Comparative retrospective analysis of magnetic field therapy and extracorporeal shock wave therapy in pain management for heel spur

Abstract

Background

Heel spurs, caused by inflammation and overstretching of the plantar fascia, are a common source of heel pain. Although various conservative and invasive treatments are used, evidence on their effectiveness remains limited.

Objective

This study aims to evaluate the effect of extracorporeal shock wave therapy (ESWT) and magnetic field application on pain levels in heel spur patients.

Methods

The files of 80 patients diagnosed with heel spurs were accessed. Patients with missing demographic information in the files, incomplete Visual Analogue Scale (VAS) values, and patients with heel pain complaints for less than 5 months were excluded from the study. A total of 39 patients who met the study criteria were included in the study. While ESWT was applied to 21 of these patients (ESWT group), magnetic field was applied to 18 patients (MA group). All patients were given plantar fascia stretching exercises as a home program. Pain scores before and after treatment were evaluated with VAS.

Results

A significant decrease was found in VAS values after the 5th session and 2 months later in both the ESWT group and the magnetic field group (p < 0.001). On the other hand, neither treatment method was found to be superior to each other (p > 0.05).

Conclusion

It was observed that the pain of the patients decreased in both the early and late periods in both applications.

Keywords

musculoskeletal pain plantar fasciitis physical therapy modalities

Introduction

Heel pain is the most common foot problem. The term heel spur was first defined by the German surgeon Plettner in 1900, using the term calcaneal spur. The term heel spur has names such as plantar fasciitis, epin calcanei, calcaneal spur in the literature.¹ However, regardless of the term used, the same pathology is defined in the literature and is described as pain felt at the attachment point of the plantar fascia to the calcaneal tubercle and along the proximal plantar fascia. It is seen at a rate of 11%-15% in adults in the society.² The probability of having heel spurs in individuals with heel pain is 30–70%.¹ While it has been reported that it is more common in obese people and women between the ages of 40–60, it has also been mentioned that it is seen in runners at earlier ages and in professional groups that work by standing for long periods of time.³ Many methods are used in the treatment of heel spurs. These methods are cortisone injection, use of insoles, stretching exercises, use of night splints, taping, electrotherapy agents, extracorporeal shock wave therapy (ESWT), and magnetic field (MA) applications.^4–7

The application of MA contributes significantly to the healing process. It is an easier, cheaper and more comfortable application.⁸ The magnetic field has been clinically proven to be safe. MA application has been documented in the literature as a practical, non-invasive method to correct selected pathological conditions and induce cell and tissue modifications.⁹ MA practices are the most effective clinical practices in the last 25 years and are related to fracture healing, analgesic effect and soft tissue edema. More than one million people worldwide have been treated in virtually all areas of fracture management, including nonunion, pseudoarthrosis, osteonecrosis, and chronic tendinitis.¹⁰

MA applications are not an invasive method. It penetrates all cells of the body and is an easy method to apply for the physician and the patient. It has longer-lasting effects than hyperthermia and is effective at an extremely low energy level.⁷ The application of static MA has been used for centuries to control pain, but the mechanism of pain reduction is unclear. One theory suggests that nociceptive C fibers have a lower threshold potential and that magnetic fields selectively reduce neuronal depolarization by altering the membrane resting potential. A second theory suggests that magnetic fields promote increased blood flow in the skin, subcutaneous, muscle, and connective tissues. A third theory proposes that ion binding kinetics in macromolecules are affected, thereby modulating cytokine and other factor release. The therapy is performed by placing magnets of different intensities (G = gauss) on the skin over the affected areas or painful pressure points. Magnets can have a “unidirectional” configuration (north pole on one side, south pole on the other) or a “bipolar” configuration (alternating north and south poles on each side).^5,6 Unlike heel spur treatment, MA application has been used in many studies and has been reported to not cause any side effects. It has been reported that MA application improves pain and stiffness in individuals with osteoarthritis,¹¹ provides osteoblast proliferation for bone formation, and has many clinical benefits.¹² MA treatment may improve diabetic neuropathy in individuals with diabetes¹³ and may be effective in reducing postoperative pain and edema after plastic surgery.¹⁴

ESWT is a method that aims to treat the problematic area by focusing shock waves created outside the body on the desired area of the body with the help of an applicator. It is aimed to reveal the inflammatory response that accelerates neurovascularization and healing.^15,16 It has been reported that shock waves of ESWT increase blood circulation in the surrounding tissues through angiogenesis in ischemic muscle, regulate the function of ion channels, resorption of calcified tissues, reduce pain, and increase the production of substance P. It is thought that shock waves stimulate neovascularization and the production of normal tissues from stem cells by disrupting the microcirculation around the tendon in tendinopathies.^17,18 Many studies have shown that ESWT is effective in the treatment of heel spurs.¹⁹ It has been reported that it enables athletic patients diagnosed with heel spurs to return to sports activities more quickly.²⁰ As a result of a meta-analysis study: ESWT should be considered when traditional treatments have failed.²¹

Many studies in the literature show that ESWT applications have very effective results on pain in individuals with heel spurs. Although it is stated in many studies that MA applications are frequently used in musculoskeletal problems, no study has been found in which they are used in the treatment of heel spurs. When the current literature was examined, no study was found comparing individuals diagnosed with heel spurs, who underwent ESWT, and individuals who underwent MA, in terms of pain. Therefore, this study was planned to investigate whether ESWT applications and MA applications are superior to each other in individuals with heel spurs. Our hypothesis is that neither treatment method will be superior to each other.

Materials and methods

Study design

This is a retrospectively designed single-center study. It was designed as a retrospective study because the study was single-centered, we had a rich data pool, the timeline of this study was completed, and the treatment process of these individuals was completed. The data were obtained from the archives of the physical therapy and rehabilitation department with the approval of the chief physician of Private Konya Hospital. The data of a total of 400 patients were examined in the physical therapy and rehabilitation department. After this review, 80 patients diagnosed with foot pain were reached. Of these 80 patients, 39 patients who were diagnosed with heel spurs and whose treatment was completed and whose data were not missing were included in the study.

Volunteer individuals between the ages of 18 and 65 who were diagnosed with heel spurs by an orthopedic physician and physical therapy and rehabilitation physician, had heel pain for at least 5 months and did not undergo surgery, and individuals who had not received physiotherapy and rehabilitation treatment before were included in this study. Those who were diagnosed with rheumatological disease, those who had steroid injections in the heel area before, those who had entrapment neuropathy and deformity in the lower extremity, those who were pregnant, those with scoliosis, those with active infection, those with the presence of malignancy, those who regularly used non-steroidal anti-inflammatory and antidepressant for any reason, or those who received any prior treatment for pain were excluded. Demographic information of the patients, such as age, height, body weight and gender, was checked.

The retrospective study was conducted in accordance with the principles of the Declaration of Helsinki and was found scientifically and ethically appropriate by the KTO Karatay University Non-drug and Medical Device Research Ethics Committee (protocol number 2022/033; date 25.05.2023).

Outcome measures

The primary outcome of this study was to compare the effect of both treatment methods on pain. For this purpose, Visual Analog Scale (VAS) was used for pain assessment. In addition, variables such as age, height, weight, Body Mass Index (BMI), marital status, occupation and presence of comorbidities were recorded to determine sample characterization.

The age, height, weight, BMI, marital status, profession, and presence of additional diseases of the patients included in the study were recorded.

VAS is used in pain assessment. The patient was explained that 0 indicates no pain, 5 indicates moderate pain, and 10 indicates unbearable pain. He was also informed about the intermediate values, and in each session, the value he gave in the previous session was told, and as a result, he was meticulously questioned how his pain changed according to that value. And patients were asked to mark their pain on a 10 cm line. VAS evaluation method, ESWT before and after application, and MA before and after application were recorded.²² Patients whose VAS measurements were taken before ESWT and MA application, the 5th session after the application and 8 weeks after the last session were evaluated.

Interventions

ESWT was applied to a total of 21 patients at the dose specified in the guide published by the International Society for Medical Shock Wave Treatment.²³ Ultrasound gel was used to ensure conductivity before treatment. The painful area on the heel was palpated and a total of 5 sessions of 2500 pulses were applied to that area and its surroundings, 3 sessions per week at 10 Hz frequency at 2.5 bar pressure.

Magnetic field device (Salus Talent/Magnetic field output 3 tesla + -30%, magnetic field frequency symmetrical biphasic pulse, 1 (tilde will be placed)100 Hz). MA application was applied to a total of 18 patients, 3 sessions per week for 15 min each. A total of 10 sessions of MA treatment protocol were applied. The painful area on the heel was palpated and the head of the device was placed in that area.

All patients in the single-center study were treated by the same healthcare professional.

Statistical analysis

Data were analyzed using the statistical package program version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics were given as number of units (n), percentage (%), mean (X), standard deviation (SD), median (M), minimum (min) and maximum (max) values. The normal distribution of the data of numerical variables was evaluated by Shapiro Wilk normality test. Parametric tests were used because numerical descriptive characteristics and variables were normally distributed. Student's t test was used for intergroup comparison of numerical descriptive characteristics and chi-square tests (Pearson chi-square/Fisher exact test) were used for intergroup comparison of categorical descriptive characteristics. Mixed design analysis of variance (ANOVA) was used to compare the variables in the groups according to follow-up times. Bonferroni correction was applied for the comparison of main effects and p < 0.05 was considered statistically significant.

Sample size was calculated using the G Power 3.1.9.2. program. The calculation was made based on a randomized study by Kapusta et al., in which they compared the long-term effectiveness of ESWT and additional ultrasound and laser therapy with VAS in 39 amateur runners with plantar fasciitis. As a result of the calculation, it was determined that a total of 44 heel spur patients should participate in the study, with a statistical power level of 80% and a significance level of 5%.²⁴

Results

A total of 39 individuals with heel spurs, 30 females (76.9%) and 9 males (23.1%), aged between 28 and 71 years (mean age: 47.82 ± 8.90), participated in the study. Mean BMI was 27.35 ± 1.62 kg/m² in the MA group and 25.60 ± 1.12 kg/m² in the ESWT group (p < 0.001). Except for BMI, the descriptive characteristics of the participants had a similar (homogeneous) distribution in the study groups (p > 0.05) (Table 1).

Table 1.

Comparison of descriptive characteristics of participants according to groups (N = 39)

	Group		Total	Test (p)
	MA	ESWT	Total
	n = 18	n = 21	n = 39
Age, (year)				t = 0.347 p = 0.731
X ± SD	48.36 ± 9.46	47.36 ± 8.61	47.82 ± 8.90
M (min-max)	48 (34–66)	48 (28–71)	48 (28–71)
BMI, (kg/m²)				t = 3.970 p < 0.001
X ± SD	27.35 ± 1.62	25.60 ± 1.12	26.40 ± 1.62
M (min-max)	26.6 (25.6–31.2)	25.6 (22.9–28.1)	26.1 (22.9–31.2)
Sex, n (%)				χ²= 0.014 p = 0.907
Woman	14 (77.8%)	16 (76.2%)	30 (76.9%)
Man	4 (22.2%)	5 (23.8%)	9 (23.1%)
Painful Side, n (%)				χ²= 3.009 p = 0.083
Right	11 (61.1%)	7 (33.3%)	18 (46.2%)
Left	7 (38.9%)	14 (66.7%)	21 (53.8%)

Bold: Statistical significance (p < 0.05), MA: Magnetic Field, ESWT: Extracorporeal Shock Wave Therapy, BMI: Body Mass Index, X: Average, SD: Standard Deviation, n: The number of participants, %: Percentage, t: Student's t Test, χ²: Chi-Square Test.

The VAS means of the participants at the time of measurement did not show a statistically significant difference between the groups (p > 0.05). VAS means showed a statistically significant decrease over time in the magnetic field and ESWT groups (p < 0.001). As a result, there was a statistically significant decrease in VAS scores in both groups (Table 2).

Table 2.

Comparison of VAS scores according to groups at follow-up times

	Group		Test statistics ^†	Model significance
	MA	ESWT		Group effect	Time effect	Group X time effect
	n = 18	n = 21		Group effect	Time effect	Group X time effect
VAS				F = 0.610 p = 0.440 η2 = 0.016	F = 1127.261 p < 0.001 η2 = 0.968	F = 0.994 p = 0.375 η2 = 0.026
Beginning (X ± SD)	8.67 ± 0.91 ^a	9.05 ± 0.67 ^a	F = 2.267 p = 0.474 η2 = 0.058
After the 5th session (X ± SD)	1.67 ± 1.24 ^b	1.52 ± 1.33 ^b	F = 0.120 p = 0.732 η2 = 0.003
Two months after treatment (X ± SD)	0.39 ± 0.50 ^c	0.62 ± 0.59 ^c	F = 1.692 p = 0.201 η2 = 0.044
Test Statistics ^ϕ	F = 632.237 p < 0.001 η2 = 0.972	F = 751.876 p < 0.001 η2 = 0.977

Bold: Statistical significance (p < 0.05), MA: magnetic field, ESWT: Extracorporeal Shock Wave Therapy, X: Average, SD: Standard Deviation, n: The number of participants, Mixed Design ANOVA (F), Effect Size (η2), ϕ Within-group comparison, † Between-group comparison, a > b > c: Differences between different letters in the same row or column are significant (p < 0.05).

Discussion

The study was conducted to determine the effect of ESWT and MA treatment on pain in people with heel spur disease. In light of the data obtained, it was determined that both treatment methods were effective on pain, but they were not superior to each other.

The most important problem in the conservative treatment of heel spurs is pain. To treat pain, it is very important to control inflammation and reduce tissue tension. There are quite different treatment methods in the literature. However, there is no consensus on which method is more effective. In the clinical practice guide for heel spurs published by the American Academy of Foot and Ankle Surgeons in 2010, stretching exercises, night splints, orthotic supports, shoe modifications and ESWT treatments are shown as treatment options.¹

Although heel pain is not among the common problems in society, it negatively affects people's quality of life and is not taken seriously at first. Patients apply to a health institution after a certain period of time after their complaints begin. In our patient group, the complaints of the patients lasted at least 5 months.

VAS is a widely used and easy-to-apply evaluation method. In many studies on heel spur treatment, VAS was used as an evaluation method.²² In our study, the average VAS score value in the ESWT group before the first session was 9.048 + 0.6690, in the 5th session (after treatment) it was 1.524 + 1.3274, and in the 2-month follow-up control it was 0.619 + 0, It was 5896. In the MA group, the average VAS score value before the first session was 8.667 + 0.9075, in the 5th session (after treatment) it was 1.667 + 1.2367, and at the 2-month follow-up control it was 0.389 + 0.5016.

ESWT is a treatment method that has few complications, is non-invasive, has a short treatment period, is easy to apply, and results are usually obtained in the early period. In this study, VAS values were recorded for pain levels in patients who underwent both ESWT and magnetic application before treatment, at the 2nd week and at the 2nd month after treatment. In this study, starting from the second week of treatment, patients’ pain levels decreased significantly compared to before treatment. It was observed that the treatments had a positive effect on pain in both groups. On the other hand, no superiority of the treatments over each other was detected.

ESWT has been most successful in treating diseases such as plantar fasciitis. It is a safe treatment and has few known side effects. These are stated as pain during application and minor hematoma.²⁵ Having pain during the application can be seen as an advantageous situation for the physiotherapist. The patient's feeling of pain during the application may prevent complications or excessive hematoma. If applied as recommended, serious complications are not expected. No complications developed in our patients.

Mechanical energy causes changes that trigger the reaction of the cell nucleus (e.g., mRNA release) that affect various cell structures such as mitochondria, endoplasmic reticulum, and intracellular vesicles. Thus, the enzymatic response of the building blocks of the cell initiates the healing process and leads to the healing of the tissue.²⁵

It has been suggested that shock waves used in the treatment of plantar fasciitis reduce pain with the support of extracellular responses that cause angiogenesis and neovascularization and through tissue healing and regeneration.²⁶ Dahmen et al.²⁷ state that, as a mechanism for reducing pain, ESWT affects local pain factors, causes overstimulation of the axon, destroys unmyelinated sensory fibers and produces an analgesic effect, as well as improves symptoms through the inflammatory response by secreting growth factors and Nitric Oxide, and stimulates the healing process with the support of neovascularization. Rompe et al.²⁸ divided 153 patients with heel pain into two groups, applied ESWT once a week to the 1st group for 3 weeks, applied plantar fascia stretching exercises to the other group for 8 weeks in addition to this treatment, and evaluated the effectiveness of the treatment on the 2nd, 4th and 24th months. They evaluated the foot functional index (AFI) in months. They found that the group in which plantar fascia stretching was applied with ESWT was more successful than the other group. In our study, plantar fascia stretching exercises were given to both groups. We think that one of the reasons for the decrease in the pain levels of the patients in both groups is the addition of plantar fascia exercises to the treatment.

In a meta-analysis study, Yao et al. compared the effectiveness of ESWT with other techniques in the treatment of lateral epicondylitis and stated that there was a decrease in VAS values and an increase in grip strength in patients who underwent ESWT.²⁹ Pettrone and McCall conducted a randomized, multicenter, double-blind, placebo-controlled study in patients with lateral epicondylitis. They reported that during the one-year follow-up period, at least 50% improvement in VAS score was observed in pain intensity in 61% of 56 patients (thirty-four) in the ESWT applied group, while at least 50% improvement in pain score was observed in 29% of 58 patients (seventeen) in the placebo group.³⁰ Shock waves occurring during ESWT application reduce pain by causing structural and neurochemical changes. This method, which is basically based on the principle of treatment with sound waves, is used in many musculoskeletal problems. When we look at these results, we show that ESWT is an effective and reliable treatment option for pain.

MA application is successfully performed to treat chronic problems in the musculoskeletal system. MA application has been clinically proven to be safe to apply. It is known as a practical, non-invasive method that triggers cell and tissue modifications that can solve chronic problems. Numerous publications have reported that the magnetic field is very important for diagnosis and treatment.^31,32 Many scientific studies show that all factors involved in the healing process (such as fibrinogen, leukocytes, fibrin, platelets, cytokines, growth factors, fibroblasts, collagen, elastin, keratinocytes, osteoblasts, free radicals) are affected.^32,33 Soft tissue and bone/cartilage systems are treated successfully, and the most important of these is the treatment of problems related to the musculoskeletal system.^33,34 In a systematic review, Markovic et al. reported that magnetic field applications reduced pain and joint stiffness in patients with knee osteoarthritis.³⁵ In their systematic review, Kull et al. aimed to evaluate the effects of MA application on pain and function in patients with non-specific low back pain and concluded that MA application seems to be a safe and beneficial treatment option in non-specific low back pain.³⁶ Ko et al. conducted a randomized controlled study in 2022 in which they aimed to see the effects of MA in patients with Achilles tendinopathy. As a result of this study, they determined that MA application was effective in relieving pain, improving function and correcting mechanical changes of the tendon.³⁷ The use of MA application in the field of physical therapy has begun to increase. When we look at the studies, MA application has begun to be used in many areas such as chronic musculoskeletal problems, fracture healing, rheumatological problems and algoneurodystrophy.

After MA application, circulation increases, toxins in the damaged area decrease and endorphin release increases, thus showing an analgesic effect by reducing sensitivity in pain receptor areas. As a result, it accelerates tissue healing and reduces pain. Magnetic fields also stabilize lysosomes and other organelles at the cellular level, regulate enzymatic activity, and promote cell proliferation by regulating calcium homeostasis. MA applications have direct and indirect effects. Direct effects; analgesic effect, neuron firing, calcium ion movement, membrane potentials, endorphin levels, nitric oxide, dopamine levels, acupuncture effects and nerve regeneration. Indirect effects are increased circulation, oxygenation of muscles and surrounding tissues, inflammation and healing.^9,10,36,37

In our study, pain levels in patients diagnosed with heel spurs who received MA treatment decreased significantly and no difference was observed between them and patients who underwent ESWT.

Markovic et al. reviewed the terms magnetic field therapy, electromagnetic field, magnetic stimulation, pulsed electromagnetic field, and low field magnetic stimulation. All of these are considered magnetic field applications.³⁵ We used pulsed electromagnetic field stimulation application.

Chang et al.³⁸ and Kane et al.³⁹ stated that there was a strong relationship between increased BMI and heel pain. The average BMI of our patients was 25.60 + 1.18 in the ESWT group and 27.35 + 1.62 in the MA group. In our study, BMI was above normal limits in both groups. In this respect, it is parallel to the literature. An increase in BMI is likely to increase the load on the feet, causing plantar fascia stretching and heel spurs. Additionally, weight gain may lead to changes in the biomechanical function of the foot, which may pave the way for heel spur formation.

Liang et al.⁴⁰ stated that female gender is associated with heel spurs. Similarly, in our study, 76.9% of the patients were women. Women generally use narrow-toed and high-heeled shoes, are exposed to hormonal changes that may affect the connective tissue, and lower extremity mechanics are different from men due to the pelvic structure, which may be the reasons for higher heel spur exposure.

While the average age in the ESWT group was 47.36 the average age in the MA group was 48.36. There was no significant difference in age between the groups.

This study is not without limitations. The most important limitation is the lack of long-term follow-up. Despite this, the improvement in the patients’ pain during the 8-week follow-up after treatment showed the effectiveness of the treatments. Another limitation was the small number of participants. As a result of the power analysis, a total of 44 patients were planned to be included in the study. However, because of the exclusion of patients with missing data from the study, 5 people were included in the study less than the targeted number of participants. This deficiency is not expected to have a major impact on the reliability and validity of the study. The fact that we have a similar number of patient populations to the study on which we based the sample size calculation suggests that this effect is at an acceptable level. Additionally, because the study was designed retrospectively, control over the intervention or conditions was not achieved, which may have made it difficult to eliminate some confounding factors that could affect the study results.

Conclusion

It was concluded that both MA treatment and ESWT treatment are effective in patients with heel spurs. However, it was observed that these two treatment methods had no advantage over each other. It is recommended that both methods can be used safely and effectively in the treatment of heel spurs. However, it is recommended to conduct randomized controlled studies involving a larger number of participants on this subject. According to these findings, we think that our study can contribute to the international literature and reveal a different awareness in physicians’ clinical approaches to the disease.

Footnotes

Acknowledgments

The authors have no acknowledgments.

ORCID iDs

Ozlem Akkoyun Sert

Kamil Yilmaz

Ethical approval

The study was approved by the KTO Karatay University Non-drug and Medical Device Research Ethics Committee (protocol number 2022/033; date 25.05.2023).

Informed consent

Not applicable.

Author contributions

Conception and design: OAS, KY; Methodology: KY; Investigation: OAS; Resources: OAS; Writing: OAS; Writing-Review and Editing: KY. Both authors have read and agreed to the published version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

Data associated with the article are not publicly available, but can be obtained from the corresponding author upon reasonable request.

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