title: Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial.
abstract: METHODS
  A randomized controlled clinical trial.
  
  
  OBJECTIVE
  To investigate the effects of trigger point (TrP) manual therapy combined with a self-stretching program for the management of patients with plantar heel pain.
  
  
  BACKGROUND
  Previous studies have reported that stretching of the calf musculature and the plantar fascia are effective management strategies for plantar heel pain. However, it is not known if the inclusion of soft tissue therapy can further improve the outcomes in this population.
  
  
  METHODS
  Sixty patients, 15 men and 45 women (mean ± SD age, 44 ± 10 years) with a clinical diagnosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. 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. Outcomes of interest were captured at baseline and at a 1-month follow-up (end of treatment period). Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction.
  
  
  RESULTS
  The 2 × 2 mixed-model analysis of variance (ANOVA) revealed a significant group-by-time interaction for the main outcomes of the study: physical function (P = .001) and bodily pain (P = .005); patients receiving a combination of self-stretching and TrP tissue intervention experienced a greater improvement in physical function and a greater reduction in pain, as compared to those receiving the self-stretching protocol. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the gastrocnemii and soleus muscles, and the calcaneus (all P<.001). Patients receiving a combination of self-stretching and TrP tissue intervention showed a greater improvement in PPT, as compared to those who received only the self-stretching protocol.
  
  
  CONCLUSIONS
  This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain.
  
  
  METHODS
  Therapy, level 1b.
authors.affiliation: Hospital Ouro Verde, Escola de Osteopatía de Madrid, Campinas, Sao Paulo, Brazil.
authors.forename: Rômulo
authors.initials: R
authors.lastname: Renan-Ordine
authors.forename: Francisco
authors.initials: F
authors.lastname: Alburquerque-Sendín
authors.forename: Daiana Priscila Rodrigues
authors.initials: DP
authors.lastname: de Souza
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Cleland
authors.forename: César
authors.initials: C
authors.lastname: Fernández-de-Las-Peñas
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D003131:Combined Modality Therapy; D036981:Fasciitis, Plantar / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D052580:Muscle Stretching Exercises; D026201:Musculoskeletal Manipulations; D009209:Myofascial Pain Syndromes / Q000628:therapy*; D010147:Pain Measurement; D016896:Treatment Outcome