Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

Original Research Article Allied sciences

International Journal of Pharma and Bio Sciences ISSN

0975-6299

EFFECTIVENESS OF CYRIAX FRICTION MASSAGE ALONG WITH

ULTRASOUND THERAPY IN PATIENTS WITH
PLANTAR FASCITIS.
ANNA JACQUELINE ABIGAIL1 AND KAMALAKANNAN.M1 *
1
Saveetha College of Physiotherapy, Saveetha University, Chennai, India.

ABSTRACT
Plantar fasciitis, a repetitive strain injury of the medial arch and heel, is one of the most common causes
1
of foot pain. Aim is to determine the effectiveness of cyriax transverse friction massage with ultrasound
therapy in the management of plantar fasciitis. Objective is To determine the effectiveness of ultrasound
therapy with cyriax transverse friction massage on pain and functional ability in patients with plantar
fascitis. Methodology: 30 Individuals were selected according to the inclusion and exclusion criteria.
Participants were randomly assigned into two groups group A and group B. Pain was measured with
Numerical Pain Rating Scale (NPRS), Foot function index (FFI) used to measure quality of life. Results:
The post-test mean value of NPRS in Group-A is 3.47(SD 0.74) and post-test mean value of NPRS in
Group-B is 1.40 (SD 0.63), this shows that Group-A is greater than Group-B with the P value (0.001),The
post-test mean value of FFI in Group-A is 93.00 (SD 1.65) and post-test mean value of FFI in Group-B is
88.3 (SD 1.29), this shows that Group-A is greater than Group-B with the P value (0.001). It has been
concluded that Cyriax tranverse friction massage with ultrasound therapy (Group B) is more effective than
(Group A) in decreasing painand improving the functional ability.

KEYWORDS: plantarfascitis, Ultrasound therapy, footpain, heel pain,cyriax friction.

KAMALAKANNAN.M*
Saveetha College of Physiotherapy,SaveethaUniversity,Chennai,India.

Received on : 08-03-2017
Revised and Accepted on : 17-04-2017
DOI: http://dx.doi.org/10.22376/ijpbs.2017.8.2.b841-848

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 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848
INTRODUCTION
Plantar fasciitis, a repetitive strain injury of the medial
arch and heel, is one of the most common causes of
1
foot pain. Plantar fasciitis is usually a repetitive
microtrauma overload injury of the attachment of the
1,2
plantar fascia at the inferior aspect of the calcaneus.
Occasionally, plantar fasciitis occurs as part of an
2
inflammatory arthropathy or spondylarthropathy. The
function of the plantar fascia is in twofold: statically, it
stabilizes the medial longitudinal arch and dynamically it
restores the arch and aids in reconfiguring the foot for
efficient toe-off. When this tissue becomes damaged,
pain and/or weakness may develop in the area. Some of
the risk factors involved are sports activities, being
overweight , prolonged standing, increased subtalar
pronation accompanying flat feet, and limited ankle
1,3
dorsiflexion, wearing faulty shoes/slippers. Plantar
fasciitis is a common and often disabling complaint and
is estimated to account for up to 15% of all foot
3
symptoms in adults. It has been estimated that it affects
as much as 10% of the general population over the
4
course of a lifetime. The condition is bilateral in up to
one-third of cases and two third of cases are unilateral.
Incidence reportedly peaks in people between the age
5
of 40 to 60 years in general population. The plantar
aponeurosis or fascia consists of 3 bands: lateral,
medial, and central. the most common site of pain in
persons with plantar fasciitis is near the origin or
enthesis of the central border of the plantar aponeurosis
at the medial tubercle of calcaneum, individuals also
complain of pain over the mid portion of the central
band. The symptoms of plantar fasciitis includes pain
over the medial part of the calcaneum, pain during the
6
first few steps after rest. Cyriax deep transverse friction
massage is a technique popularized by Dr. James
Cyriax for pain and inflammation relief in
musculoskeletal conditions. Deep friction massage is a
technique that attempts to reduce abnormal fibrous
adhesions and make scar tissue more mobile in acute,
sub- acute and chronic inflammatory conditions by
realigning the normal soft tissue fibers. This is carried
out by fingertip or by the thumb. According to Cyriax,
Deep Transverse Friction causes traumatic hyperemia
which results in increased blood flow and decrease in
7
pain. The Cyriax deep friction massage is deep and
must be applied transversely to the specific tissue
involved which enhances circulation. Cyriax's goals are
two-fold: to provide movement to the tissue itself and to
8
produce traumatic hyperemia. Transverse friction
massage (TFM) is a specific type of connective tissue
massage applied precisely to the soft-tissue structures.
The aim of the TFM is to stretch and mobilize fibrous
adhesions and tight scar tissue. The frictions should be
applied by manual pressure directly to the origin of the
plantar fascia using a repetitive back-and-forth motion,
transversely across the affected structure with adequate
sweep to cover the affected area and sufficient depth to
produce mechanical stretching of the underlying
9
structure. Therapeutic ultrasound has been used
extensively to treat a variety of conditions because of its
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documented thermal effects. Ultrasound therapy helps
in tissue repair and wound healing according to various
clinical trials. It has been a treatment of choice in soft
tissue injuries. The high frequency sound stimulates the
local tissues and increases the blood flow to the area
9,10,11
alleviating inflammation.
MATERIALS AND METHODS
Study Design: Experimental study,
Study Setting: Saveetha Medical College & Hospital
Physiotherapy Outpatient Department Saveetha
University, Sampling
Method: Simple Random Sampling technique, Sample
Size: 30.
Scientific and Ethical clearance was obtained from
Saveetha University.
Inclusion Criteria: Both gender,Age group between 30-
50years,Patients with plantar fascitis (plantar stretch test
positive), NPRS score not more than 7, Patients with
heel pain for >3 weeks.
Exclusion Criteria: Radiological evidence showing
calcaneal spur, Patients with bilateral foot pain, Clinical
disorders where therapeutic ultrasound/friction massage
is contraindicated such as infective conditions of foot,
tumor, dermatitis, calcaneal fracture, metal implant
,12,13
around the ankle. , Impaired circulation to lower
14
extremities , Neurological disorders, Corticosteroid
injection in heel for the past six months.
Materials Required: Therapeutic Ultrasound
equipment, Coupling Medium (aquasonic gel),
Treatment Couch.
Procedure: 30 Individuals were selected according to
the inclusion and exclusion criteria. Detailed procedure
was explained to the patients in colloquial terms about
the safety and simplicity of the procedure and informed
consent was obtained from those who were interested.
Participants were randomly assigned into two groups.
Pain was measured with Numerical Pain Rating Scale
(NPRS), Foot function index (FFI) used to measure
quality of life.
Group - A (Control Group)
Ultrasound therapy was given to the patient, with patient
positioned in a comfortable position preferably in prone
lying with pillow/towel roll supported in anterior part of
ankle and therapy was given by placing the transducer
head over the medial plantar aspect of the heel/painful
region using coupling medium, parameters are given in
(Table:1)
Group - B (Experimental Group)
Ultrasound therapy (Table:1) is followed by Cyriax deep
transverse friction massage. Patient was positioned in
supine lying , the patient’s foot is held by the therapist
in such a way that the plantar fascia is in stretched
position and deep transverse friction massage was
given using bilateral thumb across the affected
fibersover the medial plantar aspect of the heel for a
duration of 8 mins.(Table:2)
 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

Table1
TREATMENT PROTOCOL for Ultrasound therapy

Frequency 3MHZ
Intensity 1.5w/ cm2
Duration 7 minutes
Mode pulsed
Treatment was given for 10 days(5days/week for two weeks)

Table 2
TREATMENT PROTOCOL for Friction massage

Frequency 5 days / week for 2 weeks

Duration 8 minutes
Treatment was given for 10 days(5days/week for two weeks)

Figure 1
Ultrasound Therapy

Figure 2
Cyriax Transverse Friction Massage

Outcome measures
15,16
Numerical Pain Rating Scale (NPRS) for pain
The NPRS is ascale consisting of numbers 0 to 10, it helps to find the pain threshold of the patient subjectively, in
which 0 refers to no pain and 10 refers to worst imaginable pain.

15,16
0 indicates no pain Foot function index
1-3 indicates mild pain This questionnaire is used to evaluate the effect of foot
4-6 indicates moderate pain pain in every day life. For the following questions the
7-10 indicates severe pain subject will be asked to score each question on a scale
from 0 (no pain/no difficulty/none of the time) to 10

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 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

(worst pain imaginable/so difficult activity cannot be STATISTICAL ANALYSIS

done/all of the time)theirfoot pain over the past week.
Patient is explained/asked to read each question and
circle a number from 0-10.It includes three subscales
namely : pain subscale, disability subscale, activity
limitation subscale under which the questions are asked.
Outcome measures were taken before intervention and
at the end of 10 days treatment for both the groups and
considered as pre & post values respectively.
Statistically, results were obtained.
The collected data were tabulated & analyzed using
descriptive & inferential statistics. To all parameters
mean & standard deviation (SD) was been used. Paired
t-test will be used to analyze significant changes
between pre-test & post-test measurements. Unpaired t-
test was been used to analyze significant changes
between two groups.

Table 3
Pre test –Post test values of group – A

Group A Mean Standard deviation t value p value

Numerical Pain Rating Scale (NPRS) Pre test 6.13 0.64 14.2701 <0.001
Post test 3.47 0.74
Foot Function Index (FFI) Pre test 97.87 2.53 11.4810 <0.001
Post test 93.00 1.65
The data from the above table shows the pre-test and post-test values of Numerical Pain Rating Scale
(NPRS) and FootFunction Index (FFI) in Group-A subjects.

The pre-test mean value of NPRS is 6.13 (SD 0.64) and of FFI is 97.8 (SD 2.53 ) and the post -test mean value
post-test mean value is 3.47(SD 0.74) this shows that is 93.00 (SD 1.65) this shows that FFI scores are
NPRS scores are gradually decreasing with the P value gradually decreasing with the P value (0.001)
(0.001) statistically significant. The pre-test mean values statistically significant.

Graph 1
Showing Pre and Post Test Values of NPRS in Group-A

Graph 2
Showing Pre and Post Test Values of FFI in Group-A

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Table 4
Pre test –Post test values of group - B

Group B Mean Standard deviation t value p value

Pre test 6.07 0.59 <0.001
Numerical Pain Rating Scale (NPRS) Post test 24.9727
1.40 0.63
Foot Function Index Pre test 98.13 2.67
10.8163 <0.001
(FFI) Post test 88.33 1.29
The data from the above table shows the pre-test and post-test values of Numerical Pain Rating Scale
(NPRS) and Foot Function Index (FFI) in Group-B subjects.

The pre-test mean value of NPRS is 6.07(SD 0.59) and of FFI is 98.13 (SD 2.67) and the post -test mean value
post-test mean value is 1.40 (SD 0.63) this shows that is 88.33 (SD 1.29) this shows that FFI scores are
NPRS scores are gradually decreasing with the P value gradually decreasing with the P value (0.001)
(0.001) statistically significant. The pre-test mean values statistically significant.

Graph 3
Showing Pre and Post Test Values of NPRS in Group-B

Graph 4
Showing Pre and Post Test Valuesof FFI in Group - B

Table 5
Comparison between the post test values Group A&B

Parameter Post Test Values ‘t’ test Signifi-cance

Group A Group B
Mean Standard deviation Mean Standard deviation
Numerical Pain Rating Scale (NPRS) 3.47 0.74 1.40 0.63 8.2018 <0.001

Foot Function Index 93.00 1.65 88.3 0.33 8.6351 <0.001

(FFI)
Post test measure of mean and standard deviation for Numerical Pain Rating Scale (NPRS) and Foot Function
Index (FFI )in group A and group B in respect with ‘t’ value (student ‘t’ test)

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 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

The data from above table shows the post-test values of
Numerical Pain Rating Scale (NPRS) and Foot Function
Index (FFI) in Group-A and Group-B. The post-test
mean value of NPRS in Group-A is 3.47(SD 0.74) and
post-test mean value of NPRS in Group-B is 1.40 (SD
0.63), this shows that Group-A is greater than Group-B
with the P value (0.001) The post-test mean value of FFI
in Group-A is 93.00 (SD 1.65) and post-test mean value
of FFI in Group-B is 88.33 (SD 1.29), this shows that
Group-A is greater than Group-B with the P value
(0.001)

Graph 5
Showing Post Test - Post Test Values of NPRS inGroup-A & Group-B

Graph 6
Showing Post Test - Post Test Values of FFI inGroup-A & Group-B

RESULTS arch and heel, is one of the most common causes of

From the statistical analysis made with the quantitative
data revealed statistically significant difference between
the Group A and Group B, and also within the group.
The post-test mean value of NPRS in Group-A is
3.47(SD 0.74) and post-test mean value of NPRS in
Group-B is 1.40 (SD 0.63), this shows that Group-A is
greater than Group-B with the P value (0.001) The post-
test mean value of NPRS in Group-A is 93.00 (SD 1.65)
and post-test mean value of FFI in Group-B is 88.3 (SD
1.29), this shows that Group-A is greater than Group-B
with the P value (0.001) Statistical Analysis of post test,
Numerical Pain Rating Scale (NPRS) and Foot Function
Index (FFI) revealed that there is high statically
significant difference seen between Group A and Group
B.
DISCUSSION
Plantar fasciitis, a repetitive strain injury of the medial
16
foot pain. Plantar fasciitis is usually a repetitive
microtrauma overload injury of the attachment of the
plantar fascia at the inferior aspect of the calcaneus.
Plantar fasciitis has been reported as the leading cause
for heel pain. It is a common and often disabling
complaint and is estimated to account for up to 15% of
17
all foot symptoms in adults. It has been estimated that
it affects as much as 10% of the general population over
18
the course of a lifetime. Standley hasstated that injury
strains fibroblasts and fascia in negative ways and in
contrast manual muscle treatment strains
fibroblasts/fascia in curative ways. Both injury and
manual muscle treatment increases the number of
fibroblasts in fascia with injury creating pro-inflammatory
mediators and manual muscle treatment healing by
increasing anti-inflammatory mediators. Geoff Formosa,
Gordon Smith concluded in their study that the friction
massage applied by the using the thumb of one hand to
impart the frictions while stretching the plantar fascia
with the other hand by maintaining toe dorsiflexion. This
one-handed technique resulted in considerable effort on

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 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848
the part of the operator to maintain depth during the
treatment session. This may have resulted in a non-
uniform application of the technique during the ten-
minute sessions. Suggested the preferable use both
thumbs to apply the Transverse Friction Massage (TFM)
and stabilize the heel with the rest of the fingers in order
to impart a deeper and more controlled pressure. In this
study TFM is given using bilateral thumb , which was
found to be effective though therapist fatigue was
inevitable. The aim of this study was to determine the
effectiveness of cyriax transverse friction massage
along with ultrasound therapy in treatment of patients
with plantar fascitis. 30 subjects fulfilling the inclusion
criteria were assigned to this study by randomization
technique. The subjects were divided into 15 subjects
each. Informed consent was taken from the subjects
and the procedure was explained. Group A (n=15) were
receiving ultrasound therapy over a period of 2weeks, 5
days/week. Group B (n=15) were receiving Cyriax
transverse friction massage and ultrasound therapy
therapy over a period of 2weeks, 5 days/ week.
Numerical pain rating scale (NPRS) and Foot Function
Index(FFI) was used to as the tools for analysis. The
nd
Outcome measures were been taken at the end of 2
week. n the present study, the subjects were chosen
from age group 30-50 years. The data obtained from the
study was statistically analyzed using paired and
unpaired t-test. The result of the study revealed that
there was decrease in pain and an improvement in the
functional ability. Decrease in pain measured by NPRS
in both groups, A and B after the respective protocol.
Hence, the result of this study proves that, there will be
beneficial effect of Cyriax transverse friction massage
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Limitations
1. Small sample size.
2. Equal attention to all the patients could not be given
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3.Therapist fatigue is a major problem encountered
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Future Recommendations
A studywith large sample size is recommended and Use
of massaging probe can be considered in order to avoid
fatigue
CONCLUSION
From the result, it has been concluded that
Cyriaxtranverse friction massage with ultrasound
therapy (Group B) is more effective and befifiting the
patients than giving only ultrasound therapy (Group A) in
decreasing pain and improving the functional ability. In
this study it has found that when cyriax friction massage
is given along with ultrasound therapy for a patiens with
foot pain is reduces the foot pain and improves the
activities of daily living for the patients suffering with foot
pain (plantarfascitis).
CONFLICT OF INTEREST
Conflict of interest declared none.
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