A COMPARATIVE STUDY ON THE EFFECTIVENESS OF

MYOFASCIAL RELEASE AND DEEP FRICTION

MASSAGE IN THE MANAGEMENT OF FOOT
FUNCTION AND FLEXIBILITY AMONG
CHRONIC PLANTAR FASCIITIS
PATIENTS

A dissertation submitted in partial fulfillment of the requirement for the degree of

MASTER OF PHYSIOTHERAPY

(ELECTIVE – ADVANCED PT IN ORTHOPEDICS)

To

The Tamil Nadu Dr. M.G.R. Medical University

Chennai-600032
APRIL 2016

(Reg. No. 271410023)

RVS COLLEGE OF PHYSIOTHERAPY

(Affiliated to the Tamil Nadu Dr.M.G.R Medical University, Chennai – 32)

SULUR, COIMBATORE – 641 402

TAMIL NADU, INDIA

 CERTIFICATE

Certified that this is the bonafide work of Mrs. Rittu Susan Babu, R.V.S.

College of Physiotherapy, Sulur, Coimbatore submitted in partial fulfillment of the

requirements for Master of Physiotherapy Degree course from The Tamilnadu

Dr M.G.R Medical University under the Registration No: 271410023.

Advisor
Mrs. J.Divya, M.P.T.
Associate Professor,
RVS College of Physiotherapy
Sulur, Coimbatore.

Principal
Dr.R. Nagarani, M.P.T.,M.A, Ph.D.,
Professor and Principal
RVS College of Physiotherapy
Sulur, Coimbatore.

Place:

Date:
 A COMPARATIVE STUDY ON THE EFFECTIVENESS OF
MYOFASCIAL RELEASE AND DEEP FRICTION
MASSAGE IN THE MANAGEMENT OF FOOT
FUNCTION AND FLEXIBILITY AMONG
CHRONIC PLANTAR FASCIITIS
PATIENTS

Advisor
Mrs. J.Divya, M.P.T.
Associate Professor,
RVS College of Physiotherapy
Sulur, Coimbatore.

Principal
Dr.R. Nagarani, M.P.T.,M.A, Ph.D.,
Professor and Principal
RVS College of Physiotherapy
Sulur, Coimbatore.

A dissertation submitted in the partial fulfillment of the requirement for the

degree of Masters of physiotherapy-April 2016 to The Tami Nadu Dr. MGR

Medical University, Chennai.

 A COMPARATIVE STUDY ON THE EFFECTIVENESS OF
MYOFASCIAL RELEASE AND DEEP FRICTION
MASSAGE IN THE MANAGEMENT OF FOOT
FUNCTION AND FLEXIBILITY AMONG
CHRONIC PLANTAR FASCIITIS
PATIENTS

INTERNAL EXAMINER:

EXTERNAL EXAMINER:

A dissertation submitted in the partial fulfillment of the requirement for the

degree of Masters of physiotherapy-April 2016 to The Tami Nadu Dr. MGR

Medical University, Chennai.

 DECLARATION

I hereby declare and present my project work entitled “A COMPARATIVE

STUDY ON THE EFFECTIVENESS OF MYOFASCIAL RELEASE AND

DEEP FRICTION MASSAGE IN THE MANAGEMENT OF FOOT

FUNCTION AND FLEXIBILITY AMONG CHRONIC PLANTAR FASCIITIS

PATIENTS.”

The outcome of the original research work undertaken and carried out by me,

under the guidance of Associate Professor Mrs. J.Divya, M.P.T., RVS College of

Physiotherapy, Sulur, Coimbatore.

I also declare that the material of this project work has not formed in any way

the basis for the award of any other degree previously from The Tamil Nadu

Dr. M.G.R Medical University.

Date: Signature

Place: (Rittu Susan Babu)

 ACKNOWLEDGEMENT

I give my thanks to God almighty for providing me the wisdom and

knowledge to complete my study successfully.

This study will be an incomplete one without my gratitude towards my

‘Lovable Parents’ and my ‘husband and daughter’ who made me what I am today.

I acknowledge my sincere thanks to Chairman and Secretary of R.V.S

Educational Trust, Sulur, Coimbatore for providing me an opportunity to do this
project.

I would like to express my gratitude to our Principal Dr. R. Nagarani

M.P.T.,M.A., PhD., for providing me constant support and motivation in the form of
resources and inputs.

I would like to thank my guide Mrs. J. Divya, M.P.T., offering me

perceptive inputs and guiding me entirely through the course of my work and without
her tired less guidance and support this project would not have come through.

I immensely thank all the other faculty members of Physiotherapy department for
their encouragement, especially to Mr. Franklin Shaju, M.P.T., PhD., Assistant
professor, R.V.S College of physiotherapy, for guidance and support for completion
of my study.

I offer my thanks and gratitude to our librarians for their supports in providing
books to complete my study.

I offer my grateful thanks for all management and staff members in

Trivandrum Surgical Center Hospital, Trivandrum. I also thank all my friends for
their co-operation in completion of this project.

I take this golden opportunity to thank each and every patient who took part in
this study for their kind co-operation and needed information.

Finally, I would like to express my heartfelt thanks to MY FAMILY for their

doubtless support and encouragement that enabled me to turn this idea into reality.
 CONTENTS
SL NO. CHAPTER PAGE NO.

I INTRODUCTION 1

1.1 Need of the study 6

1.2 Statement of the study 6

1.3 Objectives of the study 6

1.4 Hypothesis 6

7
1.5 Operational definitions

II REVIEW OF LITERATURE 9

III METHODOLOGY 21

3.1 Study setting 21

3.2 Sample size 21

3.3 Variables 21

3.3.1 Dependent variables

3.3.2 Independent variables 21

3.4 Measurement tools 21

3.5 Study design 22

3.6 Duration of study 22

3.7 Criteria for selection

3.7.1 Inclusion criteria

3.7.2 Exclusion criteria 22

3.8 Orientation to the subjects 22

3.9 Test administration 23

3.10 Treatment procedure 24

IV DATA ANALYSIS AND RESULTS 28

4.1 Data analysis 28

 4.2 Results 36

V DISCUSSION 38

VI CONCLUSION 41

6.1 Limitations 41

6.2 Suggestions 42

VII BIBLIOGRAPHY 43

VIII ANNEXURES 47

1. Physiotherapy Assessment 47

2. Windlass test 50

3. Foot Function Index 51

4. Pre and post-test values of range of motion of ankle

53
dorsiflexion in group I and group II.

5. Pre and post-test values of foot function index in

54
group I and group II.
55
6. Patient consent form
 LIST OF TABLES

SL NO. TABLES PAGE NO.

1 Myofascia release technique 24

2 Stretching exercises 27

3 The comparative mean value, mean difference, standard 30

deviation and ‘t’ value between pre vs post-test of foot
function in group I

4 The comparative mean value, mean difference, standard 31

deviation and paired ‘t’ value between pre and post-test
values of foot function among Group II.

5 The comparative mean value, mean difference, standard 32

deviation and unpaired ‘t’ values of foot function between
Group I and Group II.
6 The comparative mean value, mean difference, standard 33
deviation and paired ‘t’ value between pre and post-test
values of flexibility among Group I.

7 The comparative mean value, mean difference, standard 34

deviation and paired ‘t’ value between pre and post-test
values of flexibility of ankle joint among Group II.

8 The comparative mean value, mean difference, standard 35

deviation and unpaired ‘t’ values of flexibility of ankle joint
between Group I and Group II

9 Pre and post-test Goniometer values of Flexibility of ankle 53

dorsiflexion among Group I and Group II

10 Pre and post-test Foot Function Index values of Foot 54

Function among Group I and Group II
 LIST OF FIGURES

SL NO. FIGURES PAGE NO.

1 Deep friction massage 25

2 Ultrasound therapy 26

3 The graphical representation of pre and post-test values of 30

foot function in Group A

4 The graphical representation of mean values of foot 31

function in Group B

5 The graphical representation of mean values of values of 32

foot function in Group A and B

6 The graphical representation of pre and post-test values of 33

flexibility index in Group A

7 The graphical representation of pre and post-test values of 34

flexibility index in Group B

8 The graphical representation of mean values of values of 35

flexibility in Group A and B
 CHAPTER I

INTRODUCTION

The plantar fasciitis is defined as the inflammation caused by excessive

stretching of the plantar fascia. When the plantar fascia is excessively stretched, this

can lead to heel pain, arch pain, and heel spurs. Plantar fasciitis isdescribedas apain on

the plantar surface of the foot, arising from the insertion of the plantar fascia. Various

terms have been used to describe plantar fasciitis, including jogger’s heel, tennis heel,

policeman’s heel, and even gonorrheal heel.True plantar fasciitis is characterized by

progressive pain with weight bearing as well as pain with the first few steps upon

rising from a sitting position (Placzek2008).

There are three stages of plantar fasciitis:Stage-1,acute stage (0-4

weeks)withacute reversible inflammation. Minor achy pain after heavy activity or

with first initial steps after period of inactivity. Symptoms are not constant and may

resolve after basic anti-inflammatory measures followed by stretching exercise.Stage-

2,subacute stage (4 week- 3months)withintense pain with activity and symptoms also

at rest, but can still perform routine activities. Decreased inflammatory cells and

increased angiofibroblastic invasion and develop calcaneal spur.Stage-3, chronic (3

months- 1 year)with intense pain with activity and at rest. Significant functional

limitations because of pain and cannot perform routine activities, with partial or full

rupture of plantar fascia and with extensive angiofibroblastic invasion(Hyland 2006).

Up to 10% of the population may present with heel pain over the course of

their lives,83% of these patients being active working adults between the ages of 25

and 65 years old. Women are affected by plantar fasciitis twice as often as men. In

young people, the condition occurs equally in both sexes.Prevalence rates of plantar

1
fasciitis among a population of runners have been shown to be between 4% and 22%.

The overall incidence of plantar fasciitis in the military population was 10.55 per

1,000 person-years. The association of plantar fasciitis with increasing age is

consistent with the histopathological findings of degeneration, rather than

inflammatory changes within the plantar fascia. These degenerative findings support

the hypothesis that plantar fasciitis is secondary to repetitive microtrauma caused by

prolonged weight-bearing activities. The constant overload inhibits the normal repair

process, resulting in collagen degeneration, which causes both structural changes and

perifascialedema. These changes in turn lead to a thicker heel pad, increasing heel pad

thickness leading to loss of heel pad elasticity; both of these factors are associated

with increasing age and increasing BMI(Scher 2010).

The plantar fascia is a thickened fibrous aponeurosis that originates from the

medial tubercle of the calcaneus, runs forward to insert into the deepshort transverse

ligaments of the metatarsal heads, dividing into 5 digital bands at the

metatarsophalangeal jointsand continuing forward to form the fibrous flexor sheathes

on the plantar aspect of the toes. Small plantar nerves are invested in and around the

plantar fascia, acting to register and mediate pain. The plantar fascia is made up of 3

distinct parts: the medial, central, and lateral bands. The central plantar fascia is the

thickest and strongest section, and this segment is also the most likely to be involved

with plantar fasciitis. In normal circumstances, the plantar fascia acts like a windlass

mechanism to provide tension and support through the arch. It functions as a tension

bridge in the foot, providing both static support and dynamic shock absorption

(Young,2001).

The exact cause of plantar fascia is not clear. The plantar fascia is designed to

absorb the high stresses and strains placed on the feet. But, sometimes, too much

2
pressure damages or tears the tissues. The body’s natural response to injury is

inflammation, which results in the heel pain and stiffness of plantar fasciitis. The most

common cause of plantar fasciitis is biomechanical dysfunction of the foot with

overuse and other risk factors associated with plantar fasciitis such as obesity, tighter

calf muscles that make it difficult to flex foot and bring toes up towards shin, faulty

foot mechanics (flat foot, high arch foot, inward pointing knees) causes an abnormal

walking pattern,repetitive impact activity (running/sports), improper shoes (worn, thin

soled, lack arch support, or use of high heeled shoes), and other factors like age,

family tendency, and disease such as arthritis and diabetes (Dyck 2004).

The major complaints of patients with plantar fasciitis are pain and stiffness in

the bottom of heel. This develops gradually over time. It usually affects just one foot,

but can affect both feet. Some patient describe the pain as dull, while others

experience a sharp pain, and some feel a burning or ache on the bottom of foot

extending outward from the heel. The pain is usually worse in the morning when

patients take first steps out of bed or after been sitting or lying down for a while.

Climbing stairs are also very difficult due to the heel stiffness. After prolonged

activity, the pain can flare-up due to increased inflammation. Pain is not usually felt

during the activity, but rather just after stopping(Christine 2012).

On physical examination, patient may walk with their affected foot in an

equine position to avoid placing pressure on the painful heel. Palpation of the medial

plantar calcaneal region will elicit a sharp, stabbing pain. Passive ankle/first toe

dorsiflexion can causediscomfort in the proximal plantar fascia, and can also assess

tightness of the Achilles tendon. Mild redness or swelling will also be noted. Also

evaluates the strength of muscles by checking muscle tone, reflexes, coordination, and

balance.Special test: Windlass test, described as a forced dorsiflexion of the great toe

3
which is associated with an increase of pain at the insertion of the plantar

fascia(Garceau, 2003).

In the clinical diagnosis of chronic heel pain, diagnostic imaging such as plan

radiography mainly lateral view of the ankle can provide objective information for

any stress fractures, unicameral bone cysts, and gaint cell tumors are usually

identified; ultrasound examinationdone when the diagnosis is unclear, here plantar

fascia thickness values have been used to measure; differential diagnosis includes,

plantar fascia rupture, fad pad syndrome (atrophy of heel pad, common in elderly and

diabetic patient), calcaneal bursitis (Policeman’s heel), Boxter’s nerve entrapment (no

sensory disturbance and pain in the dorsal and proximal), medial calcaneal nerve

compression (occur in tarsal tunnel), seronegativearthropathies, spinal stenosis and

L5-S1 nerve root irritation (Tahririan, 2012).

The conservativemanagement for chronic plantar fasciitis includes rest along with

ice or hot packs; soft heel pad; night splint; nonsteroidal anti-inflammatory drugs;

shock wave therapy; stretching exercises; and tapping (Joshy 1999).

Therapeutic ultrasound is a high frequency sound wave which converts electrical

energy into mechanical energy, which is accomplished by passing through a quartz

crystal. The electric current cause crystal to expand and contract, this is called as

piezoelectric effect. Ultrasound hashigh affinity for the tendons and ligaments (highly

organized without high water content). It is a method of applying deep heat to the

connectivetissue which decrease chronic plantar heel pain, inflammation, and aid

healing by both thermal and mechanical effect on target tissue resulting an increasein

local metabolism, circulation, increase in cell permeability, deform molecular

4
structures, alter diffusion and protein rate synthesis and extensibility of connective

tissue and tissue regeneration(Hooper1983)

Myofascial release is a soft tissue manipulation technique, where ‘myo’ means

muscle and fascia is located between skin and the underlying structure of muscle and

bone throughout the body. The treatment purpose is to release restrictions within the

deeper layers of fascia; here plantar fascia, grastrocnemius muscle and soleus muscle

are released. The technique is a graded stretch of soft tissue by the therapist that is

guided entirely by feedback from the recipient’s body to determine stretch direction,

force, and duration to address specific soft tissue restrictions. Aims to relax contracted

muscles, improve blood and lymphatic circulation,alleviation of pain, and stimulate

the stretch reflex in muscles.Myofascial release technique has been proposed as an

effective treatment procedure of chronic plantar fasciitis (Eric 2007).

Deep friction massageis a technique that concentrates on the deeper muscle tissues

by applying deep finger pressure on the plantar fascia. A to and fro motion of deep

pressure is provided which help to release the muscle tension, break scar tissue, and

lead to its elimination. It concentrates on specific areas, leading to soreness before and

after the massage, yet the results are definite and can be felt within just couple of

days. Deep tissue massage loosens the muscles tissues, remove muscle toxins, and

ensure proper circulation of blood and oxygen which had been affected by plantar

fasciitis. Following the treatment, it is advisable to drink a lot of water to help remove

the toxins from the body (Estrada 2005).

5
1.1 Need of the study

The reason of the study is to popularise the myofascial release technique and deep

friction massage technique as a useful intervention method to improve foot function

and flexibility among chronic plantar fasciitis patients.

1.2 Statement of study

A comparative study on the effectiveness of myofascialrelease and deep friction

massagein the management offoot function and flexibility among chronic plantar

fasciitis patients.

1.3 Objectives of the study

The objectives of the study are:

1. To find out the effectiveness of myofascial release technique on foot function

and flexibilityamong chronic plantar fasciitis patients.

2. To find out the effectiveness of deep friction massage on foot function and

flexibility among chronic plantar fasciitispatients.

3. To compare the effectiveness of myofascial release technique over deep

friction massages technique on foot function and flexibility amongchronic

plantar fasciitispatients.

1.4 Hypothesis

 It is hypothesized that there may be significant difference in foot function and

flexibility following myofascial release technique among chronic plantar

fasciitis patients.

6
  It is hypothesized that there may be significant difference in foot function and

flexibility following deep friction massage technique among chronic plantar

fasciitis patients.

 It is hypothesized there may not be significant difference between myofascial

release technique anddeep friction massage technique in the management of

foot function and flexibility among chronic plantar fasciitis patients.

1.5 Operational definitions

Plantar fasciitis

The plantar fasciitis is defined as the inflammation caused by excessive

stretching of the plantar fascia. When the plantar fascia is excessively stretched, this

can lead to heel pain, arch pain, and heel spurs (Fureyet al., 1975).

Myofascial release

Myofascial release is defined as the facilitation of mechanical, neural and

physiological adaptive potential as interfaced by myofascial system. This is

accomplished by a stretching of the muscular elastic components of the fascia, along

with the crosslinks, and changing the viscosity of the ground substance of fascia

(Shahet al., 2012).

Deep friction massage

The deep friction massage is a defined as a mechanical stimulation of the

superficial tissues over a small area by means of rhythmically applied deep pressure

and stretching (Kayseret al.,2005).

Foot function

Foot function describes theposition of foot which moves every time when

oneself take a step. The bones of the foot are arranged into 3 arches medial

7
longitudinal arch, lateral longitudinal arch, and transverse arch. These arches provide

strength and stability for a proper foot function (Michaud et al.,1993).

Flexibility

Flexibility is defined as the ability to stretch a joint to the limit of its range of

movement. Joint flexibility is defined as the range of motion allowed to a joint. A

joint range of movement is measured by the double-armed Goniometer(Medlejet

al.,2014).

8
 CHAPTER II

REVIEW OF LITERATURE

Section A: Studies on effect of myofascial release technique on chronic plantar

fasciitis.

Section B: Studies on effect of deep friction massage technique on chronic

plantar fasciitis.

Section C: Studies on effect of stretching exercise on chronic plantar fasciitis.

Section D: Studies on effect of ultrasound on chronic plantar fasciitis.

Section E: Studies on the reliability and validity of foot functional index in

measuring foot function.

Section F: Studies on the reliability and validity of goniometer in measuring

flexibility of ankle.

Section A:Studies on effect ofmyofascial release technique on chronic plantar

fasciitis.

Pattanshettyet al.,(2015)studied on immediate effect of three soft tissue

manipulation techniques on pain response in chronic plantar fasciitis with randomized

clinical trial. 60 participant with chronic plantar fasciitis were randomly allocated to

group A (myofascial release), group B (positional release technique), and group C

(passive stretching) along with therapeutic ultrasound on 1 W/cm2 for 5 minutes. VAS

scale for pain and ROM was outcome measures that were assessed for pre and

immediately post interventional. Studies concluded that reduction in pain was more in

group A individuals treated with myofascial release than compared to group B with

positional release and group C with stretching exercises.

9
 Neilet al.,(2014)studied on the use of manual therapy and exercise which

found to be more effective than traditional physical therapy interventions in patients

who suffered from plantar fasciitis. The patient who received myofascial release to

plantar fascia as well as joint mobilization and manipulation to the foot show

significant reduction in pain at 4 weeks and improvement in function at both 4 weeks

and 6 months.Concluded the study as the myofascial release is more effective in

plantar fasciitis.

Sivasankaret al.,(2014)studied on effect of ultrasound and myofascial release

on pain and function in patients with plantar fasciitis. 20 patients were selected and

divided into 2 groups as group A receive ultrasound and myofascial release, and

group B receive plantar fascia and calf stretching exercises. The treatment was given

on alternate days for a period of 2 weeks. Pain and function were used as outcome

measures, both group showed significant reduction of pain and improvement of

function. Concluded the study as ultrasound therapy and myofascial release is

effective on pain and function in patients with plantar fasciitis.

Ordine et al., (2011)conducted a randomized control trial study to check out

effectiveness of Myofascial release therapy for treating heel pain (plantar fasciitis). 4

treatment sessions given each week for total 4 weeks and result concluded that

incorporation of myofascial release technique before static stretching is superior to

isolated stretching for improving function and decreasing pain in patients with plantar

fasciitis. The subjects treated with myofascial release showed an additional benefit in

terms of reduction of pain on VAS and functional ability in terms of FFI. Hence it can

be concluded that myofascial release is an effective therapeutic option in the treatment

of plantar fasciitis.

10
 Kuhar et al., (2007)performed a randomized control trial study to check out

effectiveness of Myofascial release in treatment of Plantar Fasciitis using 30 subjects

randomly allotting into two groups. Group A control group received therapeutic

ultrasound, contrast bath, foot intrinsic muscles strengthening exercise, and plantar

fascia stretching exercise and Group B experimental group received conventional

treatment as group A added with added myofascial release technique for 15 minutes

for 10 consecutive days and results concluded that the experimental group showed

significantly higher improvement levels in term of both pain relief and in functional

ability. So myofascial release is an effective therapeutic option in the treatment of

plantar fasciitis.

Section B:Studieson effect of deep friction massage on chronic plantar fasciitis.

Formosaet al., (2014) has tested on the feasibility of a clinical trial comparing

the effect of transverse friction massage and a home exercise programmeand home

programme alone in the treatment of plantar fasciitis. 24 participants (14 females)

aged 43-77 years with plantar fasciitis of greater than 4 weeks duration. 6 treatment

session of friction massage in the first 4 weeks for experimental group together with a

home programme for 6 weeks. The control group was given a home programme for 6

weeks. Main outcome measures VAS and lower extremity functional scale measured

on assessment and every 2 week for 6 weeks. Subjects had reduction in pain at the

end of 6-week treatment. Study concluded that the study demonstrated the feasibility

of clinical trial for treatment of plantar fasciitis with friction massage and home

exercise programme.Hence it was hypothesed that friction massage as an effective

treatment for plantar fasciitis.

Higgins et al.,(2012)dida survey to determine how physical therapist treats

plantar fasciitis. The survey asked for information regarding years of experience,

11
manual techniques, stretching activities and ultrasound application. The results of this

survey were then compared to the suggestions found in the current literature. Clients

during the survey were treated with ultrasound for 6-8 minutes, friction massage 5-10

minutes and stretching for 1 minute. Concluded the survey results as, the physical

therapist use a variety of methods and modalities to treat plantar fasciitis. While the

common goal is to provide the best treatment approach for clients diagnosed with

plantar fasciitis.The result concluded that the friction massage therapy is more

effective treatment for plantar fasciitis.

Ahamedet al.,(2011) studied the efficacy of low frequency stimulation in

conjunction with specific plantar fascia friction massage, stretching exercise in

treatment of plantar heel pain. 26 patients aged 18 to 60 years, complaining of plantar

heel pain were assigned randomly to 2 treatment group. Control group received

plantar fascia deep friction massage, stretching and strengthening exercises and

experimental group received same treatment in addition to low frequency electrical

stimulation. VAS and FFI were assessed before and after 4 weeks of treatment. It was

concluded that plantar fascial friction massage, stretching and strengthening exercise

have short-term pain relief and improvement in FFI activities in patients with plantar

heel pain.

Kelleret al.,(2008) studied on the effectiveness of massage therapy on chronic

plantar fasciitis. This study consists of series of massage therapy including deep

friction massage, palmar kneading, effleurage, and petrissage on chronic plantar

fasciitis. Client subjective findings as well as VAS pain scale were used to track

progress, the treatment plan was 30 minutes of massage therapy along with

myofascial release and 5 minutes of hydro collator pack per week for 4 weeks. The

study yielded superior results due to the fact that manual manipulation of the tissues

12
was performed longer each session and the study was longer in duration. These

findings are clinically relevant and there are no complications of this study, so theses

finding are appropriate to put into clinical practices.The result concluded that the

friction massage therapy is more effective in plantar fasciitis.

Lowe et al.,(2003)hassuggested that massage technique are quite helpful in the

treatment of plantar fasciitis. Working on the lower leg muscles, especially those

involved in plantar flexion, is important because tightness in these muscles may

contribute to excess tension in the fascia running from the leg through the bottom

surface of the foot. Deep transverse friction can be used directly on the plantar fascia

to stimulate fibroblast activity and tissue healing from chronic overuse. He also stated

that longitudinal stripping methods applied to the bottom surface of the foot will help

reduce tension in the intrinsic flexor muscles. Concluded the study as transverse

friction massage is effective in relieving pain in plantar fasciitis.

Section C: Studies on effect of ultrasound on chronic plantar fasciitis.

Sivasankar et al.,(2014) did a study on effect of ultrasound and myofascial

release on pain and function in patients with plantar fasciitis. 20 patients were selected

and divided into 2 groups as group A receive ultrasound and myofascial release, and

group B receive plantar fascia and calf stretching exercises. The treatment was given

on alternate days for a period of 2 weeks. Pain and function were used as outcome

measures. ‘t’ test was done. Both group showed significant reduction of pain and

improvement of function. Concluded the study as the ultrasound therapy and

myofascial release is effective on pain and function in patients with plantar fasciitis.

Razdanet al.,(2013) have conducted an ultrasound technique showing early

promise as a quick and minimal invasive treatment for the common and painful foot

13
conditions. The finding is based on a short-term study involving just 65 patients, the

researchers noted. The author tested the procedure ultrasound therapy that uses

ultrasonic energy to cut and remove damaged, pain-generating tissue while sparing

healthy foot tissue. A combination of high frequency/low amplitude sound waves are

used to the damaged foot region. According to the study by 2 weeks after the

treatment showed more improvement in their foot disability assessment.The result

concluded the study that the ultrasound therapy is effective in alleviating pain in

plantar fasciitis.

Gracieleet al.,(2006) has studied the efficiency of continuous high power

ultrasound for plantar fasciitis treatment. 22 individuals were assessed with pain

lasting more than 6 months, through functional questionnaire and VAS for pain at the

first morning load. Individual were divided into 2 groups first group stretching alone

and second group stretching with 2 W/cm2 ultrasound. After 15 treatment sessions,

functional improvement was seen in both groups with no difference and the analysis

of reduction in pain intensity was more in group 2 (54.6%) than group 1 (46.5%).

Conclude the study as high power ultrasound is effective in reducing pain and

improving function in plantar fasciitis patients.

Robertet al.,(2001)has performed a systematic review of randomized

controlled trials in which ultrasound was used to treat people in condition like

musculoskeletal injuries and soft tissue lesions. Each trial was assigned to investigate

the contributions of active and placebo ultrasound to the patient’s outcome measured.

35 randomized clinical trials were published, the results of 10 out of 35 trials were

judged to acceptable methods using criteria based on those developed by Sackett et al.

The result of 8 trial suggest that it is not and concluded there is little evidence that

active therapeutic ultrasound is more effective than placebo ultrasound for treating

14
people with pain, a range of musculoskeletal injuries, or for promoting soft tissue

healing. Theresults of 2 suggested that therapeutic ultrasound is more effective in

treating clinical problems than placebo ultrasound.

Crawfordet al.,(1995)evaluated the therapeutic effect from ultrasound in the

treatment of plantar heel pain and to quantify the placebo effect of this electrophysical

agent. 26 patients (14 bilateral) entered the study. Out of which 6 women and 7 men

(3 bilateral episode in both sex) received true ultrasound here machine calibrated to

deliver a dose of ultrasound at 0.5 W/cm2, 3MHz, pulsed 1:4, for 8 minutes and 5

women and 8 men (3 women bilateral and 5 men bilateral episode) received placebo

treatment with sham ultrasound here only the timer on the machine activated. The

whole treatment was randomized for 8 days. The patients score was measured on

VAS before and after the treatment, and analysed using a Wilcoxon Signed-Ranks

test. Result showed both groups showed a reduction in pain, the improvement was

30% in treated group and 25% in placebo group. Concluded the study that therapeutic

ultrasound is more effective than placebo in the treatment of plantar heel pain.

Section D: Studieson effect of stretching exercise on chronic plantar fasciitis.

Shivannaet al.,(2014) studied the effectiveness of stretching on pain in people

with plantar fasciitis. 36 patients were diagnosed as having plantar fasciitis. They

were advised to stretch the calf muscle for at least 5 minutes over a given wooden

ridge. Their pain before and after calf stretching exercises was recorded on visual

analogue scale and analysed. The average baseline score on VAS was 7.5 and all

patients had significant reduction in pain score of average 4.2. The study concluded

that the plantar fascia stretching are effective on plantar fasciitis in the short-term and

improving the foot functional activityon long-term.

15
 Almubaraket al.,(2012) aimed to review the evidence of exercise therapy in

the treatment of plantar heel pain. Comprehensive search strategy was conducted to

identify randomized and quasi-randomized trials. The primary outcome was pain

intensity and secondary was functional limitation. From an initial list of 2327

potentially relevant trials, 7 trials were included such as exercise therapy sham versus

control therapy; exercise therapy versus exercises therapy and calcaneal taping;

exercise therapy versus exercise therapy and iontophoresis; exercise therapy versus

other form of exercises therapy; exercise therapy versus exercises therapy with foot

insole; exercise therapy versus exercises therapy with orthosis; and exercise therapy

versus exercise therapy and low-energy shock wave therapy. Most trials included

short-term follow up only of pain and function outcomes. The result revealed that

combining stretching with other conservative treatments is more effective than

stretching alone.

Sweeting et al.,(2011)studied on the effectiveness of stretching on pain and

function in people with plantar fasciitis. 6 studies including 365 symptomatic

participants were included. 2 compared stretching with a control, 1 study compared

stretching to both alternative and control interventions, 1 study compared stretching to

an alternative intervention, and 2 compared different stretching techniques and

durations. Quality rating on the modified Pedro scale varied form 2-8 out of a

maximum of 10 points. Most participants improved over the course of the studies, but

when stretching was compared with alternative or control interventions, the changes

only reached statistical significance. In one study that used a combination of calf

muscle stretching and plantar fascia stretching in their stretching programme. Another

study comparing different stretching techniques showed a statistically significant

reduction in some aspects of pain in favour of plantar fascia stretching over calf

16
muscle stretches in the short term. The result of this systematic review demonstrated

that patients with plantar heel pain who stretch tend to improve with regards to pain

and function.

Giovanni et al.,(2006) studied tissue specific plantar fascia stretching

exercises outcomes in patient with chronic plantar fasciitis. Suggested that effective

durations of 30 seconds to 1 minute, at least 3 sets, up to 3 sessions per day show

significant changes in range of motion have shown favourable results in treatment of

plantar fasciitis with stretching exercises of the gastronemius, soleus, and plantar

fascia.They concluded that a program of non-weight-bearing stretching exercise

specific to the plantar fascia is superior to the standard program of weight-bearing

Achilles tendon stretching exercise for the treatment of symptoms of proximal plantar

fasciitis. The result concluded that the long-term benefits of the stretch include a

marked decrease in pain.

Benedict et al.,(2003) done a prospective, randomized study done on tissue-

specific plantar fascia-stretching exercise enhances outcomes in patient with chronic

heel pain. In this study, evaluated 101 patients with chronic plantar fasciitis diagnosed

for at least 10 months. The patients were grouped into 2. The first group was given a

plantar fascia tissue-stretching program and the second group with Achilles tendon-

stretching program. All patients were educated by a video on plantar fasciitis, were

given specific insoles and an anti-inflammatory medication for 3 weeks. At 8 weeks,

82 patients had completed the therapy regimen and were reevaluated. The result

concluded that patients with plantar fascia specific stretching showed statistically

significant improvement compared with Achille tendon stretching program.

17
Section E: Studieson the reliability and validity of Foot Functional Index in

measuring foot function.

Vendittoet al.,(2013) had developed a brief outcome measure to assess foot

and ankle conditions, the psychometric properties of a modified version of original

FFI were examined. 86 subjects with musculoskeletal foot and ankle disorders were

enrolled. The internal consistency and test-retest reliability were evaluated by using

Cronabach’s and intraclass correlation coefficient (ICC). Criterion validity was tested

by Pearson’s correlation coefficient between 17 items of Italian FFI and the lower

extremity functional scale (LEFS). The responsiveness was calculated using the

receiver operating characteristic curve (ROC). Concluded that FFI is a reliable and

valid scale to evaluate the effectiveness of treatment in patients with musculoskeletal

foot and ankle disorders.

Wu SH et al., (2008) performed a study to evaluate the reliability and validity

of foot function index among patients with plantar fasciitis and the results concluded

the foot function index to be a very reliable and valid outcome measure to assess pain

and disability among patients with plantar fasciitis

Garceau et al., (2003) studied on the sensitivity and specificity of the

Windlass test in diagnosing plantar fasciitis. 22 patients with plantar fasciitis and 23

patients with other type of foot pain and 30 patients in control group were evalutated

with Windlass test in weight-bearing and non-weight-bearing position. There joint

flexibility was measured by FFI. Result found was the patients with plantar fasciitis

group had greater disability, as measured by FFI. Their average score of 3.34

compared to the other foot pain group. It was concluded that the foot function index to

18
be a very reliable and valid outcome measure for high specificity and low level of

sensitivity Windlass test and it can be used in evaluating patients with plantar fasciitis.

Budiman et al., (1991)studied on the foot function index which was

developed to measure the impact of foot pathology on function in terms of pain,

disability and activity limitation in patients. It is a self-administered index consisting

of 23 items divided into 3 sub-scales, where both total and sub-scales scores are

produced and was examined for test-retest reliability internal consistency, and

construct and criterion validity. A total of 87 patients with rheumatoid arthritis were

used in the study. Test-retest reliability of FI total and sub-scale scores ranged from

0.87 to 0.69, internal consistency ranged from 0.96 to 0.73 with the exception of

factor analysis supported the construct validity of total index and sub-scale. Strong

correlation between the FFI total and sub-scale scores and clinical measures of foot

pathology supported the criterion validity of the index. It has been proved that FFI is a

reasonable tool to use with low functioning individuals with foot disorders.

Section F: Studies on the reliability and validity of goniometer in measuring

flexibility of ankle.

Weisset al.,(2013) had done anintratester reliability on 52 adults for detecting

real differences for quadriceps angle measurement based on standardised protocols

and surface goniometry. They said that the surface goniometry protocol described

appeared to be reliable for young women and men on measuring the range of motion.

Nussbaumeret al.,(2010) conducted a study to evaluate the construct validity

of goniometers by measuring knee ROM in healthy controls the results showed that

the goniometer provide greater value and good test retest value.

19
 Sullivan et al., (2007) studied that the reliability and validity of goniometer in

45 subjects. It was concluded from the study that the ROM measurements taken with

the universal goniometer of the extremity joints generally have good to excellent

reliability. Reliability does not vary depending on the joint and motion being

measured.

Riddle et al., (1987)purposeof the study was to examine the intratester and

intertester reliabilities for clinical goniometric measurements of shoulder passive

range of motion (PROM)using two different sizes of universal goniometers. Repeated

PROM measurements of shoulder flexion, extension, abduction, shoulder horizontal

abduction, horizontal adduction, lateral (external) rotation, and medial (internal)

rotation were taken of two groups of 50 subjects each. The result of the study shows

that Goniometric PROM measurements for the shoulder appear to be highly reliable

when taken by the same physical therapist, regardless of the size of the goniometer

used. The degree of intertester reliability for these measurements appears to be range-

of motion specific.

20
 CHAPTER III

METHODOLOGY

3.1 Study setting

This study was conducted at TSC Hospital, Trivandrum,Kerala.

3.2 Sample size

30 subjects wereselected who fulfilled the inclusion and exclusion criteria and

were divided into 2groups.

1. Group A (n=15): Myofascial release technique along with stretching

exercise and therapeutic ultrasound.

2. Group B (n=15): Deep friction massagealong with stretching exercise and

therapeutic ultrasound.

3.3 Variables

3.3.1 Dependent Variables

1. Foot function

2. Flexibility

3.3.2 Independent Variables

1. Myofascial release technique along with stretching exercise and

therapeutic ultrasound.

2. Deep friction massages technique along withstretching exercises and

therapeutic ultrasound.

3.4 Measurement Tools

Variables Tools

Foot function Foot function index

Flexibility–foot dorsiflexion Goniometer

21
3.5 Study designs

Pre-test and post-testexperimentaldesign.

3.6 Duration of study

The duration of study was one year.

3.7 Criteria for selection

3.7.1Inclusion criteria

1. Clinically diagnosed chronic plantar fasciitis patients.

2. Windlass test positive.

3. Age group between 40-65 years.

4. Females and Males included.

5. Patients who are willing to participate.

6. Patients who can understand and cooperate.

3.7.2 Exclusion Criteria

1. Subjects with clinical disorders such as infective conditions of foot,

tumour, and calcaneal fracture.

2. Skin Disease.

3. Majortrauma or surgery in and around ankle joint and foot.

4. Impairedcirculation to lower extremities.

5. Referredpaindue to sciatica and other neurological disorders.

6. Foot deformities.

7. Obesity.

3.8 Orientation to the subjects

All the participants who were clinically diagnosed as chronic plantar fasciitis

were screened after finding their suitability as per subjects who fulfil the inclusion

and exclusion criteria and were briefed about the purpose of the study and the

22
 intervention. The therapist had given a detail orientation to the various techniques

such as myofascialrelease to group A and deep friction massage to group B with

the test procedures such asfoot function indexandrange of motionto measure foot

function andflexibility. The consent and full cooperation of each participant was

sought after complete explanation of the condition and demonstration of the

procedures involved in the study.

3.9Test administration

Foot function

Purpose: To assess the foot function index (FFI). The patient is asked to

indicate how the foot pain has affected his/her ability to manage in everyday life.

Equipment required:Foot function index, a numeric scales to assess foot

function.

Procedure:There are about 23 questions divided into 3 sections. Each

patienthas to score their pain, disability, and limitation of activity based on the

questionnaire provided. Accordingto a scale, score range from 0 to 10 for all 23

questions. Zero indicates no pain, no difficulty and none of the time. Ten indicates

worst pain imaginable, so difficult unable to do and all the time.

Flexibility

Purpose: To assess the flexibility of foot by measuring the dorsiflexion of

ankle joint to know the present level of range of motion.

Equipment required:Goniometer.

Procedure:Dorsiflexion of ankle is measured with the patient sitting with

knee flexed to 90 degree and by keeping the fulcrum of goniometer over the lateral

malleolus of the affected foot with the stationary arm parallel to the fibula and

moveable arm parallel to the fifth metatarsal and then measure the dorsiflexion.

23
3.10Treatment procedure

Myofascial release technique

Table-1: Shows different myofascial release technique

Slno Muscle Method Figure

1 Grastrocnemius With the patient prone lying and the

therapist standing at the foot end of

table facing towards head of the

patient. Therapist places elbow to the

bulky muscle gastrocnemius to

release the tightness and also use

fingers to release fascia of

gastrocnemius tendon with the

therapist facing towards the feet

while standing at the patients side

around mid-thigh level, repeated for

3-5 times.

2 Soleus With the patient prone lying and a

bolster placed at the feet to induce

10-15 degrees of knee flexion and the

therapist facing towards the head

while standing at the foot end of the

table, using elbow pressure applied to

release the tightness, repeated for 3-5

times.

24
3 Plantar fascia With the patient prone lying and the

therapist place fistover the sole. Then

move in to and fro direction, while

maintaining a steady pressure.

Treatment continues until therapist

feel tissues relax, for 3-5 times.

Treatment duration: One session per day alternately for 5 weeks.

Deep friction massage technique

Position of patient: Half lying

Therapist position: Standing.

Area of application: Plantar fascia.

Duration: 10 minutes

Method of application:The patient were positioned comfortably and deep friction

massage was applied directly to the origin of plantar fascia using a repetitive back and

forth motion, across the affected structure with adequate sweep to cover the affected

area and sufficient depth to produce mechanical stretching of the underlying structure,

with great toe in dorsiflexion throughout the procedure in order to maintain a stretch

to the plantar fascia.

Treatment duration: One session per day alternately for 5 weeks.

Figure-1: Shows deep friction massage.

25
Ultrasound therapy

Position of patient: Prone with foot placed outside the treatment table.

Therapist position: Standing.

Area of application: Around the plantar aspect of the foot.

Parameters

Frequency: 1 MHz, continuous mode.

Intensity: 1 watts/cm2

Duration: 8 minutes.

Method of application:The patient were positioned comfortably, and the part was

cleaned and ultrasonic gel was applied to the involved site and then the transducer

headstock moved in a slow, continuous, and in circular pattern over foot in order to

obtain ultrasound waves concentration, thus achieving a focal application without

producing undesirable effects on adjacent tissues.

Treatment duration: One session one day for alternate days for 5 weeks.

Figure-2 Shows ultrasound therapy.

26
Stretching exercises

Table-2: Shows different stretching exercises

Slno Muscle Method Figure

1 Grastrocnemius With the patient supine and knee

extended, pressure was placed over

bottom of the foot while the ankle was

held in dorsi-flexion.Stretch held for

30 seconds and repeated for 3-5 times.

2 Soleus With the patient prone and knee flexed

to 90 degree and passively dorsiflexes

the foot.The stretch is held for 30

seconds and repeated for 3-5 times.

3 Plantar fascia With the patient supine and by

supporting the ankle, thetherapist

places fingers on patient’s (toes)

metatarsophalangeal jointand extends

till the patient feels the stretch on the

plantar fascia.The stretch is held for

30 seconds and repeated for 3-5 times.

Treatment duration: One session per day for alternate days for 5 weeks.

Home advices for both groups:

1. Wear shoes with adequate arch support and cushioned heels.

2. Avoid prolong standing.

3. Avoid exercise and walking barefoot on hard surfaces.

4. Advised home programme with stretching and strengthening exercises.

27
 CHAPTER IV

DATA ANALYSIS AND RESULTS

4.1 Data analysis

The chapter deals with systematic presentation of the analysed data followed

by the interpretation of the data.

Paired’t’ test was used as a parametric test to find the intra group significance.

Unpaired’t’ test was used as a parametric test to find the inter group significance.

a) Paired‘t’ tests

∑d
d̅ =
n

∑ d
√∑d −
n
s=
n−1

Where,

d – Difference between pre-test and post test values

∑𝑑
𝑑̅ = 𝑛 – Mean of difference between pre test and post test values

n – Total number of subjects

s – Standard deviation

28
b) Un paired t’ test

∑ x − x̅ +∑ x − x̅
s=√
n +n −

x̅ − x̅ n n
T= √
S n +n

Where,

S = Standard deviation

𝑛 = Number of subjects in Group A

𝑛 = Number of subjects in Group B

𝑥̅ = Mean of the difference in values between pre-test and post-test in Group-

𝑥̅ = Mean of the difference in values between pre-test and post-test in Group-

29
Table-3

The table shows mean value, mean difference, standard deviation, and paired‘t’

value between pre- test and post-test scores of foot function among group A.

Measurement Mean Mean Standard Paired ‘t’

difference deviation value

Pre- test 86.47

72.54 5.47 51.1*

Post- test 13.93

*< 0.005 level of significance

In group A calculated paired‘t’ value offoot function indexis 51.1 and the‘t’

table value is 2.977 at 0.005 level of significance. Since the calculated‘t’ value is

more than the‘t’ table value, it shows that there is significant difference infoot

functionfollowing myofascial release technique among chronic plantar fasciitis

patients.

100
86.47

72.54
60

13.93
20

pre test post test mean difference

-20

Figure 3: Shows the graphical representation of pre and post-test values of foot

functionin Group A.

30
Table-4

The table shows mean value, mean difference, standard deviation, and paired‘t’

value between pre- test and post-test scores of foot function among group B.

Measurement Mean Mean Standard Paired ‘t’

difference deviation value

Pre- test 83.79

64.41 3.58 70.3*

Post- test 19.38

*< 0.005 level of significance

In group A calculated paired‘t’ value offoot function indexis 70.3 and the‘t’

table value is 2.977 at 0.005 level of significance. Since the calculated‘t’ value is

more than the‘t’ table value, it shows that there is significant difference infoot

functionfollowing deep friction massage technique among chronic plantar fasciitis

patients.

100
83.79
64.41
60

19.38
20

pre test post test mean difference

-20

Figure 4: Shows the graphical representation of pre and post-test values of

footfunctionin Group B.

31
Table-5

The table shows mean value, mean difference, standard deviation, and

unpaired‘t’ value of foot function between Group A and Group B.

SI.no Groups Improvement Standard Un paired ‘t’

deviation Test

Mean MeanDifference

72.2
1 GROUP-A

7.2 1.91 16.614*

2 GROUP-B 65

*<0.005 level of significance

In group A and group B,calculated unpaired‘t’ value of foot function index is

16.614and the‘t’table value is 2.763 at 0.005 level. Since the calculated‘t’ value is

more than the‘t’table value, means there is significant difference between myofascial

release and deep friction massage in improving foot function among chronic plantar

fasciitis patients.

80 72.2
70 65
60
50
40
30
20
7.2
10
0
Group A Group B mean difference

Figure 5: Shows the graphical representation of pre and post-test values of foot

function in Group A and B.

32
Table-6

The table shows mean value, mean difference, standard deviation, and paired‘t’

value between pre- test and post-test scores of flexibility among group A.

Measurement Mean Mean Standard Paired ‘t’

difference deviation value

Pre- test 7.73

9.47 2.030 18.12*

Post- test 17.2

*<0.005 level of significance

In group A, calculated paired‘t’ value of flexibility is 18.12andthe‘t’ table

value is 2.977 at 0.005 level. Since the calculated‘t’ value is more thanthe‘t’ table

value, it shows that there is significant difference inankle dorsiflexion following

myofascial release technique among chronic plantar fasciitis patients.

20
17.2

9.47
10
7.73

0
pre test post test mean difference

Figure 6: Shows the graphical representation of pre and post-test values of

flexibility in Group A.

33
Table-7

The table shows mean value, mean difference, standard deviation, and paired‘t’

value between pre- test and post-test scores of flexibility among group B.

Measurement Mean Mean Standard Paired ‘t’

difference deviation value

Pre- test 7.66

7.84 1.709 17.89*

Post- test 15.6

*< 0.005 level of significance

In group B, calculated paired‘t’ value of flexibility is 17.89 and the‘t’ table

value is 2.977 at 0.005 level. Since the calculated‘t’ value is more than the ‘t’ table

value, it shows that there is significant difference inankle dorsiflexionfollowing deep

friction massage technique among chronic plantar fasciitis patients.

20
15.6

10 7.84
7.76

0
pre test post test mean difference

Figure 7: Shows the graphical representation of pre and post-test values of

flexibility in Group B.

34
Table-8

The table shows mean value, mean difference, standard deviation, and

unpaired‘t’ value of flexibility between Group A and Group B.

SI.no Groups Improvement Standard Un paired ‘t’

deviation Test

Mean MeanDifference

9.5
1 GROUP-A

1.6 1.233 2.92*

7.9
2 GROUP-B

*<0.005 level of significance

In group A and group B calculated un paired‘t’ value for flexibility is

2.92andthe‘t’ table value is 2.763 at 0.005 level. Since the calculated‘t’ value is more

than the‘t’ table value, it shows that there is significant difference between myofascial

release and deep friction massage in improving ankle dorsiflexionamong chronic

plantar fasciitis patients.

9.5
10
7.9
8
6
4
1.6
2
0
Group A Group B mean difference

Figure 8: Shows the graphical representation of pre and post-test values of

flexibilityin Group A and B.

35
4.2 Results

30 plantar fasciitis subjects were selected for the study. The subjects were

randomly divided into 2 equal groups, group A and group B. For group

A, myofascialrelease technique was given and for group B, deep friction massage

technique was given along with ultrasound and stretching exercises.

The patients were treated one session per day alternatively for 5 weeks. Before

starting the treatment, the foot function was graded by foot function index and the

flexibility of ankle dorsiflexion was graded by goniometer. The measurement was

repeated at the end of the study.

Analysis of dependent variable foot function in Group A: The calculated

paired ‘t’ value of foot function index is51.1 and the ‘t’ table value is 2.977 at 0.005

level of significance. Hence, the calculated ’t’ value is greater than the ‘t’ value and

there is significant difference in foot function following myofascial release technique

among chronic plantar fasciitis patients.

Analysis of dependent variable foot function in Group B: The calculated

paired ‘t’ valueof foot function index is 70.3and the table ‘t’ value is 2.977 at 0.005

level of significance. Hence, the calculated ’t’ value is greater than the ‘t’ value there

is significant difference in foot function following deep friction massage technique

among chronic plantar fasciitis patients.

Comparing the dependent variable foot function between Group A and

Group B:The calculated unpaired‘t’ value of foot function index is 16.614 and the ‘t’

table value is 2.763 at 0.005 level of significance. Hence the calculated‘t’ value is

greater thantable ‘t’ value there in significant difference betweenmyofascial release

and deep friction massage technique in improving foot function among chronic

plantar fasciitis patients.

36
 When comparing the mean values of group A and B, group A subjects treated

with myofascial release showed more difference than group B. Hence it is concluded

that myofascial release is more effective than deep friction massage in improving the

foot function among chronic plantar fasciitis patients

Analysis of dependent variable flexibility in group A:The calculated

paired‘t’ value of flexibility is 18.12and the table‘t’ value is 2.977 at 0.005 level of

significance. Hence the calculated‘t’ value is greater than the table‘t’ value is

significant difference in ankle dorsiflexion following myofascial release.

Analysis of dependent variable flexibility in group B:The calculated

paired‘t’ valueof flexibility is 17.89and the table‘t’ value is 2.977 at 0.005 level of

significance. Hence the calculated‘t’ value is greater than the table‘t’ value is

significant difference in ankle dorsiflexion following deep friction massage.

Comparing the dependent variable flexibility between Group A and

Group B:The calculated unpaired‘t’ valueof flexibility is 2.92 and the‘t’ table value

is 2.763 at 0.005 level of significance. Hence the calculated‘t’ value is greater than

table‘t’ value there in significant difference betweenmyofascial release and deep

friction massage technique in improvingankle dorsiflexion among chronic plantar

fasciitis patients.

When comparing the mean values of group A and B, group A subjects treated

with myofascial release showed more difference than group B. Hence it is concluded

that myofascial release is more effective than deep friction massage in improving the

flexibility of ankle dorsiflexion among chronic plantar fasciitis patients.

37
 CHAPTER V

DISCUSSION

Plantar fasciitis is a common cause of hind foot pain. Plantar fasciitis is

thought to be caused by non-inflammatory degenerative changes in theplantar fascia.

Plantar fascia is a thick band of connective tissue that runs along the bottom of the

foot from the heel to the base of each of the five toes. It is thinner and weaker at the

heel and gets thicker and stronger as it fans out towards toes. Because of this structure

it is more susceptible to micro trauma, tearing and inflammation of the heel called

plantar fasciitis.

A clinical trial was conducted to compare the effectiveness of myofascial

release and deep friction massage along with passive stretching and therapeutic

ultrasound on foot function and flexibility on individual with chronic plantar fasciitis.

The statistical data shows there is an increase in foot function and flexibility of ankle

dorsiflexion at the end of 5_weeks of treatment period.

Therapeutic ultrasound deliverscontinuous energy wave which produce

thermal and nonthermal(mechanical) effects. The physiological effect of thermal

include increased tissue temperature, increased local blood flow, increased

extensibility of tissue and reduced viscosity of fluid elements in the tissue. This

mechanical effect accelerate tissue metabolism by promoting cellular permeability

and ion transport across cellular membrane. Ultrasound affect the sensitivity of

sensory receptors such as muscle spindle and high threshold mechanoreceptors in

skeletal muscle and that this led to the increased range of motion. Therefore

therapeutic ultrasound used for relief of pain and muscle spasm and for improvement

of joint contracture and wounded tissues(Katsuyuki 2014).

38
 Therapeutic ultrasound has shown to relieve pain in plantar fasciitis. Dosage

of ultrasound in this study was based on the evidence suggested by Hronkovaet al.,

2000 which reduced pain in 50% of patients. So continuous ultrasound was preferred

for soft tissue repair and for the study 1 MHz frequency with an output of 1 W/cm2

was chosen, as it is capable of reaching to deeper tissues.

The goal of myofascial release is to release fascia restriction and restore its

tissue. This technique is used to ease pressure in the fibrous bands of the connective

tissue function, or fascia. Gentle and sustained stretching of myofascial release is

believed to free adhesions and softens and lengthens the fascia. By freeing up

fascia,myofascialrelease helps in improving circulation and nervous system

transmission and normalizes the connective tissue by softening, lengthening, and

realign the fascia(Renan-Ordine 2011).

Result of the present study shows that there is significant difference in foot

function and flexibility of ankle dorsiflexion by myofascial release.It is supported by

Kuharet al.,2007, who performed a randomized control trial study to check out

effectiveness of Myofascial release in treatment of Plantar Fasciitis, using 30 subjects

randomly allotting into two groups for 10 consecutive days and results concluded that

the experimental group with myofascial release showed significantly higher

improvement levels in term of both pain relief and in functional ability.

Frictionmassage involves the application of friction and pressure at depth to

the lesion which is considered to be the cause of pain or reduced function.Force is

applied perpendicular to the fibres in an attempt to separate each fibres, mechanically,

promotes local hyperemia, analgesia, and reduction of adherent scar tissue to

ligament, tendon and muscle structure. The result of friction massage is to resets of

sarcomere lengthening which improves the soft tissue healing but also realign the

39
muscle fibres by offering the effective stretching and mobilization to the taut bands

(Dean, 2003).

Result of the present study shows that there is significant difference in foot

function and flexibility of ankle dorsiflexion bydeep friction massage. It is supported

by Formosa et al.,2014 whohas tested on the feasibility of a clinical trial comparing

the effect of transverse friction massage and home exercise programme in the

treatment of plantar fasciitis with 24 participants aged 43-77 years with plantar

fasciitis of greater than 4 weeks duration. Subjects had reduction in pain at the end of

6-week treatmentwith friction massage.

The present study is concluded on the basis of the improvement in the foot

function and flexibility among chronic plantar fasciitis patients, when comparing both

the techniques group Apatients treated with myofascial release technique shows more

improvement in foot functionandflexibility than group B patients treated with deep

friction massage technique.

Hence, first and second hypothesis are accepted and reject the third

hypothesis.

40
 CHAPTER VI

CONCLUSION

A comparative study was conducted to evaluate the effectiveness of

myofascial release technique and deep friction massage technique on foot function

and flexibility among chronic plantar fasciitis patients.

30 patients with chronic plantar fasciitis were included in the study and

divided into two groups, group A and B, each group consist of 15 patients.

Group A was treated with myofascial release and Group B was treated with

deep friction massage along with therapeutic ultrasound and passive stretching

exercise. Foot function of ankle was assessed before and after intervention by foot

function index and flexibility was assessed before and after intervention by

goniometer.

The present study statistically demonstrates that both the technique is effective

in improving the foot function and flexibility in subjects with chronic plantar fasciitis.

But when comparing the mean values it was found that there was mean significant

improvement in patients treated with myofascial release technique than deep friction

massage techniques.

6.1 Limitations

 Occupation.

 Home exercises.

 The study did not include follow up.

41
6.2 Suggestions

 The study can be compared with other treatment variables.

 The study can be conducted for other age groups.

42
 CHAPTER VII

BIBLOGRAPHY

Books

 Jeffrey D.Placzek and David A.Boyce; Orthopaedic Physiotherapy Secret;

2nd edition; reprinted 2008; Elsevier publication; page 610.

 Susan O’Sullivan and Thomas J Schmitz; Physical Rehabilitation;

4thedition; Jaypee publication; page 170-174.

 JayantJoshy and PrakashKotwal;Essentials of Orthopaedics and applied

Physiotherapy; 4th edition; Elsevier publication; page no 558.

 Paul. D hooper;Physical modalities a primer for chiropractic; Williams

publications; edition 8th; page 92.

 BudimanMak E, Conrad KJ, Roach KE; Foot function index: A measure of

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research;Myofascial release; December 2012; Volume 2 issue 2.

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Koji Abe; Effects of therapeutic ultrasound on range of motion and stretch

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Release in Treatment of Plantar Fasciitis: A RCT; Indian Journal of

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Fernandez-de-Las-Penas C; Effectiveness of Myofascial trigger point

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volume2; page 8.

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control study; The Journal of Bone and Joint Surgery(American); 2003.

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46
 ANNEXURES

ANNEXURE-I

PHYSIOTHERAPY ASSESSMENT

1) Subjective Examination

a) Name :

b) Age : Date of birth :

c) Sex : M F

d) Occupation :

e) Weight :

f) Chief complaints :

g) Duration :

2) History collection

a) Present Medical history

b) Past Medical history

c) Social history

d) Family history

e) Associated problems

3) Pain assessment (VAS)

a) Onset

b) Duration

c) Site/Side

d) Type

e) Nature

f) Aggravating factor

g) Relieving factor

47
4) Objective Assessment

a) On observation

 General body built

 Posture

 Gait

 Attitude of limb

 Deformity

 Redness

 Skin changes

 External appliances

b) On palpation

 Warmth

 Swelling

 Local tenderness

 Oedema

 Muscle spasm

c) On examination

 Vital signs

 Motor examination

o Muscle muscle testing

o Range of motion assessment

Movement AROM PROM

Dorsiflexion

Plantarflexion

48
  Sensory examination

o Superficial Sensations

o Deep Sensations

5) Special test

 Windlass test

6) Investigation

 X-ray

7) Diagnosis

49
ANNEXURE-II

Special test:Windlass test

Patient position: Sitting with 90 degree knee flexion on treatment table.

Therapist position: Sitting.

Procedure:The examiner stabilizes the ankle in neutral position with one hand

and grasps the proximal segment of the hallux with the other hand. The

interphalangeal joints were allowed to flex so that the flexor halluces longus muscle

would not restrict motion. Thegreat toe was passivelydorsiflexed to end range or until

the subject felt pain.

Implication:A positive Windlass test was defined as that reproducing the

subjects specific pain.

50
ANNEXURE-III

Foot Function Index

Patient Name: _______________________________ Date:____________

M / F: ______________ Age: _______ Hospital No: ___________

This questionnaire has been designed to give your therapist information as to

how your foot pain has affected your ability to manage in everyday life. Please

answer every question. For each of the following questions, we would like you to

score each question on a scale from 0 (no pain or difficulty) to 10 (worst pain

imaginable or so difficult it required help) that best describes your foot over the past

week. Please read each question and place a number from 0-10 in the corresponding

box.

No Pain 1 23 4 5 6 7 8 9 10Worst Pain Imaginable

Pain subscale: How severe is your foot pain.

Foot pain at its worst? Foot pain in morning?

Pain walking barefoot? Pain standing barefoot?

Pain walking with shoes? Pain standing with shoes?

Pain walking with orthotics? Pain standing with orthotics?

Foot pain at end of day?

Disability Subscale: How much difficulty did you have

Difficulty walking in house? Difficulty walking outside?

Difficulty walking 4 blocks? Difficulty climbing stairs?

Difficulty descending stairs? Difficulty standing tip toe?

Difficulty getting up from chair? Difficulty climbing curbs?

Difficulty walking fast?

Activity Limitation Subscale: How much of the time do you

51
Stay inside all day because of feet? Stay in bed because of feet?

Limit activities because of feet? Use assistive device indoors?

Use assistive device outdoors?

Office use only

Total score :

____ / 230 points.

PT incharge:

Group

Patient no:

Score: ___/230 x 100 = ___%

High scores indicate greater disability/decreased function.

52
ANNEXURE-IV

Table-9: Preandpost-testvaluesof range of motion of ankle dorsiflexion

inGroupA and B.

Sl.No GROUP A GROUP B

PRETEST POSTTEST PRETEST POSTTEST

1 15 19 15 20

2 10 18 10 18

3 10 20 12 20

4 8 16 8 18

5 9 19 6 15

6 5 12 5 17

7 6 13 7 18

8 7 14 7 15

9 5 12 9 18

10 8 15 8 19

11 6 14 7 16

12 5 14 6 15

13 7 16 5 14

14 8 15 5 18

15 6 17 6 18

53
ANNEXURE-V

Table10: Preandpost-testvalues of foot function index inGroup A and B.

Sl.No GROUP A GROUP B

Pretest in % Post test in % Pretest in % Post test in %

1 76.52 6.95 73.91 9.56

2 78.26 9.56 78.26 11.73

3 87.39 8.69 82.17 19.56

4 86.95 13.39 85.21 21.3

5 81.3 15.21 91.3 19.56

6 85.65 13.04 80.86 12.6

7 80.43 8.69 95.21 30.43

8 92.6 21.73 82.6 20.86

9 78.69 8.26 80.86 19.56

10 85.21 17.39 84.34 21.3

11 82.17 12.17 93.91 36.95

12 96 26.95 85.65 23.91

13 83.91 12.6 81.3 15.65

14 97.82 25.21 78.69 14.78

15 84.78 8.69 82.6 13.04

54
ANNEXURE-VI

PATIENTCONSENTFORM

I ……………………………………………….Voluntarily consent to

participate in the research named on “A COMPARITIVE STUDY ON THE

EFFECTIVENESS OF MYOFASCIAL RELEASE AND DEEP FRICTION

MASSAGE IN THE MANGEMENT OFFOOT FUNCTION AND

FLEXIBLITY AMONG CHRONIC PLANTAR FASICIITIS PATIENTS”.

The researcher has explained me the treatment approach in brief, risk of

participation and has answered the questions related to the study to my satisfaction.

Signature of patient Signature of researcher

Name and signature of witness

Place:

Date:

55