facilitate the removal of the newly formed calcium acetate into the 
blood, and thereby remove it from the localized area of heel pain (Costa & 
Dyson, 2007). 

5 
 
The effect of shockwave and the ultrasound has been compared on feet 
pain and quality of life in the patients with calcaneal spur. There was a 
significant improvement in the feet pain and quality of life. However, the 
patients treated with shockwave had significantly greater pain decrease and 
life quality improvement, and those benefits were still present three months 
after the treatment (Lizis & Hudáková, 2016). 
Shockwave could be used as a pretreatment of cell membranes for 
electroporation. The Shockwave possible role of multiple Nano bubbles was 
examined. It has also been shown that not only would the multiple Nano 
bubbles make it possible to create larger pores, but also increase the pore 
density on the surface. The multi-pore scenario would be useful practically 
in enhancing material throughout into cells. (Hu et al., 2019). 
Direct and indirect Shockwave effects described concerning stone 
disintegration could also contribute to transient increase membrane 
permeability on application of low energy shockwave to eukaryotic cell 
membranes. Low energy shockwave can deliver macromolecules of up to 
2,000,000 molecular weight into the cytoplasm of cells. (Tyagi & Chuang, 
2018). 
Low energy shockwave has a significant effect on the permeability of 
tissue. Consequently, it might be used to deliver substance such as Acetic 
acid. Accordingly, Shockwave might help to improve the outcomes with 
calcaneal spur patients. Therefore, the present study might help in treatment 
of calcaneal spur patient and might improve the quality of life in fast and 
efficient way.  

6 
 
➢ Delimitations:  
This study will be delimited to calcaneal spur patients, selected from 
outpatient clinics at faculty of physical therapy on Beni-Suef University on 
the following criteria:   
1. The patient's age ranged from 30 to 65 years  
2. Patients with calcaneal spur. 
3. Patients with intact sensory perception.  
4. At least 6 weeks from last corticosteroid injection; 4 weeks from the 
last local anesthetic injection, iontophoresis, ultrasound, and 
electrotherapy (Gerdesmeyer et al., 2008) 
5. X-Ray will be used to measure the length of calcaneal spur. 
6. Algometry will be used to measure Pain pressure threshold. 
7. Visual Analogue scale will be used to measure Pain intensity level. 
8. Foot and Ankle Ability Measure (FAAM) questionnaire will be used to 
measure physical function.  
➢ Basic Assumptions: 
The following assumptions are necessarily for the development of the 
study: 
• The instructions that will give to all patients for assessment should be 
accurately, clearly, and faithfully followed. 
• All patients will be cooperative during the assessment and treatment 
procedures. 

7 
 
➢ Hypothesis: 
The null hypotheses of this study stated as the following: 
- H0 : there is no statistical significant effect of the use of extracorporeal 
acetic acid shockwave phonophoresis on length of calcaneal spur, pain 
pressure threshold, pain intensity level and physical function in 
patients with calcaneal spur. 
- H0: there is no statistically significant effect of the use of 
extracorporeal Shockwave on length of calcaneal spur, pain pressure 
threshold, pain intensity level and physical function in patients with 
calcaneal spur. 
- H0: there is no statistically significant difference between 
extracorporeal 
shockwave 
versus 
acetic 
acid 
shockwave 
phonophoresis on length of calcaneal spur, pain pressure threshold, 
pain intensity level and physical function in patients with calcaneal 
spur. 
 
 
 
 
 
 
 
 
 
 
 
 

8 
 
➢ Definition of terms: 
The following terms defined for clear understanding of the 
terminology used in the presented study: 
Calcaneal spur: is an osteophyte outgrowth just medial process of calcaneal 
tuberosity. 
 
Shockwave: is an acoustic wave characterized by high positive pressures of 
more than 1000 bar (100 MPa), which can be developed within an extremely 
short rise time (10-9 seconds) and followed by a low-pressure phase of 
tensile stress equivalent to 100 bar (10 MPa). 
 
Energy flux density: is a term used to reflect the amount of energy 
delivered to a specific area of tissue. measured in (Mj/mm2) (Speed C , 
2014) 
 
Enthesis is the site of attachment of tendon, ligament, fascia, or capsule to 
bone. 
 
 
 
 
 
 
 
 
 
 

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CHAPTER II 
REVIEW OF LITERATURE 
 
This study conducted to investigate the efficacy of Shockwave 
phonophoresis on calcaneal spur patients. 
In this part of the current study, the review of the related researches and 
studies of the main concepts presented under the following headings: 
• Foot anatomy and calcaneal spur. 
• Shockwave. 
• Acetic acid and abnormal calcifications.   
1. Foot anatomy and calcaneal spur: 
a. Foot anatomy: 
The foot consists of 26 bones, more than 30 articulations, more than 100 
ligaments and 30 muscles act in foot segment. All of these joints must 
interact harmoniously and in combination to achieve a smooth motion. The 
foot moves in three planes, with most of the motion occurring in the rear 
foot; this will enabling three fundamental functions: supporting, shock 
absorbing, and weight bearing (Woźniacka et al., 2013) 
The foot divided into three regions:  
➢ The rear foot: consisting of the talus and the calcaneus.  
➢ The mid foot: including the navicular, cuneiforms, and the cuboid.  
➢ The forefoot : containing the metatarsals and the phalanges (Standring, 
2016) 

10 
 
The tarsal bones arranged in a proximal and distal row, similar to the 
carpal bones in the wrist. The talus and calcaneus make up the proximal row 
in the foot, while the medial, intermediate, and lateral cuneiforms and the 
cuboid comprise the distal row. The navicular bone is interspersed between 
the talus and the cuneiform. The bones of the toes are very similar to the 
hand with the second through fifth toes consisting of metatarsal, proximal, 
middle, and distal phalanges. The first toe – similar to the thumb – does not 
contain a middle phalanx.  
b. Foot musculature: 
The foot and ankle are worked by both extrinsic and intrinsic musculature. 
The extrinsic muscles all originate from proximal to the foot. The intrinsic 
muscles of the foot originate and insert within the foot and act primarily on 
the toes. Their secondary function is to maintain postural balance through 
stabilization of the osteocartilaginous architecture of the foot. 
The plantar muscles of the foot can be thought of as organized by layers 
from sole of the foot progressing deep to the bony structures .The first layer 
consists of muscles found just beneath the plantar aponeurosis – the flexor 
digitorum brevis, the abductor hallucis, and the abductor digiti minimi. 
These muscles extend from calcaneus to toes and create a functional group 
that assists in maintaining foot concavity. All three have been described as 
local pedicles muscle flaps, and all have type I vascular supply. The flexor 
digitorum brevis is supplied by branches of the posterior tibial artery via the 
medial and lateral plantar arteries on its proximal deep surface. The abductor 
hallucis is supplied by a dominant pedicle on its deep surface and by a 
branch of the medial plantar artery in the proximal foot. The abductor digiti 

11 
 
Figure 1: the first layer of foot muscles (the outer layer) adapted from(Paulsen, 
2019) 
minimi muscle receives its dominant pedicle from a lateral branch of the 
proximal lateral plantar artery. 
The first layer for the plantar foot is separated from the second layer by 
the tendons of the extrinsic muscles of the flexor digitorum longus and the 
flexor hallucis longus. Also, the medial and lateral plantar artery and nerve 
course in this intermediary plane (see Fig 1). (Paulsen, 2019) 
 
The second layer consists of the quadratus plantae muscle and the 
lumbricals muscles of the foot. The quadratus plantae is one of the few 

12 
 
Figure 2: the second layer of foot muscles (the middle layer) adapted 
from(Paulsen, 2019) 
muscles of the foot that does not have an similar structure in the hand. It has 
two heads extending from the medial and lateral border of the calcaneus, 
inserts into the tendon of the flexor digitorum longus, and aids in 
plantarflexion of the second to fifth toes. The lumbricals of the foot mirror 
those of the hand in their unique attribute of both originating and inserting 
on tendons. These four muscles arise from the medial side of the flexor 
digitorum longus and insert on the extensor system of the second through 
fifth phalanges .The foot lumbricals follow the same course as those of the 
hand and flex the metatarsophalangeal joints and extend the interphalangeal 
joints (see Fig 2). 
\ 
 
 
 
 
 
 
 
 
 

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Figure 3: the third layer of foot muscles adapted from(Paulsen, 2019) 
The third layer consists of the flexor hallucis brevis, the adductor hallucis, 
and flexor digiti minimi brevis. These form a small, deep intrinsic 
musculature that contributes in the maintenance of the longitudinal plantar 
arch and participates in the stabilization of intrinsic foot osteoligamentous 
intercalation and balance (see Fig 3). 
 
 
The fourth layer is the interosseous compartment that contains both the 
plantar and the dorsal interossei. The three plantar interosseous muscles 
adduct the toes. The four dorsal interosseous muscles abduct the toes. The 
adduction–abduction activity of the interossei is based through the axis of 
the second toe, making this toe the least mobile at the metatarsophalangeal 

14 
 
Figure 4: the fourth layer of foot muscles adapted from(Paulsen, 2019) 
joints. Tendons of the tibialis posterior and the peroneus longus are 
considered part of the fourth layer (see Fig 4). 
The dorsum of the foot contains two muscles – the extensor digitorum 
brevis and extensor hallucis brevis. These muscles perform accessory toe 
extension function to the extrinsic toe extensors. The loss of these muscles 
does not significantly affect toe extension or impede ambulation. The 
extensor digitorum brevis extends the second through fifth toes while the 
extensor hallucis brevis extends the great toe. The extensor digitorum brevis 
receives its blood supply from the lateral tarsal artery, a branch off the 
dorsalis pedis. The extensor digitorum brevis is a useful muscle flap for 
small skin defects of the proximal foot and ankle. It can also be used as joint 
interposition to prevent fusion in nearby tarsal joints (e.g., calcaneonavicular 
bar)(Kleiber, 2018) 
c. Planter fascia anatomy and histology: 
Planter fascia (plantar aponeurosis) is a strong connective tissue structure 
that helps maintain the longitudinal arch of the foot besides absorbing forces 

15 
 
placed on the foot across the mid-tarsal joints. Planter fascia consists of three 
bundles:  
1) Central bundles (CP): (thickest bundle) and it thickness more 
proximally than distally. It originate from the medial tubercle of the 
calcaneus and extends distally becoming wider and covering the 
plantar surface of the flexor digitorum brevis muscle. Distally, it 
divides 
into 
five 
digitations 
that 
insert 
into 
the 
five 
metatarsophalangeal joints 
2) Medial bundles (MP): (thinnest one). It arises from the middle of the 
central bundle and covering  the plantar surface of the abductor 
hallucis muscle and inserts into the capsule of the first metatarsal joint  
3) Lateral bundles (LP): also it thickness more proximally than distally. 
It originate from the lateral margin of the medial calcaneal tubercle and 
covering the plantar surface of the abductor digiti minimi muscle and 
inserts into the capsule of the fifth metatarsal joint (see Fig 5)(Stecco 
et al., 2013)(Draghi  et al., 2017)(Chen et al., 2014) 
 
 
 
  
 
 
 
 
 
 
 
Figure 5 : on left Axial view of the plantar aponeurosis. LP, lateral part; CP, 
central part; MP, medial part; L, length; W, width. On right five central part 
central bundle adapted from (Chen  et al., 2014) 

16 
 
 
 
 
Stecco et al., Claim very important facts about the histological and 
anatomical future about planter fascia. The planter fascia was: 
1. Planter fascia closely connected with paratenon of Achilles tendon than 
to the Achilles tendon; through the periosteum of the calcaneus confirm 
the idea that the calf muscle problems can participate in planter fascia 
pathology (See Fig 6). 
2. Planter fascia has important role the foot sense of proprioception and 
that because it is rich in nerve endings and Pacini and Ruffini corpuscles 
were present, particularly in the medial and lateral portions, and on the 
surface of the muscles.   
3. Planter fasciitis can be treated by injection of hyaluronic acid 
(hyaluronan) because the normal planter fascia rich in Hyaluronic acid, 
probably produced by fibroblastic-like cells described as ‘fasciacytes’. 
(Stecco et al., 2013). 
 
 
 
 
 
 
 
 
 
 
 

17 
 
Figure 6: continuity of Achilles tendon paratenon with planter fascia. 
Adapted from (Stecco et al., 2013). 
 
 
 
d. Calcaneal spur and planter fasciitis: 
A Calcaneal Spur is an osteophyte outgrowth just medial process of 
calcaneal tuberosity. Calcaneal Spur affects the resting & activity pain and 
ankle muscle strength of patients suffering from this condition 
(Büyükturan, 2017).Moreover, some authors define it as projections of 
more than 1 or 2 mm, while others use microscopy or subjective assessment 
(Kirkpatrick et al., 2017) 
The prevalence of calcaneal spur among difference ethnicities 
approximately the same; in the young to middle-aged population calcaneal 
Spur occurrence is 11–21%. However, this rate increases with age to 55% in 
those over 62, to 59–78% in those with current or previous heel pain, and up 
to 81% in those with osteoarthritis (Kirkpatrick et al., 2017) 
Calcaneal Spur developed on calcaneal tuberosity that located on the 
posterior plantar surface of the calcaneus. The majority of PCS arise from 
the medial process of the tuberosity, but they can also originate from the 
lateral processes and the sulcus (see Fig. 7)(Kirkpatrick et al., 2017) 
 
 
 
 

18 
 
Figure 7:calcaneal spur in real bone adapted from (Kirkpatrick et
al., 2017) 
 
 
 
Calcaneal spurs have been recorded in 45% to 85% of patients with 
plantar fasciitis but also in 10% to 63% of asymptomatic controls. Moroney 
et al., reported that plantar calcaneal spurs affects more women, higher BMI 
,abnormal foot biomechanics. and elderly. In addition to that, they 
susceptible four times higher than peers for diabetes mellitus and ten time 
higher for osteoarthritis (Moroney et al., 2014). 
However, Plantar fasciitis is an abnormal degenerative inflammatory 
condition in which  plantar fascia became shortening by changes in the 
collagen matrix of the plantar fascia, which progresses to accompanied 
by pain and functional changes of gait (D’Andréa et al., 2009) 
The cause of plantar fasciitis is multifactorial. Biomechanical risk factors 
include those causing repetitive stress on the planter fascia, such as foot 
abnormalities, inappropriate footwear, and obesity, activities that involve 
prolonged standing, walking or running (Draghi et al., 2017). 
Menz et al., investigate the correlation between calcaneal spur and fascial 
thickening and found that it is commonly to be coexisted in about (30%) of 
cases. while calcaneal spurs without fascial thickening were found only on 
(4%) cases. In fact, The histological studies suggest that fascial thickening 
may trigger the development of the spur, and that spur formation may be a 
protective mechanism to reinforce the enthesis against further damage from 
compressive loads (Menz et al., 2019). 

19 
 
However, some author contradict that and mention that the majority of 
calcaneal spurs founded deep to the planter fascia and  surrounded by 
fibrocartilage. They postulated to function as an adaptive response to 
redistribute the forces away from the calcaneal insertion site to the 
surrounding tissues via a reinforcement effect. The calcaneal spur trabecular 
pattern is consistent with a vertically oriented ground force vector and is in 
agreement with key associations listed above, i.e., obesity, age, and 
alterations in foot structure, all factors that control the heel pressure 
(Kirkpatrick et al., 2017) 
Moreover, Moroney et al., concluded that the calcaneal spur and planter 
facilities are separated phenomena and planter heal pain patient can be 
complain from spur, fasciitis or both. In addition, Li and Muehleman have 
documented that the trabeculae within these calcaneal spurs are not oriented 
in the direction of soft-tissue traction but rather in a vertical orientation 
(Moroney et al., 2014). 
Li & Muehleman et al., the calcaneal Spur may be closely associated 
with any intrinsic muscle on the first layer of the foot which consists of the 
abductor hallucis (AH), flexor digitorum brevis (FDB) and abductor digiti 
minimi (ADM); The second layer consists of quadratus plantae and it 
attaches deep to the calcaneal Spur. Tanz (1963) was one of the earliest 
authors to show that calcaneal Spur can arise from muscle rather than from 
the planter fascia itself. The FDB attaches to the medial process of the 
calcaneal tuberosity or the apex of the calcaneal Spur if present, anterior and 
superior to the attachment of the planter fascia (Forman & Green, 1990). 
The FDB inserts into the periosteum of the calcaneal Spur along with the 
planter fascia in (22%) of cases, most commonly at the spurs distal tip and 

20 
 
inferior aspects (14%), but also at the superior aspect 8% (Li & Muehleman 
., 2007) 
The calcaneal Spur is oriented along the axis of the planter fascia and 
FDB approximately half of the time Abreu et al., The ADM also attaches 
directly to the calcaneal Spur, although not as extensively as the FDB does; 
the calcaneal Spur is aligned with the ADM 20–50% of the time (Smith et al. 
2007). The AH arises just medial to the FDB origin and has been 
hypothesized to contribute to calcaneal Spur formation (Forman & Green, 
1990). calcaneal Spur have also been shown to arise from around the 
calcaneal insertion point of the long plantar ligament (Smith et al., 2007) 
(Abreu et al., 2003) (Kirkpatrick et al., 2017) 
Factors which may be important in determining whether a given 
calcaneal spur will cause an individual heel pain include the size of the spur, 
whether there is compression of the inferior calcaneal nerve, spur factures, 
concurrent inflammation, fat pad abnormalities or degeneration, and the 
individual’s occupational environment (Kirkpatrick et al., 2017). 
Irving, et al. researched the risk factors associated with chronic heel pain 
in a systematic review. They included 16 papers and found that the age and 
Body mass index (BMI) were correlated to the incidence of calcaneal Spur 
(Büyükturan, 2017). 
There is also evidence that certain individuals have a genetic 
predisposition to generate new bone and undergo osteogenesis at levels of 
mechanical stress, which are not sufficient to initiate bone growth in others. 
This more supported by association between increase incidences of 
osteoarthritis ten folds in calcaneal spur patients (Kirkpatrick et al., 2017). 

21 
 
2. Extracorporeal Shockwave therapy (ESWT): 
Valchanou and Michailov were the first to use the (ESWT) to treat 
musculoskeletal conditions in 1991. (ESWT) is an acoustic wave 
characterized by high positive pressures of more than 1000 bar (100 MPa), 
which can be developed within an extremely short rise time (10-9 seconds) 
and followed by a low-pressure phase of tensile stress equivalent to 100 bar 
(10 MPa). Because the pulse duration of the Shockwave is extremely short 
(3 to 5 µs) and is generated at low frequencies, it is minimally absorbed by 
the tissues and therefore no thermal effect is generated (Bonder et al., 
2003). 
Sound waves (or Pressure waves) are oscillating mechanical waves that 
can travel through gas, liquids and solids. A Shockwave is a non-linear 
special type of pressure wave, characterized by a short rise time. The total 
duration of a Shockwave is around 10 µs. Shockwave has positive and 
negative phase. During the positive phase ( pressure phase) , Shockwave 
with high pressure pass and gradually become absorbed. However, 
Shockwave may hit an interface & reflected. On other side, the negative 
phase (tensile phase) of the Shockwave causes cavitation at the tissue 
interfaces. During cavitation, air bubbles may be formed because of the 
negative pressure. These bubbles subsequently collapse with high speed, 
generating an additional wave of Shockwave or micro jets of fluid. (van der 
Worp et al., 2013) (Vulpiani et al., 2015)(Tyagi & Chuang., 
2018)(López-Marín et al., 2017) 
Many of the physical effects of Shockwave therapy considered dependent 
on the energy delivered to an area. The concentrated Shockwave energy per 
unit area, the energy flux density,(EFD), measured in (mJ/mm2), is a term 
used to reflect the flow of Shockwave energy in a perpendicular direction to 

22 
 
the direction of propagation and is taken as one of the most important 
parameters of Shockwave dosage. There remains no agreement as to the 
definition of ‘high and ‘low’ energy ESWT, but as a guideline, low- energy 
ESWT is EFD ≤ 0.12 Mj/mm2 (4 bar), and high energy is > 0.12 mJ/mm2 (4 
bar) (to convert between bar and Mj/mm2 see Tab 1) (Speed, 2014) 
However, Change K et al., claim that intensity of energy flux density 
divided into three category and recommend the highest intensity is more 
effective in pain relief:  
a. Low intensity(L-FSW) (energy flux density= < 0.08mJ/mm2) 
b.  Medium intensity(M-FSW) 
(energy flux density = 0.08 
- 
0.28mJ/mm2) 
c. High intensity (H-FSW) (energy flux density = ≥ 0.28mJ/mm2)(Chang 
et al., 2012) 
Moreover, another classification for energy density by wang et al.,: 
1. low- (energy flux density <0.1 mJ/mm2) 
2.  medium- (energy flux density: 0.1–0.2 mJ/mm2) 
3. high-energy (energy flux density ≥0.2 mJ/mm2)(Wang et al., 2019) 
 
Table 1: conversion from bar to Mj/mm 
Bars 
Mj 
Mj/mm2 
2 
90 
.09 
3 
120 
.12 
4 
150 
.18 
5 
180 
.38 
 

23 
 
The most important physical parameters of Shockwave therapy for the 
treatment of orthopedic disorders include the pressure distribution, 
energy flux density and the total acoustic energy (Wang, 2012). 
a. Shockwave versus ultrasound: 
Extracorporeal Shockwave and ultrasound waves are sound waves with 
different characteristics. Shockwave pattern is Uniphasic  and characterized 
by initial rise of a high peak pressure, up to 50 MPa (500 bar) within 10 
nanoseconds, followed by low tensile amplitude, up to 10 MPa with a broad 
frequency spectrum in the range of 16 to 20 MHz While ultrasound waves 
are typically biphasic and have a peak pressure of 0.5 bar.  However, the 
peak pressure of Shockwave is approximately 1000 times that of ultrasound 
wave. (Vulpiani et al., 2015)(Wang, 2012). 
Sound waves (or Pressure waves) are oscillating mechanical waves that 
can travel through gas, liquids and solids. While a Shockwave is a non-linear 
special type of pressure wave (see Fig. 8), characterized by a short rise time  
around 10 µs. Shockwave have positive and negative phase. During the 
positive phase (pressure phase), Shockwave with high-pressure pass and 
gradually become absorbed. On other side, the negative phase (tensile phase) 
of the Shockwave causes cavitation at the tissue interfaces. During 
cavitation, air bubbles may be formed because of the negative pressure. 
These bubbles subsequently collapse with high speed, generating an 
additional wave of Shockwave or micro-jets of fluid. (van der Worp et al., 
2013)(Tyagi & Chuang, 2018). 

24 
 
Figure 8 : form of shockwave adapted from (Schmitz et al., 2013) 
 
b. Types of Shockwave: 
1. Focused Shockwave therapy (FSWT): single acoustic pulses are 
generated with either a spark gap (electrohydraulic principle), a 
technology similar to a loud speaker (electromagnetic principle) or 
piezocrystals (piezoelectric principle).  
2. Radial Shockwave therapy (RSWT): represent an alternative to FSWT 
and produced ballistically by accelerating a bullet to hit an applicator, 
which transforms the kinetic energy into radially expanding acoustic 
impulses. In another word, a projectile is fired within a guiding tube that 
strikes a metal applicator placed on the skin. The projectile generates 
stress waves in the applicator that transmit pressure waves into tissue (see 
Fig 9) (Schmitz et al., 2015)(Contaldo et al., 2012) 
Moreover, if there are any disturbance at the pathway of FSWT it is 
will disturb the acoustic wave pathway and consequently, weakening the 
Shockwave energy (i.e. the energy flux density) at the target. The same 

25 
 
Figure 9 Types of Shockwave, gray dotes is an obstacle like calcification in muscles. Adapted from 
(Schmitz et al 2015) 
disturbances would not influence the energy of radial Shockwave at the 
target. This is probably the cause why in muscle tissue, the energy of 
focused Shockwave decreased by >50% compared with measurements in 
water, whereas for radial Shockwave, measurements in muscle tissue and 
water were the same.(Schmitz et al., 2015) (Wang, 2012)(Frairia & Berta 
2011). 
 
c. Method of generation of Shockwave: 
Two types of Shockwave generation:  
1. Focused Shockwave therapy (FSWT): High- energy extracorporeal 
Shockwave that has been used to treat urolithiasis, the formation of stone 
in the bladder or urinary tract. There are three different types of energy 
sources classically generated:  
• Electrohydraulic method: in which device contains tips of two 
electrodes submerged in a fluid, when voltage is applied the fluid 
is vaporized which causes rapid expansion in the surrounding 
fluid which in turn lead to Shockwave propagation (see Fig. 10A). 
•  Electromagnetic method: in which device contains a coil 
rounded 
around 
metallic 
membrane. 
Because 
of 
that, 
Electromagnetic filed will generated when high voltage current 
pass through the metallic membranes. Moreover, that lead to fluid 

26 
 
disturbance and corresponding Shockwave propagation (see Fig. 
10B). 
• Piezoelectric method: in which device contain large number of 
Piezo electrical plates are embedded into a bowel shaped device 
and submerged in a medium; when voltage is applied to the 
piezoelectric effect occur, expansion and contraction of plates, , 
which in turn induces a mechanical disturbance in the medium 
and resulting in Shockwave propagation (see Fig. 10C). 
3. Radial Shockwave therapy (RSWT) : Low energy extracorporeal 
Shockwave (LESW) that had been used recently to treat a different 
musculoskeletal condition like, Calcaneal Spur, Shoulder impingement, 
Trigger point release…etc. there are two method of production by using 
magnetic field or compressed air (pneumatic principle) accelerating a 
projectile, using compressed air, through a tube on the end of which an 
applicator is placed. The projectile hits the applicator and the applicator 
transmits the generated pressure wave into the body (see Fig. 10D).  
(Katzet al, 2020) (Wang, 2012) 

27 
 
Figure 10:  Schematic representation types of FSWT (A–C) and RSWT (D) generators. 
(A) Electrohydraulic principle: two electrode tips (spark-gap) (1) reflectors (2), 
convergent/focused point (3). (B) Electromagnetic principle: a coil (4). metal membrane 
(5), an adjacent membrane (6) an acoustic lens (7) convergent/focused point (8). (C) 
Piezoelectric principle: piezocrystals (9) a bowl-shaped device (10); convergent/focused 
point (11). (D) Ballistic principle (RSWT): compressed air (pneumatic principle; 12) a 
projectile (13) a guiding tube (14) a metal applicator (15) transmition pressure waves into 
tissue (16) Adapted from (Schmitz et al 2015) 
e. Focused Shockwave therapy versus radial Shockwave therapy: 
 Radial Shockwave therapy more superficial than Focused Shockwave 
therapy but  have been shown to be effective for treating musculoskeletal 
disorders that are more superficial, with clinical results that are similar to 
those of focal Shockwave (D’Andréa et al., 2009) 
In a systemic review done by speed C in which the author investigated 
the evidence base for the use of these modalities. The result showed 
evidence for the benefit of FSWT and of RSWT or radial pulse therapy 
(RPT) in a number of soft tissue musculoskeletal conditions, and evidence 
that both treatment modalities are safe. (Speed , 2014) 

28 
 
There are two significant variances in wave characteristics between 
RSWT and FSWT. First, RSWT have a more superficial effect, compared to 
FSWT, which reach a maximal energy in the focus in deeper body tissues. It 
was shown that a RSWT device generates a pressure field extending to 40 
mm in water, whereas the pressure field generated during FSWT may reach 
a distance that is about twofold as high. How these measures relate to 
biological tissue is unknown. These measures are also dependent on the 
device that is used and the energy setting. Overall, FSWT will travel further 
and have more impact on deeper body tissues. Second, research has shown 
that pressure waves generated by RSWT from a fundamental point of view 
cannot be called Shockwave because they lack the characteristic physical 
features of Shockwave such as a short rise time, a high peak pressure and 
nonlinearity (van der Worp et al., 2013). 
Moreover, Radial extracorporeal Shockwave therapy (RSWT) is 
extensively used as a non-invasive treatment of various musculoskeletal 
disorders. Several studies discuss the mechanisms of RSWT on cellular and 
molecular level which include the mediation of cell apoptosis, enhanced 
angiogenesis and wound healing as well as new bone formation. The 
working principle of RSWT devices is illustrated in (Fig 10D). For the 
reason that radial Shockwave are not like Shockwave in the strict physical 
properties, some researchers called RSWT “radial pressure wave treatment 
(RPWT)” (Contaldo et al., 2012) , “radial pulse therapy (RPT)” (Speed, 
2014), “low-energy radial- pulsed–activated (EPAT) Shockwave (sound 
wave)” or “Acoustic Wave Therapy (AWT)” (Császár et al., 2015). 
 

29 
 
Furthermore, conflicting reports exist in the literature as to whether at 
all radial extracorporeal Shockwave (RSWT) can generate cavitation, which 
refers to the rapid formation, expansion, and forceful collapse of vapor 
bubbles in liquids subject to rapid pressure changes. Cavitation exerts 
important therapeutic bioeffects; also produce unwanted side effects 
including hematomas, blood vessel rupture, and permanent injury to organs 
such as kidneys and lungs. In this respect an early review about ESWT 
published in 2003, 2006, 2015 concluded that RSWT devices were in fact 
capable of generating cavitation. In conclusion, FSWT & (RPWT) or 
(RSWT) produce cavitation activity which is  limited to the area of the 
applicator head in RSWT applicators .(Contaldo et al., 2012)(Császár et 
al., 2015). 
 
d. Mechanism of Shockwave therapy: 
The mechanism of action of Shockwave in human still unclear. It 
speculated that ESWT could induce analgesics effect via excitability of the 
axon and destroy unmyelinated sensory fibers. However, many authors 
suggest that when shockwave pass human tissues. It speculated that four 
biological stages occurs. The first stage is the direct physical (mechanical) 
impact of the shockwave, which lead to extracellular cavitation, ionizes the 
particles and increase of membrane permeability. The second stage is the 
physical-chemical stage. This includes the connection of diffusible radicals 
with biomolecules from stimulated cells. ESWT may influence lysosomes 
and mitochondria, and interfere with cell metabolism. The third stage is the 
chemical stage, which may be accompanied by intracellular reactions and 
molecular changes in actual cells. A high temperature is grown locally 
during cavitation, which prompts the development of radicals. The fourth 

30 
 
stage  is the biological stage . Physiological responses take place in this 
stage when the changes from the chemical phases persist. These four stages 
include the most important biological effects of shockwave (Wang et al., 
2019)(Frairia & Berta, 2011)(Tyagi & Chuang, 2018). 
 
f. Shockwave and cell permeability:  
Shockwave characterized by discontinuous changes in pressure, 
temperature, and density of the medium in which they applied. When 
Shockwave applied on lipid bilayer membranes, the high particle velocity 
induced by the Shockwave pulse can disrupt and displace the lipid molecules 
and temporarily increase the membrane permeability. Application of 
shockwave has been proven to increase permeability of the lipid bilayer 
allowing for delivery of drugs into the cell (Kfoury et al., 2019). 
Molecular dynamics simulations demonstrated that the shockwave 
initially hits the membrane and followed by a Nano jet produced by the 
collapse of the nanobuble, which formed due to acoustic micro cavitation 
effect. Because the pressure acting on the bubble from the outside is 
generally not homogeneous, its collapse, resulting in the development of a 
fluid micro jet into the cell membrane along the direction of shockwave 
propagation. Therefore, LESW results in reversible permeabilization of cells 
in targeted tissue, and can deliver molecules of up to 2,000,000 molecular 
weight into the cytoplasm of cells. The ability to deliver macromolecules of 
large molecular weight by cell permeabilization (see Fig 11)(Tyagi & 
Chuang, 2018)(Li et al., 2013). 
Kodama et al. suggested that Shockwave could cause shear force 
generated because of liquid movement relative to the cells, which 

31 
 
temporarily affect plasma membrane permeability. The pressure  impulse 
(which is defined as the integral of the pressure over a time interval), rather 
than the peak pressure of the Shockwave, plays an important role in increase 
permeability for delivering macromolecules into cells (Kfouryet al., 2019) 
López-Marín et al., study show that membrane poration by Shockwave 
is critically dependent on the collapse of nano bubble formed due to acoustic 
micro cavitation effect. Two dimensional pressure maps revealed that even 
distribution of the shock pressure along the lateral area of the membrane is 
disturbed by the nanobuble, which leads to the membrane poration. The size 
of the pore formed depends on shockwave velocity, pressure waveform, 
Energy flux density and shockwave duration (Tyagi & Chuang, 2018). 
The positive peak pressure of Shockwave is considered to affect the 
material based on the plasticity nature of the material and recent study on 
immortalized cell line and tumor derived cell line reported differences in 
membrane permeabilization of two cell lines. Researches used scanning 
electron microscopy to report that shockwave induced transient 
deformations at the cell membrane. Cell size decreased and hole like 
structures noted after shockwave application. Trypan blue dye exclusion test 
indicated that cell membranes were poration by shockwave application but 
resealed after a few seconds. Deformations of the cell membrane lasted for 
at least 5 min, allowing their observation in fixed cells. the mechanisms for 
shockwave mediated membrane permeability are still poorly understood 
(López-Marín et al., 2017). 

32 
 
Figure 11 Typical pressure waveform of a shockwave as used in some biomedical applications (a) and schematic 
diagram of the dynamics of an air microbubble in fluid subjected to the passage of a shockwave (b). The positive 
pressure peak compresses the bubble at time= 0. Once the shockwave has passed, the bubble expands and 
collapses. adapted from (López-Marín et al., 2017) 
 
g. Shockwave and calcaneal spur: 
The primary effect is the direct mechanical forces that result in the 
maximal beneficial pulse energy concentrated at the treatment site. in 
addition to that, the secondary effect is the indirect mechanical forces by 
cavitation, which may cause negative effect or damage to the tissues which 
can help in calcaneal spur destruction (Wang, 2012)(Frairia & Berta, 
2011) (Schmitz C et al., 2013) 
Xian Li et al., conducted meta-analysis research compared the 
effectiveness of eight modalities for treating plantar fasciitis (Shockwave 
therapy), both Intracorporeal pneumatic shock therapy (IPST) and 
extracorporeal shock therapy (FSWT (3 groups low, medium, high energy 
flux density), RSWT), Low level LASER therapy, Ultrasound therapy (US), 
and noninvasive interactive neurostimulation (NIN) ultrasound-guided 
pulsed radiofrequency (UGPRF) treatment were included. The therapies 
compared these modalities with each other or with a sham group.  Regarding 
the three follow up effectiveness time points, RSWT provided relatively 

33 
 
more effective and stable pain relief compared with other modalities. 
Consequently, RSWT is a promising candidate for clinical applications. 
FSW therapies and US can also be considered treatment candidates. 
However, H-FSW and UGPRF not recommended (X. Li et al., 2018). 
3. Calcaneal spur and Acetic acid: 
An acetic acid gel is an important component used via ultrasound 
phonophoresis to treat bone calcification deposits. It is composed of calcium 
carbonate (CaCO3) which exposed to active acetate radical and replace the 
carbonate 
forming 
the 
blood 
soluble 
calcium 
acetate 
molecule 
Ca(CH3COO)2 (Pamplona et al., 2017). 
Shtofmakher G et al., describe that the use of acetic acid as ionized 
solution to treat insertional Achilles tendonitis (Calcaneal exostoses of the 
Achilles tendon) pain. They claim that a significant improvement in pain and 
function as the acetic acid helps to convert exostoses composed of calcium 
carbonate (CaCO3) to more chemically active acetate radical and replace the 
carbonate 
forming 
the 
blood 
soluble 
calcium 
acetate 
molecule 
(Ca(C3H3O2)2). In another study by Japour et al., they describe that 
transdermal application of acetic acid through iontophoresis was shown to 
be an effective conservative treatment modality for heel pain. (Kilfoil et 
al.,2014). 
The use of acetic acid iontophoresis treatments for chronic heel pain has 
shown promising results within 3–4 weeks and over an extended follow up 
period of greater than 2 years. It has been hypothesized that the 
physiological responses to chronically inflamed tissue results in higher 
concentrations of insoluble calcium carbonate to an injured area which 
contributes to the constant pain cycle and abnormal restructuring of 
myofascial tissue. The acetate ion in acetic acid combines with the calcium 

34 
 
ion in calcium carbonate to form more soluble calcium acetate, see blow 
chemical equation, which is then able to dissolve within local blood 
circulation and removed from the site of injury   (Costa & Dyson, 2007) 
 
CaCO3 + 2H (C2H3O2) →Ca (C2H3O2)2 + H2O + CO2 
 
 
 
 
 
 
 
 
 
 
 
 

35 
 
CHAPTER III 
SUBJECTS, MATERIALS AND METHODS 
The current study will conducted to investigate the efficacy of Shockwave 
phonophoresis on calcaneal spur, this study will conducted at outpatient 
clinic in faculty of physical therapy at Beni-Suef University, Beni-Suef 
governorate, Egypt. 
1. Design of the study:  
Double-blinded pretest posttest randomized control design will used. 
2. Subjects: 
The age of participant will range from 30 to 65 years. These patients will be 
allocated from the outpatient clinic in faculty of physical therapy at Beni-
Suef University. The purpose, nature and potential risk of the study will be 
explained to all participant and they will sign a written informed consent 
prior to participation (Appendix I).  Forty patients from both gender will be 
involved in this study and will randomly subdivided into two equal groups in 
number: 
Group (A): (experimental group 1) this group composed of 20 subjects 
represented the experimental group 1. They will receive 6 sessions acetic 
acid shockwaves phonophoresis with Time between sessions 5-7 days plus 
exercise and dietary advice.  
Group (B): (experimental group 2) this group composed of 20 subjects and 
represented the experimental group 2 who will receive 6 sessions of 
Shockwave plus exercise and dietary advice.   

36 
 
Group (C): (Control Group):  This group composed of 20 subjects they will 
take conventional physical therapy program (Exercise) 
 
3. Inclusion criteria: 
Subjects included in this study will having all of the following criteria: 
• Heel pain with calcaneal spur. 
• Calcaneal spur in lateral calcaneal x-ray.  
• Patient’s age ranged from 30 to 65 years.  
• Body mass index less than 30 Kg/M2. 
• Patients with calcaneal spur. 
• Patients with intact sensory perception.  
• At least 6 weeks from last corticosteroid injection; 4 weeks from the 
last local anesthetic injection, iontophoresis, ultrasound, and 
electrotherapy (Gerdesmeyer et al., 2008). 
4. Exclusive criteria:  
Subjects excluded in this study for any of the following cases: 
• 
History of fracture or surgery of the heel or ankle.  
• 
Presence of inflammatory joint disease.  
• 
Marked osteoporotic patient. 
• 
Presence of ankylosing spondylitis Heart pacemaker use. 
• 
Patient on anticoagulant and coagulation disease. 
• 
Skin wound or ulcers. 

37 
 
5. Martials:  
The study materials will divided into two different categories: 
a. Evaluative Equipment: 
1. X-ray Machine: The best method of assessment of skeletal structure of 
foot by using radiographic techniques, which considered as the gold 
standard for assessment bone deformity and alignment of foot in weight 
bearing position. It will used to scan the foot and calcaneus before and 
after treatment; it consists of operating console of x ray machine, x ray 
tube, x ray cassette, digital radiography systems and desktop computer 
with windows operating system to measure the length and width of the 
calcaneal spur. (Rajakaruna et al., 2015). 
 
2. Pressure pain threshold (PPT): A handheld pressure algometry will be 
used to measure heel tenderness threshold. The threshold is the minimum 
force required producing the sensation of pain. The PA is a force gauge 
equipped with a rubber tip and calibrated in kg/cm2 (Model FDX, 
Algometer, WAGNER instruments, Greenwich, CT) (Alotaibi et al., 
2015). 
 
3. Visual analogue scale (VAS):  are used to express the severity of illness 
(usually pain) by patients by making a mark determining a decimal 
number from 0 to 100 (mm) on line with ‘no pain’ to the left and sever 
pain could be to the right. The subjects rated their perception of pain by 
making a mark on the VAS line. The distance from the left to the mark 
will measured and the accuracy will adjusted to one decimal place (see 
appendix III) (Kamper, 2012). 

38 
 
4. Foot and Ankle Ability Measure (FAAM): is a self-report measure that 
assesses physical function of individuals with lower leg, foot, and ankle 
musculoskeletal disorders. FAAM is assess activity of daily living ADLs 
(26 items) and sport activity (8 items). (Irrgang M et al., 2005). FAAM 
is a reliable, responsive, and valid measure of physical function for 
individuals with a broad range of musculoskeletal disorders of the lower 
leg, foot, and ankle (see appendix II) (Martin et al, 2005). 
 
 
b. Therapeutic Equipment:  
1. Shockwave apparatus: Gymna Shockmaster 500 device will be used in 
this study. This device is a radial shockwave device, pneumatically 
generated and composed from (Fig12): Device Shockmaster 500, 
Communicating Wire between applicator and device, Hand piece 
applicators that is light ergonomically well design hand piece applicator, 
D-Actor 20 mm applicator and Trolley Shockmaster 500. The device 
allow variability in the setting with Frequency range 0,5 - 21 Hz and  
Pressure range 0,3 - 5 bar. 
2. Acetic acid gel: 5% concentration acetic acid gel form will be applied to 
the foot as a coupling media instead of ultrasound gel between the 
applicator and the body surface  (Pamplona et al., 2017). 
3. Exercise program: designed to adjust foot mechanics by stretch tight 
structure and strength the weak muscles. 
4. Advices: Dietary advices and advices to alter calcaneal spur pain. 

39 
 
6. Methods:  
A verbal explanation about the important of the study procedure, main 
aim and conceptual approach will explained to every patient. The 
procedure of this study will divided into two main procedures: 
A. Measurement methods: 
Before starting the study, a consent form will be taken from each 
participant in this study as an agreement to be included in the present study. 
Each participant will examined medically to exclude any abnormal medical 
problem, which previously mentioned. Measurement will taken pretest 
assessment and posttest assessment and post one month follow up as follow: 
1. X-ray: 
Lateral calcaneal x-ray helps to evaluate bony conditions of the foot for 
example, Calcaneal spur, calcaneal stress fractures may be visualized on 
lateral calcaneal and that help in excluding any condition not suitable with 
Figure 12: shockwave apparatus adapted from https://gymna.com/en/products/shockwave-
therapy/gymna-shockmaster-500 

40 
 
Figure 13 : X-ray machine 
this research. Each patient should do at least two x-rays ,one before and 
another after, computer aided linear measurements will recorded for spur 
length and width in (mm) from tip to base as defined by a line determining 
the calcaneal border as described by many authors (Fig. 13) (Kuyucu et 
al.,2015)(Büyükturan, 2017) (Gladman et al., 2014) 
 
 
 
 
 
 
 
 
 
 
2. Pressure pain threshold (PPT): 
The procedure will be explained to the participant prior administration of 
the algometer and Measurement will be by Wagner base line algometry. 
Then the therapist will instruct the patient to recline in supine position. The 
investigator will palpate and mark the tender point over the medial 
tuberosity of the calcareous. After that, therapist will apply the algometry 

41 
 
Figure 14 WAGNER FDX 50 algometer 
over the mark placed on the medial tuberosity of the calcaneus. The 
algometer contact head will aligned perpendicularly to the tender point, with 
the investigator gradually increasing the algometer force until the patient 
reported pain. The algometer reading will recorded in newton’s. Higher 
algometer scores indicate greater force tolerance and, thus, less tenderness. 
Lower algometer readings indicate less force tolerance and, thus, greater 
heel tenderness. The reliability and validity of the algometer as a subjective 
outcome measure of tenderness has been supported in various studies (see 
Fig. 14). (Wibowo et al ., 2017) (Sangam et al., 2015)(Alotaibi et al., 
2015) 
 
 
 
 
 
 
 
 
 
3. Pain intensity level assessment: 
• Each patient will be instructed to mark his/her level of pain on visual 
analogue scale. Then, the distance will be measured by ruler in 

42 
 
millimeter (mm) from 0 direction and recorded in patient file. See in 
Appendix III  (Janusz, 2017). 
4. Activity of daily living: 
• Foot and Ankle Ability Measure (FAAM) scale will measure disability: 
which is a self-report outcome instrument developed to assess physical 
function for individuals with foot and ankle related impairments. 
Patient will choose from (0-4) where zero mean unable to do and four 
mean no difficulty (see appendix II). This instrument includes two 
subscales: 
a.  Activities of Daily Living (ADLs) subscale of 26 items 
b. Sports subscale of 8 items 
B. Therapeutic methods: 
1. Shockwave therapy: 
• The shockwave will be applied for both group: 
a.  Group A: Shockwave (with 5% Acetic acid gel). 
b. Group B: Shockwave (with ultrasound coupling medium gel). 
c. Group C: conventional physical therapy program (Exercise). 
• Once per week for 6 weeks for Shockwave. 
• The intensity of Shockwave adjusted according to highest energy flux 
density the patient can tolerate. To achieve the best improvement in 
pain relief, the energy level of ESWT will adjusted to the maximum 
level that patients can tolerate the pain induced by ESWT 
• Application at the most painful sit on Calcaneus.  
• Total Energy flow density will calculated (as the product of the number 
of treatment sessions, the number of impulses per treatment session and 
the EFD of the impulses)(Schmitz et al., 2015). 

43 
 
1. Exercise program:  
a. Stretching exercise:  
• Standing calf-stretching exercise: stretching gastrocnemius & Soleus 
and Posterior Tibialis Muscle stretch muscle: In sitting and standing 
position for 15-30 seconds and Repeat three times. 
• Towel stretch: stretching exercise for planter fascia in sitting and 
standing position for 15-30 seconds (Repeat three times) 
• Ice bottle applied as a home advice to stretch intrinsic foot muscles and 
analgesic effect. 
b. Strengthening exercise: 
• Some authors suggest that calcaneal length related to the dorsal and 
plantar flexor muscle strengths, which in turn affect the foot and lead to 
abnormal loading which increase the susceptibility for injury and pain 
(Sonu & Aman, 2015) (Büyükturan, 2017). 
• Towel pickup exercise to strengthen intrinsic muscles of the foot  
• Marble pickups exercise: patients will be instructed to collect 10 
marbles from ground, by toes, and put it in a bowl and repeat it (3sets). 
• Calf raises exercises 
• Static and dynamic balance exercise. 
2. Advices: 
• Advices to alter calcaneal spur pain: rest, modified shoes, modified 
activity, use ice cubes regularly. 
• Dietary advices to decrease gout and adjust body weight. 
 
 

44 
 
Data collection: 
In this study, data collection will be conducted via data collection sheet 
and then the data will be collected in large table to form raw data that will be 
used as base for statistical analysis. 
Statistical Analysis: 
▪ All analysis will be carried out using the statistical package SPSS 
V.25.00 (IBM Corporation). 
▪ Data will be expressed as mean and SD or median (in case of violation 
of normality) for continuous variables and as percentages for 
categorical data.  
▪ The Shapiro-Wilks test will be used to test the normality of the data. 
▪ 2-way mixed Design MANOVA will be used to compare the groups 
for normally distributed data. 
▪ 2-way mixed Design MANOVA will be used to compare the groups 
for normally distributed data. 
▪ Kruskal Wallis and Mann-Whitney tests will be used to compare the 
groups for non-parametric and not normally distributed data. 
▪ Age and gender will be considers as an independent variable.  
▪ Pairwise multiple comparisons will be performed using the Bonferroni 
correction test. 
▪ All tests are two-sided, and statistical significance will be set at 
p<0.05.  

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Appendix I 
Consent Form 
I am\ ...................Freely and voluntarily consent to participate in 
this research study under the supervision and direction of the 
research\ Mostafa Ali Elwan. A thorough description of the study 
procedures has been explained to me, and I understand that I may 
withdraw my consent and discontinue participation in this study 
research at any time without prejudice to me. Signature of 
Participant:                                  Date:       \     \ 
 
 
 
 
 
 
 
 
 
 

VIII 
 
Appendix II 
 

IX 
 
 

X 
 
Appendix III 
 
 
Visual analogue scale: (measurement in mm 0 is no pain & 10 
is maximum pain)