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

Renan-Ordine R, Alburquerque-Sendí N F, Rodrigues de Souza DP, Cleland JA, Fernández-de-Las-Peñas C. J Orthop Sports Phys Ther. 2011 Feb;41(2):43-50.

This is a nice study investigating an intervention for plantar heel pain (a.k.a. plantar fascitis or plantar fasciopathy) that many clinicians may use in treatments without a lot of objective evidence to indicate whether or not the treatment is effective. The investigators evaluated the effects of trigger point manual therapy combined with a self-stretching program among 60 patients with plantar heal pain in a randomized, controlled, clinical trial (comparative efficacy trial). The study included two groups: patients performing a self-stretching protocol and a second group performing the self-stretching protocol along with soft tissue trigger point manual therapy. All of the participants attended a physical therapy clinic 4 days per week for 4 weeks. The stretching protocol involved stretching 2 times/day with 20s holds and 20s rest for 3 minutes/stretching exercise (stretches included a standing calf stretch with the knee flexed, standing calf stretchwith the knee straight, and plantar fascia stretch). The manual therapy included trigger point pressure release techniques(in the gastrocnemius) and a neuromuscular technique (longitudinal stroke). The authors provide a nice description of these techniques and videos of the techniques are posted on the journal’s website (https://www.jospt.org/issues/articleID.2540,type.1/article_detail.asp). The investigators reported that the group receiving stretching and manual therapy had greater improvement in function and a greater reduction in pain as well as point tenderness compared to the patients only stretching. The authors acknowledge 3 potential limitations to the study: 1) the investigators did not  ensure that both groups had the same amount of time of hands on treatment from the clinician (perhaps a sham hands on treatment could have been used), 2) only 1 clinician was used (so we can’t know for sure if we can generalize these findings to all clinicians), and 3)  we cannot determine if the addition of manual therapy will provided extended pain relief.

This study supports the concept that the addition of myofascial trigger point manual therapy combined with self-stretching may provide better short-term relief than self-stretching alone. More research is needed to endorse this treatment as a key component of treatment recommendations for heel pain but it appears to be a potential tool in our arsenal to manage this painful condition (and we all know heel pain can be challenging to treat). The authors noted that 4 patients in the manual therapy group reported slight soreness after treatment for 2 days after the first 2 sessions compared to 2 patients reporting similar soreness in the self-stretching alone group. If you opt to include this in your treatment plan then it may be worth advising your patient that this could happen and recommend how you would like them to manage this increased soreness.

Written by: Jeffrey Driban
Reviewed by: Stephen Thomas