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IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL

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Background and Objectives: Plantar fasciitis is a common foot disorder in which patients have pain and tenderness at the sole of the foot. Rest, exercises, orthotics, taping, cryotherapy, therapeutic ultrasound, electrical stimulation, whirlpool bath, and iontophoresis have been widely used to relieve plantar pain. Long term use of manual therapy techniques like myofascial release technique, positional release therapy and passive stretching have been used in the past to reduce pain and improve ankle range of motion. The present study aimed to evaluate and compare the immediate effectiveness of myofascial release technique, positional release therapy and passive stretching on pain response and ankle flexibility in chronic plantar fasciitis. Material and methodology: A total of 60 participants with chronic plantar fasciitis were randomly allocated to Group A (myofascial release group) and Group B (positional release group) and Group C (passive stretching). Therapeutic ultrasound with intensity of 1W/cm2 and frequency of 1MHz for 5 min was given for a single session to all the patients and then given the manual techniques. Visual analogue scale, range of motion of the ankle were outcome measures that were assessed pre- and immediately post-interventional. Results: The study demonstrated statistical significant reduction in pain, in all three groups (p
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Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
875
Original Article
IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION
TECHNIQUES ON PAIN RESPONSE AND FLEXIBILITY IN CHRONIC
PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL
Renu B.Pattanshetty *
1
, Amit S.Raikar
2
.
*1
Assistant Professor, KLEU Institute Of Physiotherapy, Belgaum, Karnataka, India.
2
Post Graduate Student, KLEU Institute Of Physiotherapy, Belgaum, Karnataka, India.
Background and Objectives: Plantar fasciitis is a common foot disorder in which patients have pain and
tenderness at the sole of the foot. Rest, exercises, orthotics, taping, cryotherapy, therapeutic ultrasound, electrical
stimulation, whirlpool bath, and iontophoresis have been widely used to relieve plantar pain. Long term use of
manual therapy techniques like myofascial release technique, positional release therapy and passive stretching
have been used in the past to reduce pain and improve ankle range of motion. The present study aimed to
evaluate and compare the immediate effectiveness of myofascial release technique, positional release therapy
and passive stretching on pain response and ankle flexibility in chronic plantar fasciitis.
Material and methodology: A total of 60 participants with chronic plantar fasciitis were randomly allocated to
Group A (myofascial release group) and Group B (positional release group) and Group C (passive stretching).
Therapeutic ultrasound with intensity of 1W/cm
2
and frequency of 1MHz for 5 min was given for a single
session to all the patients and then given the manual techniques. Visual analogue scale, range of motion of the
ankle were outcome measures that were assessed pre- and immediately post-interventional.
Results: The study demonstrated statistical significant reduction in pain, in all three groups (p<0.0001). Ankle
range of motion showed significant improvement in Group A (MFR). Group C (passive stretching) demonstrated
significant improvement (p=0.001) as compared to Group B (PRT).
Conclusion: All three manual techniques with therapeutic ultrasound were effective in immediate relief of pain
and improving ankle range of motion in subjects with chronic plantar fasciitis.
KEYWORDS: Plantar fasciitis, myofascial release, positional release therapy, passive stretching, therapeutic
ultrasound.
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Renu B. Pattanshetty, MPT; Ph.D. Assistant Professor, KLEU
Institute Of Physiotherapy, Belgaum-590010, Karnataka, India. Contact No.: +919448482564
E-Mail: renu_kori@rediffmail.com
International Journal of Physiotherapy and Research,
Int J Physiother Res 2015, Vol 3(1):875-84. ISSN 2321-1822
DOI: 10.16965/ijpr.2015.101
The human ankle/foot complex meet the stability
demands of providing a stable base of support
for the body in a variety of weight bearing
postures without undue muscular activities and
energy expenditure, and acting as a ‘rigid’ lever
for the mobility demands by dampening of rotat-
ions imposed by the more proximal joints of the
lower limb,being flexible to absorb the shock of
the superimposed body weight as the foot hits
the ground and allowing the foot to conform to
the changing and varied terrain on which the
foot is placed. Four of Cailliet’s criteria for
normal foot are absence of pain, normal muscle
balance, central heel and straight and mobile
Quick Response code
Access this Article online
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DOI: 10.16965/ijpr.2015.101
Received: 07-01-2015
Peer Review: 07-01-2015
Revised: None
Accepted : 23-01-2015
Published (O): 11-02-2015
Published (P): 11-02-2015
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
876
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
toes [1].
Plantar fascia called as plantar aponeurosis, lies
superficial to the muscles of the plantar surface
of the foot. It has thick central part which covers
the central muscle of the 1
st
layer, Flexor
digitorum brevis and is immediately deep to the
superficial fascia of the plantar surface. It acts
as a truss, maintaining the medical longitudinal
arch of the foot, and assists during the gait cycle
and facilities shock absorption during weight
bearing activites[2].
Foot complaints are common in general practice
and their incidence increases with age. Three
out of four people complains of foot pain during
the course of a life time [3], While approximately
20% of people aged 65 years or older complains
of non traumatic foot problems [4]. Plantar
fasciitis has been experienced by 10% of the
population [5].
The foot is subjected to various types of injuries
like laceration, contusion, ligaments sprains and
rupture, fracture, penetrating wounds, etc In
addition, pathologic changes are imposed on the
foot by congenital abnormalities, bacterial and
fungal infections and dermatologic lesions, ill
fitting shoes,walking on hard surfaces [6].
Different authors have described heel pain as
achilles spurs, retrocalcaneal bursitis,
subcalcaneal pain, posterior heel pain, plantar
fasciitis etc. Heel pain commonly occurs in
weight bearing due to inflammation of thick
tissue at the sole. Stress to plantar fascia may
also result from injury, or a bruise incurred while
walking, running, or jumping on hard surfaces;
or being overweight [7]. Hence, causes of heel
pain may be described as plantar, lateral, medial,
posterior, and diffuse [8], and may either be
caused due to injury to the soft tissue, bone,
nerve or plantar fascia [9].
Plantar fasciitis an inflammation of the plantar
fascia is one of the most common causes of foot
pain in which pain and tenderness are located
inferiorly at the plantar fascia origin [10]. It is
more common in sports that involves running,
long distance walking, dances, tennis players,
basket ball players and non athletes whose
occupation requires prolonged weight bearing
[11]. Other causes are mechanical stress
involving compressive forces making foots
longitudinal arch flat [5]. Repeated micro
traumas cause inflammation at the origin of the
plantar fascia over the calcaneal medical
tuberosity. Traction forces during the support
phase on gait lead to an inflammatory process,
resulting in fibrosis and degeneration [12].
There is a loss of flexibility as the disease
progresses due to calcaneal tendon retraction,
fatigue, fascial inextensibility, and poor
mechanics [5].
Though etiology is unknown in approximately
85% of cases, plantar fasciitis can occur in
association with various arthritides. In an
athlete, plantar fasciitis appears to be
associated with overuse, training errors, training
on unyielding surfaces and improper or
excessively worn foot wear. Sudden increase in
weight bearing activity, particularly those
involving running can cause micro-trauma to the
plantar fascia. In elderly adults, plantar fasciitis
is often attributable to poor intrinsic muscle
strength and poor force attenuation secondary
to acquired pesplanusand compounded by a
decrease in the bodys healing capacity [13].
Patients with plantar fasciitis typically present
with inferior heel pain on weight bearing and
pain often persist for months to years. Pain may
be throbbing, searing or piercing, especially with
the first few steps in the morning or after periods
of inactivity. The discomfort often improves after
further ambulation but worsens with continued
activity, often limiting daily activities. The
patient usually has tenderness around the
medial calcaneal tuberosity at the plantar
aponeurosis [14].
Medical and surgical management for plantar
include non-steroidal anti inflammatory drugs,
local cortisone injections, resection of the
calcaneal spur or part of the plantar fascia near
its origin, stripping off the soft tissue from the
plantar surface of the calcaneus and excision
of the medial inferior tubercle of the calcaneus.
Other therapies include acupuncture, electron
generating devices, insoles with magnetic foil,
extracorporeal shock wave therapy [15].
Various physiotherapy treatment protocols have
been advocated in the past such as rest, taping,
orthotics,silicon heel cups, stretching, myo-
fascial release and positional release therapy.
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
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Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Electrotherapy modalities liketherape-utic
ultrasound, phonophoresis, laser, microwave
diathermy, iontophoresis, cryotherapy, contrast
bath have been tried in past. Non weight-bearing
stretching exercises have shown to helpful in
reducing severe pain which occurs in the morning
[16].
Therapeutic Ultrasound is a method of applying
deep heat to connective tissue [15]
which plays
an important role in relieving plantar heel pain
by both thermal and mechanical effect on target
tissue resulting in increased local metabolism,
circulation and extensibility of connective tissue
and tissue regeneration. To obtain increase in
the viscoelastic properties of collagen, an
elevation in tissue temperature of greater than
to 4°C is indicated [17].
Stretching of the shortened and contracted
plantar flexors may positively influence an
individual’s functional activities of daily living
and decrease the risk of injury. Regardless of
the type of fitness and rehabilitation program,
the goal of stretching is to change the physical
characteristics of connective tissue [18].
Myofascial release technique is a soft tissue
mobilization technique mostly given in the
chronic conditions that causes tightness and
restriction in soft tissues. This technique has
been proposed to act as a catalyst in the
resolution of chronic plantar fasciitis [19].
Positional release therapy is an indirect
myofascial technique focused on the neurologic
component of the neuro-vascular myofascial
somatic dysfunction.This technique is proposed
to increase muscle flexibility by placing the
muscle in a shortened position to promote-
muscle relaxation in contrast to placing the
muscle in a lengthened or stretched position
[20].
Since there is dearth of literature to show the
immediate effectiveness of myofascial release
therapy, positional release technique and
passive stretching, in chronic plantar fasciitis,
the present study was proposed to evaluate and
compare the three manual techniques on
immediate response to pain and flexibility in
chronic plantar fasciitis. It was hypothesized that
there would be no difference in pain and
flexibility with myofascial release, positional
release therapy and passive stretching after a
single session in chronic plantar fasciitis.
METHODOLOGY
Participants: Subjects between 18 and 60 years
old with chronic plantar fasciitis with duration
of more than three months and willing to
participate in the study were recruited. The data
was collected from the physiotherapy outpatient
department at an Indian tertiary care set-up
during the study period extending from nine
months.Subjects were excluded if they had
clinical disorder where therapeutic ultrasound
is contraindicated such as infective conditions
of foot, tumor, and calcaneal fracture, metal
implant around ankle, Subjects with clinical
disorder where myofascial release is
contraindicated such as dermatitis, Ankle
ankylosis, congenital foot deformities,
corticosteroids injection in heel in past three
months and subjects with referred pain due to
sciatica and other neurological disorders were
excluded.
Ethical approval for the study was granted by
the Institutional Ethical Committee and the
procedures were conducted according to the
declaration of Helsinki.
Study design: This study was pre post
experimental design with random allocation of
the subjects by envelope method to either of
the three groups (myofascial group, positional
release group and passive stretching group)
using non probability sampling method. Total
number of Sample size was calculated to be 60
participants ( error = 80 and level of
significance = p 0.05)
Procedure: Subjects were initially examined for
assessing compliance with inclusion and
exclusion criteria. In addition, demographic and
anthropometry data of each subject were
recorded. After this initial evaluation, they were
randomly allocated to one of the three study
groups A, B and C respectively.
Group A: Myofascial release group [19]
Participants were placed in prone lying position
with foot placed outside the plinth. Then the part
was cleaned and gel was applied to the involved
site and then transducer head was moved in slow
circular manner for 5 minutes. Subjects underwe-
α
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
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nt myofascial release manually by using thumb
and plantar cupping by using heel of hand and
fingers technique for 10 min in supine lying for
single session (photograph no. 2).
Group B: Positional release group [20]
Subjects were given positional release technique
manually by applying brief mechanical pressure
on the tender point with one fingertip in order
to determine tenderness. The foot was then
positioned, into pure plantar flexion and gentle
fine tuned by rotation, until the score in the
tender point reduced to at least 70%. This
position was held for 90 seconds following
which slow release of pressure was applied and
returned to neutral position; this was carried out
in a single session (Photograph. 3).
Group C: passive stretching group [18]
For stretching ankle plantar flexors , firstly the
Fig. 1: Consort Study Flow Chart.
soleus muscle was stretched with knee flexed
and then gastrocnemius muscle was stretched
with knee extended, over pressure was placed
up on the bottom of the foot while the ankle
was held in dorsi-flexion in supine lying. Passive
plantar fascia stretching was performed in
supine lying by application of force distal to the
metatarsophalangeal joints on the affected side,
pulling the toes upward towards the shin until a
stretch was felt in the sole of the foot.
Stretchings were performed for three repetitions
each held for count of 30 sec for a single session
in supine lying (Photograph no. 3).
Therapeutic ultrasound with intensity of
1W/cm
2
and frequency of 1MHz for 5 min was
given for a single session to all the patients.
(Photograph no. 1)
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
879
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Outcome measures:
1. Pain: This was recorded by 10 cm horizontal
visual analogue scale (VAS), the participants
were asked to mark their intensity of pain on a
10 cm long line in the data collection sheet with
numbers 0 to 10 where 0 symbolized no pain
and 10 was severe pain.
2. Ankle Range Of Motion (ROM): Ankle plantar
and dorsi flexion ROM was measured by
Universal Goniometer. They were measured with
subjects in high sitting position with ankle placed
in 90º as the starting position, this reading was
transposed and recorded as 0º.The Fulcrum was
centered over the lateral aspect of the lateral
malleolus, the proximal arm aligned with the
lateral midline of the fibula, using the head of
fibula as the reference and the digital arm
parallel to the lateral aspect of the 5
th
metatarsal. The average of the three readings
was recorded.
VAS score and ROM for each group were
measured pre and immediately post intervention,
in all the 3 groups.
Data analysis:
Analysis of raw data was done using SPSS
windows version 13.0 version. Descriptive
statistics were used to define the demographic
characteristics of the sample. Various statistical
measures such as mean, standard deviation and
tests of significance such as Chi-Square test,
student paired ttest, one-way Analysis of
Variance (ANOVA) and multiple comparison
Scheffe test were utilized for this purpose.
Nominal data using F test , ANOVA and
Chi-Square test was done. Intra group
comparison of the pre interventional and post
interventional outcome measures was done by
using student paired ‘ttest whereas one way
ANOVA and multiple comparison Scheffe test
was used to measure the inter group difference.
Probability values less than 0.05 were considered
statistically significant ( p 0.05).
RESULTS
A total of 60 subjects with chronic plantar
fasciitis accepted to participate in the study out
of which 30 were males and 30 were females.
There were 11 males and 9 females in group A,
9 males and 11 females in group B, 10 males
and 10 females in group C. (c
2
= 0.40, p=0.8187).
The average age of the subjects in group A was
34.25 ± 13.89 years, group B subjects was 36.60
± 14.58 years and group C subjects mean age
was 37.85 ± 13.78 years. Age was well matched
in all three groups (F= 0.3367, p= 0.7155). There
was no significant difference between the mean
BMI values of the subjects in three the groups.
(F= 0.4794,p= 0.6216)
The pre-interventional values of Visual analogue
score within the group was 7.92 ± 0.98, 7.30 ±
1.68, and 7.13 ± 1.56 in group A, B and C
respectively whereas post-interventional values
of Visual analogue score was 3.68 ± 1.71, 3.13
± 1.85, and 3.78 ± 2.03, in group A, B, and C
respectively. VAS scores were statistically
significant post interventional for all the three
groups (p < 0.0001). The inter group analysis
for VAS showed no significant difference in the
reduction of pain when compared between all
the three groups.
Values of pre-interventional ankle active
dorsiflexion range of motion in group A was
16.60 ± 1.10 degrees, group B was 16.60 ± 1.64
degrees, and group C was 16.80 ± 1.54 degrees
whereas post-interventional ankle dorsiflexion
range in group A was 20.00 ± 1.03 degrees, group
B was 17.65 ± 1.57 degrees, and group C was
20.30 ± 1.13 degrees. Comparing pre- and post-
interventional valuesof ankle active dorsiflexion
range of motion, values in all the three groups
had shown statistical significant difference
(p<0.0001). The inter group analysis for active
dorsiflexion range of motion showed statistically
significant difference between group A versus
group B (p<0.0001), group A verses group C
showed no statistically significant difference
(p=0.754), group B verses group C showed
statistically significant difference (p<0.0001).
Comparison of pre-interventional versus post-
interventional values, all the three groups
showed statistical significant difference
(p<0.0001) in improving ankle plantarflexion
range of motion. The inter group analysis for the
same showed statistically significant difference
between group A and group B (p=0.0025).
comparison of Group B and group C showed
statistically significant difference (p=0.0263).
However, group A verses group C showed no
statistically significant difference (p=0.6912).
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
880
Photograph1: Patient receiving
therapeutic ultrasound.
Photograph 2: Patient receiving
myofascial release therapy.
Photograph 3: Patient receiving
positional release therapy.
Photograph 4: Passive stretching of
soleus.
Photograph 5: Stretching of plantar
fascia.
Photograph 6: Passive stretching
of gastrocnemius.
Table 1: Age distribution & Anthropometric variables.
Groups
Mean Age
(Years)
Mean BMI
Group A 34.25 ± 13.89 24.13 ± 2.21
Group B 36.60 ± 14.58 23.60 ± 2.99
Group C 37.85 ± 13.78 23.37 ± 2.25
Table 2: Gender Distribution in all the three groups.
Gender
Group A
Group B
Group C
11
9
10
Females
9
11
10
Total
20
20
20
Table 3: Mean changes in Visual Analogue Scale
Scores (cms) in all the three groups.
Pre Treatment Post Treatment
Group A 7.92 ± 0.98 3.68 ± 1.71
Group B 7.30 ± 1.68 3.13 ± 1.85
Group C 7.13 ± 1.56 3.48 ± 2.03
Groups
Visual Analogue Scale (cms)
Pre Treatment Post Treatment Pre Treatment Post Treatment
Group A 16.60º± 1.10º 20.00º ± 1.03º 41.3 ± 1.8 44.05º ± 1.76º
Group B 16.60º ± 1.64º 17.65º ± 1.57º 40.8 ± 3.0 41.30º ± 2.90º
Group C 16.80º ± 1.54º 20.30º ± 1.13º 40.85º ± 2.98º 43.40º ± 2.35º
Groups
DORSI FLEXION ROM PLANTAR FLEXION ROM
Table 4: Mean differences in ankle Range of Motion
(ROM in degrees) in all the three groups.
Table 5: Comparison of VAS and ankle range of motion
in all the three groups.
Dorsiflexion ROM Plantar-flexion ROM
Value
Visual Analogue Scale
Pre Treatment Vs.
Post Treatment
Groups
<0.0001
Significant
Group A p
Group B p
<0.0001
Significant
<0.0001
Significant
<0.0001
Significant
<0.0001
Significant
Group C p
Pre Treatment
Vs.
Post Treatment
Pre Treatment
Vs.
Post Treatment
<0.0001
Significant
<
0.0001
Significant
0.00043
Significant
<0.0001
Significant
Table 6: Comparison of visual analogue scale score
(VAS) in all the three groups (pre and post interventional)
VAS Score Source of variance SS DF MS F ‘p’
Between group 6.9803 2 3.4902
Within group 117.909 57 2.0686
Between group 3.1103 2 1.5552
Within group 198.487 57 3.4822
Visual Analogue Scale
Pre Interventional 1.6872 0.1941
Post Interventional 0.4466 0.642
Table 7: Comparison of ankle dorsi-flexion ROM in all
the three groups.
Active ROM Source of variance SS DF MS F p’
Between group 0.5333 2 0.2667
Within group 118.8 57 2.0842
Between group 84.233 2 42.116
Within group 90.75 57 1.5921
DORSIFLEXION (ROM)
Pre Interventional 0.1279 0.8802
Post Interventional 26.453 7.468
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
881
Table 8: Comparison of ankle plantar-flexion range of
motion in all the three groups.
Source of variance SS DF MS F p
Between group 3.3333 2 1.6667
Within group 413.65 57 7.257
Between group 82.633 2 41.316
Within group 323.95 57 5.6833
0.7955
PLANTARFLEXION (ROM)
Passive ROM
Pre Interventional
0.2297
Post Interventional
7.2698 0.0015
Table 9: Comparison of ankle ROM post- treatment in
all the three groups.
Dorsiflexion(ROM) Plantarflexion( ROM)
Significant Significant
Not Significant Not Significant
Significant Significant
‘p' value
GROUPS
0.75483 0.6912
<0.0001 0.0263
Group A
Vs.
Group B
Group A
Vs.
Group C
Group B
Vs.
Group C
<0.0001 0.0025
DISCUSSION AND CONCLUSION
This clinical trial was conducted to evaluate and
compare the immediate effectiveness of
myofascial release technique, positional release
technique and passive stretching on pain and
flexibility in subjects with chronic plantar fasciitis
along with therapeutic ultrasound. (Figure: 1)
All the three groups had equal number of
participants and were well matched in term of
gender distribution. Age group of subjects
ranged between 18 to 65 years. Majority of the
patients afflicted with subcalcaneal heel pain
are between 40 to 60 years of age, although the
range has been reported to be 8 to 80 years of
age [21].
A similar study reported that
subcalcaneal pain is a common orthopedic
problem that generally occurs in persons
ranging from 30 to 70 years of age [22].
Mean body mass index (BMI) of the subjects in
all the groups were 24.13 ± 2.21 for Group A
and 23.60 ± 2.99 in Group B and 23.37 ± 2.25 in
Group C. According to WHO standard ideal BMI
is in the range of 18.5 - 24.9 [23].
The BMI in all
the three groups were well matched.
Therapeutic ultra sound has shown to relieve
pain in plantar fasciitis, the results of which are
similar to the present study. Therapeutic
Ultrasound refers to mechanical vibrations
which are essentially the same as sound waves
but of a higher frequency. Therapeutic
frequencies of ultrasound range from 0.5 to 5
MHz. It has been estimated that for an output
of 1W/cm
2
there is a temperature rise of 0.8°C/
min [24].
If local temperature is raised between
40°C to 45°C hyperaemia will result [25].
To
achieve a useful therapeutic effect the tissue
temperature has tobe maintained between
thesevalues for at least 5 mins [26].
Also heating
fibrous tissue structures such as joint capsules,
ligaments, tendons and scar tissue may cause
a temporary increase in their extensibility, and
hence a decrease in joint stiffness. Mild heating
can also have the effect of reducing pain and
muscle spasm and promoting healing process
[27].
Pain relief may also occur due to the non
thermal effects of pulsed ultrasound in the form
of stimulation of histamine release from mast
cells and factors released from macrophages
that accelerate the normal resolution of
inflammation [26].
Therapeutic ultrasound has
the potential to accelerate normal resolution of
inflammation provided that the inflammatory
stimulus is removed [28].
The dosage for
therapeutic ultrasound used in the present study
was based on the evidence suggested by Hana
Hronkova et al [29].
Which has caused complete
disappearance of pain in 50% of the subjects
Pulsed Ultrasound was preferred for soft tissue
repair and 1 MHz frequency was chosen as it is
capable of reaching to deeper tissues [25].
Myofascial release has also shown to
decreasepain and improve functional foot index
in subjects with plantar fasciitis
30
, the results
of which are similar to the present study.
Myofascial release technique and passive
stretching with therapeutic ultrasound has
shown to relieve pain and normalize the
connective tissue by softening, lengthening and
realigns the fascia [31].
Patients with plantar
fasciitis present with reduced ankle range of
motion and great toe dorsiflexion due to pain
and a concomitant tight achilles.
32
Restricted
movement in ankle may also be due to
hyperactivity of the myotatic reflex arc which is
caused by excessive gamma gain [33].
The goal
of MFR is to release fascia restriction and
restore its tissue. This technique is used to ease
pressure in the fibrous bands of the connective
tissue function, or fascia. Gentle and sustained
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
882
stretching of myofascial release is believed to
free adhesions and softens and lengthens the
fascia. By freeing up fascia that may be
impending blood vessels or nerves, myofascial
release helps in improving circulation and
nervous system transmission. This technique has
been widely used in physical therapy treatments
in the chronic conditions causing tightness and
restriction in soft tissues. It helps in change of
the viscosity of the ground substance to a more
fluid state which eliminates the fascia’s
excessive pressure on the pain sensitive
structure and restores proper alignment. There
is sufficient evidence to support the
effectiveness of deep tissue procedures in
treating strain/sprain injuries [34,35].
It has also
shown to stimulate fibroblast proliferation,
leading to collagen synthesis that may promote
healing of plantar fasciitis by replacing
degenerated tissue with a stronger and more
functional tissue [36.37].
The reasons mentioned
above may explain the reason for relieving pain,
improvement range of motion in myofascial
release therapy group similar to the study [30].
Direct MFR is a highly effective technique for
subjects with plantar fasciitis who need to
recover quickly. All the treatment methods were
equally beneficial in relieving pain and improving
ROM.
Positional release therapy is a technique
proposed to increase muscle flexibility by
placing the muscle in a shortened position to
promote muscle relaxation in contrast to placing
the muscle in a lengthened or stretched position
[20].
Also called as counter-strain therapy, it is
an indirect myofascial technique focusing on the
neurologic component of the neuro-vascular
myofascial somatic dysfunction. The use of body
positioning, tender points to identify the lesion
and to monitor the therapeutic intervention are
some of the Positional release therapy indirect
approaches with respect to tissue resistance
[31].
The neurophysiologic rationale underlying
the therapy is based on the fact that alteration
in afferent neurons affect somatic joint
dysfunction. Restricted movement may be due
to hyperactivity of the myotatic reflex arc, which
is caused by excessive gamma gain. By
positioning the patients muscle in the position
of ease for a short period of time, the gamma
gain decreases, thereby allowing the hyperactive
reflex arc to return to its original state and range
of motion to increase. This technique has been
proposed for resolving dysfunction in chronic,
subacute and acute condition [38]. The treatment
duration (90 sec) for Positional release therapy
selected for this study produced immediate
significant pain relief which further suggests
that this time duration may be used in similar
clinical set-ups in alleviating pain in chronic
plantar fasciitis [33].
Pain relief may also occur
due to decrease in the intrafusal and extrafusal
fiber disparity and reset of the inappropriate
proprioceptive activity. Korr has provided a
conceptual model how different manipulative
techniques like isometrics and stretching may
be effective in treatment of somatic dysfunction
[39].
Wynne MM et al demonstrated reduction
in pain and improvement in functional ability
using positional release therapy results of which
are similar to the present study [23]. Use of
positional release therapy normalizes myotatic
reflex arc thus producing movement gains, which
may explain the reason for improvement in ankle
ROM in the present study. But when compared
to MFR and Passive Stretching ROM gains were
to a lesser extent. Stretching is a term used to
describe any therapeutic maneuver designed to
increase mobility of soft tissue and subsequently
improve ROM by elongating structures that have
adaptively shortened and have become
hypomobile over time. When a muscle is
stretched and elongated, the stretch force is
transmitted to the muscle fibers via the
connective tissue (endomysium and perimysium)
in and around the fibers. It is hypothesized that
molecular interactions link these noncontractile
elements to the contractile unit of muscle, the
sarcomere. During passive stretch both
longitudinal and lateral force transduction
occurs [40].
Since stretching is an integral part
of treatment component of physical fitness and
rehabilitation programmes, it is thought to
positively influence performance and injury
prevention especially in the athletes. Shortening
and contracture of the plantar flexors may cause
limitations in ROM that restrict the normal action
of muscle. This condition may be managed with
a stretching program, which may decrease the
risk of injury. Regardless of the type of program,
the goal of stretching is to change the physical
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
Int J Physiother Res 2015;3(1):875-84. ISSN 2321-1822
883
characteristics of connective tissue. Passive
stretching along with therapeutic ultrasound
demonstrated marked reduction in pain and
improvement in range of motion in the present
study and it correlates well with the results of
study by CA Knight et al. The author suggested
stretching of the Achilles tendon and plantar
fascia, performed 3-5 times daily, showed
significant decrease in pain in plantar fascia [18].
However, the present study aimed to evaluate
the immediate effectiveness of stretching
rather than a long term study. To conclude, the
present study is the first to report the immediate
effectiveness of myofascial release technique,
positional release therapy and passive stretching
on pain response and flexibility in chronic
plantar fasciitis in all three groups. Future
research should consider using a larger sample
size in different populations like athletes and
elderly population along with different electrical
modalities, more number of treatment sessions
and a follow-up.
CLINICAL MESSAGE:
Use of manual techniques like myofascial
release therapy, positional release therapy or
passive stretching may be used along with
therapeutic ultrasound in the treatment of
chronic of plantar fasciitis instead of using
therapeutic ultrasound in achieving immediate
relief of pain and improving ankle range of
motion.
ACKNOWLEDGEMENTS:
We would like to mention a special thanks to
M.D. Mallapur, Lecturer, Dept. of community
medicine, JN Medical College, Belgaum,
Karnataka for helping us with the analysis of the
data and also like to thank all the individuals
who participated in the study.
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How to cite this article:
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT
TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND FLEXIBILITY
IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL. Int J
Physiother Res 2015;3(1):875-884. DOI: 10.16965/ijpr.2015.101
Renu B.Pattanshetty, Amit S.Raikar. IMMEDIATE EFFECT OF THREE SOFT TISSUE MANIPULATION TECHNIQUES ON PAIN RESPONSE AND
FLEXIBILITY IN CHRONIC PLANTAR FASCIITIS: A RANDOMIZED CLINICAL TRIAL.
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Background: Disorder of plantar fascia caused from overuse, excessive overload or prolonged standing time is called plantar fasciitis. Conservative treatment is a primary choice of treatment for plantar fasciitis and physiotherapist play a vital role. Interventions such as ultrasound, soft tissue massage, orthotics, taping, hot pack, cold pack, stretching and strengthening exercises are used by physiotherapists for treatment of this condition. Objectives: This study is aimed to evaluate and compare the effectiveness of myofascial release technique and static stretching of plantar fascia, on pain among adults with plantar fasciitis. Methods: All the subjects were screened as per the inclusion & exclusion criteria. After getting their written consent, a total of 42 plantar fasciitis patients with mean age of 28 years were included in the study. They were randomly allocated into two groups with n= 21 in each group. Group A was given Myofascial Release Technique whereas Group B was given Static Stretching on the affected plantar fascia. The interventions were carried out for twice a week for two weeks. Visual Analogue Scale was used as the outcome measure and it was measured pre- and post-intervention at baseline during week one and at the end of treatment at week two. Results: The study demonstrated statistically significant difference between pre-treatment and post-treatment visual analogue scale scores, in both groups: MFR (p < .0001) and Static Stretching (p < .0011). Conclusion: Both MFR as well as static stretching are effective in reducing pain in plantar fasciitis patients. KEY WORDS: Plantar Fasciitis, Static Stretching, Myofascial Release, Pain, Visual Analogue Scale.
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Background: Plantar fasciitis is a common cause of pain in the heel which occurs as a result of inflammation of the plantar aponeurosis at its attachment on the calcaneal tuberosity. Myofascial Release Technique is intended to improve the mobility of soft tissue through application of a slow, controlled mechanical stress directly into a restriction. Pressure is gradually increased or repeated until the mobility of the tissue is felt to improve. Purpose: The purpose is to study the scientific evidences regarding the effect of the myofascial release technique in plantar fasciitis. Methodology: A search for relevant articles was carried out using key words- plantar fasciitis, myofascial release technique, pain and function and search engines- Google Scholar, PubMed, PEDro, ScienceDirect, ResearchGate and CINAHL. Studies were selected from year 2010-2019. Ten studies were included in which there were 7 RCT, 1 Prospective experimental study, 1 Quasi Experimental study and 1 Pre-post interventional study. Results: 10 studies were reviewed from which 7 studies concluded that MFR is more effective than a control group receiving sham treatment or conventional treatment and 3 studies highlighted MFR to be equally effective to alternative treatments. Conclusion: Based on the analysis of these 10 articles, it can be concluded that MFR is an effective treatment regimen in individuals with Plantar Fasciitis. Clinical Implication: MFR is found to be effective in reducing pain and improving functions in individuals with plantar fasciitis, therefore MFR technique can be considered as an adjunctive treatment in plantar fasciitis. Keywords: Plantar Fasciitis, Myofascial Release Technique, Pain, Function.
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That plantar fasciitis is one of the most common causes of heel pain is beyond dispute. It is also by far the most common sports injury presenting to the office of the sports podiatrist (Bartold, 2001, Sports Medicine for Specific Ages and Abilities. Churchill Livingstone, Edinburgh, p. 425) and accounts for approximately 15% of all foot related complaints (Lutter, 1997, Med. J Allina. 6(2) http://www.allina.com). The term plantar fasciitis itself has been responsible for considerable confusion, since the condition usually presents as a combination of clinical entities, rather than the discrete diagnosis of plantar fasciitis. For this reason, it may be preferable to consider the condition a syndrome, and alter the nomenclature to plantar heel pain syndrome (PHPS).Despite its wide distribution in the sporting and general communities, there remains widespread debate on its aetiology and dissatisfaction with a lack of reliable treatment outcomes. This paper describes the unique anatomical and biomechanical features of plantar fasciitis which may in part explain its resistance to treatment. The history and physical examination are described along with potential differential diagnoses. Because plantar fasciitis is multi-faceted in nature, treatment may be directed at the wrong focus, resulting in poor outcomes and prognosis. The most common conservative management techniques are described, and a new, reliable method of taping is proposed.
Article
Plantar fasciitis is a common cause for heel pain and is the result of a degenerative process of the plantar fascia at its calcaneal attachment. Age, obesity, excessive weight bearing and tight Achilles tendon are the common predisposing factors. Though this is a self-limiting condition, the time for resolution of symptoms is highly variable. Commonly used treatments are rest, analgesics, heat and cold application, stretching exercises, splints and orthoses. Local infiltration with steroids, radiotherapy, extracorporeal shock wave treatment and surgery are used in more resistant cases. We review the current understanding and concepts in the treatment of this condition.
Article
Purpose The aim of this study was to compare the immediate effect, on pain threshold, following a single treatment of tender points in the upper trapezius muscle involving a classical and a modified application of the strain/counterstrain technique. Methods Fifty-four subjects presenting with mechanical neck pain, 16 men and 38 women, aged 18–64 years old, participated in this study. Subjects underwent a screening process to establish the presence of tender points in the upper trapezius muscle. Subjects were divided randomly into three groups: group A was treated with the classical strain/counterstrain technique, group B was treated with the modified application of the technique which included a longitudinal stroke during the application of strain/counterstrain, and group C was a control group. The outcome measure was the visual analogue scale assessing local pain elicited by the application of 4.5 kg/cm2 of pressure on the tender point. It was assessed pre-treatment and 2 min post-treatment by an assessor blinded to the treatment allocation of the subject. Results Within-group changes showed a significant improvement in the visual analogue scale following either classical or modified application of the strain/counterstrain technique (P < 0.001). The control group did not show any change (P > 0.3). Pre-post effect sizes were large in both strain/counterstrain groups (D = 1.1), but small in the control group (D = 0.01). Differences were found between both strain/counterstrain groups as compared to the control group (P < 0.001), but not between both strain/counterstrain groups (P = 0.8). Conclusions Our results suggest that strain/counterstrain was effective in reducing tenderness of tender points in the upper trapezius muscle. The application of a longitudinal stroke during the strain/counterstrain did not influence the effectiveness of the classical description of the technique.
Article
BASIC PRINCIPLES Sports Medicine and Sports Therapy. Principles of Treatment. Physical Modalities. Connective Tissue Healing and Classification of Ligament and Tendon Pathology. Muscle Injury: Classification and Healing. Bone: A Specialized Connective Tissue REGIONAL CONSIDERATIONS Selected Conditions of the Foot. Hell Pain and Problems of the Hindfoot. Ankle Region. Exercise-Induced Leg Pain. Internal Derangement and Other Selected Lesions of the Knee. Anterior Knee Pain and the Patellofemoral Pain Syndrome. Bursitis and Knee Extensor Mechanism in Pain Syndromes. Knee Ligament Injuries: Classification and Examination. Knee Ligament Injuries: Treatment. Soft Tissue Injuries of the Thigh. Problems of the Hip, Pelvis, And Sacroiliac Joint. Injuries to the Thorax, Abdominopelvic Viscera, And Genitourinary System. Injuries and Conditions of the Neck and Spine. Injuries to the Head and Face. The Shoulder Region. The Elbow Region. Forearm, Wrist and Hand. Running, Injury Patterns, And Prevention APPENDICES Banned and Restricted Doping Classes and Methods. Travel with Atheletes. Traveller's Diarrhea (Emporiatric Enteritis). Temperature Control: Heat-Induced Injury. Participation Health Screening. Selected Protocols and Standards for Fitness Testing Index
Article
The purpose of this study was to examine the effect of deep transverse frictions on the healing of a minor sprain of the knee medial collateral ligament, in rabbits, using histological observations. Right knees of 18 animals were manually sprained; left knees served as controls. Deep transverse frictions were given five times to six animals; ten times to six animals. It was not possible on stained tissue sections to distinguish (P > 0.05) either between sprained or unsprained ligaments, or between treated and untreated sprained ligaments. The hypothesis that deep transverse frictions promote repair of sprained ligaments is not supported by the results of this study.J Orthop Sports Phys 1984;6(2):89-94.
Article
The healing response after tendon injury is defined by cell matrix adaptive capability. There are distinct macrotraumatic and microtraumatic injury patterns and a spectrum of pathologic responses from inflammation to tissue degeneration, as characterized by the tendinosis phenomenon. Epigenetic and genetic factors govern recovery from tendon injury. The potential for future modulation of injury repair by protein mediators or growth factors appears promising.
Article
This study reports the results of the use of molded ankle foot orthosis night splints for the treatment of recalcitrant plantar fasciitis on 14 patients with a total of 18 symptomatic feet. All patients had symptoms for greater than 1 year and had previously undergone treatment with non-steroidal anti-inflammatory medicines, cortisone injections, shoe modifications, and physical therapy without resolution. All patients were provided with custom-molded polypropylene ankle foot orthoses in 5 degrees of dorsiflexion to be used as a night splint. With continued use of nonsteroidal anti-inflammatory medication, Tuli heel cups, Spenco liners, and general stretching exercises, successful resolution occurred in 11 patients in less than 4 months. There were three failures. It is felt that the use of night splints provides a useful, cost-effective adjunct to current therapeutic regimens of plantar fasciitis.