Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Evaluation of the efficacy of trigger points combined with extracorporeal shock waves in the treatment of plantar fasciitis: heel temperature and plantar pressure

BACKGROUND

Plantar fasciitis (PF) is the most common cause of heel pain. Among conservative treatments, extracorporeal shock wave therapy (ESWT) is considered effective for refractory PF. Studies have shown that applying ESWT to the trigger points (TrPs) in the triceps surae may play an important role in pain treatment in patients with PF. Therefore, the purpose of this study was to combine the concept of trigger points and ESWT to explore the effect of this combination on plantar temperature and pressure in patients with PF.

METHODS

After applying inclusion and exclusion criteria, 86 patients with PF were recruited from the pain clinic of Huadong Hospital, Fudan University and randomly divided into experimental (n = 43) and control groups (n = 43). The experimental group was treated with extracorporeal shock waves to treat the medial heel pain point and the gastrocnemius and soleus TrPs. The control group was only treated with extracorporeal shock waves at the medial heel pain point. The two groups were treated twice with an interval of 1 week. Primary measurements included a numerical rating scale (NRS) score (overall, first step, heel pain during daily activities), and secondary measurements included heel temperature, Roles-Maudsley score (RMS), and plantar pressure. All assessments were performed before treatment (i.e., baseline) and 6 and 12 weeks after treatment.

RESULTS

During the trial, 3 patients in the experimental group withdrew from the study, 2 due to interruption of the course of treatment by the COVID-19 epidemic and 1 due to personal reasons. In the control group, 3 patients fell and were removed due to swelling of the heel. Therefore, only 80 patients with PF were finally included. After treatment, the two groups showed good results in NRS score (overall, first step, heel pain during daily activities), RMS, and plantar temperature, especially in the experimental group, who showed a significantly better effect than the control group.

CONCLUSION

ESWT of the heel combined with the triceps trigger point of the calf can more effectively improve the pain, function and quality of life of refractory PF than ESWT of the heel alone. In addition, ESWT of the heel combined with the triceps trigger point of the calf can effectively reduce the skin temperature of the heel on the symptomatic side, indicating that the heel temperature as measured by infrared thermal imaging may be used as an independent tool to evaluate the therapeutic effect for patients with chronic PF. Although extracorporeal shock waves combined with TrPs treatment can cause changes in the patients' gait structure, plantar pressure is still difficult to use as an independent tool to evaluate the therapeutic effect for PF.

TRIAL REGISTRATION

Registered in the Chinese Clinical Trial Registry ( www.chictr.org.cn ) on 12/17/2021 with the following code: ChiCTR-INR-2,100,054,439.

Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore

Introduction

Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play.

Method

A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus.

Results

Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF.

Conclusion

The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Comparison of the short-term efficacy of peloid and paraffin treatments on pain and quality of life in the treatment of plantar fasciitis: a randomized controlled study

Although peloid, paraffin, and exercise treatments are effective in patients with plantar fasciitis, there had been no comprehensive and comparative studies of these treatments for plantar fasciitis. The aim of our study was to evaluate the effects of peloid, paraffin, and exercise treatments on pain, functional status, and quality of life in patients with plantar fasciitis. A total of 104 patients, aged 18 years and over, who applied to our clinic with heel pain and were diagnosed with plantar fasciitis according to the American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain guideline, with pain at the level of 3 and more severe according to the visual analog scale were randomly divided into three groups: the peloid group (peloid therapy and home exercise), the paraffin group (paraffin therapy and home exercise), and the control group (home exercise). Peloid and paraffin applications were applied 5 days a week, a total of 15 sessions in 3 weeks. Participants were evaluated with the visual analog scale, heel tenderness index, and the foot and ankle outcome score before treatment, after treatment, and at the first month after treatment. Compared to pre-treatment evaluation, significant improvements were observed in all parameters after treatment and at the first month controls in all 3 groups (p < 0.05). In the peloidotherapy and paraffin therapy added groups, pain reduction and quality of life increase were higher than the exercise group (p < 0.05). Adding peloidotherapy or paraffin therapy to the home exercise program in the treatment of plantar fasciitis can further reduce pain and improve quality of life.

Acute effects of thoracolumbar fascia release techniques on range of motion, proprioception, and muscular endurance in healthy young adults

PURPOSE

This study investigates the acute effects of Graston and myofascial release on thoracolumbar fascia (TLF) on lumbar range of motion (ROM), lumbar and cervical proprioception, and trunk muscle endurance in healthy young adults.

METHOD

Twenty-four healthy young individuals were included in the study. Individuals were randomly divided into two groups as Graston technique (GT) (n = 12) and myofascial release (MFR) (n = 12). GT group received a fascial treatment with a graston instrument and the MFR group (n = 12) received manual myofascial treatment. Both techniques were applied for 10 min and as a single session. Lumbar ROM (goniometer), lumbar proprioception (digital inclinometer), cervical proprioception (CROM device), and trunk muscle endurance (with McGill Endurance Test) were evaluated before and after treatment.

RESULTS

Age, gender and body mass index of individuals in both groups were similar (p > 0.05). In both GT and MFR groups, an increase in ROM in the flexion direction (p < 0.05) and a decrease in the angle of deviation in proprioception in the flexion direction were determined (p < 0.05). Neither technique had a significant effect on cervical proprioception and trunk muscle endurance (p > 0.05). In addition, no difference was found between the effectiveness of Graston and myofascial release (p > 0.05).

CONCLUSION

This study showed that Graston and myofascial release applied to TLF in healthy young adults effectively improve lumbar ROM and proprioception in the acute period. Considering these results, both Graston and myofascial release can be used to provide elasticity of TLF and improve proprioceptive return.

An assessment of plantar fascia with ultrasound findings in patients with plantar fasciitis: a systematic review

INTRODUCTION

Plantar fasciitis (PFS) is described by an intense pain over medial tubercle of calcaneus, increased with the first step after waking up, after rest and during weightbearing activity. It is the most common cause of plantar heel pain in adults with the prevalence estimated 10% of the general population. Ultrasound imaging is commonly being used to measure the PF thickness, evaluate the efficacy of different treatments and a guide therapeutic technique in patients with PFS. The objective of this study was to systematically review the studies that were previously published to evaluate the role of ultrasound in the assessment of PF in patients with PFS.

METHODS

A systematic search was carried out over the last 5 years from 2017 to 2022 on basis the following electronic databases: Science Direct, Scopus, Web of Science, Springer and PubMed. The keywords that used in the searching were: ultrasound, sonography, ultrasonography, plantar fasciitis, imaging of plantar fascia, physiotherapy of plantar fasciitis, interventional treatment of plantar fasciitis, randomized controlled trial of plantar fasciitis and interventional ultrasound. The review focused on the assessment of PF in patients with PFS underwent different interventions using B-mode, shear wave elastography (SWE) and color Doppler ultrasound.

RESULTS

During the search process, 1661 were recorded using the proper keywords from 2017 to 2022 in which 666 original articles were found after removing the review and duplicated articles. Of these, thirty articles met the inclusion criteria and included in this review. The articles have assessed the PF in patients with PFS under different conditions using different ultrasound modes. Twenty-six articles evaluated the effectiveness of different treatment on PF in patients with PFS using different ultrasound modes. In 8 of 26 articles, the ultrasound was used as both an assessment tool of PF and guide therapeutic technique in patients with PFS. In 18 articles, the ultrasound was used as only assessment tool to identify the PF thickness and its observation changes in patients with PFS. Four articles compared the PF thickness and its intrafascial changes between patients with PFS and healthy subjects.

CONCLUSION

The ultrasound can be a reliable tool in assessment the effect of different interventions on PF by evaluating its thickness, echogenicity and stiffness changes in patients with PFS. There were different methods and treatments were used among the studies.

Effectiveness of Dry Needling and Ischemic Trigger Point Compression in the Gluteus Medius in Patients with Non-Specific Low Back Pain: A Randomized Short-Term Clinical Trial

BACKGROUND

The presence of latent myofascial trigger points (MTrPs) in the gluteus medius is one of the possible causes of non-specific low back pain. Dry needling (DN) and ischemic compression (IC) techniques may be useful for the treatment of these MTrPs.

METHODS

For this study, 80 participants were randomly divided into two groups: the dry needling group, who received a single session of DN to the gluteus medius muscle plus hyperalgesia (n = 40), and the IC group, who received a single session of IC to the gluteus medius muscle plus hyperalgesia (n = 40). Pain intensity, the pressure pain threshold (PPT), range of motion (ROM), and quality of life were assessed at baseline, immediately after treatment, after 48 h, and one week after treatment.

RESULTS

Statistically significant differences were shown between the two groups immediately after the intervention, showing a decrease in PPT (p < 0.05) in the DN group and an increase in PPT in the IC group. These values increased more and were better maintained at 48 h and after one week of treatment in the DN group than in the IC group. Quality of life improved in both groups, with greater improvement in the DN group than in the IC group.

CONCLUSIONS

IC could be more advisable than DN with respect to UDP and pain intensity in the most hyperalgesic latent MTrPs of the gluteus medius muscle in subjects with non-specific low back pain, immediately after treatment. DN may be more effective than IC in terms of PPT, pain intensity, and quality of life in treating latent plus hyperalgesic gluteus medius muscle MTrPs in subjects with non-specific low back pain after 48 h and after one week of treatment.

Analyzing the Interaction between Clinical, Neurophysiological and Psychological Outcomes Underlying Chronic Plantar Heel Pain: A Network Analysis Study

Plantar heel pain (PHP) is one of the most common foot pain conditions in adults. Several biological and psychological factors could be involved in chronic PHP in a complex matrix. However, reciprocal interactions between these factors are unknown. The aim of the present study was to use network analysis to quantify potential multivariate relationships between pain-related, function, clinical, mechanosensitivity, psychological, and health-related variables in individuals with PHP. Demographic (age, gender), pain-related (pain intensity), function, clinical (myofascial trigger points [TrPs]), mechanosensitivity (pressure pain thresholds), psychological (Beck Depression Inventory), and health-related variables (EQ-5D-5L) were collected in 81 PHP patients. Network connectivity analysis was conducted to quantify the adjusted correlations between the modeled variables and to assess their centrality indices. The connectivity network showed local associations between pain-related variables, foot function, and mechanosensitivity. Additionally, associations between quality of life, depression, and pain-related variables were found, while TrPs was associated with quality of life and mechanosensitivity. The node with the highest strength centrality was the worst pain intensity, while mechanosensitivity and worst pain intensity showed the highest closeness and betweenness centrality. This is the first study to apply network modeling to understand the connections between pain-related, function, clinical, mechanosensitivity, psychological, and health-related variables in PHP. The role of pain severity and mechanosensitivity is highlighted and supported by the network. Thus, this study reveals potential factors that could be the target in the management of PHP, promoting a comprehensive and effective therapeutic approach.

A Prospective Randomized Controlled Trial Comparing Physical Therapy With Independent Home Stretching for Plantar Fasciitis

BACKGROUND

Although formal physical therapy (PT) is effective in treating plantar fasciitis (PF), it is unclear how this compares with home-based plantar fascia stretching (HS).

METHODS

Fifty-seven patients with PF were enrolled in a prospective randomized trial comparing PT with HS. Visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM), and Short Form (36) Health Survey (SF-36) scores were analyzed at 6 weeks, 3 months, 6 months, and 1 year.

RESULTS

At 6 months, VAS improved in both HS (35% decrease; P < 0.001) and PT (26% decrease; P = 0.002) relative to baseline. FAAM Activities of Daily Living scores improved 13.0% (P = 0.005) in HS and 21.3% (P < 0.001) in PT at 6 months relative to baseline. The SF-36 Physical Component Summary Scores demonstrated improvement at all time points in both groups. There were no notable intergroup differences in VAS, FAAM, or SF-36 at any time point.

DICUSSION

The clinical outcomes of a home stretching protocol and PT did not markedly differ for the treatment of PF.

LEVEL OF EVIDENCE

Therapeutic Level I.

Features of Extrinsic Plantar Muscles in Patients with Plantar Fasciitis by Ultrasound Imaging: A Retrospective Case Control Research

The present study aimed to compare by ultrasound imaging (USI) the tibial posterior (TP), medial gastrocnemius (MG) and soleus muscle in patients with and without plantar fasciitis (PF). A sample of 42 individuals was recruited and divided into two groups: PF and a healthy group. The thickness, cross-sectional area (CSA), echointensity and echovariation were assessed in both groups by USI. TP, soleus and MG variables did not report differences (p > 0.05) for thickness and CSA. For the echotexture parameters significant differences were found for MG echointensity (p = 0.002), MG echovariation (p = 0.002) and soleus echointensity (p = 0.012). Non-significant differences (p > 0.05) were reported for soleus echovariation, TP echointensity and TP echovariation variables. The thickness and CSA of the TP, GM and soleus muscle did not show significant differences between individuals with and without PF measured by USI. Muscle quality assessment reported an increase of the MG echointensity and echovariation, as well as a decrease of echointensity of the soleus muscle in the PF group with respect to the healthy group. Therefore, the evaluation of the structure and muscle quality of the extrinsic foot muscles may be beneficial for the diagnosis and monitoring the physical therapy interventions.

Muscle Quality Assessment by Ultrasound Imaging of the Intrinsic Foot Muscles in Individuals with and without Plantar Fasciitis: A Case-Control Study

Objective: The primary aim of the present study was to compare the echo intensity (EI) and echovariation (EV) of the intrinsic foot muscles (IFMs) between individuals with and without plantar fasciitis (PF), using ultrasound imaging. The secondary objective was to study the intra-rater reliability of the echotexture variables. Methods: A case−control study was conducted with 64 participants, who were divided into the following two groups: A, the PF group (n = 32); B, the healthy group (n = 32). Results: The comparison between the two groups did not identify significant differences (p > 0.05) between the flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), quadratus plantae (QP) and abductor hallucis brevis (AHB) variables for the EI and EV. Moreover, excellent intra-rater reliability was reported for the following ultrasound imaging EI variables: ABH (ICC = 0.951), FHB (ICC = 0.949), FDB (ICC = 0.981) and QP (ICC = 0.984). Conclusions: The muscle quality assessment using the EI and EV variables did not identify differences in the FHB, FDB, AHB and QP muscles between individuals with and without PF through USI evaluation. The reliability of all the IFM measurements was reported to be excellent.

Perforating Fat Injections for Chronic Plantar Fasciitis: A Randomized, Crossover Clinical Trial

SUMMARY

Plantar fasciitis affects 2 million patients per year. Ten percent of cases are chronic, with thickened plantar fascia. Treatment may lead to prolonged recovery, foot instability, and scar. The authors hypothesized that perforating fat injections would decrease plantar fascia thickness, reduce pain, and improve quality of life. Adults with plantar fascia greater than 4 mm for whom standard treatment had failed were included in a prospective, randomized, crossover pilot study. Group 1 (intervention) was followed for 12 months. Group 2 was observed for 6 months, injected, and then followed for 6 months. Validated patient reported outcome measures, ultrasound, and complications were assessed. Group 1 had nine female patients and group 2 had five patients. A total of 2.6 ± 1.6 ml of fat was injected per foot at one to two sites. In group 1, plantar fascia thickness decreased from screening at 6 and 12 months (p < 0.05). Group 2 had decreased plantar fascia thickness from screening to 6 months after injection (p < 0.05). Group 1 had pain improvements at 6 and 12 months compared with screening (p < 0.01). Group 2 reported no pain difference after injections (p > 0.05). Group 1 had improved activities of daily living and sports activity at 6 and 12 months compared with screening (p < 0.003). Group 2 noted increased sports activity 6 months after injection compared with screening (p < 0.03). In conclusion, perforating fat injections for chronic plantar fasciitis demonstrate significant improvement in pain, function, and plantar fascia thickness.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Effect of visual feedback during ultrasound-guided hydrodissection for myofascial pain syndrome: An exploratory, prospective, observational clinical trial on the expectations for treatment

Expectations for treatment have a favorable effect on the subsequent course of pain and behavior in patients. It is not known whether receiving hydrodissection while patients view their ultrasound image with doctors (visual feedback) is associated with positive treatment expectations. This was an exploratory, prospective, observational clinical trial. We explored the possibility that visual feedback immediately after ultrasound-guided hydrodissection increases the expectations for treatment, which could be one of the related factors for pain reduction. Treatment expectations were set as mediators of pain using path analysis. The primary endpoint was the numerical rating scale to assess expectations for treatment immediately after hydrodissection, between with and without the visual feedback. During 2019 and 2020, 136 outpatients received ultrasound-guided hydrodissection for myofascial pain syndrome. Of these, 65 (47.8%) patients received visual feedback during ultrasound-guided hydrodissection. Compared with the non-visual feedback group, the visual feedback group had higher expectations for treatment immediately after hydrodissection, and their expectations were maintained at day 14 of treatment (p < 0.001). A numerical rating scale (NRS) to assess expectations for treatment was similar before hydrodissection and immediately after hydrodissection was 8.4 (standard deviations, 1.6) in the visual feedback and 5.9 (standard deviations, 2.6) in the visual feedback. The proportion of increased expectations immediately after hydrodissection was 90.8% (95% CI: 83.7-97.9) in visual feedback group and 38.0% (95% CI: 26.7-49.3) in non-visual feedback group (p < 0.001). In the visual feedback group, 67.7% of patients showed improvement in pain numerical rating scale score by 50% or more at day 14, whereas such improvement was observed in only 36.6% of the non-visual feedback group (p < 0.001). Based on path analysis, the visual feedback had the greatest influence on pain numerical rating scale reduction at 14 days, indirectly due to increased expectations for treatment as a mediator (β = 0.434). However, the adjusted R ² values, which is the overall fit of the model, was low at 0.298. Visual feedback during ultrasound-guided hydrodissection increases the expectations for treatment immediately after hydrodissection, which could be one of the related factors for pain reduction in patients with myofascial pain syndrome.

Comparison of Alternative Methods to Improve Weight-Bearing Sagittal Plane Anterior Leg Rotation

ABSTRACT

vonGaza, GL, and Chiu, LZF. Comparison of alternative methods to improve weight-bearing sagittal plane anterior leg rotation. J Strength Cond Res 35(12): 3315-3321, 2021-Promoting rearfoot plantar flexion may permit greater sagittal plane anterior leg rotation in weight-bearing tasks. Anterior leg rotation, where the proximal tibia translates forward, is required for tasks such as squatting and landing from a jump. Twenty-eight individuals with less than 25° anterior leg rotation during a weight-bearing lunge test were enrolled and randomly assigned to self-massage and stretching only (n = 15; 14 subjects retained) or self-massage and stretching plus gastrocnemius exercise (n = 13). Anterior leg rotation was assessed during a weight-bearing lunge test and a partial squat; 95% confidence interval (95% CI) of the change score and Cohen's d effect size were calculated. Anterior leg rotation in the weight-bearing lunge increased in the self-massage and stretching only (left: 95% CI [2.1°-5.4°], d = 1.14; right: 95% CI [2.3°-6.0°], d = 1.22) and self-massage and stretching plus gastrocnemius exercise (left: 95% CI [2.3°-7.5°], d = 1.71; right: 95% CI [4.2°-8.6°], d = 1.48) groups. There were no changes in anterior leg rotation in the partial squat for self-massage and stretching only (left: 95% CI [-1.2° to 2.5°], d = 0.15; right: 95% CI [-0.5° to 2.6°], d = 0.24) or self-massage and stretching plus gastrocnemius exercise (left: 95% CI [-0.2° to 4.8°], d = 0.55; right: 95% CI [-0.2° to 4.0°], d = 0.59) groups. Increases in anterior leg rotation in the weight-bearing lunge may be due to decreased passive stiffness in the plantar structures.

Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

Effectiveness of Massage Including Proximal Trigger Point Release for Plantar Fasciitis: a Case Report

BACKGROUND

Plantar fasciitis (PF) is a common degenerative condition of the plantar fascia. Symptoms include tenderness on the plantar surface of the foot, pain on walking after inactivity, and difficulty with daily activities. Rest, non-steroidal anti-inflammatories, and manual therapies are frequently used treatments for PF. Trigger point release (TrPR) for PF has been found as a viable treatment option.

OBJECTIVE

To determine the effects of massage, including proximal TrPR, for pain and functional limitations in a patient with PF.

METHOD

A student massage therapist from MacEwan University administered five massages, one initial and one final assessment over five weeks to a 46-year-old female with diagnosed PF. She complained of unilateral plantar heel pain (PHP) and deep pulling from mid-glutes to the distal lower limb bilaterally. Evaluation involved active and passive range of motion, myotomes, dermatomes, reflexes, and orthopedic tests. The treatment aim was to decrease PHP by releasing active trigger points (TrPs) along the posterior lower extremity to the plantar surface of the foot, lengthening the associated muscles and plantar fascia. Hydrotherapy, Swedish massage, TrPR, myofascial release, and stretches were implemented. Pain was measured using the numerical rating scale pre- and post-treatments, and the Foot Function Index was used to assess function at the first, middle, and last appointments to assess the effectiveness of massage including proximal TrPR for PF.

RESULTS

PHP and functional impairments decreased throughout the five-week period.

CONCLUSION

The results indicate massage, including proximal TrPR, may decrease pain and functional impairments in patients with PF. Further research is necessary to measure its efficacy and confirm TrPR as a treatment option.

Cost-Effectiveness of Two Dry Needling Interventions for Plantar Heel Pain: A Secondary Analysis of an RCT

Plantar heel pain is a common cause of foot pain that affects patients’ quality of life and represents a significant cost for the healthcare system. Dry needling and percutaneous needle electrolysis are two minimally invasive treatments that were shown to be effective for the management of plantar heel pain. The aim of our study was to compare these two treatments in terms of health and economic consequences based on the results of a published randomized controlled trial. For this, we evaluated the costs from the point of view of the hospital and we carried out a cost-effectiveness study using quality of life as the main variable according to the Eq-5D-5L questionnaire. The cost of the complete treatment with dry needling (DN) was €178.86, while the percutaneous needle electrolysis (PNE) was €200.90. The quality of life of patients improved and was translated into +0.615 quality-adjusted life years (QALYs) for DN and +0.669 for PNE. PNE presented an average incremental cost-effectiveness ratio (ICER) of €411.34/QALY against DN. These results indicate that PNE had a better cost-effectiveness ratio for the treatment of plantar heel pain than DN.

Extracorporeal Shock Wave Therapy Combined With Oral Medication and Exercise for Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

To compare extracorporeal shock wave therapy combined with oral medication and an exercise program vs sham treatment with medication and exercise for the treatment of chronic low back pain (CLBP).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic at a university hospital.

PARTICIPANTS

Eligibility criteria were age older than 18 years and duration of CLBP exceeding 3 months. Exclusion criteria were concurrent treatment or history of surgery for CLBP, cancer, fractures, infections, and disk degeneration.

INTERVENTION

The intervention group received extracorporeal shock wave therapy once a week for 4 weeks along with oral medications and an exercise program. The control group received sham extracorporeal shock wave therapy along with oral medications and an exercise program.

MAIN OUTCOME MEASURES

Visual analog scale and Oswestry Disability Index (ODI) were used to assess pain and disability at baseline and after 3 months.

RESULTS

The pain score in the intervention group (N=16) was 6.6 at baseline and 3.0 after 1 month (P<.0001) and 1.8 after 3 months (P<.0001). In the control group (N=16), the pain score was 6.8 at baseline, 4.6 after 1 month (P<.0001), and 1.1 after 3 months (P<.0001). ODI scores decreased significantly in both groups compared with baseline values (first month: P<.001, third month: P<.05). The mean ODI score did not differ significantly between the groups (P=.942).

CONCLUSION

Extracorporeal shock wave therapy combined with oral medication and exercise was safe and effective in the short-term treatment of chronic low back pain.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

Combining Patient Education With Dry Needling and Ischemic Compression for Treating Myofascial Trigger Points in Office Workers With Neck Pain: A Single-Blinded, Randomized Trial

Objective

The purpose of this study was to compare immediate and short-term effects of combining dray needling (DN) + patient education vs ischemic compression (IC) + patient education for treating myofascial trigger points (MTP) in office workers with neck pain.

Methods

This was a single-blinded, randomized trial. Thirty-two participants were randomly assigned to either DN + patient education or IC + patient education group. Both groups received 2 treatment sessions with a 48-hour time interval. Pain intensity, cervical range of motion, Neck Disability Index, and satisfaction were measured.

Results

Pain intensity and neck disability level decreased, whereas the cervical range of motion (side-bending and rotation) increased in both groups. Analysis of variance revealed a significant interaction of group × treatment only for pain intensity, indicating a greater reduction in the IC group. Satisfaction generally increased in the follow-up assessment in both groups.

Conclusion

Both intervention groups had some positive immediate and short-term effects after 2 treatment sessions. However, IC + patient education was more effective than DN + patient education in the treatment of MTPs in office workers with neck pain.

Effect of myofascial release on lower limb range of motion, sit and reach and horizontal jump distance in male university students

OBJECTIVE

Evaluate the effects of Myofascial release (MR) on lower limb ROM, sit and reach and horizontal jump distance in male university students.

STUDY DESIGN

Quasi-experimental study.

BACKGROUND

MR is a technique that aims to stretch fascia to increase range of motion (ROM), relieve pressure points and improve performance. However, there is limited evidence of its actual effects on flexibility and physical performance.

METHODS

Twenty-one uninjured, male university students received MR (11 on the first session and the other 10 on the second session 24 h later), completed lower limb ROM assessments, the sit and reach and the horizontal jump tests in a randomized order. MR was performed before the tests with a myofascial stick in the anterior and posterior aspects of the right and left thigh and calf muscles. Each muscle group was massaged for 90 s, totaling 9 min of MR. The testing conditions with MR and without MR were compared using Student t-tests and the effect sizes (ES) were calculated.

RESULTS

There were no significant differences between the testing conditions on horizontal jump distance. However, the sit and reach distance (28 ± 9 vs. 32 ± 9 cm, p = 0.001; ES = 0.44), left hip extension (10 ± 2 vs. 8 ± 2°, p = 0.006; ES = 1.00) and left plantar flexion (36 ± 7 vs. 39 ± 7°, p = 0.044; ES = 0.43) were higher with MR.

CONCLUSIONS

MR increased sit and reach distance, left hip extension and plantar flexion, but it did not affect horizontal jump distance in uninjured, male university students.

Immediate effect of foam roller on pain and ankle range of motion in patients with plantar fasciitis: A randomized controlled trial

Background:

Stretching has been proven to be effective on pain and range of motion (ROM) in patients with plantar fasciitis. Despite recent gain in popularity and the proposed theories of effectiveness of foam roller, there is a lack of literature on the effect of foam rolling on plantar fasciitis.

Objective:

The objective of this study was to compare the effects of foam rolling and stretching on pain and ankle ROM in patients with plantar fasciitis.

Methods:

A total of 50 participants were included and randomly allocated to the stretching and foam roller groups. Visual analog scale (VAS), pressure pain thresholds (PPTs) for gastrocnemius, soleus and plantar fascia and weight-bearing lunge test (WBLT) measurements were recorded at baseline and immediately after treatment.

Results:

Within-group analysis has shown there is a statistically significant difference (p<0.001) in all the outcome measures in both foam roller and self-stretching groups. The between-groups analysis showed no statistical significance difference in VAS, plantar fascia PPT and WBLT parameters (with p-values of 0.171, 0.372 and 0.861, respectively); however, significant differences were found in gastrocnemius PPT (p=0.029) and soleus PPT (p=0.013).

Conclusion:

It was seen that both stretching and foam rolling techniques helped in reducing pain and increasing the ROM. However, the effectiveness of foam roller was superior to stretching in terms of increase in PPTs at gastrocnemius and soleus.

Clinical Trial Registration No:

CTRI/2018/01/011398.

Name of registry:

The Clinical Trials Registry — India (CTRI); https://ctri.nic.in.

Trigger point dry needling, manual therapy and exercise versus manual therapy and exercise for the management of Achilles tendinopathy: a feasibility study

OBJECTIVES

The effects of trigger point dry needling (TDN) on myofascial trigger points (MTP) in Achilles tendinopathy (AT) are unknown. We conducted a study to test the feasibility of a large randomized controlled trial (RCT) to compare the effects of TDN to MT and exercise in a patient population with AT.

METHODS

Twenty-two subjects were randomly assigned to a control (MT+Ex) or experimental group (TDN+MT+Ex) and completed eight treatment sessions over 4 weeks with follow up at 3 months. TDN was performed to MTPs in the gastrocnemius, soleus or tibialis posterior each session. The same MT and exercise program was conducted in both groups.

RESULTS

Two of three criteria for feasibility were met. The attrition rate at 4-week and 3-month follow-up was 18.1% and 68%, respectively. Significant differences (p < .05) reported for within group analysis for FAAM, NPRS, pain pressure threshold and strength in both groups at 4 weeks and 3 months. The GROC was significant for MT + Ex at 3 months. No between group differences were found.  The MCID for the FAAM, GROC was surpassed in both groups at 4 weeks and 3 months and NPRS for the MT + Ex group at 4 weeks.

DISCUSSION

A large RCT to investigate the effects of TDN on MTP in AT is not feasible without modifications due to low recruitment and high attrition rate. Modifications to study design should give consideration for closed or national health-care system for access to large patient populations and reduced financial burden to subjects.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03261504F.

Comparing two dry needling interventions for plantar heel pain: a randomised controlled trial

OBJECTIVES

To compare the effectiveness of dry needling (DN) versus percutaneous needle electrolysis (PNE) for improving the level of pain, function and quality of life (QoL) of patients suffering from plantar heel pain (PHP) provoked by myofascial trigger points.

DESIGN

A prospective, parallel-group, randomised controlled trial with blinded outcome assessment.

SETTING

A single treatment facility in the State of Kuwait.

PARTICIPANTS

118 participants were screened for eligibility. Of these, 102 participants were enrolled (30 men (49.5±8.9 years) and 72 women (48.1±8.8 years)) and 68 of them completed the trial.

INTERVENTIONS

Two parallel groups, one study arm received DN and a stretching protocol whereas the other arm received percutaneous needling electrolysis with a stretching protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the Foot Pain domain of the Foot Health Status Questionnaire, with 13 questions related to foot health-related domains. Secondary outcome measures included the 0-10 numerical rating scale pain visual analogue scale (VAS) scores, performed before and after each treatment session. In addition, QoL was measured using the EuroQoL-5 dimensions. All measurements were taken at baseline, at 4, 8, 12, 26 and 52 weeks.

RESULTS

Foot Pain domain improved at all time points for DN group (p<0.001; 29.7 (17.8 to 41.5)) and percutaneous needling electrolysis group (p<0.001; 32.7 (18.3 to 47.0)), without significant differences between groups. Pain VAS scores decreased at all time points for both DN (p<0.001; -2.6 (-4.0 to -1.2)) and percutaneous needling electrolysis group (p<0.001; -3.0 (-4.5 to -1.6)). QoL improved at 4 weeks for both DN (p<0.01; 0.15 (0.5 to 0.25)) and percutaneous needling electrolysis group (p<0.01; 0.09 (0.01 to 0.17)) and at 8 and 52 weeks for the PNE group (p<0.01; 0.10 (0.02 to 0.18)), with significant differences between groups for the QoL at 52 weeks (p<0.05; 0.10 (0.01 to 0.18)). There were two small haematomas in the PNE group and one in the DN group. No serious adverse events were reported.

CONCLUSIONS

Both PNE and DN were effective for PHP management, reducing mean and maximum pain since the first treatment session, with long lasting effects (52 weeks) and significant differences between groups in the case of QoL at 52 weeks in favour of the PNE group.

TRIAL REGISTRATION NUMBER

NCT03236779.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review

PURPOSE OF REVIEW

Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis.

RECENT FINDINGS

This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving.

CONCLUSION

While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

Association between trigger points in hamstring, posterior leg, foot muscles and plantar fasciopathy: A cross- sectional study

BACKROUND

Plantar Fasciopathy (PF) is soreness or irritability experienced underneath infero-medial aspect of the heel. It is a multifactorial disorder where myofascial involvement also seems to be associated with it, in which, muscles of posterior thigh, leg and foot muscles are affected. Trigger points in these muscles may interfere with biomechanics and normal functioning of the lower limb.

OBJECTIVE

To find an association between trigger points of the posterior thigh, leg and foot muscles and plantar fasciopathy.

STUDY DESIGN

A cross sectional study.

METHODS

100 patients with plantar fasciopathy who fulfilled inclusion criteria were included in this study. They were examined for trigger points by manual palpation in posterior thigh, leg and foot muscles. Totally 15 muscles were examined on both affected and unaffected side.

RESULTS

Results showed that myofascial trigger points were more prevalent in medial gastrocnemius (98%, Chi-square: 110.07, p < 0.05, Phi-0.74), quadratus plantae (83%, Chi-square:126.96, p < 0.05, Phi- 0.79), soleus (69%, Chi-square: 28.88, p < 0.05, Phi-0.38), tibialis posterior (46%, Chi-square 41.98 p<0.05%, Phi-0.50), abductor hallucis (42%, Chi-square: 43.61 p<0.05% Phi-0.46), flexor halluces longus (41%, Chisquare: 39.25, p < 0.05, Phi-0.44) than other muscles on the affected side. Whereas, on the unaffected side, trigger points were more prevalent among peroneus longus (50%, Chi-square: 26.14, p < 0.05, Phi-0.36) followed by medial gastrocnemius (26%, Chisquare: 110.07, p < 0.05, Phi-0.74).

CONCLUSION

Plantar fasciopathy is strongly associated with trigger points of medial gastrocnemius, quadratus plantae followed by soleus, tibialis posterior, abductor hallucis and flexor hallucis longus.

Calf stretching and plantar fascia-specific stretching for plantar fasciitis: A systematic review and meta-analysis

BACKGROUND

Plantar fasciitis (PF) is the most common cause of heel pain. A calf stretching (CS) and a plantar fascia-specific stretching (PFSS) are two stretching techniques commonly administered by health care providers.

OBJECTIVE

To evaluate the literature on the application of these two stretching techniques in the treatment of PF and investigate their effectiveness and efficacy.

METHOD

A search of PubMed, Web of Sciences, PEDro, CINHAL and Scopus was conducted. Studies that applied stretching as a co-intervention were excluded. The risk of bias was assessed to determine the internal validity of the included trials. The GRADE approach was adopted to determine the overall quality. Pooled analysis was performed to determine the treatment effects of CS and PFSS in terms of the mean difference in the visual analog scale pain score.

RESULTS

Eight articles were found that represented randomized controlled trial and met the inclusion criteria. There was very low-quality evidence that the combined CS and PFSS was less effective in the short term than the other therapies. Comparison between CS and PFSS revealed moderate quality evidence for a larger effect of pain score reduction for PFSS treatment over CS, while very low-quality evidence supported that combined CS and PFSS or CS alone was superior to sham stretching.

CONCLUSION

There was moderate to very low-quality evidence of the effectiveness of stretching for PF. The treatment effect of stretching was large and comparable to other therapies. Future trials of higher quality are needed to clarify findings or to confirm findings.

Prediction Model of Soleus Muscle Depth Based on Anthropometric Features: Potential Applications for Dry Needling

This study was conducted to investigate if anthropometric features can predict the depth of the soleus muscle, as assessed with ultrasound imaging, in a sample of healthy individuals to assist clinicians in the application of dry needling. A diagnostic study to calculate the accuracy of a prediction model for soleus muscle depth, as assessed with ultrasonography, in the middle-third and distal-third of the calf, based on anthropometric features such as age, height, weight, body mass index (BMI), calf length, mid-third and distal-third calf girth, was conducted on 48 asymptomatic healthy subjects (75% male) involving a total of 96 calves. Multiple linear regression analyses were used to determine which variables contributed significantly to the variance in the soleus muscle depth at middle-third and distal-third of the calf by gender. Women were found to have a deeper soleus muscle than men (p < 0.001). Weight, height, BMI, and mid-third calf perimeter explained 69.9% of variance in men, whereas mid-third calf perimeter, calf length, height, and distal-third calf girth explained 73% of the variance in women of the distal-third soleus depth (p < 0.001). Additionally, mid-third calf girth and calf length explained 28.8% of variance in men, whereas mid-third calf perimeter, calf length, and weight explained 67.8% of variance in women of the mid-third soleus depth (p < 0.001). This study identified anthropometric features that predict soleus muscle depth, as assessed with ultrasound, in asymptomatic individuals, but these features are different in men and women. Our findings could assist clinicians in choosing the proper length of the needle to avoiding passing through the soleus during dry needling.

Active Muscle Trigger Points Are Associated with Pain and Related Disability in Patients with Plantar Heel Pain: A Case-Control Study

OBJECTIVE

Pain experienced by patients with plantar heel pain has been associated with fascia thickness. It is possible that referred muscle pain may also be related to symptoms experienced by these patients. Our aim was to systematically investigate if the referred pain elicited by trigger points in the leg and foot musculature reproduces the symptoms in individuals with plantar heel pain and to determine the association of trigger points (TrPs) with pain and related disability.

METHODS

A case-control study was conducted. Thirty-five individuals with unilateral chronic plantar heel pain and 35 matched comparable healthy controls participated. An assessor blinded to the subject's condition explored TrPs in the flexor hallucis brevis, adductor hallucis, quadratus plantae, and internal gastrocnemius. Pain and related disability were assessed with a numerical pain rating scale (0-10), the Foot Function Index, and the Foot Health Status Questionnaire.

RESULTS

The number of TrPs for each patient with plantar heel pain was 4 ± 3 (2.5 ± 2 active TrPs, 1.5 ± 1.8 latent TrPs). Healthy controls only had latent TrPs (mean = 1 ± 1). Active TrPs in the quadratus plantae (N = 20, 62.5%), and flexor hallucis brevis (N = 19, 59%) were the most prevalent in patients with plantar heel pain. A greater number of active, but not latent, TrPs was associated with higher foot pain variables (0.413 < rs < 0.561, P < 0.01), higher impact of foot pain (0.350 < rs < 0.473, P < 0.05) and worse related disability (-0.447 < rs < -0.35456, P < 0.05).

CONCLUSIONS

The referred pain elicited by active TrPs in the foot muscles reproduced the symptoms in patients with plantar heel pain. A greater number of active TrPs was associated with higher pain and related disability in patients with plantar heel pain.

Three-Dimensional Ankle Exercise with Combined Isotonic Technique for an Obese Subject with Plantar Fasciitis: A Case Study

Background and objectives: Obese people have many foot-related disorders and plantar fasciitis (PF) is the most common disorder among them. However, research on the role of therapeutic exercises in PF is lacking and there is no evidence to suggest its benefits. As such, a further insight into therapeutic exercises is needed within this group. This case study investigated the effect of three-dimensional (3D) ankle exercises using a combined isotonic (CI) technique on function and balance in an obese subject with PF. Material and methods: The subject in this study was a 28-year-old obese woman who was diagnosed with PF by an orthopedic surgeon. A 3D ankle exercise program was commenced three times a week for 15 min over 4 weeks. The evaluations were conducted at five intervals: pre-test, and at 1, 2, 3 and 4 weeks from the initiation of the intervention. The tests were conducted in the following order: the patient-specific functional scale test (PSFS), an ultrasound of the plantar fascia, the heel pressure and balance test, the pressure pain threshold (PPT), and the 4-way ankle strength test. Results: The mean score of the PSFS test reduced by 70.55% after 4 weeks of the intervention. The thickness of the plantar fascia and heel pressure measured during single-leg standing decreased by 6.67% and 10.37%, respectively, after 4 weeks of the intervention. The anteroposterior and medial-lateral balance ability showed improvements of 8.29% and 8.61%, respectively, after 4 weeks of the intervention. The PPT improved by 38.01% after 4 weeks of the intervention. In the 4-way ankle strength test, dorsiflexion, plantar flexion, inversion, and eversion increased by 14.46%, 9.63%, 4.3% and 13.25%, respectively, after 4 weeks of the intervention. Conclusion: 3D ankle exercises utilizing the CI technique were shown to be effective in improving foot function, pressure pain, and muscle strength in dorsiflexion and inversion in an obese patient with PF.

Effects of Strengthening and Stretching Exercises on the Temporospatial Gait Parameters in Patients With Plantar Fasciitis: A Randomized Controlled Trial

Objective

To investigate the effects of physical therapy interventions using strengthening and stretching exercise programs on pain and temporospatial gait parameters in patients with plantar fasciitis (PF).

Methods

Eighty-four patients with PF participated in the study and were randomly assigned to the strengthening or stretching exercise groups. All patients received 8 physical therapy interventions two times per week in the first 4 weeks and performed daily strengthening or stretching exercises three times per day. After 4 weeks, they continued the assigned exercise programs every day for 8 weeks. Pain visual analogue scale (VAS) scores at the worst and in the morning and temporospatial gait parameters were evaluated at the baseline, intermediate of the intervention, end of the intervention, and the first and second month follow-up.

Results

There were significant effects of the time on the worst pain, morning pain, cadence, stride time, stride length, total double support, and gait speed, but there was no effect on step width. In addition, the main effect of the group and the interaction effects of the time and the group were not found in any parameters. For intra-group comparisons, there were significant differences in worst pain, morning pain, cadence, and stride time among the assessment times in both groups. For inter-group comparisons, there were no significant differences in all parameters.

Conclusion

Both strengthening and stretching exercise programs significantly reduced pain and improved gait in patients with PF.

Outpatient vs Home Management Protocol Results for Plantar Fasciitis

BACKGROUND

We compared the effectiveness of stretching and strengthening exercises combined with myofascial releasing and mobilization techniques to a stretching and strengthening only home program in plantar fasciitis (PF) management.

METHOD

The study included 53 feet of 47 patients with plantar fasciitis (35 women / 12 men; mean age 48.9±11.2 years). Pain, disability, and activity restrictions were assessed by Foot Function Index (FFI), and first step pain was graded by visual analog scale (VAS). Ankle range of motion (ROM), gastrocnemius-soleus flexibility, proprioception, dynamic balance, and foot sensation were also considered. The patients were randomly divided into outpatient clinic treatment (Outpatient, n = 27 feet) and home rehabilitation groups (Home, n = 26 feet). Patient education was routine for all at the beginning of the management programs. In the Outpatient group, the foot-ankle-hip exercise program, myofascial releasing, and joint and soft tissue mobilization techniques were "hands on" at a clinic (twice a week for 8 weeks), whereas the Home group completed their home rehabilitation program on their own (8 weeks' duration with follow-ups every week).

RESULTS

VAS, FFI, ROM, balance, proprioception, foot sense, and flexibility improved at the eighth week in both groups according to intragroup comparison (P < .05). When the 2 groups were compared, the results of plantar flexion range, balance, proprioception, foot sensation, flexibility, FFI, and VAS showed significant improvements in the Outpatient vs the Home group (P < .05). Also, the FFI and VAS scores at the sixth month were superior in the Outpatient group (P < .05).

CONCLUSION

A combined supervised management protocol had superior clinical results in plantar fasciitis management.

LEVEL OF EVIDENCE

Level II, comparative study.

A global approach for plantar fasciitis with extracorporeal shockwaves treatment

Extracorporeal Shockwaves Treatment is considered an effective therapeutic option for plantar fasciitis, but the standard application in the medial insertion of the plantar fascia on the calcaneus has provided ambiguous evidences. In this case, a 63-year man with plantar fasciitis was treated in a 3-session program and Foot and Ankle Outcome Scale and Foot Functional Index questionnaires were chosen for the clinical outcome evaluation. The therapy was focused on the active trigger or myofascial points of the leg, thigh and pelvis in order to return the correct equilibrium of the myofascial system of the whole limb. The patient has already reported an improvement after the second session (FAOS: 76 vs 33, FFI: 85%) which was confirmed in the third one and in the 1-month follow up (FAOS: 79, FFI: 6%) Results suggest that plantar fasciitis may be due to proximal rigidity or tension of the fascia and a global approach using ESWT may have a similar or better outcome respect to the standard application.

Effectiveness of Manual Therapy, Customised Foot Orthoses and Combined Therapy in the Management of Plantar Fasciitis-a RCT

Background: Plantar fasciitis (PF) is one of the most common causes of plantar heel pain. Objective: To evaluate the effectiveness of three different treatment approaches in the management of PF. Methods: Sixty-three patients (44 female, 19 men; 48.4 ± 9.8 years) were randomly assigned into a manual therapy (MT), customised foot orthosis (FO) and a combined therapy (combined) group. The primary outcomes of pain and function were evaluated using the American Orthopaedic Foot and Ankle Society-Ankle Hindfoot Scale (AOFAS-AHS) and the patient reported outcome measure (PROM) Foot Pain and Function Scale (FPFS). Data were evaluated at baseline (T0) and at follow-up sessions after 1 month, 2 months and 3 months (T1–T3). Results: All three treatments showed statistically significant (p < 0.01) improvements in both scales from T0 to T1. However, the MT group showed greater improvements than both other groups (p < 0.01). Conclusion: Manual therapy, customised foot orthoses and combined treatments of PF all reduced pain and function, with the greatest benefits shown by isolated manual therapy.

Effects of myofascial trigger point dry cupping on pain and function in patients with plantar heel pain: A randomized controlled trial

OBJECTIVE

To investigate the effects of dry cupping on calf muscle myofascial trigger points (MTrPs) on pain and function in patients with plantar heel pain.

METHODS

Seventy-one patients were randomly divided into an intervention group or control group. Both groups performed stretching exercises for the calf muscle and plantar fascia and ankle dorsiflexion exercises. The intervention group also received dry cupping. The primary outcome measures were visual analogue scale (VAS), pressure pain threshold (PPT), and patient-specific functional scale (PSFS). The secondary outcomes were ankle dorsiflexion range of motion (ROM) and ankle plantar flexor strength. These measurements were performed at baseline, immediately after intervention, and after 2 days.

RESULTS

Current VAS significantly decreased immediately in the intervention group (p = 0.002), but not in the control group (p ≥ 0.220). Morning VAS decreased significantly in both groups (p < 0.001) after 2 days, but decreased more in the intervention group (p = 0.006). Trigger point PPT significantly improved immediately in the intervention group (p = 0.003), but not in the control group (p = 0.112). Both groups improved significantly in PSFS (p < 0.001) and ankle dorsiflexion ROM (p < 0.001). Plantar flexor strength significantly increased immediately in the intervention group (p < 0.001), but not in the control group (p = 0.556).

CONCLUSION

Adding dry cupping on calf MTrPs to self-stretching and ankle dorsiflexion exercises for patients with plantar heel pain was superior to only self-stretching and active ankle dorsiflexion exercises in pain, ankle dorsiflexion ROM, and plantar flexor strength.

Instrument-Assisted Soft-Tissue Mobilization for the Management of Chronic Plantar Heel Pain: A Pilot Study

BACKGROUND

The purpose of this study was to determine feasibility of further investigation of treatment with instrument-assisted soft-tissue mobilization (IASTM), using the Graston technique, compared with conservative care for treatment of chronic plantar heel pain (CPHP).

METHODS

Eleven participants with plantar heel pain lasting 6 weeks to 1 year were randomly assigned to one of two groups, with each group receiving up to eight physical therapy visits. Both groups received the same stretching, exercise, and home program, but the experimental group also received IASTM using the Graston technique. Outcome measures of pain and function were recorded at baseline, after final treatment, and 90 days later. Feasibility of a larger study was determined considering recruitment and retention rates, compliance, successful application of the protocol and estimates of the treatment effect.

RESULTS

Both groups demonstrated improvements in current pain (pain at time of survey), pain with the first step in the morning, and function after final treatment and at 90-day follow up. Medium-to-large effect sizes between groups were noted, and sample size estimates demonstrated a need for at least 42 participants to realize a group difference. A larger-scale study was determined to be feasible with modifications including a larger sample size and higher recruitment rate.

CONCLUSIONS

This pilot study demonstrates that inclusion of IASTM using the Graston technique for CPHP lasting longer than 6 weeks is a feasible intervention warranting further study. Clinically important changes in the IASTM group and moderate-to-large between-group effect sizes suggest that further research is warranted to determine whether these trends are meaningful.

The Parameters of Foam Rolling, Self-Myofascial Release Treatment: A Review of the Literature

Self-myofascial release (SMR) is a well-known and popular therapy. Its growing popularity is based on high effectiveness and availability. However, there is a lack of agreement about which parameters should be used to optimize the effects of the therapy. The purpose of this review is to critically select and assess current literature and ascertain the values of the follow­ing parameters: (1) therapy duration, (2) volume of applied pressure, (3) speed and (4) frequency of roll, (5) type of roller, (6) the number of treatment applications during one session, (7) the duration of intervals between applications that yield the best results in terms of soft tissue.

The authors launched their research in May 2018. The search strategy included the electronic databases EBSCOhost and PubMed. The following inclusion criteria were assessed:

- English language, high quality manuscripts (evaluation in PEDro scale)

- at least one of the groups using the foam roller, tennis ball or the stick to fascial release

- basic parameters of therapy described.A total 55 articles met the inclusion criteria. Patients can usually withstand a maximum tolerable pressure for 30-120 seconds, repeated 1-3 times, separated by 30 seconds of rest. The intensity of a single rolling movement should be moderate, and the movement should last about 3 seconds. Keeping the roller on particularly sensitive areas is recommended to release tension and enhance blood perfusion.Currently, there is no consensus on an optimal FR programme. However, there is a tendency to use SMR tools with a physiol­ogy-based method to enhance therapeutic efficiency.

Comparing two dry needling interventions for plantar heel pain: a protocol for a randomized controlled trial

Background

Both manual therapy techniques and dry needling have shown to be effective treatment options for the treatment of plantar heel pain; however, in recent years, other techniques based on dry needling (DN), such as percutaneous needle electrolysis (PNE), have also emerged. Currently, PNE is being used in clinical practice to manage myofascial trigger points, despite the lack of studies comparing the effects of this technique over dry needling. Therefore, the aim of this randomized controlled study is to compare the effectiveness of DN versus PNE for improving the level of pain experienced by patients suffering from plantar heel pain provoked by myofascial trigger points.

Methods

A randomized controlled trial will be conducted with blinded participants and outcome assessors. A sample of 94 patients with a medical diagnosis of plantar heel pain will be recruited and divided into two treatment groups. Eligible participants will be randomly allocated to either (a) treatment group with DN and a self-stretching home program or (b) treatment group with PNE and a self-stretching home program. Each group will receive one treatment session per week over a period of 4 weeks. The primary outcome measure will be the pain subscale of the Foot Health Status Questionnaire. The secondary outcome measures will be a visual analogue scale for pain (average and highest level of pain experienced during the previous 48 h; level of pain immediately after the treatment session) and health-related quality of life (assessed using the EuroQoL-5 dimensions). Cost-effectiveness data will be extracted based on the EuroQoL-5 dimensions. Follow-up measurements will take place at baseline and at 4, 8, 12, 26, and 52 weeks.

Discussion

The justification for this trial is the need to improve current understanding regarding the effectiveness of treatments targeting the rehabilitation of plantar heel pain. This study will be the first randomized controlled trial to directly compare the effectiveness of DN and PNE combined with a specific stretching program for the treatment of plantar heel pain provoked by myofascial trigger points.

Trial registration

Clinical Trials NCT03236779. Registered at clinicaltrials.gov 2 August 2017.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial

Study Design

Randomized, single-blinded, multi-center, parallel-group trial.

Objectives

To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF).

Background

The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population.

Methods

One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes.

Results

The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group.

Conclusion

The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months).

Level of evidence

Therapy, Level 1b.

Changes in Muscle Stiffness of the Trapezius Muscle After Application of Ischemic Compression into Myofascial Trigger Points in Professional Basketball Players

The study aimed to assess the effects of compression trigger point therapy on the stiffness of the trapezius muscle in professional basketball players (Part A), and the reliability of the MyotonPRO device in clinical evaluation of athletes (Part B). Twelve professional basketball players participated in Part A of the study (mean age: 19.8 ± 2.4 years, body height 197 ± 8.2 cm, body mass: 91.8 ± 11.8 kg), with unilateral neck or shoulder pain at the dominant side. Part B tested twelve right-handed male athletes (mean ± SD; age: 20.4 ± 1.2 years; body height: 178.6 ± 7.7 cm; body mass: 73.2 ± 12.6 kg). Stiffness measurements were obtained directly before and after a single session trigger point compression therapy. Measurements were performed bilaterally over 5 points covering the trapezius muscle. The effects were evaluated using a full-factorial repeated measure ANOVA and the Bonferroni post-hoc test for equal variance. A p-value < .05 was considered significant. The RM ANOVA revealed a significant decrease in muscle stiffness for the upper trapezius muscle. Specifically, muscle stiffness decreased from 243.7 ± 30.5 to 215.0 ± 48.5 N/m (11.8%), (p = .008) (Part A). The test-retest relative reliability of trapezius muscle stiffness was found to be high (ICC from 0.821 to 0.913 for measurement points). The average SEM was 23.59 N/m and the MDC 65.34 N/m, respectively (Part B). The present study showed that a single session of compression trigger point therapy can be used to significantly decrease the stiffness of the upper trapezius among professional basketball players.

Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial

INTRODUCTION

Plantar heel pain (PHP) is a common condition managed by physical therapists that can, at times, be difficult to treat. Management of PHP is complicated by a variety of pathoanatomic features associated with PHP in addition to several treatment approaches with varying efficacy. Although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP. Purpose: The purpose of this case series is to describe physical therapist decision-making of individualized multimodal treatment for PHP cases presenting with varied clinical presentations. Treatment incorporated clinical guidelines and recent evidence including a combination of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions. A common clinical decision-making framework was used to progress individualized treatment from a focus on symptom modulation initially to increased load tolerance of involved tissues and graded activity. In each case, patients met their individual goals and demonstrated clinically meaningful improvements in pain, function, and global rating of change that were maintained at the 1-2-year follow-up. Implications: This case series provides details of physical therapist management of a variety of PHP clinical presentations that can be used to complement clinical practice guidelines in the management of PHP.

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review

OBJECTIVE

To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions.

METHODS

A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen's d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups.

RESULTS

Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5-21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7-3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions.

DISCUSSION

MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF.

LEVEL OF EVIDENCE

Treatment, level 1a.

Manual therapy for plantar heel pain

BACKGROUND

Manual therapy employed in the treatment of plantar heel pain includes joint or soft tissue mobilizations. Efficacy of these methods is still under debate.

AIMS

To determine whether manual therapy, consisting of deep massage, myofascial release or joint mobilization is effective in treating plantar heel pain.

METHODS

A critical review of all available studies with an emphasis on randomized controlled trials (RCTs) was performed. PubMed, PEDro, and Google Scholar databases were searched for keywords relating to plantar heel pain, joint, and soft tissue mobilizations. There were no search limitations or language restrictions. The reference lists of all retrieved articles were searched. The PEDro score was used to assess the quality of the reviewed papers.

RESULTS

A total of six relevant RCTs were found: two examined the effectiveness of joint mobilization on plantar heel pain and four the effectiveness of soft tissue techniques. Five studies showed a positive short-term effect after manual therapy treatment, mostly soft tissue mobilizations, with or without stretching exercises for patients with plantar heel pain, compared to other treatments. One study observed that adding joint mobilization to the treatment of plantar heel pain was not effective. The quality of all studies was moderate to high.

CONCLUSIONS

According to reviewed moderate and high-quality RCTs, soft tissue mobilization is an effective modality for treating plantar heel pain. Outcomes of joint mobilizations are controversial. Further studies are needed to evaluate the short and long-term effect of different soft tissue mobilization techniques.