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Indian Journal of Physiotherapy and Occupational Therapy

Effectiveness of Myofascial Release in Treatment of Plantar Fasciitis: A RCT

Author(s): Suman Kuhar, Khatri Subhash, Jeba Chitra

Vol. 1, No. 3 (2007-07 - 2007-09)

(1)Suman Kuhar, (2)Khatri Subhash, (3)Jeba Chitra

(1)Post Graduate Student, (2)Professor and Principal, (3)Assistant Professor, K.L.E.S. Institute of Physiotherapy, J. N. Medical College Campus, Belgaum, Karnataka

Print-ISSN: 0973-5666, Electronic – ISSN: 0973-5674,

ABSTRACT

Purpose of study: To find out the effectiveness of myofascial release in treatment of plantar fasciitis.

Materials and Methods: 30 subjects with the clinical diagnosis of chronic plantar fasciitis were randomly allocated to two study groups. Group A (control) received therapeutic ultrasound(1 MHz, 1 Watt/cm2,pulsed mode 1:4,5 minutes), contrast bath for 20 minutes, foot intrinsic muscles strengthening exercises, plantar fascia stretching exercises and group B (experimental) received conventional treatment as group A added with myofascial release for 15 minutes for 10 consecutive days. The outcome was assessed in terms of VAS and Foot Function Index.

Results: In this study we found that there was significant change in pain relief as per the VAS score (p=0.000) and functional ability as per Foot Function Index (p= 0.024).

Conclusion: It is concluded that myofascial release is an effective therapeutic option in the treatment of plantar fasciitis.

Key Words: Plantar fasciitis, myofascial release.

INTRODUCTION

Plantar fasciitis is the most common cause of inferior heel pain. The word ‘fasciitis’ assumes inflammation is an inherent component of this condition.

It is typically precipitated by biomechanical stress.

Plantar fascia is plantar aponeurosis, lies superficial to the muscles of the plantar surface of the foot. Plantar fascia has a thick central part which covers the central muscle of the 1st layer, flexor digitorum brevis and is immediately deep to the superficial fascia of the plantar surface. It acts as a truss, maintaining the medial longitudinal arch of the foot, and assists during the gait cycle and facilitates shock absorption during weight bearing activities. Plantar fasciitis has been reported across a wide sample of the community. In the non athletic population, it is most frequently seen in weight bearing occupations.65% of non sports demographics are over weight, with unilateral involvement most common in 70% of cases. Second major distribution of plantar fasciitis is in the athletic population, 10% of all running athletes. Basket ball, tennis, football, long distance runner and dance have all noted high frequency of plantar fasciitis.1

The classic presentation of plantar fascia is pain on the sole of foot at the inferior region of the heel. Patient report the pain to be particularly bad with the first step taken on rising in the morning or after an extended refrain from weight bearing activity. After few steps and through the course of the day, the heel pain diminishes, but returns if intense or prolonged weight bearing activity is undertaken. Initial reports of heel pain may be diffuse or migratory; with time it usually focuses around the area of the medial calcaneal tuberosity. Generally, pain is most significant when weight bearing activities are involved.2

Various physiotherapy treatment protocols have been advocated in the past such as rest, taping, orthosis- night splint, Silicon heel cups, stretching and myofascial release. Electrotherapy modalities in the form of ultrasound, phonophoresis, laser, microwave diathermy, iontophoresis, cryotherapy, contrast bath have been given in past.13 Myofascial release has been one of the physical therapy treatments given in the chronic conditions that causes tightness and restriction in soft tissues (e.g.:- fibromyalgia and post polio syndrome),asymmetrical muscle weakness due to peripheral neuropathy and in inflexible rib cage due to chronic respiratory disease and also in plantar fasciitis.

Myofascial release is a soft tissue mobilization technique. If the condition is treated in the acute stage, then symptoms will be aggravated. If treated in the chronic stage, the symptoms will alleviate. Myofascial release techniques stem from the foundation that fascia, a connective tissue found throughout the body, reorganizes itself in response to physical stress and thickness along the lines of tension.3 By myofascial release there is a change in 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.4 Hence this technique is proposed to act as a catalyst in the resolution of plantar fasciitis.

The present study was undertaken with the intention to find out the effectiveness of myofascial release in plantar fasciitis, in conjunction with conventional treatment and to compare the effectiveness of MFR over conventional treatment.

METHODOLOGY

The study was carried out in patients referred to Physiotherapy department of K.L.E.’s Hospital and Research Center, Belgaum, for treatment of plantar fasciitis. It was a randomized controlled trial study. Consent to carry out the study was granted by the Institutional ethical clearance committee. Both male and female (30 subjects) individuals suffering with heel pain and clinically diagnosed plantar fasciitis since 6 weeks referred to physiotherapy department and willing to take treatment for 10 successive days, were enrolled for that study.

INCLUSION CRITERIA

Subjects were selected for the study if they fulfilled the following criteria:

  1. Clinically diagnosed cases of plantar fasciitis not less than 6 weeks.
  2. Those who were willing to precipitate in the study and willing to take treatment for 10 successive days.
  3. Heel pain felt maximally over plantar aspect of heel
  4. Pain in the heel on the first step in the morning
  5. No history of rest pain in heel

EXCLUSION CRITERIA

  1. Subjects with clinical disorder where therapeutic ultrasound is contraindicated such as infective conditions of foot, tumor, calcaneal fracture, metal implant around ankle.
  2. Subjects with clinical disorder where myofascial release is contraindicated as dermatitis.
  3. Subjects with impaired circulation to lower extremities
  4. Subjects with referred pain due to sciatica and other neurological disorders.
  5. Arthritis
  6. Corticosteroids injection in heel preceding 3 months

Subjects selected for the study were randomly allocated to 2 groups – group A (Control group) and group B (Experimental group). For this purpose randomization is done by allocating subjects with odd number to control group and even number to experimental group. Then examination for sensory impairment by Semmes-Weinstein monofilaments, foot deformity, type of foot, Achilles tendon tightness, peripheral pulsations, foot wears. This was followed by objective assessment of the involved foot for tenderness, temperature, and swelling, pain on plantar fascia stretch and pain intensity in terms of the Visual Analog Scale (VAS). In addition to this functional assessment based on Foot Function Index was carried out. After this participants were randomly allocated to two groups, group A and group B.

Group A (control group): Participants were treated with

  1. Ultrasound with the output of 1W/cm2 for 5 minutes using a pulsed mode 1: 4 ratio with frequency of 1MHz for 10 sittings for 10 consecutive days.
  2. Contrast bath was given for 20 minutes for 10 days.5
  3. Exercises for intrinsic muscles strengthening
    1. Towel curl up For towel curl ups participants sat with foot flat on the end of towel placed on a smooth surface small weight is kept at the other end of towel. Keeping the heel on the floor, the towel was pulled towards the body by curling the towel with the toes, for 10 minutes.
    2. Active ankle exercises: For active ankle exercises – dorsiflexion, plantar flexion, inversion and eversion in supine lying 10 times.
    3. TA stretching: Active tendon Achilles stretching in standing by leaning against the wall, holding each stretch for 1 minute and repeating 5 times each session.
    4. Plantar fascia stretching with tennis ball. Subject sitting on the chair rolling foot on the ball for 5 minutes.6,7

Group B (experimental group): Subjects received conventional treatment as group A added with myofascial release by using thumb, plantar cupping and fingers technique for 15 minutes.

All the subjects were advised to use soft heel foot wear, not to stand for long time and not to walk bare foot. Participants were instructed not to do any stretching exercises at home.

Outcome was assessed, at the end of 10th day of intervention, based on Foot Function Index and pain on VAS.

RESULTS

The results of this study were analyzed in terms of pain relief by VAS and functional ability by FFI.

STATISTICAL ANALYSIS:

Statistical analysis was done by the GraphPad Prism software 4 version and also manually which was done to cross check the outcomes. Statistical measures such as unpaired ‘t’ test and Mann Whitney U test were used to analyze the data. The results were considered statistical significant with p < 0.05.

Unpaired ‘t’ test was used to compare the difference of FFI scores on 1st and 10th day. Mann Whitney U test was used to compare the difference of VAS on 1st and 10th day.

DEMOGRAPHIC AND ANTHROPOMETRIC PROFILE:

Thirty subjects were studied and out of which fifteen were male and fifteen were female. Experimental group consisted of nine male and six female. Control group consisted of six male and nine female. (Table No. I)

AGE:

The average age of subjects in experimental group was 42.46 years ± 10.26 and in control group was 43.73 years ± 9.88. (‘t’ = 0.344, p = 0.733, df = 28). (Table II, III)

HEIGHT:

The average height of subjects in experimental group was 1.59 mts ± 0.065 and in control group was 1.57 mts ± 0.091. (‘t’ = 0.690, p = 0.496, df = 28). (Table II, III)

BODY WEIGHT:

The average body weight of subjects in experimental group was 61.6 kgs ± 8.69 and in control group was 65.8 ±11.63. (‘t’ = 1.119, p = 0.272, df = 28) (Table II, III)

BODY MASS INDEX:

The average BMI of subjects in experimental group was 24.22 kgs/m2 ± 2.38 and of subjects in control group was 26.36 kgs/m2 ± 3.95. (‘t’ = 1.792, p = 0.084, df = 28) (Table II, III)

VISUAL ANALOGUE SCALE

  • The average VAS score for experimental group on 1st day was 8.8 ±0.94 and on 10th day was 1.6 ±0.73
  • The average VAS score for control group on 1st day was 8 ± 1.13 and on 10th day was 3.67 ± 1.49.
  • The p value for VAS on 1st day for both groups was 0.074 and on 10th day was 0.000, which showed a statistical significant difference between 1st and 10th day score. (Table IV)

FOOT FUNCTION INDEX

  • The average FFI for experimental group on day 1st was 69.4% ± 12.33 and on day 10th was 16.20% ±3.89.
  • The average score for control group on day 1st was 46% ± 19.39 and on day 10th was 19.80 % ± 4.36.
  • The p value for FFI of both groups on day 1st was 0.000 and on 10th day 0.024, which showed a statistical significant difference between 1st and 10th day score. (Table V)

Table I: Sex Distribution:

Groups Male Female Total
A (Control) 06 09 15
B(Experimental) 09 06 15
Total 15 15 30

Table II: Demographic Profile

Groups Age(yrs) Height(Mts) Bodyweight(Kgs) BMI(Kg/m2 )
Mean SD Mean SD Mean SD Mean SD
Experimental 42.46 10.26 1.59 0.065 61.6 8.69 24.22 2.38
Control 43.73 9.88 1.57 0.091 65.8 11.63 26.36 3.95

Table III: ‘t’ and p values

Parameters ‘t’ value ‘p’ value
Age 0.344 0.733
Height 0.690 0.496
Weight 1.119 0.272
BMI 1.792 0.084

Table IV: Pain relief (Mean change in VAS score)

Groups Day 1st Day 10th
Experimental 8.8±0.94 1.6±0.73
Control 8±1.13 3.67±1.49
Mann-Whitney
U test (p)
0.074 0.000

Table V: Foot Function Index (FFI scores)

Groups Day 1st Day 10th
Experimental 69.4±12.33 16.20±3.89
Control 46±19.39 19.80±4.36
‘t’ 3.942 2.384
df 28 28
p 0.000 0.024

DISCUSSION

Plantar fasciitis is one of the conditions, which can be treated by a wide variety of physiotherapy methods. It is still difficult to formulate all proof guidelines for the management of plantar fasciitis. Various methods of treatment exist with own claims of success without any attempts of comparing the maximal effective methods. The objective of this study was to find out the effectiveness of myofascial release in treatment of plantar fasciitis.

In the present study, age group participated was between 28 to 62 years. The majority of patients afflicted with plantar fasciitis are 40 to 60 years of age8, although the range has been reported to be 8 to 80 years of age. It has been reported that subcalcaneal pain is a common orthopaedic problem that generally occurs in person 30 to 70 years of age. Body mass index of the subjects has been assessed for both groups and mean BMI was found which were 24.22 kgs/mt2 for experimental group and 26.36kgs/mt2 for control group. According to WHO standard ideal BMI is in range of 18.5 – 24.9.9

One of the risk factor for plantar fasciitis is sudden gain in body weight or obesity. In this study experimental group subjects were within range and control group subjects were overweight. Analysis of pain relief was done by subjective VAS by statistical mean. Mean and standard deviation of pain in terms of VAS was done and found that the average of VAS score for experimental group on 1st day was 8.8±0.94 and on 10th day was 1.6±0.73. The average VAS score for control group on 1st day was 8 ± 1.13 and on 10th day was 3.67 ± 1.49.The p value for VAS on 1st day for both groups was 0.074 and on 10th day was 0.000, which showed a statistical significant difference between 1st and 10th day score.

Functional assessment was done by using foot function index. Foot Function Index (FFI) was designed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction in a rheumatoid arthritis population. During its validation it was examined for test-retest reliability, internal consistency, and construct and criterion validity. It has good test? retest reliability (intraclass correlation coefficient ranging from 0.69 to 0.87) and a high degree of internal consistency (Cronbach’s ± ranging from 0.73 to 0.95). The Foot Function Index was originally developed to assess the effect of foot orthoses on foot pathology in people with rheumatoid arthritis, however its developers suggest its use need not be restricted to this group. In fact, few studies have used the FFI in research unrelated to rheumatoid arthritis; although in each study the authors changed the questionnaire in some way without investigating the effect on validity or reliability.

In this study average FFI for experimental group on day 1st was 69.4% ± 12.33 and on day 10th was 16.20% ±3.89.The average score for control group on day 1st was 46% ± 19.39 and on day 10th was 19.80% ± 4.36. The p value for FFI of both groups on day 1st was 0.000 and on 10th day 0.024, which showed a statistical significant difference between 1st and 10th day score. FFI was used because it includes all the activities which are part of our daily normal function. Since majority of subjects who participated in this study were house wives and from other occupations which needs prolong standing for their work for their work.

In this study both groups received therapeutic ultrasound as apart of conventional treatment for plantar fasciitis. According to a study performed by Hana Hronkova in 200092 in which the group which received ultrasound for plantar fasciitis showed significant reduction in pain.

In contrast, study done by Crawford F, et al in 1996 therapeutic ultrasound was given to patients with heel pain and found no evidence to support the effectiveness of therapeutic ultrasound.10 for therapeutic ultrasound the dosage used in this study was chosen from evidence available. Pulsed ultrasound was used as it’s preferred for soft tissue repair as affirmed by Young11 and 1 MHz was chosen as it is capable of reaching to deeper layer. Pain relief could have occurred due to the non thermal effects of pulsed ultrasound in the form of stimulation of histamine release from mast cells and factors from macrophages that accelerated the normal resolution of inflammation as suggested by young and Dyson12 Although the results are contradictory to a review carried out by Robert and Baker of 35 randomized controlled trials looking at evidence of the biophysical effects of ultrasound out of which only 2 trials were found to be more effective than placebo ultrasound and ten of the 35 trials studied were judged to be robust.13

Experimental group showed more improvement in terms of both pain relief and in functional ability. This can be attributed to myofascial release which experimental group received in addition to conventional treatment. Myofascial release refers to soft tissue manipulation techniques.

Myofascial release therapy uses hands on manipulation of the whole body to promote healing and relieving pain. Injuries, stress, trauma and poor postures can cause restriction to fascia. The goal of myofascial release is to release is to release fascia restriction and restore its tissue. This technique is used to ease pressure in the fibrous bands of the connective tissue, or fascia. Gentle and sustained 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 is also said to enhance the body’s innate restorative powers by improving circulation and nervous system transmission. Some practitioners contend that the method also release pent-up emotions that may be contributing to pain and stress in the body. Myofascial release works on a broader swath of muscles and connective tissue.

The movement has been likened to kneading a piece of taffy- a gentle stretching that gradually softens, lengthens, and realigns the fascia. Direct myofascial release method works directly on the restricted fascia. MFR seeks for changes in the myofascial structures by stretching, elongation of fascia or mobilizing adhesive tissues.

Study done by Shirat Ling, DO, 1999, concluded that direct myofascial release is a highly effective technique for plantar fasciitis patients who need to recover quickly. All the treatment methods are equally beneficial in the treatment of plantar fasciitis. It can be concluded that myofascial release is an effective therapeutic option in the treatment of plantar fasciitis. Hence the sample size studied, further research can be done with a larger sample using the same protocol.

CONCLUSION

On the basis of present study, it can be concluded that conservative treatment approach like physiotherapy in the treatment of plantar fasciitis, is beneficial. Although both the conventional treatment and myofascial release have found to be effective in alleviation of symptoms and associated disability in plantar fasciitis However the subjects treated with myofascial release showed an additional benefit in terms of reduction of pain on VAS and functional ability in terms of FFI. Hence it can be concluded that myofascial release is an effective therapeutic option in the treatment of plantar fasciitis.

REFERENCES

  1. Simon J. Bartold. Plantar heel pain syndrome: overview and management. Journal of Bodywork and Movement Therapies.2004; 214-226.
  2. Mario Roxas, ND. Plantar fasciitis: Diagnosis and Therapeutic Considerations. Alternative Medicine Review 2005. Vol 10(2) 83-93.
  3. Barnes, J F. Mind and Body Bioenergy of healing, PT and OT Today, Nov1996.
  4. Travell, J. Simons. Myofascial pain and dysfunction. The trigger point manual.Vol.1.Williams&Willkins.Baltimore.1983.
  5. John Low and Ann Reed: electrotherapy explained principles and practice, 3rd Ed. Butterworth Heinemann, oxford; 2000, 195-199.
  6. Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician 2001; 63:467-474, 477-478.
  7. Mario Roxas, ND.Plantar fasciitis: Diagnosis and Therapeutic Consideration. Alternative Medicine Review 2005; Vol 10, No.2: 86.
  8. Gill LH.Conservative treatment for painful heel syndrome. Proceeding of the third Annual Summer Meeting. Foot Ankle.1987: 8: 122.
  9. Racette SB et al. Obesity: Overview of prevalence, etiology and treatment. Physical therapy2003; 83:276-288.
  10. Crowford F. Snaith M. How effective is therapeutic ultrasound in the treatment of heel pain? Ann Rheum Dis., 1996; 55:265-7.
  11. Young, S. ‘Ultrasound therapy’ in: Kitchen, S and Bazin, S (Eds) Clayton’s Electrotherapy, WB Saunders, Philadelphia, 10th edn, 1996, 243-267.
  12. Young, SR and Dyson, M. ‘Macrophages responsiveness to therapeutic ultrasound’. Ultrasound in medicine and Biology, 1990, 16,261-269.
  13. Roberts, VJ and Baker, KG. A review of therapeutic ultrasound: Effectiveness studies?. Physical Therapy, 2001, 81, 7, 1339-50.

Patient Receiving Myofascial Release

Patient Receiving Myofascial Release

Intrinsic Muscle Strengthening Exercise

Intrinsic Muscle Strengthening Exercise

Plantar Fascia Stretching

Plantar Fascia Stretching

Corresponding Author: Suman Kuhar
Post Graduate Student, K.L.E.S. Institute of Physiotherapy, J. N. Medical College Campus,
Belgaum – 590 010, Karnataka INDIA
Email: kuhar_suman(at)yahoo.com
Mobile No.: +91-9986-726842

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