732762
research-article2017
FAIXXX10.1177/1071100717732762Foot & Ankle InternationalEngkananuwat et al
Article
Foot & Ankle International®
Effectiveness of the Simultaneous Stretching
1–8
© The Author(s) 2017
Reprints and permissions:
of the Achilles Tendon and Plantar Fascia in sagepub.com/journalsPermissions.nav
DOI: 10.1177/1071100717732762
https://doi.org/10.1177/1071100717732762
Individuals With Plantar Fasciitis journals.sagepub.com/home/fai
Phoomchai Engkananuwat, PT, BSc1, Rotsalai Kanlayanaphotporn, PT, PhD1,
and Nithima Purepong, PT, PhD2
Abstract
Background: Since the plantar fascia and the Achilles tendon are anatomically connected, it is plausible that stretching of
both structures simultaneously will result in a better outcome for plantar fasciitis.
Methods: Fifty participants aged 40 to 60 years with a history of plantar fasciitis greater than 1 month were recruited.
They were prospectively randomized into 2 groups. Group 1 was instructed to stretch the Achilles tendon while group 2
simultaneously stretched the Achilles tendon and plantar fascia.
Results: After 4 weeks of both stretching protocols, participants in group 2 demonstrated a significantly greater pressure
pain threshold than participants in group 1 (P = .040) with post hoc analysis. No significant differences between groups
were demonstrated in other variables (P > .05). Concerning within-group comparisons, both interventions resulted in
significant reductions in pain at first step in the morning and average pain at the medial plantar calcaneal region over the
past 24 hours, while there were increases in the pressure pain threshold, visual analog scale–foot and ankle score, and
range of motion in ankle dorsiflexion (P < .001). More participants in group 2 described their symptoms as being much
improved to being completely improved than those in group 1.
Conclusion: The simultaneous stretching of the Achilles tendon and plantar fascia for 4 weeks was a more effective
intervention for plantar fasciitis. Patients who reported complete relief from symptoms at the end of the 4-week intervention
in the simultaneous stretching group (n = 14; 56%) were double that of the stretching of the Achilles tendon–only group
(n = 7; 28%).
Level of Evidence: II, lesser quality RCT or prospective comparative study.
Keywords: plantar heel pain, plantar fascia, plantar fasciitis, Achilles tendon, stretching
Plantar fasciitis is a common foot complaint encountered stretching of the Achilles tendon and/or plantar fascia are
by clinicians. It is most common among people aged 40 to reported to be effective treatments for plantar fasciitis.4,11,22
60 years.3 Patients classically describe medial plantar heel Both intermittent and sustained stretching of the Achilles
pain on weightbearing, which is exacerbated with the first tendon resulted in the reduction in foot and ankle pain as
step after a period of nonweightbearing, typically in the well as improvement in foot and ankle function.19 With
morning.12,26 Although several factors have been proposed plantar fascia–specific stretching, superior improvement in
as causes of plantar fasciitis, biomechanical abnormalities plantar fasciitis compared to the stretching of the Achilles
are considered to play a major role in this condition.2,10,25 tendon was demonstrated.4 Stretching of both the Achilles
These include tightness of the Achilles tendon and plantar
fascia, reductions in strength in some foot and ankle mus-
cles, and abnormal foot alignment. With repetitive use of
1
the foot and ankle, the plantar fascia is loaded and can Department of Physical Therapy, Faculty of Allied Health Sciences,
develop chronic degenerative changes with marked thick- Chulalongkorn University, Bangkok, Thailand
2
Carolina Asia Center, The University of North Carolina at Chapel Hill,
ening and fibrosis within the fascia.26 NC, USA
Treatment of plantar fasciitis can take the form of either
operative or nonoperative interventions. However, nonop- Corresponding Author:
Rotsalai Kanlayanaphotporn, PT, PhD, Department of Physical Therapy,
erative interventions are advocated initially as it was shown Faculty of Allied Health Sciences, Chulalongkorn University, 154 Rama 1
that approximately 90% of patients responded positively to Road, Soi Chula 12, Pathumwan, Bangkok 10330, Thailand.
treatment.14 Among the various nonoperative interventions, Email: [email protected], [email protected]
2 Foot & Ankle International 00(0)
tendon and plantar fascia in a consecutive manner also Consequently, this study required at least 24 participants
resulted in positive outcomes.22 per group. Table 1 summarizes the characteristics of the
Considering that the Achilles tendon and the plantar fas- participants in each group. No significant differences
cia are connected along the myofascial meridian of the between groups in demographic details and pretreatment
superficial back line,13 it is therefore plausible that stretch- data were found (P > .05).
ing of these 2 structures simultaneously will result in greater
pain relief and lower foot and ankle disability. The objec-
Outcome Measures
tives of this study were therefore to investigate the effects of
simultaneous stretching of the Achilles tendon and plantar Pain intensity. Two pain variables were measured: pain at
fascia as well as to compare the effects of this simultaneous first step in the morning and average pain at the medial
stretching with the stretching of the Achilles tendon by plantar calcaneal region over the past 24 hours. The former
itself in patients with plantar fasciitis. was measured using the 11-point NPRS. The latter was
measured using the VAS for pain. It is a 10-cm line of
which 0 represents no pain and 10 represents the worst pain
Methods imaginable.
This study was performed from March 2016 to April 2017.
A total of 50 patients with unilateral plantar fasciitis between Pressure pain threshold. Pressure pain threshold was mea-
the ages of 40 and 60 years at a local physical therapy clinic sured with a pressure algometer (JTECH Medical, Midvale,
participated in this study. Patients were recruited by conve- UT) with the surface area of the round tip of 1 cm2. The
nience sampling. To be eligible for inclusion, the partici- instrument was found to be highly reliable with a Cron-
pants were required to have experienced plantar heel pain bach’s α of 0.94 to 0.98.18 The algometer probe tip was
for at least 1 month, have tenderness on palpation of the applied gradually perpendicularly over the tender point of
medial plantar calcaneal region, and have pain on the first the plantar fascia at the medial plantar calcaneal region.
step in the morning greater than or equal to 4 out of 10 on Participants were instructed to report when the pressure
an 11-point Numeric Pain Rating Scale (NPRS), and this changed to pain, and the readings of the algometer were
pain had to decrease with movement such as walking.9,10,12,14 registered. The mean of 3 trials with 10 seconds between
Participants were excluded if they had any of the following each trial was calculated and used for analysis. In this study,
conditions: precautions to manual therapy (ie, tumor, rheu- the tender point was defined as the point where the partici-
matoid arthritis, osteoporosis, severe vascular disease, etc), pants were unable to tolerate a pressure of more than 3 kg/
diabetes mellitus, a history of fracture of the lower extremi- cm2 or where the pressure threshold was at least 2 kg/cm2
ties, prior surgery to the plantar fascia or lower extremities, lower than the asymptomatic side.18
prior corticosteroid injections, neural problems in lower
extremities with a positive Tinel’s sign or paresthesia, any Ankle range of motion. Passive ankle dorsiflexion and plan-
conditions that could be referring pain to the heel, and preg- tarflexion were measured when the participants were lying
nancy. A physical therapist conducted a screening examina- supine with the knees extended. A universal goniometer
tion for the above-mentioned conditions. Any individuals was aligned with a pivot point over the lateral malleolus, a
who did not intend to refrain from use of other treatments or stationary arm parallel to the fibula, and a movable arm par-
medications during the study period were also excluded. allel to the fifth metatarsal.21 The mean of 3 trials in each
Prior to taking part in this study, written consent was direction was used for analysis.
obtained from all participants in accordance with approval
from the Ethics Review Committee of the university. Foot and ankle disability. Foot and ankle disability was
The sample size for this study was calculated for 2 pri- assessed by the Thai version of the VAS–foot and ankle (FA)
mary outcomes: average pain change over the past 24 hours questionnaire.1 It consists of 20 items of 3 different question
and the pressure pain threshold. The calculations were categories (4 relating to pain, 11 to functional limitation, and
based on detecting a pain difference between groups of 15 5 to other complaints). Each item was scored 0 to 100 points,
mm with a standard deviation of 17.5 mm on a 0- to 100- where 0 represents the most severe disability and 100 repre-
mm visual analog scale (VAS).22 The expected between- sents no disability. The highest possible total score was
group difference for the pressure pain threshold at the divided by 20 so the final score ranged from 0 to 100 points.
calcaneal region was 1.2 kg/cm2 with a standard deviation The lower the score, the higher the foot and ankle disability.
of 1.3 kg/cm2.22 Configuration error was set at α = 0.05 with The VAS-FA has been shown to be highly reliable with an
a power of 0.80. These parameters generated a sample size intraclass correlation coefficient of 0.995 and Cronbach’s α
of at least 24 participants per group for testing the average of 0.995.1 Although, the VAS-FA has not been validated in
pain change over the past 24 hours and at least 19 partici- patients with plantar fasciitis, the score demonstrated mod-
pants per group for testing the pressure pain threshold. erate correlations with physical functioning, role physical,
Engkananuwat et al 3
Table 1. Participants’ Characteristics and Outcome Measures at Pretreatment (N = 50).a
Mean Difference (95% CI)
Variables Group 1 (n = 25) Group 2 (n = 25) (Groups 2 – 1) P Value
Sex, male/female, No. 10/15 8/17
Symptomatic side, left/right, No. 12/13 13/12
Walking duration, min/d 120-240 120-240
Age, y 49.8 ± 6.5 49.7 ± 6.5 −0.2 ± 10 (–3.5 to 3.9) .931
Body mass index, kg/m2 23.7 ± 2.9 23.7 ± 2.8 0.0 ± 3.0 (–1.6 to 1.6) .983
Pain duration, mo 6.0 ± 4.5 8.5 ± 7.1 2.6 ± 8.5 (–0.8 to 5.9) .134
Pain intensity
Pain at first step in the morning 5.4 ± 1.3 5.8 ± 1.2 0.4 ± 1.3 (–0.4 to 1.1) .319
Average pain at the medial plantar calcaneal 4.0 ± 1.4 3.9 ± 1.1 −0.1 ± 1.6 (–0.8 to 0.6) .824
region over the past 24 hours, cm
Pressure pain threshold, kg/cm2 2.5 ± 1.3 2.1 ± 0.9 −0.4 ± 1.3 (–1.1 to 0.2) .167
Ankle range of motion, deg
Dorsiflexion 12.2 ± 5.1 11.7 ± 4.8 −0.5 ± 6.1 (–3.3 to 2.3) .733
Plantarflexion 35.7 ± 6.9 36.6 ± 6.7 0.9 ± 9.8 (–2.9 to 4.8) .638
VAS-FA 81.8 ± 1.1 82.6 ± 4.4 0.8 ± 6.8 (–2.5 to 4.1) .635
Abbreviations: CI, confidence interval; VAS-FA, visual analog scale–foot and ankle.
a
Values are presented as mean ± standard deviation unless otherwise indicated.
bodily pain domains, and total score of the Short Form 36 in their calf and the Achilles tendon area. Group 2 simultane-
health survey questionnaire (P < 0.001 and r > 0.5) in ously stretched the Achilles tendon and plantar fascia by
patients with foot- and ankle-related problems.1 standing on a specially developed stretching instrument
(Figure 2).20 The device consisted of 2 wooden bases cov-
Global perceived effect. Clinical success in the participants’ ered with a Bene-feet mat (Ledraplastic, Osoppo, Italy),
perspective was examined by the Global Perceived Effect which was composed of many long flexible spikes with the
questionnaire. This single-item questionnaire asked partici- shorter spikes located at the front and the back and the taller
pants to rank their perceived change after a 4-week inter- ones in the middle. This aimed to push the plantar fascia
vention. It consisted of a 7-point scale ranging from 1 to 7 upward and stretch the plantar fascia. However, the device
(1 = completely recovered, 2 = much improved, 3 = slightly has not had any basic science studies examining its effec-
improved, 4 = no change, 5 = slightly worsened, 6 = much tiveness in stretching the plantar fascia. Each wooden base
worsened, and 7 = worse than ever).16 This measure has not was equipped with a goniometer and a motor that could
been validated in a plantar fasciitis population but has been move the base up and down independently for each foot. The
shown to provide a valid measure for determining the effect speed of movement was set at 0.8 to 1.3 degrees per second
of an intervention in several musculoskeletal disorders.6,7 to provide a gentle stretch to the Achilles tendon and the
plantar fascia with minimal risk of injury.
Medication or other treatment questionnaire. Participants The stretching for both groups was 5 sets of a 20-second
were asked whether they had received any medication or stretch and a 20-second rest. The stretch was performed
other treatments during the 4-week intervention. They were twice a day for 5 days per week for 4 consecutive weeks.
required to write the name, amount, and frequency of medi- All participants were required to record their exercise in an
cation or types of treatment received. exercise log, which was collected at the end of the 4-week
intervention.
Two researchers were involved in this study. One
Procedure researcher instructed participants on how to perform the
Using a computer-generated randomized table of numbers, stretching. Prior to the intervention, the other researcher,
the qualified participants were randomly assigned into 2 who was blinded to the participants’ group, collected the
groups. Group 1 was instructed to stretch the Achilles ten- pretreatment data of pain intensity at first step in the morn-
don by placing the symptomatic foot furthest away from the ing, average pain at the medial plantar calcaneal region over
wall (Figure 1). The second toe and the calcaneus were the past 24 hours, pressure pain threshold, ankle range of
aligned in the sagittal plane. Participants were instructed to motion, and foot and ankle disability. At the end of the
lean forward toward the wall while keeping the symptomatic 4-week intervention, the same outcome measures as the
heel on the floor and the knee straight until they felt a stretch pretreatment data and the global perceived effect were
4 Foot & Ankle International 00(0)
Figure 1. Stretching of the Achilles tendon by placing the
symptomatic foot furthest away from the wall (group 1).
recorded as the posttreatment data. Any received medica-
tions and other treatments that might have been taken
throughout the intervention period were documented.
Finally, all participants were scheduled to return to the
physical therapy clinic for a 3-month follow-up. This was to
assess the prolonged effects of both interventions on aver-
age pain at the medial plantar calcaneal region over the past
24 hours and foot and ankle disability.
Statistical Analysis
SPSS version 17 (SPSS, Inc, an IBM Company, Chicago,
IL) was used for statistical analysis. A total of 7 dependent
variables were analyzed: pain at first step in the morning,
average pain at the medial plantar calcaneal region over the
past 24 hours, pressure pain threshold, ankle dorsiflexion
range of motion, ankle plantarflexion range of motion, foot
and ankle disability, and global perceived effect. Means and
standard deviations (SDs) were calculated. Separate 2-way
repeated-measures analyses of variance (ANOVAs) were
performed to investigate the effects of treatment interven-
tion (group 1 and group 2) and time (pretreatment and post-
treatment) for all dependent variables except the global
perceived effect. Post hoc pairwise comparisons were
adjusted for multiple comparisons using Bonferroni’s pro-
cedure. Differences were considered statistically significant
when P < .05.
Results
Most participants showed high degrees of adherence to Figure 2. Stretching of the Achilles tendon and plantar fascia
both interventions. Of the 20 possible sessions, participants by standing on a specially developed stretching instrument
in group 1 attended a mean (SD) of 16.7 (1.8) sessions on (group 2).
Engkananuwat et al 5
Table 2. Mean ± Standard Deviation Changes Between Pretreatment and Posttreatment at 4 Weeks for Each Variable and the
Results of 2-Way Repeated-Measures Analyses of Variance Testing for the Effects of Group, Time, and Interaction Between Group
and Time.
Within-Group Changes Between-Group Changes Interaction
Variables/Group (95% CI) (Pre – Post) P Value (95% CI) (Groups 2 – 1) P Value Effect, P value
Pain at first step in the morning
Group 1 3.4 ± 1.2 (2.9 to 3.9) <.001a 0.1 ± 0.3 (−0.4 to 0.6) .752 .115
Group 2 4.0 ± 1.3 (3.5 to 4.5) <.001a
Average pain at the medial plantar calcaneal region over the past 24 hours, cm
Group 1 2.5 ± 1.3 (1.9 to 3.0) <.001a −0.3 ± 0.1 (−0.8 to 0.1) .148 .148
Group 2 3.0 ± 1.0 (2.6 to 3.4) <.001a
Pressure pain threshold, kg/cm2
Group 1 −1.8 ± 1.6 (−2.5 to −1.1) <.001a 0.4 ± 0.6 (–0.4 to 1.2) .288 .003b
Group 2 −3.5 ± 2.3 (−4.5 to −2.6) <.001a
Ankle dorsiflexion, deg
Group 1 −3.4 ± 3.2 (−4.7 to −2.1) <.001a −0.4 ± 1.2 (−2.8 to 2.1) .775 .752
Group 2 −3.6 ± 2.5 (−4.7 to −2.6) <.001a
Ankle plantarflexion, deg
Group 1 −3.8 ± 7.9 (−7.1 to −0.6) .041b −0.7 ± 1.2 (−3.4 to 2.1) .641 .157
Group 2 −0.7 ± 7.3 (−3.7 to 2.3) .640
VAS-FA
Group 1 −7.5 ± 3.5 (−8.9 to −6.0) <.001a −1.3 ± 1.2 (−1.5 to 4.1) .350 .280
Group 2 −8.5 ± 3.4 (−9.9 to −7.1) <.001a
Abbreviations: CI, confidence interval; VAS-FA, visual analog scale–foot and ankle.
a
Significant at P < .001.
b
Significant at P < .05.
Table 3. Means ± Standard Deviations (95% Confidence Interval) at Pretreatment, 4 Weeks, and 3 Months of the Interventions for
the Average Pain at the Medial Plantar Calcaneal Region Over the Past 24 Hours and Foot and Ankle Disability.
Variables Pretreatment At 4 Weeks At 3 Months
Average pain at the medial plantar calcaneal region over the past 24 hours, cm
Group 1 4.0 ± 1.4 (3.5-4.5) 1.5 ± 0.6 (1.3-1.7) 1.4 ± 0.4 (1.3-1.6)
Group 2 3.9 ± 1.1 (3.4-4.2) 1.0 ± 0.5 (0.7-1.2) 0.9 ± 0.4 (0.8-1.1)
VAS-FA
Group 1 81.8 ± 1.1 (79.5-84.1) 89.3 ± 5.7 (87.4-91.1) 91.0 ± 2.9 (90.0-92.0)
Group 2 82.6 ± 4.4 (80.3-84.9) 91.1 ± 3.0 (89.3-92.9) 93.5 ± 2.0 (92.5-94.5)
Abbreviation: VAS-FA, visual analog scale–foot and ankle.
average while participants in group 2 attended 16.6 (1.7) ses- between groups were demonstrated in other variables (P >
sions. After 4 weeks of the interventions, the results of the .05). Regarding within-group comparisons, both interven-
2-way ANOVAs showed a significant interaction effect tions resulted in reductions in pain at first step in the morning
between group and time in only 1 variable: pressure pain and average pain at the medial plantar calcaneal region over
threshold (P = .003), as shown in Table 2. Post hoc analysis the past 24 hours, while there were increases in pressure pain
revealed that the pressure pain threshold increased signifi- threshold, VAS-FA score, and range of motion in ankle dorsi-
cantly at posttreatment in both groups (P < .001). The mean flexion (P < .001). At 3-month follow-up, all participants
(SD) pressure pain thresholds at 4 weeks for group 1 and returned to the physical therapy clinic. It was noted that the
group 2 were 4.3 (1.9) kg/cm2 and 5.6 (2.4) kg/cm2, respec- average pain at the medial plantar calcaneal region over the
tively. With post hoc analysis, the intervention in group 2 past 24 hours and VAS-FA score of both groups changed
resulted in a significantly greater pressure pain threshold at slightly in comparison to those at 4 weeks (Table 3).
posttreatment than the intervention in group 1 (P = .040) with Subjectively, most of the participants did not seek any addi-
the mean difference of 1.3 kg/cm2. No significant differences tional treatment for their symptoms at 3-month follow-up.
6 Foot & Ankle International 00(0)
Table 4. Number of Participants Who Rated Their Global comparison with studies that used similar stretching inter-
Perceived Effect in Each of the 7-Point Scale Categories at 4 ventions for the Achilles tendon reveals that the present
Weeks (N = 50). study resulted in better outcomes between pretreatment
Global Perceived Effect Scale Group 1, No. Group 2, No. and posttreatment variables. In this study, the mean reduc-
tion of pain at first step in the morning was 3.4 points,
1: completely recovered 7 14 and the mean increase in pressure pain threshold was 1.8
2: much improved 12 10 kg/cm2. In contrast, the previous studies reported the mean
3: slightly improved 6 1
reduction of pain at first step in the morning and the mean
4: no change 0 0
increase in pressure pain threshold of 1.3 points4 and 0.3
5: slightly worsened 0 0
kg/cm2,22 respectively. These discrepancies might be due
6: much worsened 0 0
to the differences in the participants’ characteristics. The
7: worse than ever 0 0
Total 25 25
greater chronicity of the symptoms of longer than 4 months
in the previous studies might cause the tissue to be stiffer
and more difficult to stretch.
Because of the statistically nonsignificant differences in The magnitude of the mean within-group changes in
average pain at the medial plantar calcaneal region over the pain intensity and pressure pain threshold between pretreat-
past 24 hours between groups, retrospective statistical ment and posttreatment values for both stretching interven-
power analysis was conducted. The pooled standard devia- tions in this study is noteworthy. The changes were clinically
tions of the average pain at the medial plantar calcaneal relevant as they were larger than the minimum clinically
region over the past 24 hours at 4-week and 3-month fol- important change documented by previous studies. The
low-ups were 0.55 cm and 0.40 cm, respectively (Table 3). pain reductions of 2.5 to 4.0 points were more than the
As a result, the minimum number needed to detect the pain 2-point minimum clinically important change for pain.5,15
difference of 1.5 cm on a 0- to 10-cm VAS between groups The increases in pressure pain threshold of 1.8 to 3.5 kg/
with a power of 95% would be 4 participants in each group. cm2 were greater than the smallest difference for the change
This suggests that the statistically nonsignificant differ- in pressure pain threshold at the heel of 1.6 kg/cm2.24 These
ences between groups found in the current study can be results therefore suggest that the effects of the interventions
confidently accepted. used in this study were clinically relevant.
All participants in both groups reported that their symp- In general, it is noted that the mean changes between
toms had improved after 4 weeks of intervention. More par- pretreatment and posttreatment for most of the variables in
ticipants in group 2 (96%) described their symptoms as the simultaneous stretching intervention were greater than
being much improved to being completely improved than the stretching of the Achilles tendon intervention (Table 2).
those in group 1 (76%) (Table 4). Only 1 participant in The reasons for the greater pain-relieving effect of the
group 1 reported the use of medication at the fourth week of simultaneous stretching intervention could be that higher
the intervention for general muscle soreness, and this was tension was generated within the Achilles tendon and plan-
due to extraordinarily hard work that week. tar fascia. With greater tension, greater flexibility and range
of motion are expected. As it has been found that the tissue
being stretched develops greater stretch tolerance,8 this
Discussion might then allow the tissue to move with less pain. In the
The results of this study suggest that simultaneous stretch- current study, greater pain reductions were observed both
ing of the Achilles and plantar fascia might improve pain for pain at first step in the morning and average pain at the
relief within this short follow-up time period (4 weeks). The medial plantar calcaneal region over the past 24 hours. This
simultaneous stretching of the Achilles tendon and plantar hypoalgesic effect of the stretching therefore helped to
fascia showed significantly greater reduction in pressure increase the pressure pain threshold. Consequently, foot and
pain threshold. A better global perceived effect was also ankle disability was improved.
described among participants who received the simultane- Interestingly, the good results found in this study were
ous stretching intervention. The effects of both interven- obtained with a protocol that required the participants to
tions on the average pain at the medial plantar calcaneal perform the stretching program 5 days per week and not a
region over the past 24 hours and VAS-FA score at 4 weeks daily program as in previous studies.4,19,22 These findings
after the interventions tended to change slightly at 3-month support the guidelines generally recommended that the
follow-up. stretch should be performed at least 2 to 3 days per week by
To the best of the researchers’ knowledge, this is the holding the stretch for 15 to 30 seconds and repeating 2 to 4
first study on the effect of the simultaneous stretching of times.17 The total stretching time of the current study was
the Achilles tendon and plantar fascia. Direct comparison 200 seconds per day, which was therefore deemed sufficient
with previous studies is therefore inappropriate. However, for improving tissue flexibility.
Engkananuwat et al 7
The increase in the ankle range of motion in plantarflex- superior in the pressure pain threshold and the clinical suc-
ion was unexpected. Since the stretching occurred in the cess in the participants’ perspective.
posterior structures, the increase in range of motion should
occur only in the direction of dorsiflexion. The mean Declaration of Conflicting Interests
increases in ankle dorsiflexion of 3.4 to 3.6 degrees in this The author(s) declared the following potential conflicts of interest
study coincided with the mean increase of approximately 2 with respect to the research, authorship, and/or publication of this
degrees in ankle dorsiflexion reported by a previous study article: The authors have a patent (1501006139) pending. ICMJE
that performed an intermittent Achilles tendon stretching forms for all authors are available online.
for 4 weeks.19 However, these results should be interpreted
with care. Due to the mean change of less than 5 degrees Funding
being considered a measurement error,23 the changes would The author(s) received no financial support for the research,
have no clinical significance. authorship, and/or publication of this article.
In this study, participants who reported complete recov-
ery from their symptoms at the end of the 4-week interven- References
tion in the simultaneous stretching group (56%) were
1. Angthong C, Chernchujit B, Suntharapa T, et al. Visual ana-
double that of the stretching of the Achilles tendon group
logue scale foot and ankle: validity and reliability of Thai
(28%). These outcomes indicate that the simultaneous version of the new outcome score in subjective form. J Med
stretching of the Achilles tendon and plantar fascia is supe- Assoc Thai. 2011;94(8):952-957.
rior to the stretching of the Achilles tendon. 2. Bolivar YA, Munuera PV, Padillo JP. Relationship between
The results of the current study should be interpreted tightness of the posterior muscles of the lower limb and plan-
with consideration of some potential limitations. First, tar fasciitis. Foot Ankle Int 2013;34(1):42-48.
this study investigated the effects of the stretching inter- 3. Buchbinder R. Clinical practice: plantar fasciitis. N Engl J
ventions for 4 weeks. Studies examining the effects of Med. 2004;350(21):2159-2166.
these stretching interventions over a longer duration are 4. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-
required. Second, the participants included in this study specific plantar fascia-stretching exercise enhances outcomes
had plantar fasciitis for at least 1 month. Different changes in patients with chronic heel pain: a prospective, randomized
study. J Bone Joint Surg Am. 2003;85(7):1270-1277.
in the patients’ outcomes might be obtained from the par-
5. Farrar JT, Young JP, LaMoreaux L, et al. Clinical importance
ticipants with longer pain duration. Third, the participants of change in chronic pain intensity measured on an 11-point
were deemed to have minimal foot and ankle disability numerical rating scale. Pain. 2001;94:149-158.
such that their mean VAS-FA scores were greater than 80. 6. Fischer D, Stewart AL, Bloch DA, et al. Capturing the
The effects of the stretching interventions used in the patient’s view of change as a clinical outcome measure.
present study in individuals with higher levels of foot and JAMA. 1999;282(12):1157-1162.
ankle disability are unknown. Fourth, this study measured 7. Kamper SJ, Ostelo RW, Knol DL, et al. Global Perceived Effect
the ankle dorsiflexion only with the knees extended, scales provided reliable assessments of health transition in people
which represented mainly the length of the gastrocnemius with musculoskeletal disorders, but ratings are strongly influ-
muscle. Nevertheless, both stretching interventions in enced by current status. J Clin Epidemiol 2010;63(7):760-766.e1.
this study could also have an effect on the length of the 8. Knudson D. The biomechanics of stretching. J Exerc Sci
Physiother. 2006;2:3-12.
soleus muscle that blends with the gastrocnemius muscle
9. Lareau CR, Sawyer GA, Wang JH, et al. Plantar and medial
to form the Achilles tendon. Future study should also heel pain: diagnosis and management. J Am Acad Orthop
examine the ankle dorsiflexion with knee flexion to assess Surg. 2014;22(6):372-380.
the effects of the stretching interventions on the soleus 10. League AC. Current concepts review: plantar fasciitis. Foot
tightness. Ankle Int. 2008;29(3):358-366.
11. Martin RL, Davenport TE, Reischl SF, et al. Heel pain-
plantar fasciitis: revision 2014. J Orthop Sports Phys Ther.
Conclusion 2014;44(11):A1-A33.
The results of this study suggest that the simultaneous 12. Martinelli N, Bonifacini C, Romeo G. Current therapeutic
stretching of the Achilles tendon and plantar fascia might approaches for plantar fasciitis. Orthop Res Rev. 2014;6:33-40.
improve pain relief for plantar fasciitis within this short 13. Myers TW. Anatomy Trains: Myofascial Meridians for
Manual and Movement Therapists. 2nd ed. Edinburgh, UK:
follow-up time period (4 weeks). Patients who reported
Churchill Livingstone Elsevier; 2009.
complete relief from symptoms at the end of the 4-week 14. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treat-
intervention in the simultaneous stretching group (n = 14; ment. J Am Acad Orthop Surg. 2008;16(6):338-346.
56%) were double that of the stretching of the Achilles ten- 15. Ostelo RW, Deyo RA, Stratford P, et al. Interpreting change
don group (n = 7; 28%). In comparison with the stretching scores for pain and functional status in low back pain: towards
of the Achilles tendon by itself, the simultaneous stretching international consensus regarding minimal important change.
of the Achilles tendon and plantar fascia tended to be Spine. 2008;33(1):90-94.
8 Foot & Ankle International 00(0)
16. Ostelo RWJG, de Vet HCW. Clinically important out- 22. Renan-Ordine R, Alburquerque-Sendin F, de Souza DP, et al.
comes in low back pain. Best Pract Res Clin Rheumatol. Effectiveness of myofascial trigger point manual therapy
2005;19(4):593-607. combined with a self-stretching protocol for the management
17. Page P. Current concepts in muscle stretching for exercise and of plantar heel pain: a randomized controlled trial. J Orthop
rehabilitation. Inter J Sports Phys Ther. 2012;7(1):109-119. Sports Phys Ther. 2011;41(2):43-50.
18. Park G, Kim CW, Park SB, et al. Reliability and usefulness 23. Rome K, Cowieson F. A reliability study of the univer-
of the pressure pain threshold measurement in patients with sal goniometer, fluid goniometer, and electrogoniometer
myofascial pain. Ann Rehabil Med. 2011;35(3):412-417. for the measurement of ankle dorsiflexion. Foot Ankle Int.
19. Porter D, Barrill E, Oneacre K, et al. The effects of duration 1996;17(1):28-32.
and frequency of Achilles tendon stretching on dorsiflex- 24. Saban B, Masharawi Y. Pain threshold tests in patients with
ion and outcome in painful heel syndrome: a randomized, heel pain syndrome. Foot Ankle Int. 2016;37(7):730-736.
blinded, control study. Foot Ankle Int. 2002;23(7):619-624. 25. Sullivan J, Burns J, Adams R, et al. Musculoskeletal and
20. Purepong N, Kanlayanaphotporn R, Eksakulkla S. The activity-related factors associated with plantar heel pain. Foot
Continuous Passive Movement Stretching Machine for Calf Ankle Int. 2015;36(1):37-45.
Muscle. Thai patent application no. 1501006139, 2015. 26. Thompson JV, Saini SS, Reb CW, et al. Diagnosis and
21. Reese NB, Bandy WD. Joint Range of Motion and Muscle management of plantar fasciitis. J Am Osteopath Assoc.
Length Testing. Philadelphia, PA: W. B. Saunders; 2002. 2014;114(12):900-906.
