G Model

YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS

The Foot xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

The Foot
journal homepage: www.elsevier.com/locate/foot

Effectiveness of myofascial release in the management of plantar heel

pain: A randomized controlled trial
M.S. Ajimsha a,b,∗ , D. Binsu b , S. Chithra b
a
Department of Physiotherapy, Hamad Medical Corporation, Doha, Qatar
b
Myofascial Therapy and Research Foundation, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: Previous studies have reported that stretching of the calf musculature and the plantar fas-
Received 11 December 2013 cia are effective management strategies for plantar heel pain (PHP). However, it is unclear whether
Received in revised form 7 March 2014 myofascial release (MFR) can improve the outcomes in this population.
Accepted 11 March 2014
Objective: To investigate whether myofascial release (MFR) reduces the pain and functional disability
associated with plantar heel pain (PHP) in comparison with a control group receiving sham ultrasound
Keywords:
therapy (SUST).
Plantar heel pain
Design: Randomized, controlled, double blinded trial.
Myofascial restrictions
Myofascial release
Setting: Nonprofit research foundation clinic in India.
Method: Sixty-six patients, 17 men and 49 women with a clinical diagnosis of PHP were randomly assigned
into MFR or a control group and given 12 sessions of treatment per client over 4 weeks. The Foot Function
Index (FFI) scale was used to assess pain severity and functional disability. The primary outcome measure
was the difference in FFI scale scores between week 1 (pretest score), week 4 (posttest score), and follow-
up at week 12 after randomization. Additionally, pressure pain thresholds (PPT) were assessed over the
affected gastrocnemii and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment
allocation.
Results: The simple main effects analysis showed that the MFR group performed better than the con-
trol group in weeks 4 and 12 (P < 0.001). Patients in the MFR and control groups reported a 72.4% and
7.4% reduction, respectively, in their pain and functional disability in week 4 compared with that in
week 1, which persisted as 60.6% in the follow-up at week 12 in the MFR group compared to the base-
line. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the
gastrocnemii and soleus muscles, and the calcaneus (P < 0.05).
Conclusions: This study provides evidence that MFR is more effective than a control intervention for PHP.

© 2014 Elsevier Ltd. All rights reserved.

1. Introduction
Plantar fasciitis (PF) or plantar heel pain (PHP) is the most com-
monly reported cause of inferior heel pain [1]. It has been estimated
that PHP affects as much as 10% of the general population over
the course of a lifetime [2]. In fact, some authors have reported
that PHP accounts for between 8% and 15% of foot complaints in
nonathletic and athletic populations [3,4]. The incidence of PHP
peaks in people between the ages of 40 and 60 years with no bias
∗ Corresponding author at: Department of Physiotherapy, Hamad Medical Corpo-
ration, Doha 3050, Qatar. Tel.: +974 55021106.
E-mail addresses: ajimshaw.ms@gmail.com, ajimshaw1979@gmail.com
(M.S. Ajimsha).
toward either sex [4]. To date, there is evidence that this condition
may not be characterized by inflammation but, rather, by nonin-
flammatory degenerative changes in the plantar fascia [5]. Both
surgical and nonsurgical approaches have been proposed for the
management of plantar heel pain [6]. There has been limited evi-
dence for the effectiveness of corticosteroid therapy, conflicting
evidence for low-energy extracorporeal shockwave therapy, and
no evidence for therapeutic ultrasound or low-intensity laser, in
reducing pain in individuals with plantar heel pain [7,8]. Stretch-
ing of the gastrocnemii muscle and the plantar fascia have shown
moderate evidence of effectiveness in the short term management
of plantar heel pain [7,8]. Simons et al. [9] have suggested that
myofascial restrictions/muscle trigger points (TrPs) in the gastroc-
nemii muscles may be involved in the development of plantar heel
pain. TrPs are defined as hyperirritable areas associated within a

http://dx.doi.org/10.1016/j.foot.2014.03.005
0958-2592/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
G Model
YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS
2 M.S. Ajimsha et al. / The Foot xxx (2014) xxx–xxx
myofascial restriction that are painful on compression, contraction,
or stretching of the muscles/fascia, and elicit a referred pain distant
to the TrP [9]. Chen et al. in their study have concluded that the stiff-
ness of TrP myofascial restrictions was 50% greater than that of the
surrounding muscle tissues [10]. It is probable that the increased
stiffness induced by myofascial restrictions with TrPs may interfere
with the extensibility of the muscles or the fascia.
Myofascial release (MFR) is the application of a low load, long
duration stretch to the myofascial complex, intended to restore
optimal length, decrease pain, and improve function [11].
It has been hypothesized that fascial restrictions in one part
of the body cause undue tension in other parts of the body due
to fascial continuity. This may result in stress on any structures
that are enveloped, divided, or supported by fascia [12]. Myofas-
cial practitioners believe that by restoring the length and health of
restricted connective tissue, pressure can be relieved on pain sen-
sitive structures such as nerves and blood vessels. MFR generally
involves slow, sustained pressure (120–300 s) applied to restricted
fascial layers either directly (direct technique MFR) or indirectly
(indirect technique MFR). The rationale for these techniques can be
traced to various studies that investigated plastic, viscoelastic, and
piezoelectric properties of connective tissue [12–14].
MFR is being used to treat patients with PHP, but there are
few formal reports of its efficacy. The MFR used in this study was
the direct technique MFR (DTMFR), as promoted by Stanborough
[15]. During DTMFR, pressure is applied directly on restricted fas-
cia; practitioners use knuckles, elbow, or other tools to slowly sink
into the fascia and apply a few kilograms of force to contact the
restricted fascia, apply tension, or stretch the fascia. The primary
objective of the present study was to evaluate the efficacy of MFR on
pain, disability and pressure pain threshold for the management of
PHP in comparison with a control group receiving sham ultra sound
therapy (SUST), treating fascia of the gastrocnemii, soleus and plan-
tar fascia in accordance with the fascial meridians proposed by
Myers [16].
2. Methods
This study was carried out in the clinical wing of Myofascial
Therapy and Research Foundation, Kerala, India. Patients with a
primary complaint of unilateral plantar heel pain were screened
for possible inclusion in this study. Inclusion criteria for the study
was male and female patients aged 20–50 years, with a primary
complaint of unilateral plantar heel pain with the following clin-
ical features [17–19]: (1) insidious onset of sharp pain under the
plantar heel surface upon weight bearing after a period of non-
weight bearing; (2) plantar heel pain that increases in the morning
with the first steps after waking up; and (3) symptoms decreas-
ing with slight levels of activity, such as walking. Clinical history
intake of the participants included questions related to the onset
of pain and duration of the symptoms, and previous medication
and treatments. Patients were excluded if they exhibited any of
the following: (1) red flags to manual therapies (i.e., tumor, frac-
ture, rheumatoid arthritis, osteoporosis, severe vascular disease,
etc.), (2) bilateral plantar heel pain, (3) prior surgery in the lower
extremity, (4) diagnosis of fibromyalgia syndrome, or (5) previous
manual therapy interventions for the foot region.
The Research Ethics Committee of the Myofascial Therapy and
Research Foundation reviewed the study and raised no objections
from an ethical point of view. Between March 2011 and June 2013,
87 patients with a primary complaint of unilateral plantar heel pain
were referred to the Myofascial Therapy and Research Foundation.
Of these, 66 individuals who met the inclusion criteria and provided
written informed consent were randomized to the MFR or to the
control arm of the study. Participants were asked to maintain a
Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
pain and medication diary in which any medication or change in
pain pattern during the treatment period was to be recorded with
date and time. Two evaluators blinded to the group to which the
participants belonged analyzed scores from the FFI and PPT.
3. Outcome measures
3.1. Foot Function Index (FFI)
FFI was developed to measure the impact of foot pathology on
function in terms of pain, disability and activity restriction. The FFI
is a self-administered index consisting of 23 items that measure
pain, disability, and activity restriction. Scoring is based on a visual
analog scale [20,21]. The Foot Function Index has been reported
to be reliable, valid, and sensitive to change in subjects with foot
pathologies [20,21].
3.2. Pressure pain thresholds (PPT)
PPT is the minimal pressure when the sensation of pressure
changes to pain [22] was assessed with a mechanical pressure
Algometer (Baseline FPK 20). The device consists of a round rub-
ber disk (1 cm2 ) attached to a force gauge (kg). The pressure (force
divided by the surface area) was applied at a rate of approximately
0.1 kg/cm2 /s. The mean of 3 trials was calculated for each tested
location and used for the main analysis. Thirty seconds were used
between each trial. To investigate hypoalgesic effects of both inter-
ventions, PPT was assessed at 3 predetermined locations on the
affected leg: gastrocnemii (middle point over the muscle belly),
soleus (centered point of the muscle belly at 10 cm over Achilles
tendon) muscles, and over the posterior aspect of the calcaneus by
a blinded assessor. The reliability of algometry has been reported
to be high (intraclass correlation coefficient [ICC] = 0.91; 95% CI:
0.82, 0.97) [23,24]. In the current study, intra-examiner reliability
was calculated from the 3 trials over each location and ranged from
0.92 to 0.95, suggesting high repeatability of the measurement.
4. Study protocol
The 2 interventions were provided 3 times weekly for 4 weeks
(weeks 1–4), with a minimum of a 1 day gap between the 2 sessions;
the duration of each treatment session was 30 min. Both groups
were treated by clinicians blinded to the group and the outcome
of the study. Both the treatments were only applied to the affected
side. Outcome measures were captured at Week 1 (pretest score),
Week 4 (posttest score), and follow-up at Week 12 after random-
ization. Patients were unaware of the true objective of the study in
that they were aware of the ethical implications without revealing
the details of the intervention that was being evaluated. All sub-
jects were informed of the true nature of the study at the end of the
study.
4.1. MFR technique
We used the following treatment protocol for all the patients
in the MFR group [15,16]. The techniques were administered by
Physiotherapists certified in MFR who had been trained in the tech-
niques for at least 100 h and with a median experience of 12 months
with the technique.
The protocol was as follows.
4.1.1. MFR for gastrocnemius
Client’s position: Prone, with feet off the end of the table to allow
for easy dorsiflexion.
G Model
YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS
M.S. Ajimsha et al. / The Foot xxx (2014) xxx–xxx
Fig. 1. MFR of the gastrocnemii using elbow.
Therapist’s position: Facing toward head while standing at the
foot end of the table for technique number 1 and 3, facing toward
the feet while standing at the client’s side, at around mid-thigh level
for technique number 2 and 3.
Technique 1: Use an elbow flexed to 90◦ and take up a contact in
the Tendo Achilles (Fig. 1). Establish a line of tension in a superior
direction and slowly engage the tissues while the client dorsiflexes.
Focus of the release will be at the junction of the tendon and the
muscles (5 mts × 1 repetition).
Technique 2: Use the index and middle fingers of each hand to
take up a contact on the tendons of the gastrocnemii at the epi-
condyles of the femur (Fig. 2). Put a line of tension in an inferior
direction and slowly apply the pressure into the tendinous struc-
tures of the posterior knee. Continue this down into the superior
portions of the fibrous part of the muscle, engage the tissues while
the client dorsiflexes (5 mts × 1 repetition).
Technique 3: Use the index, middle and ring fingers of each hand
to get into the medial and lateral aspects of the calcaneus (Fig. 3).
Begin the release proximally, slowly establish a line of tension in
an inferior direction and engage the tissue while the client com-
pletes 3 repetitions of dorsiflexion from plantar flexion (5 mts × 1
repetition).
4.1.2. MFR for soleus
Client’s position: Prone with feet over a bolster to induce 10–15◦
of knee flexion and put the gastrocnemii off stretch.
Therapist’s position: Facing toward the head while standing at
the foot end of the table.
Technique: Use an elbow to contact into the Tendo Achilles
(Fig. 4). Apply pressure gradually through the tendon into the
Fig. 2. Finger placements for release of the gastrocnemii tendons in the posterior
aspect of the knee.
Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
3
Fig. 3. Initial finger placements for the release of the fascia at the calcaneus.
investing layer of fascia that lies between the soleus and the gas-
trocnemii. Take up a line of tension in a superior direction and
engage the tissue while the client dorsiflexes (5 mts × 1 repetition).
4.1.3. MFR for plantar myofasciae
Client’s position: Prone with feet off the end of the table to allow
for easy dorsiflexion.
Therapist’s position: Sitting on a stool at the end of the table.
Technique: Use the knuckles to engage the soft tissue just ante-
rior of the calcaneus (Fig. 5). Take up a line of tension in an anterior
direction. Work to the ball of the foot as well as into deeper layers
with toe flexion and extension from the patient’s side (5 mts × 2
repetitions).
4.2. Control intervention
Patients in the control group received sham ultrasound ther-
apy (SUST) over the gastrocnemii, soleus and plantar fascia in the
same areas of the application of MFR (in the other group) for 30 min
per treatment session, three times a week for 4 weeks. SUST units
were prepared by removing the ultrasound producing quartz crys-
tal from the treatment transducer head of the ultrasound therapy
units without the knowledge of the attending therapist. After the
completion of the study, patients in the control arm were provided
MFR therapy, as advised by the ethics committee.
5. Statistics
Participants in both groups (MFR group, n = 34; control group,
n = 32) were comparable at baseline, as shown in Table 1. The
primary outcome measure was the difference in FFT scale scores
between baseline (pretest score), Week 4 (posttest score), and
Fig. 4. Soleus release with 10–15◦ of knee flexion.
G Model
YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS
4 M.S. Ajimsha et al. / The Foot xxx (2014) xxx–xxx

Fig. 6. Effects of group and time on FFI value.

initiation of treatment, and this was reported to have subsided

within a week without any medications.
The patients in the MFR group reported a 72.4% reduction in their
Fig. 5. Release of the plantar myofasciae using a soft fist. pain and functional disability as shown in the FFI score in Week 4,
which persisted as 60.6% in the follow-up at Week 12 compared
Table 1
to the baseline. Patients in the control group reported a 7.4% and
Summary of baseline characteristics. 2.0% reduction in their pain and disability in Week 4 and Week
12, respectively (Fig. 6). The proportion of responders, defined as
Characteristics MFR group (n = 33) Control group (n = 32)
participants who had at least a 50% reduction in pain and functional
Men:woman 7:26 10:22 disability between Weeks 1 and 4, was 100% in the MFR group and
Age (y) 42.4 ± 4.6 40.8 ± 7.1
0% in the control group.
Duration of condition (mo) 4.0 ± 0.6 4.1 ± 0.5
Body mass index (kg/m2 ) 26.3 ± 3.5 27.9 ± 5.0 The mean differences between groups vary by time. This indi-
cates the possible existence of their interaction effect (Table 2).
Note: Data are mean ± SD or as otherwise noted.
We have examined the effect of group and time on the FFI value
by conducting, first, a 2-way ANOVA. The dependent variable, the
follow-up at Week 12 after randomization. Additionally, pressure FFI value, was normally distributed approximately for the groups,
pain thresholds (PPT) were assessed over the affected gastrocne- formed by the combination of the group and time because the size
mii and soleus muscles, and over the calcaneus. Statistical analysis of the sample is more than 30 for each group. The test’s between-
of the data was done by using a 2 × 3 (group × time) analysis subject effects showed that the MFR group significantly performed
of variance (ANOVA) and repeated-measures of 2 × 3 ANOVAs. better than the control group in Weeks 4 and 12 (P < 0.001) (Table 4),
The between-groups (group), within-groups (time) and mixed but there were no differences between the groups at baseline
groups (group × time) were examined by using Pillai trace, Wilk , (P < 0.533).
Hotelling trace and Roy largest root methods. We used Mauchly’s A 2 × 2 (group × time) repeated-measures ANOVA and a 2 × 3
sphericity test for validating the ANOVAs. In accordance with the (group × time) repeated-measures ANOVA were also conducted.
primary objective of the study, we compared the FFT scores of the There were significant main effects of time, group, and the
MFR and control groups at different time intervals. A P < 0.05 was time × group interaction. We found that the interactions between
accepted as statistically significant. time and group were significant based on univariate and multivari-
ate method ANOVAs. Significant pairs of MFR and control groups
vary at Weeks 4 and 12 due to the interaction effect between group
6. Results
type and time.

Of the 66 individuals recruited into this study, 65 participants

(MFR group, n = 33; control group, n = 32) completed the study
protocol. One participant from the control group dropped out
of the study without providing any specific reason and the data
was excluded from the results presented below. Within the study
period, no serious adverse events occurred in either of the groups as
recorded in the patient diary. All the participants (n = 65) attained
100% engagement rate to their allotted sessions. Five patients from
the MFR group reported an increase of pain in the first week after
6.1. Changes in pressure pain thresholds
The 2 × 2 ANOVA revealed significant group-by-time interac-
tions for changes in PPT over the gastrocnemii (F = 23.406, P < 0.001)
and soleus (F = 22.232, P < 0.001) muscles, and over the calcaneus
(F = 16.641, P < 0.001). Patients in the MFR group demonstrated a
greater improvement in PPT, as compared to the control group
(P < 0.01) (Table 3).

Table 2
FFI scores of MFR and control groups at different intervals.

Group Time

Baseline Week 4 Week 12

Control 61.38 ± 5.22 (58.58–64.15) 56.85 ± 6.91 (53.02–58.88) 60.15 ± 8.11 (56.05–63.26)
MFR 63.01 ± 4.44 (59.43–64.79) 17.39 ± 4.02 (16.08–21.26) 24.81 ± 3.98 (22.73–26.89)

Note: Data are expressed as mean ± SD (95% confidence interval of the mean).

Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
G Model
YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS
M.S. Ajimsha et al. / The Foot xxx (2014) xxx–xxx 5

Table 3
PPT scores of MFR and control groups at different intervals.

Group Time

Baseline Week 4 Week 12

Gastrocnemius
Control 2.0 ± 0.22 (1.8–2.1) 2.2 ± 0.51 (2.0–2.4) 2.1 ± 0.32 (2.0–2.2)
MFR 1.8 ± 0.44 (1.7–2.1) 2.9 ± 0.82 (2.8–3.1) 2.6 ± 0.54 (2.4–2.7)
Soleus
Control 2.2 ± 0.52 (2.0–2.4) 2.2 ± 0.31 (2.1–2.3) 2.1 ± 0.72 (2.0–2.3)
MFR 2.0 ± 0.48 (1.9–2.2) 3.1 ± 0.91 (2.8–3.2) 2.7 ± 0.65 (2.6–2.9)
Calcaneus
Control 2.3 ± 0.77 (2.2–2.7) 2.5 ± 0.67 (2.3–2.6) 2.4 ± 0.48 (2.2–2.7)
MFR 2.1 ± 0.38 (1.9–2.2) 3.4 ± 0.95 (3.1–3.6) 3.1 ± 0.78 (2.9–3.2)

Note: Data are expressed as mean ± SD (95% confidence interval of the mean).

Table 4
FFI pairwise comparisons of group and time.

Time Group I Group II Mean difference (group SE P* 95% Confidence

I value − group II value) interval for difference*

Baseline Control MFR 0.895 0.948 0.533 0.621–1.321

Week 4 Control MFR 6.813† 0.810 0.000 5.160–8.465
Week 12 Control MFR 4.250† 0.844 0.000 2.529–5.971

Note: Based on estimated marginal means.

*
Adjustment for multiple comparisons: least significant difference (equivalent to no adjustment).
†
The mean difference is significant at the 0.05 level.

We observed that the interactions between time and group were
significant based on univariate and multivariate methods for all 3
repeated-measures ANOVAs. Significant pairs of MFR and control
groups vary at Weeks 4 and 12 due to the interaction effect between
group type and time.
7. Discussion
The principal finding of the current study is that the MFR inter-
vention tested in this trial was significantly more effective than
SUST over the pain, functional disability and pressure pain thresh-
old of PHP.
PHP is thought to be caused by noninflammatory degenerative
changes in the plantar fascia [5]. Histological assessments of tissues
from patients with chronically painful plantar fascia demonstrate
findings more consistent with a failed healing response process,
without histopathological evidence of inflammation. The tissue is
characterized histologically by infiltration with macrophages, lym-
phocytes, and plasma cells; tissue destruction; and repair involving
immature vascularization and fibrosis [5]. The normal fascia tis-
sue is replaced by an angiofibroblastic hyperplastic tissue which
spreads itself throughout the surrounding tissue creating a self-
perpetuating cycle of degeneration [5].
The exact mechanisms of the efficacy of MFR in the manage-
ment of plantar heel pain is unclear, but they may be related to
a decrease in tension over the plantar fascia or decrease of risk
factors, such as tightness of the gastrocnemii and soleus mus-
cles and restricted ankle dorsiflexion. A study by Meltzer et al.
[25] has shown that treatment with MFR after repetitive strain
injury resulted in normalization in apoptotic rate, cell morphol-
ogy changes, and reorientation of fibroblasts. It is possible that
treatment with MFR in PHP may result in a halt in the degenera-
tive process of the plantar fascia by facilitating the healing process
and the fascial architecture to return toward normality. According
to Schleip [12], under normative conditions, fascia and connective
tissues tend to move with minimal restrictions. However, injuries
resulting from physical trauma, repetitive strain injury, and inflam-
mation are thought to decrease fascial tissue length and elasticity,
resulting in fascial restriction. It is also possible that pain relief due
to MFR is secondary to returning the fascial tissue to its normative
length by collagen reorganization; this is a hypothesis that mer-
its investigation. It has also been proposed that compressing the
sarcomeres by direct pressure, combined with active contraction
or stretching of the involved muscle, may equalize the length of
the sarcomeres and consequently decrease the pain [26]; however,
this theory has not been scientifically investigated [27]. As with any
massotherapy techniques, the analgesics effect of MFR can also be
attributable to the stimulation of afferent pathways and the exci-
tation of afferent A delta fibers, which can cause segmental pain
modulation [28] as well as modulation through the activation of
descending pain inhibiting systems [29,30]. However, the follow-
up at Week 12 has shown that the treatment effects were less
evident compared with Week 4 after the treatment. This may be
explained because, at the 12-week follow-up, the treatment effect
obtained may be disguised by the continuation of the daily activi-
ties with the same causative factors or by the natural course of the
disease.
Additionally, we also found an increase in PPT over the affected
leg within the MFR group. Again effect sizes were large, supporting a
clinical effect of the intervention over mechanical pain sensitivity.
Our results support that MFR treatment decreases pressure pain
sensitivity, which is again in agreement with the previous studies
on segmental antinociceptive effects [30,31].
8. Study limitations
One limitation of this trial was that we only conducted a
short-term follow up. We do not know if these effects would be
maintained for longer periods. In this study it was impossible to
interpret weather MFR to the gastrocnemii, soleus or the plantar
fascia brought the improvement. Future comparative analyses are
advocated to find an answer to it. A slight improvement over time
occurred in the control group at Week 4; this could be due to a
“meaning response” [32]. It will be of interest if further studies can
be conducted to compare the effectiveness MFR with established
treatments like arch supports, self stretching or even with surgical
procedures.

Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
G Model
YFOOT-1313; No. of Pages 6 ARTICLE IN PRESS
6 M.S. Ajimsha et al. / The Foot xxx (2014) xxx–xxx
9. Conclusions
The MFR investigated in this trial was more effective than a con-
trol intervention with SUST for the treatment of PHP. MFR can be
a simple and cost effective addition to the non-surgical manage-
ment of PHP. A significant proportion of individuals with PHP might
benefit from the use of MFR. The mechanisms underlying these
responses merit further investigation.
9.1. Implications
Physical therapists are advised to consider MFR as an adjunct to
their conservative managements for the treatment of plantar heel
pain.
Acknowledgments
We thank all the practitioners and professionals of MFTRF, India
and the physicians who participated in the consensus process and
analysis to establish the trial interventions. We are expressing our
special gratitude to Mr. Shean Capati, PT, for his photo shoot assis-
tance.
References
[1] Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physi-
cian 2011;84:676–82.
[2] Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a
matched case–control study. J Bone Joint Surg Am 2003;85-A:872–7.
[3] Rome K, Howe T, Haslock I. Risk factors associated with the development of
plantar heel pain in athletes. Foot 2001;11:119–25.
[4] Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD.
A retrospective case-control analysis of 2002 running injuries. Br J Sports Med
2002;36:95–101.
[5] Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fas-
ciosis) without inflammation. J Am Podiatr Med Assoc 2003;93:234–7.
[6] Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad
Orthop Surg 2008;16:338–46.
[7] McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel
pain – plantar fasciitis: clinical practice guildelines linked to the interna-
tional classification of function, disability, and health from the orthopaedic
section of the American Physical Therapy Association. J Orthop Sports Phys
Ther 2008;38:A1–18.
[8] Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane
Database Syst Rev 2003:CD000416.
[9] Simons DG, Travel JG, Simons LS. Myofascial pain and dysfunction: the trigger
point manual, vol. 1: The upper half of body. 2nd ed. Baltimore, MD: William
and Wilkins; 1999.
Please cite this article in press as: Ajimsha MS, et al. Effectiveness of myofascial release in the management of plantar heel pain: A
randomized controlled trial. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.005
[10] Chen Q, Bensamoun S, Basford JR, Thompson JM, An KN. Identification and
quantification of myofascial taut bands with magnetic resonance elastography.
Arch Phys Med Rehabil 2007;88:1658–61.
[11] Barnes JF. Myofascial release: the search for excellence. 10th ed. Paoli, PA:
Rehabilitation Services Inc.; 1990.
[12] Schleip R. Fascial plasticity—a new neurobiological explanation: part I. J Bodyw
Mov Ther 2003;7:11–9.
[13] Greenman PE. Principles of manual medicine. Philadelphia: Lippincott Williams
& Wilkins; 2003. p. 155–8.
[14] Pischinger A. Matrix and matrix regulation: basis for a holistic theory in
medicine. Brussels: Haug International; 1991.
[15] Stanborough M. The upper extremities. Direct release myofascial technique.
Edinburgh: Churchill Livingstone; 2004. p. 172–5.
[16] Myers TW. Anatomy trains: myofascial meridians for manual and movement
therapists. 2nd ed. Edinburgh: Churchill Livingstone; 2009.
[17] Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step.
Cleve Clin J Med 2006;73:465–71.
[18] Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med
2004;350:2159–66.
[19] Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis
and therapy. Am Fam Physician 2005;72:2237–42.
[20] Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of
foot pain and disability. J Clin Epidemiol 1991;44:561–70.
[21] Saag KG, Saltzman CL, Brown CK, Budiman-Mak E. The Foot Function Index for
measuring rheumatoid arthritis pain: evaluating side-to-side reliability. Foot
Ankle Int 1996;17:506–10.
[22] Vanderweeen L, Oostendorp RA, Vaes P, Duquet W. Pressure algometry in man-
ual therapy. Man Ther 1996;1:258–65.
[23] Chesterton LS, Sim J, Wright CC, Foster NE. Interrater reliability of algometry in
measuring pressure pain thresholds in healthy humans, using multiple raters.
Clin J Pain 2007;23:760–6.
[24] Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernández-
de-Las-Peñas C. Effectiveness of myofascial trigger point manual therapy
combined with a self-stretching protocol for the management of plan-
tar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther
2011;41(2):43–50.
[25] Meltzer KR, Cao TV, Schad JF, King H, Stoll ST, Standley PR. In vitro mod-
eling of repetitive motion injury and myofascial release. J Bodyw Mov Ther
2010;14:162–71.
[26] Simons DG. Understanding effective treatments of myofascial trigger points. J
Bodyw Mov Ther 2002;6:81–8.
[27] Dommerholt J, Shah J. Myofascial pain syndrome. In: Fishman S, Ballantyne J,
Rathmell J, editors. Bonica’s management of pain. Baltimore, MD: Lippincott
Williams & Wilkins; 2010.
[28] Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971–9.
[29] Le-Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (DNIC).
II. Lack of effect on non convergent neurons, supraspinal involvement and
theoretical implications. Pain 1979;6:305–27.
[30] Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofas-
cial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med
2010;42:463–8.
[31] Srbely JZ, Dickey JP, Lowerison M, Edwards AM, Nolet PS, Wong LL. Stimulation
of myofascial trigger points with ultrasound induces segmental antinociceptive
effects: a randomized controlled study. Pain 2008;139:260–6.
[32] Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the
meaning response. Ann Int Med 2002;136:471–6.