Journal of Bodywork & Movement Therapies (2013) 17, 453e461

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CROSSOVER RANDOMISED CONTROLLED TRIAL

The immediate effect of triceps surae

myofascial trigger point therapy on
restricted active ankle joint dorsiflexion in
recreational runners: A crossover
randomised controlled trial
Rob Grieve, PhD*, Amy Cranston, BSc 1, Andrew Henderson,
BSc 1, Rachel John, BSc 1, George Malone, BSc 1,
Christopher Mayall, BSc 1

Department of Allied Health Professions, Faculty of Health and Life Sciences, Glenside Campus,
University of the West of England (UWE), Blackberry Hill, Bristol BS16 1DD, United Kingdom

Received 28 November 2012; received in revised form 23 January 2013; accepted 30 January 2013

KEYWORDS Summary Objectives: To investigate the immediate effect on restricted active ankle joint
Myofascial trigger dorsiflexion range of motion (ROM), after a single intervention of myofascial trigger point
points; (MTrP) therapy on latent triceps surae MTrPs in recreational runners.
Range of motion; Design: A crossover randomised controlled trial.
Latent trigger points; Participants: Twenty-two recreational runners (11 men and 11 women; mean age 24.57; 8.7
Goniometry; years) with a restricted active ankle joint dorsiflexion and presence of latent MTrPs.
Myofascial pain Intervention: Participants were screened for a restriction in active ankle dorsiflexion in either
syndrome knee flexion (soleus) or knee extension (gastrocnemius) and the presence of latent MTrPs. Par-
ticipants were randomly allocated a week apart to both the intervention (combined pressure
release and 10 s passive stretch) and the control condition.
Results: A clinically meaningful (large effect size) and statistically significant increase in ankle
ROM in the intervention compared to the control group was achieved, for the soleus
(p Z 0.004) and the gastrocnemius (p Z 0.026).
Conclusion: Apart from the statistical significance (p < 0.05), these results are clinically relevant
due to the immediate increase in ankle dorsiflexion. These results must be viewed in caution due

* Corresponding author.
E-mail address: [email protected] (R. Grieve).
1
Final year sports therapy and rehabilitation students at time of data collection.

1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.02.001
454 R. Grieve et al.

to the carry-over effect in the RCT crossover design and the combined MTrP therapy approach.
ª 2013 Elsevier Ltd. All rights reserved.

Introduction prevalent in healthy patients and may be a source of

sensory-motor dysfunction (Ge and Arendt-Nielsen, 2011)
Running has many health benefits, although it also poses and could develop into active MTrPs (Dommerholt, 2011; Ge
a significant risk of injury (Kindred et al., 2011). The and Arendt-Nielsen, 2011).
average runner has a 37e56% risk of injury during the There is a paucity of clinical evidence on the efficacy of
course of a single year’s training (McDaniel et al., 2010). manual therapy on MTrPs/MPS in the lower limb, specifi-
Despite efforts from biomechanics researchers, 30e70% of cally evident in the triceps surae. A revised systematic lit-
all runners will have a running related injury each year and erature review (SLR) on the effectiveness of non invasive
this number has not declined over the past forty years treatments for active MTrP pain found twenty-three of the
(Herzog, 2012). twenty six included trials assessed the treatment of MTrPs
An adequate ankle range of motion (ROM) is considered in the neck and/or upper trapezius region (Rickards, 2011).
to be a necessary component for functional activities such Specifically related to MTrP intervention in the lower
as running, ascending/descending stairs and normal gait limb and the triceps surae, the immediate effect of soleus
(Cavanagh, 1990; Donatelli, 1996; Brukner and Khan, 2006). TrP pressure release showed a possible relationship be-
A disturbance of ankle ROM, may affect not only the tween latent MTrPs in the soleus and restricted ankle ROM
ankleefoot complex but also the remaining joints of the (Grieve et al., 2011). In clinical practice, manual therapy of
lower extremities (Jia-Yuan You et al., 2009). Intrinsic active and latent MTrPs in the gastrocnemius and soleus has
factors such as anatomical and biomechanical abnormal- been effective in the management of plantar heel pain
ities, lack of flexibility, poor strength and muscle imbal- (Renan-Ordine et al., 2011). Two case studies have also
ances are the most frequently associated risk factors examined TrP pressure release in the lower limb; one for
related to foot and ankle running-related injuries reduced ankle ROM (Wu et al., 2005) and the other for
(Hintermann and Nigg, 1998). With the increase in leisure hamstring dysfunction (Grieve, 2006).
activity participation there exists a parallel increase in the There is minimal research suggesting that TrP pressure
number of related injuries reported, with increased release on latent MTrPs may be an effective intervention
intrinsic and extrinsic risk factors becoming more apparent for restriction in ankle ROM, however there is evidence
(Kennedy et al., 2005). suggesting that MTrPs may cause restricted joint ROM
Adequate range of ankle dorsiflexion (>10 ) is required (Travell and Simons, 1983, 1992; Simons et al., 1999; Lucas
in mid stance of gait to allow for the tibia to advance over et al., 2004; Fernández de las Peñas et al., 2005; Blanco
the foot when propelling the body forwards during normal et al., 2006). It has been previously proposed that soleus
gait (Norkin and White, 2003). Reduced ankle dorsiflexion MTrPs specifically relate to a restriction of ankle dorsi-
may alter lower limb biomechanics during gait placing the flexion (Travell and Simons, 1992). Restricted joint ROM is
lower limb in an increased predisposition to injury (Fong commonly observed in healthy patients with latent MTPs,
et al., 2011) and may limit subtalar joint movement, pre- which may be due to the shortened sarcomeres inducing
venting the ankle joint reaching a stable closed pack posi- the shortening of the contracted taut band resulting in joint
tion needed during walking and running (Drewes et al., restriction (Ge and Arendt-Nielsen, 2011).
2009). It is thought that increasing ankle dorsiflexion will The primary aim of this RCT is to investigate the im-
benefit runners by reducing the degree of subtalar joint mediate effect on restricted active ankle joint dorsiflexion
pronation, keeping the subtalar joint closest to its optimal ROM, after a single intervention of MTrP therapy on latent
position and limiting unwanted movement which could MTrPs in the triceps surae (gastrocnemius and soleus) in
predispose to injury (Donatelli, 1996). asymptomatic recreational runners. This study builds on
MTrPs are defined as hyperirritable areas within taut the previous work by Grieve et al. (2011).
bands of skeletal muscle and classified as either active or
latent (Travell and Simons, 1983; Simons et al., 1999).
Active MTrPs are associated with spontaneous local and Methods
referred pain, whereas latent MTrPs only evoke local and
referred pain when direct pressure is applied to them Participants
(Travell and Simons, 1992; Simons et al., 1999). Active
MTrPs found in a specific region of the body (neck, back and Thirty healthy staff and students from the University of the
shoulder) are often referred to collectively as a myofascial West of England, Bristol volunteered for this study and were
pain syndrome (MPS) (Simons et al., 1999). Latent MTrPs, included if they ran at least twice weekly, had a unilateral
like active MTrPs, may cause allodynia at the trigger point restriction of active ankle dorsiflexion (<10 ) in either or
site and hyperalgesia away from the MTrP following applied both knee flexion (soleus) or knee extension (gastro-
pressure (Dommerholt, 2011) and may be associated with cnemius) and at least one identifiable latent MTrP within
peripheral and central sensitisation (Dommerholt, 2011; Ge the soleus or gastrocnemius muscles. The exclusion criteria
and Arendt-Nielsen, 2011). Active and latent MTrPs exhibit were: under 18 years old, diagnosis of Fibromyalgia Syn-
motor, sensory and autonomic components (Dommerholt drome, inability to lie prone or flex the knee to 90 , Talipes
et al., 2011). Related to this study, latent MTrPs are Equinovarus, previous ankle fractures and/or surgery within
Triceps surae trigger points and restricted ankle joint dorsiflexion 455

last 12 months, manual therapy to the triceps surae within Procedure

the last 3 months and any neurological or poor general
health that would impair sensory input. The overall procedure lasted between 30 and 40 min per
Ethical approval was granted from the School of Health participant and is depicted in a flow diagram Fig. 1.
and Social Care Ethics Sub Committee, University of the
West of England, Bristol. Informed consent was obtained Lower limb dominance protocol
from all participants and any relevant concerns and ques-
tions were dealt with before data collection.
To ensure standardisation, the dominant leg for each par-
ticipant was chosen as the limb to assess for inclusion and
exclusion criteria in this study. The lower limb dominance
Research design protocol identified the dominant leg as the leg that positively
scored two or more in the following three tasks (Wang et al.,
The study was a crossover single blind randomised con- 1993), namely kick a ball (dominant leg used to kick the ball);
trolled trial (RCT). After screening, each participant was hop on one leg (dominant leg weight bears) and step up onto
initially randomly assigned to either the intervention (MTrP a raised platform (dominant leg leads).
therapy) or the control group (no intervention). Each par-
ticipant was allocated to both the intervention and control
Identification of gastrocnemius and soleus MTrPs
group a week apart, therefore each individual participant
served as their own control.
The triceps surae were palpated for the presence of latent
MTrPs at four sites, previously identified in the literature by
Travell and Simons (1992). As identified in Fig. 2, gastro-
Randomisation cnemius MTrPs 3 & 4 and Soleus MTrPs 1 & 2 sites were
examined, as these are the more common and symptomatic
Block randomisation, utilising an online randomisation tool triceps surae MTrPs (Travell and Simons, 1992). Each par-
‘Research Randomizer’ http://www.randomizer.org ticipant lay prone, the knee was flexed to 90 and the lower
(Urbaniak and Plous, 2009). The randomiser ensured each leg supported by the researcher for the identification of
group appeared an equal number of times whilst simulta- soleus MTrPs and extended for the gastrocnemius. For the
neously randomly allocating participants to each group. identification of all MTrPs, the potential MTrP sites were
palpated with the pad of the fingers and/or thumb (flat
palpation). All identified gastrocnemius and soleus MTrPs
Screening Stage 1: were marked on the participant’s skin as a cross for future
TrP pressure release in the intervention group (Fig. 2).
Exclusion criteria The 4 essential diagnostic criteria for identifying a latent
Excluded if any exclusion
criteria exhibited or active trigger point were based on the following physical
Screening Stage 2:
signs and symptoms (Simons et al., 1999);

Identification of restricted active

ankle dorsiflexion ROM(≤10º)in 1. A palpable taut band within the skeletal muscle
Excluded with >10° active ankle
either the gastrocnemius or soleus
dorsiflexion both gastrocnemius
2. A hypersensitive tender spot/nodule within a taut band
and soleus 3. Recognition of current pain complaint by pressure on
Screening Stage 3: the tender nodule
Identification of ≥1 soleus MTrPs in 4. Painful limit to full stretch range of motion
the limb with restricted ankle
dorsiflexion Excluded if latent MTrPs not
identified in both the gastrocnemius As inclusion into this study included reduced ankle ROM,
and soleus
for positive identification of a MTrP, at least 2 or more of
the above essential diagnostic criteria were present on
Randomised Group Assignment
examination. If no MTrPs were found in both the gastro-
cnemius and soleus the potential participant was excluded
from the study. The researcher responsible for

Intervention Group Control Group

Intervention Group Control Group

Outcome Measure:
Post-test active ankle
dorsiflexion ROM

Figure 2 Four MTrP sites marked in both the gastrocnemius

Figure 1 Flow diagram of procedure. and soleus.
456 R. Grieve et al.

MTrP identification attended MTrP training with a clini-

cian experienced in MTrP clinical practice, as a training
period for identification of MTrPs is essential to achieve
accurate and reliable results (Gerwin et al., 1997).

Outcome measures

Ankle dorsiflexion measurement

Active ankle dorsiflexion ROM was the main outcome
measure for this RCT. Three measurements were taken to
calculate a mean ROM using a two-armed, 360 plastic
goniometer (Baseline). Each participant was positioned in
prone lying with a 90 knee bend to determine a restriction
purely in soleus and then measured with the knee in Figure 4 TrP pressure release technique to the medial head
extension for a gastrocnemius restriction (Root et al., 1977; of gastrocnemius.
Petty, 2005).
The participant was asked to actively maximally dorsiflex
the barrier release concept (Lewit, 1999). The researcher
their ankle and measurements were taken from plantargrade
slowly applied an increasing thumb pressure directly over
(0 ) (Rome, 1996). If unable to reach plantargrade, then
the marked gastrocnemius and soleus MTrP site (Fig. 4) until
the measurement was taken from the degree of range
the first instance of tissue resistance (barrier) was felt. This
available and recorded as a negative value. In order to isolate
point was usually perceived as tender but not painful to the
saggittal plane ankle joint dorsiflexion ROM, goniometric
participant, this pressure was maintained until the
measurements were taken in an open chain position (Lang
researcher felt a release in muscle tension underneath the
et al., 1997).
palpating thumb.
The position of the goniometer is illustrated in Fig. 3 and
The participant was positioned in prone with the leg in
followed the landmark guidelines suggested by Norkin and
full extension, as this TrP pressure release is claimed to be
White (2003), namely: the fulcrum of the goniometer is
more effective when executed with the muscle in
aligned with the lateral malleolus, proximal arm of the
a lengthened position (Simons et al., 1999).
goniometer aligned with the fibula and the distal arm
Post TrP pressure release, a 1  10 s passive stretch in
adjacent to the lateral aspect of the 5th metatarsal. The
both knee flexion and extension (Fig. 5) was performed.
Norkin and White (2003) protocol was followed, as clinical
This process was repeated until all identified MTrPs had
judgement based on ankle dorsiflexion goniometric changes
been de-activated within the allotted 10 min intervention
of less than 10 are invalid if rigid protocols are not fol-
time allowance.
lowed (Rome and Cowieson, 1996). One researcher took all
three goniometric measurements pre and post inter-
vention/control to increase intra-rater reliability limiting Intervention group
random errors within the results (Johnson and Closs, 2006).
The researcher was also blinded to the group allocation of The Intervention procedure consisted of; baseline active
each participant. ROM measurements, followed by 10 min of TrP pressure
release treatment to the identified MTrPs in the Gastro-
MTrP therapy cnemius and Soleus, followed by 1  10 s passive stretch in
both knee flexion and extension. Finally the same baseline
TrP pressure release was performed according to the active ROM measurements were re-measured. The
techniques described by Simons et al. (1999), and employed researcher undertaking MTrP therapy was blind to the re-
sults of the pre- and post-intervention goniometric ankle
ROM measurements.

Figure 3 Goniometer position to measure active ankle dor- Figure 5 Passive stretch of gastrocnemius post TrP pressure
siflexion (Adapted from Norkin and White, 2003). release.
Triceps surae trigger points and restricted ankle joint dorsiflexion 457

Control group 24.5; 8.7). During the screening process 8 potential par-
ticipants were excluded as they did not meet the inclusion
Participants in this group received no intervention or sham criteria.
therapy, but followed the same procedure as those of the The descriptive data for the pre- and post-ROM mea-
intervention group. The control procedure consisted of; surements, for the intervention and control groups are
baseline active ROM measurements, followed by 10 min of presented in Table 1. The mean ankle pre intervention ROM
supervised rest, with the same active ROM re-measured fol- for the Soleus is (>10 ), whereas in the gastrocnemius the
lowing rest. The control procedure replicated the conditions pre intervention ROM is (<10 ). The mean ankle ROM value
of the intervention group, which enabled the concealment of in the soleus intervention group increased to 4 from pre-
group allocation from the researcher administering the pre and post-ROM measurements compared to 1 in the control
and post treatment ankle dorsiflexion ROM. group. The mean ankle ROM value in the gastrocnemius
intervention group increased to 3 from pre- and post-ROM
Data analysis measurements compared to 1 in the control group. The
individual ankle dorsiflexion ROM scores pre- and post-MTrP
Data were analysed with SPSS version 19.0 (IBM SPSS). A therapy in the intervention group is displayed in Table 2.
sample size calculation was performed using Power and A paired samples t-test showed a statistically significant
Precision software (Biostat) on the output from the Grieve increase in ankle dorsiflexion ROM for soleus in the inter-
et al. (2011) pilot RCT; standard deviations (SD) of the vention compared to the control group (t Z 3.25, df Z 21,
difference pre and post intervention (3.5); 1 group sample p Z 0.004) multivariate partial Eta Squared Z 0.33. A paired
paired t-tests; a Z 0.05; using 80% power and a clinical samples t-test showed a statistically significant increase in
effect of 3 increase in ankle ROM. Data analysis was con- ankle dorsiflexion ROM for gastrocnemius in the intervention
ducted at a 95% confidence interval (CI) and a probability compared to the control group (t Z 32.40, df Z 21,
(p) value of <0.5 was considered statistically significant. p Z 0.026) multivariate partial Eta Squared Z 0.22. The Eta
Descriptive data for the group characteristics were calcu- Squared statistic of 0.33 and 0.22 indicating a large effect
lated (gender; age) including the mean values and SD for size (Cohen, 1988). The sample size calculation found that
the pre- and post-ROM data in both groups. The mean a minimum of 11 participants per group was required to
change in ankle ROM between the pre- and post- detect a significant increase in ankle ROM.
measurements for both groups was calculated. The ROM
pre- and post-data for both the experimental and control
Discussion
group was normally distributed (Shapiro Wilk test, p > 0.05)
and met the criteria for parametric testing. The paired t-
test was used for one sample repeated measures to analyse The results of this study demonstrate a statistically signif-
statistical significance between the intervention and con- icant change in ankle dorsiflexion ROM immediately post
trol conditions, as the crossover RCT design ensured that MTrP therapy to the triceps surae of recreational runners.
the same participants were allocated to both the control Statistical significance however does not take into consid-
and intervention groups. The guidelines proposed by Cohen eration information about the strength of the relationship
(1988, pp. 284e7) for interpreting the ETA squared statistic (effect size) and whether the relationship is clinically
for the paired t-test effect size are 0.01e0.05 Z small meaningful or important (Kraemer et al., 2003; Gemmell
effect; 0.06e0.13 Z moderate effect and greater than et al., 2008).
0.14 Z large effect (Pallant, 2010). After a single course of MTrP therapy an immediate
mean ankle dorsiflexion ROM increase of 4 with the knee
flexed (soleus MTrPs) and 3 with the knee extended (gas-
Results trocnemius MTrPs) was measured by goniometry. Clinicians
using goniometric ROM outcome measures should only as-
Twenty-two volunteers were recruited for the study sume that a real clinical change in ankle dorsiflexion ROM
(11 females and 11 males; range 18e50; mean age has occurred when there has been a ROM change of more
than 5 (Croxford et al., 1998). Gait laboratory data how-
ever, demonstrate that foot clearance is sensitive to small
Table 1 Descriptive data for pre- and post-mean ankle angular changes (2.07 ) at the ankle (Winter, 1992). As
dorsiflexion ROM scores, SD for each group and the mean the overall treatment effect in the intervention group was
ROM change in the pre- and post-intervention or control an immediate increased ankle ROM of 4 (soleus) and 3
group. (gastrocnemius) this may be clinically important informa-
Pre Post Change tion. Foot clearance (as the foot swings through during the
ROM ( ) swing phase of gait) was not identified as a problem in this
Mean ( ) SD Mean ( ) SD RCT although for runners this may be an issue on uneven
Intervention soleus 11 4.3 15 4.3 4 terrain in trail or fell running. Further clinical significance
Intervention 7 2.6 10 3.3 3 of MTrP therapy on immediate ankle dorsiflxion is achieved
gastrocnemius by reviewing individual instead of group mean scores. For
Control soleus 12 3.8 13 4.0 1 ankle dorsiflexion ROM for the soleus (knee flexed), eight
Control 7 2.3 8 2.9 1 participants showed an immediate increase of 5 or more,
gastrocnemius with three participants showing immediate ROM increases
post MTrP therapy of 7 , 9 and 10 respectively. For ankle
458 R. Grieve et al.

Table 2 The individual ankle dorsiflexion ROM scores pre- and post-MTrP therapy and change in ROM in the intervention group.
Participant Ankle df (ROM) soleus Ankle df (ROM) gastrocnemius
 
Pre intervention( ) Post intervention( ) Change Pre intervention( ) Post intervention( ) Change
ROM( ) ROM( )
1 20 25 5 13 15 2
2 15 16 1 4 5 1
3 17 17 0 9 9 0
4 15 17 2 6 12 6
5 9 13 4 7 7 0
6 6 8 2 1 4 3
7 9 14 5 4 7 3
8 8 15 7 8 12 4
9 5 9 4 7 6 1
10 13 14 1 9 12 3
11 7 10 3 5 6 1
12 13 16 3 6 11 5
13 9 19 10 8 13 5
14 16 17 1 9 15 6
15 5 14 9 5 9 4
16 10 15 5 8 13 5
17 16 20 4 8 11 3
18 13 19 6 10 12 2
19 10 13 3 5 11 6
20 12 17 5 5 10 5
21 15 18 3 9 11 2
22 7 7 0 4 4 0
Mean ROM( ) 11 15 4 7 10 3

dorsiflexion ROM for the gastrocnemius (knee extended), recruited. Grieve et al. (2011) used a parallel group RCT
seven participants showed an immediate increase of 5 or design, whereas this current trial had a crossover study
more, with two participants showing a ROM increases post design, with each participant receiving both the inter-
MTrP therapy of 6 . vention and control condition, which may prevent con-
A review of the literature indicates that this may be the founding variables influencing the outcome of results
first study that has specifically analysed the effects of TrP (Bahrke, 2002).
pressure release of the triceps surae on restricted ankle Two case studies have also examined TrP pressure
dorsiflexion ROM. This study evolves from the Grieve et al. release in the lower limb with ROM as an outcome measure;
(2011) pilot RCT that investigated the immediate effect of one for reduced ankle ROM (Wu et al., 2005) and the other
soleus TrP pressure release compared to a control group in for hamstring dysfunction (Grieve, 2006). Wu et al. (2005)
patients with restricted ankle joint dorsiflexion. This cur- analysed the gait of a woman suffering from MPS and
rent study, also investigated the combined effect of TrP chronic calf tightness. Following an 8 week treatment
pressure release and a 10 s passive stretch on both the programme of TrP pressure release, transverse friction
soleus and gastrocnemius, whereas Grieve et al. (2011), massage and proprioceptive neuromuscular facilitation
demonstrated that a single treatment of TrP pressure stretches to the gastrocnemius, there were significant im-
release to the soleus had a statistically significant imme- provements in ankle dorsiflexion ROM of the affected limb
diate effect on restricted active ankle dorsiflexion. The Wu et al. (2005). These findings are of clinical relevance as
findings of this study are similar to Grieve et al. (2011) in ankle dorsiflexion improved from 10 (pre intervention) to
that a moderate to high treatment effect size was estab- 18 (post intervention). A patient presenting with a proxi-
lished in the intervention group, suggesting that the results mal hamstring rupture and a chronic restriction in ankle
were clinically meaningful. dorsiflexion, showed an immediate increase in dorsiflexion
A key limitation of Grieve et al. (2011), was that the from a value of 0 e10 after an application of TrP pressure
sample (n Z 20) was predominantly female (n Z 15), release and a passive stretch (Grieve, 2006). Following four
thereby reducing the external validity. Females have sessions the patient regained full ankle ROM and long-term
a larger ankle ROM than men due to differences in viscoe- efficacy of the intervention was supported on follow-up 7
lastic properties of the Achilles tendon (Kato et al., 2005) months later.
and a possibly higher prevalence of MPS and MTrPs (Sola A case series/study may have methodological limitations
et al., 1955; Drewes and Jennun, 1995). In this current with regard to making causal inferences about the rela-
study, the influence of gender as a confounding factor was tionship between treatment and outcome; however it may
reduced as equal numbers of men to woman were be helpful in generating a hypothesis to be tested in further
Triceps surae trigger points and restricted ankle joint dorsiflexion 459

analytical studies (Brighton et al., 2003). A case study may goniometer measurements. Apart from measurement bias,
act as a foundation and alert researchers and health care the combined MTrP approach although commonly used in
professionals to critically important trends (Chaitow, 2006), clinical practice may be a confounding factor. In this current
as demonstrated in this study. study the overall effect cannot be attributed to a single
The following authors have utilised ROM as an outcome treatment method as either one of the manual techniques
measure in the management of MTrPs (Hanten et al., 2000; (TrP pressure release or passive stretch) may have produced
Hou et al., 2002; Fernandez de las Penas et al., 2004; the results independently.
Blanco et al., 2006; Chatchawan et al., 2005; Gemmell Apart from the above limitations the researchers
et al., 2008; Buttagat et al., 2011; Bron et al., 2011). involved in this study followed clear protocols and
Although none of these studies have focussed on the lower attempted to ensure internal validity by reducing bias
limb, between them they have investigated the efficacy of through randomisation (initial intervention and control
TrP pressure release, post-isometric relaxation technique groups allocation) and blinding (researchers measuring
and massage. This study utilised a MTrP therapy approach ankle dorsiflexion blinded to group allocation/intervention
often used in clinical practice that comprises a TrP pressure and goniometric ROM scores). The above attempt to ensure
technique and post passive stretch. TrP pressure release internal validity is in stark contrast to the findings of an SLR
has been advised with a passive stretch of the muscle in on the reliability of physical examination for MTrP diagnosis
order to seek maximal improvements of ROM (Trampas (Lucas et al., 2009). The majority of the studies reviewed
et al., 2010). Apart from ROM, compression followed by by Lucas et al. (2009) did not report important methodo-
sustained stretching is effective in reducing MTrPs sensi- logical quality aspects such as blinding of the raters to
tivity and pain intensity (Hanten et al., 2000). Short term clinical information or randomisation during the examina-
improvement in both physical function and pressure pain tion process.
thresholds (PPT) was achieved when TrP pressure release
was combined with a self stretching protocol compared to
stretching alone in patients with plantar heel pain (Renan- Conclusion
Ordine et al., 2011).
This study has further added to the evidence concerning
the immediate effectiveness and resultant clinical impli-
Limitations and methodological considerations cations of the MTrP approach in increasing restricted ankle
dorsiflexion ROM. The findings suggest that a possible
The RCT crossover research design may have influenced treatment method for runners and non runners with
a higher mean dorsiflexion ROM increase in the control reduced ankle dorsiflexion could be the MTrP therapy
group due to carry-over effects from the intervention approach. Importantly the findings of this study should be
condition. To reduce the effects of this carry-over a wash interpreted with caution as a number of limitations and
out period of seven days between the control and inter- methodological constraints have been identified.
vention (or two treatments) has been recommended to Further recommendations for future research in this
limit the effect of the initial intervention (Machin et al., area would include a comparison between active stretching
2006). This study used a seven day was out period which and TrP pressure release alone or in combination with
did not appear long enough therefore a longer wash out a passive stretch as used in this study.
period is recommended for future studies using a MTrP
intervention and a crossover design.
Researcher experience may also affect the identification Acknowledgements
and treatment of MTrPs as clinicians with greater experi-
ence in the identification and treatment of MTrPs produce The authors would like to thank Dr. Shea Palmer (University
more reliable results (Gerwin et al., 1997; Majlesi and of the West of England) for statistical advice.
Unalan, 2010). The researcher’s involved in MTrP identifi-
cation and therapy attended a specific training seminar and
had been taught about the subject at undergraduate level. References
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10 years MTrP experience, as final year sports therapy and Bahrke, M.S., 2002. Performance-enhancing Substances in Sport
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clinical expertise and experience in MTrP assessment and Blanco, C.R., Fernandez de las Penas, C.F., Xumet, J.E.,
treatment. The use of a student clinician for data collection Algaba, C.P., Rabadan, M.F., de la Quintana, M.C., 2006.
with insufficient examination procedure practice may be Changes in active mouth opening following a single treatment of
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