Last week we looked at a study that compared myofascial release with sham ultrasound, in people with plantar fascia pain, and found that myofascial release did better in all areas, functional and pain relief.  

This week’s article is looking at deep massage to the posterior calf musculature and adding in a neural mobilization for the treatment of heel pain.  The title is: Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: A pilot randomized clinical trial.  This article was published in 2014, in the journal Manual Therapy.  As always, if you click on the title you will be taken to a page where you can read the abstract.  

Plantar heel pain, plantar fasciitis, is a common affliction in the world.  This accounts for about 15% of all foot complaints.  

The premise of this study is simple.  It is to see if “…deep, soft tissue massage to posterior calf muscles with neural mobilization combined with stretching exercises… would lead to increased pain relief and improved function compared to local ultrasound therapy combined with the same stretching exercise program… for patients with [plantar heel pain]”.

This was a good study, there was blinding involved, meaning that the people evaluating the  subjects in the study do not know if the subject was in the massage group or ultrasound group.  In addition, there was randomization of the subjects into the two groups.  Both of those aspects of the study make this a higher quality study than most.  

The treatments occurred 1-2x/week for a total of 8 treatments over 6 weeks.  Notice that this is different from the study mentioned in last week’s blog post.  This is because we do not know that the optimum treatment frequency is for people with plantar fasciitis.  

 

The therapist is applying a fair amount of pressure on the clients calf muscle, try to massage the deeper aspects of calf musculature

Getting into the deep calf musculature
from: www.painreliefclinic.co.uk

They do not go into as much detail describing the soft tissue technique used in this study.  However, they do reference Cyriax and state that the techniques were ”…directed to the incompliant and painful areas of the posterior calf muscle group”.  Each massage session was 10 minutes in length.  It is assumed that the massage was only done on the side of the plantar fasciitis.  

 

The reason the authors of this study chose ultrasound is because there is no evidence to support it use in this type of client and “…yet ultrasound continues to be a commonly used intervention”.  

 

The picture on the left show a gastrocnemius stretch, with the person having the leg they are stretching is straight. The picture on the right, shows a soleus stretch, as the leg being stretched is bent.

Straight back leg = gastrocnemius stretch
bent back leg = soleus stretch
from: www.knee-pain-explained.com

There was a stretching protocol given to both groups.  Standing calf stretches, one for the gastrocnemius and one for the soleus.  The stretches were performed with the client standing, facing a wall.  The stretch was meant for the back leg.  To stretch the gastrocnemius, the back knee was kept straight.  For the soleus stretch, the back knee was bent.  It is important that while doing these stretches the heel, of the leg being stretched, stay on the floor.  

 

One addition exercise was given to the experimental group.  The exercises was a passive straight leg raise using a long belt.  Basically it caused the person doing the exercise to perform a straight leg raise with dorsiflexion, top of the foot pulled towards the shin.  

There is a lady on her back, she is pulling on a belt that is around her right foot. this is lifting her right leg up, with a straight knee and her toes pulled towards her shin

Passive neural mobilization, the leg is not working to lift itself
from: physiorehab.in

How would this help someone with plantar heel pain?  The sciatic nerve goes down the leg and just about the knee, splits into two nerves, the tibial nerve which continues down the same pathway, and the common peroneal nerve, which travels to the lateral part of the foot.  

The tibial nerve passes behind the inside ankle bone, medial malleolus, and enters the foot.  This nerve then divides into the medial and lateral plantar nerves.  The tibial nerve enters the foot through the tarsal tunnel which is very close to where the plantar fasciitis pain is felt.  

 

The researchers used the Foot and Ankle Computerized Adaptive Test, CAT, for functional testing and a visual analogue scale, VAS, for measurements before and after the experiment.  

Visual analog scale

Visual analog scale
from: www.physio-pedia.com

So the experimental group got; massage, stretches and neural mobilization.  Where the control group got stretches and ultrasound.  There were 36 subjects in the experimental group and 33 in the control group to start.  The subjects were randomly allocated.  The number of dropouts in this study was quite high, I thought, 10 in the experimental group and 8 in the control group.  At least, they were similar numbers of dropouts.  

What did the researchers find out?  

The experimental group had a much larger increase in the CAT test, then the ultrasound group did.  When using the CAT test, a higher score is better.  

However, with the VAS scores, where a lower score is better, 0 = no pain, there was no difference at the end of experiment.  Both groups had about the same drop in their VAS scores and both groups were statistically significant.

 

The therapist is using ultrasound on the bottom of the client's right foot, in the area of where plantar fasciitis pain typically occurs

There is no evidence showing the use of ultrasound for plantar fasciitis
from: readaptation-universelle.com

A couple of limitations of this study was that the subjects were given the protocol to do the exercises but there was no daily log to fill in.  So compliance by both groups could be questioned.  As mentioned above, there were a number of dropouts out of both groups, = about 25% of the total number of participants in the study.  There was no true control group, wait and see, over the course of the study.  The outcome measures of this study were only done at the beginning of the study and after 6 weeks.  There was no short term follow up or long term follow up.  Which intervention relieved pain the quickest?  Did a number of subject relapse with their heel pain soon after the experiment was over?  Both questions cannot be answered do to the lack of data collected.  

 

Posterior calf massage therapy and neural mobilization had superior functional outcomes, in the short term, over ultrasound and stretching.  

 

What does this tell you, when you are looking for someone to help you with your plantar heel pain?  First off, the past two studies, both of which are quite well done, have shown that massage of the calf muscles will decrease plantar heel pain.  

Second, if your health care professional chooses to use ultrasound for the majority of your treatment session.  You should not go back and waste your hard earned money on them.  If they ask why you did not return, tell them that you read this blog post (and others).  You could direct them to this post to help educate themselves. 

What else have I found that works for plantar heel pain?  Exercises and not just stretching.  When we continually stretch muscles, we make them weaker.  This has been shown in a few studies that stretching the calf muscles leads to decreased jump height and decreased reaction time.  We need to strengthen the muscles!  Not just the calf musculature but the intrinsics the tiny foot muscles.  Those muscles are there for a reason!  

 

I find that using a dry needling technique for the foot intrinsics works really well, if the client can handle it.  I practice IMS, intramuscular stimulation, and it can be pretty painful getting into the deep muscles.  Most people state that it feels like their feet cramp right up.  But after the cramping stops, they are in awe.  They can stand up and walk around with minimal or no pain in their feet!  
If you have any questions about plantar heel pain/ fasciitis or any other treatment techniques that you find really help your clients or any advice that has worked for your foot pain, please leave a comment!