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Effectiveness of Manual Therapy Combined With Standard Treatment in the Management of Plantar Fasciitis

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT01439932
Recruitment Status : Completed
First Posted : September 23, 2011
Last Update Posted : February 20, 2013
Clalit Health Services
Information provided by (Responsible Party):
Meir Medical Center

Brief Summary:

Background: Plantar fasciitis (PF) is a common problem that tends to attack about 10% of the population during life. This is a degenerative condition of the plantar fascia at its insertion at the bottom of the heel. Pain appears mainly on the first steps in the morning or after prolonged lack of weight bearing. The pain intensity can be very high and this can cause functional limitations and reduce quality of life.

Despite the high prevalence of the PF, treatment is controversial and not supported by extensive research. Review of the previous studies on various treatments, mentioned steroid injections, shock waves, night splint, orthotics, heel padding and stretching exercises.

Limitation of ankle dorsi flexion is a common finding and thought to be a contributing factor to the development of pathology. So far, this issue had been addressed mainly by soft tissue therapy techniques to improve ankle range of motion in patients with PF. Only one study (Joshua et al 2009) evaluated the effect of ankle joint mobilizations of PF. However, in this study mobilizations were part of complex therapy and therefore the effect of treatment cannot be attributed solely to them.

The purpose of this study is to evaluate the effectiveness of ankle and mid-foot joints mobilization on pain and function of patients with PF.

The hypothesis is that manual mobilizations of ankle and midfoot joints in addition to conventional physical therapy will improve pain and function significantly more than conventional treatment, in patients with PF.

Methods: 50 patients, age 18-75 with a diagnosis of PF that meet the inclusion criteria will be recruited and randomly divided into two groups. Both groups will receive commonly accepted physical therapy treatment that includes stretching exercise of the plantar fascia and triceps surae muscles and ultrasound therapy at the site of symptoms. The study group will receive in addition manual mobilizations to the ankle and midfoot joints. The procedures will take place at the physiotherapy clinic Bat-Yamon of General Health Services and will last four weeks, twice a week.

Condition or disease Intervention/treatment Phase
Plantar Calcaneal Spur Fasciitis, Plantar Device: algometer Not Applicable

Detailed Description:

A prospective randomized double-blinded controlled clinical trial. Setting: Bat-Yamon physical therapy clinic of Clalit health services in Bat Yam.

Ethical considerations: The research proposal will be submitted for the approval of the Helsinki Committee at Meir Hospital in Kefar Saba. All patients will sign informed consent form according to the laws of medical ethics.

Subjects will be recruited from all the population of patients who are referred to physical therapy for the treatment of PF with diagnosis of plantar fasciitis or calcaneal spur.

Randomization will be carried out using envelopes that will be prepared in advance. Each patient will receive at the end of the baseline examination envelope with the type of treatment for which will be delivered only to the therapist so that the examiner and the patient will be blind to the treatment group.

Baseline and final evaluations will be performed by the examiner-therapist and treatments performed by three physical therapists at the Bat-Yamon clinic with experience of at least 3 years which will receive proper instruction and training.

Baseline examination will be performed after completing informed consent form and will include demographic information to be filled by patient, clinical interview and examination by the examiner. Demographic information includes age, gender, weight, BMI (calculated by the examiner), history of the problem, habits related to physical activity and occupation and general health.

The interview will refer to etiology and nature of symptoms. The clinical examination will include observation of foot structure and gait pattern, the presence of hit or swelling. Palpation for pain location and for ruling out fat pad Syndrome, clunk test and neurodynamic of tibial nerve will be performed to rule out tarsal tunnel syndrome (TTS). Patients with suspicion for one of these diagnoses will not be recruited. Dorsi flexion range of motion in both legs will be measured and compared to the range at the end of treatment. Measurement will be taken in two ways, once weight bearing with inclinometer - the patient stands in lounge position while tested leg in front and asked to bend the knee of this leg as possible without lifting the heel off the floor. The angle measured is the angle between the tibia and a vertical line to the floor.Second time without weight bearing with Goniometer- the patient lies on his back with a pillow under the tested knee , the therapist performs maximum dorsi flexion passively and asks the patient to add an active movement in the same direction. The angle measured is between fibula and fifth metatarsus

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 50 participants
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: Single (Investigator)
Primary Purpose: Treatment
Official Title: Effectiveness of Manual Therapy Combined With Standard Treatment in the Management of Plantar Fasciitis, a Randomized Control Trial
Study Start Date : October 2011
Actual Primary Completion Date : January 2013
Actual Study Completion Date : February 2013

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: ankle mobilization for pain release

stretching exercise for the plantar fascia and triceps surae muscles three times a day throughout the study period.

During each visit the exercise performance will be checked by the therapist. In addition, participants from both groups will get ultra sound therapy in frequency of 1 MHz, power of 1.5 watts per centimeter-squared, pulses of 50% for 5 minutes.

The study group will receive the same treatment and a number of manual techniques that include antero-posterior (AP) mobilization for talocrural joint in two variations (weight baring and non-weight baring) to improve the range of dorsi flexion, subtalar joint mobilization to improve range of eversion and mid-tarsal mobilization to improve pronation / supination of the forefoot. Each technique will be carried out for 1 to 1.5 minutes for a total of 5 minutes of manual treatment.

All patients will receive information and guidance to practice at home.

Device: algometer

Pressure algometer (Algometry) - This is an instrument that measures pain threshold (the minimum pressure required to produce pain). The instrument consists of a flat disk size centimeter square attached to pressure transducer and measuring electrodes. The disk is placed vertically on the point of pain and therapist increases the intensity of the pressure until initial pain appears (when sense of pressure becomes sense of pain.) Score is determined by average of three repeated measurements with 30 seconds break between each.

The algometer allows an objective assessment of pain in addition to LEFS score which is a subjective tool. The algometer test was found to be valid and reliable in repeated measurements (interrater, intrarater) by Andrew A. Fischerin 1987 with healthy people [Andrew 1987]. In another study high reliability was found for averaging between three repeated tests: ICC = 0.91 (CI 0.82; 0.97 95%). [Linda et al 2007]

Other Name: SBMEDIC Electronics

Primary Outcome Measures :
  1. Numeric Pain Rating Scale 0-10 [ Time Frame: one year and two months ]
    The participant will rate his pain intensity at first step in the morning on a scale of numbers between 0-10 when 0 means "no pain" and 10 means "very severe pain". NPRS is a valid and reliable tool for assessment of pain intensity and is a common tool in studies on PF.

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 75 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Age 18-75
  • Pain allocated at the bottom of heel and produced by pressure
  • Pain in the morning at first steps or after prolonged non-weight bearing
  • NPRS morning pain score of 3 or higher

Exclusion Criteria:

  • Tumors
  • Prolonged use of steroids
  • Fracture below knee during the last year
  • Prior foot surgeries
  • A positive diagnosis of Tarsal Tunnel Syndrome (TTS) / Fat Pad Syndrome
  • Pregnancy
  • Lack of availability in the coming month

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01439932

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Clalit Health Services, Tel-Aviv district, Bat Yamon
Bat Yam, Israel
Sponsors and Collaborators
Meir Medical Center
Clalit Health Services
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Study Director: Anat Shashua, BPT
Publications automatically indexed to this study by Identifier (NCT Number):
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Responsible Party: Meir Medical Center Identifier: NCT01439932    
Other Study ID Numbers: MMC11XXX-XXKCTIL
PF-001-ISR ( Other Identifier: Clalit Health Services )
First Posted: September 23, 2011    Key Record Dates
Last Update Posted: February 20, 2013
Last Verified: September 2011
Keywords provided by Meir Medical Center:
plantar fasciitis
heel pain
manual treatment
dorsi flexion
Additional relevant MeSH terms:
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Fasciitis, Plantar
Heel Spur
Musculoskeletal Diseases
Foot Diseases
Bone Diseases