Journal of Manual & Manipulative Therapy, 2018

VOL. 26, NO. 2, 55–65

https://doi.org/10.1080/10669817.2017.1322736

REVIEW

Does manual therapy improve pain and function in patients with plantar
fasciitis? A systematic review
John J. Frasera,b  , Revay Corbetta, Chris Donnerc and Jay Hertela 
a
Department of Kinesiology, University of Virginia, Charlottesville, VA, USA; bUS Navy Medicine Professional Development Center, Bethesda,
MD, USA; cAthletics Program, Lindsey Wilson College, Columbia, KY, USA

ABSTRACT KEYWORDS
Objective: To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients Mobilization; manipulation;
improves pain and function more effectively than other interventions. heel pain; soft tissue;
Methods: A systematic review of all randomized control trials (RCTs) investigating the effects aponeurosis; plantar fascia
of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in
English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research
quality was appraised utilizing the PEDro scale. Cohen’s d effect sizes (ES) and associated 95%
confidence intervals (CI) were calculated between treatment groups.
Results: Seven RCTs were selected that employed MT as a primary independent variable and pain
and function as dependent variables. Inclusion of MT in treatment yielded greater improvement
in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5–21.5) and
algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7–3.0) from 4 weeks
to 6 months when compared to interventions such as stretching, strengthening, or modalities.
Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies
(3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions.
Discussion: MT is clearly associated with improved function and may be associated with pain
reduction in PF patients. It is recommended that clinicians consider use of both joint and soft
tissue mobilization techniques in conjunction with stretching and strengthening when treating
patients with PF.
Level of Evidence: Treatment, level 1a.

Introduction same diagnostic umbrella. Evidence suggests that intrin-

sic and extrinsic risk factors, both modifiable and non-
Plantar heel pain is a common musculoskeletal com-
modifiable, influence the outcome of PF [12,13]. These
plaint that affects an estimated 1–2 million people per
elements consist of factors such as prolonged standing,
year in the United States (US)[1–3] and approximately
inappropriate footwear, previous injury, limited dorsi-
10% of the population at some point during their lives
[4]. Among the potential etiologies of plantar heel pain, flexion of the ankle, hyperpronation of the foot, weak
plantar fasciitis (PF) is the most common [5–7]. PF is a calf musculature, aging, and increased Body Mass Index
clinical condition marked with complaints of sharp pain [12,13]. Alteration of ankle-foot biomechanics resulting
in the heel starting from the medial border of the plantar from soft tissue or joint limitation is postulated to con-
fascia continuing to its insertion at the medial tuberosity tribute to the development of PF [7,14–16] and may be
of the calcaneus. Pain is often provoked with loading and remedied from treatments such as manual therapy (MT).
with the initial few steps following periods of inactivity, More than 1 million ambulatory patient care visits
such as rising from sleep in morning, and often increase are made annually for assessment and treatment of
toward the end of the day [5,7,8]. PF in the US [3,17]. It is important for clinicians to be
The symptoms associated with PF are frequently able to treat these patients comprehensively using
attributed to inflammation of the plantar fascia. Other evidence-based interventions. Recommendations for
evidence has suggested an alternative mechanism to using MT, such as soft tissue mobilization and joint mobi-
the onset of PF [9]. In plantar fasciosis, degenerative lization or manipulation, in conservative treatment have
changes and microscopic tearing [9] may lead to thick- recently been reported. In a 2008 clinical practice guide-
ening of the plantar fascia [10,11]. For this manuscript, line (CPG) put forth by the Orthopaedic Section of the
PF and plantar fasciosis will be encompassed under the American Physical Therapy Association, MT received a

CONTACT  John J. Fraser  jjf5ac@virginia.edu

This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government. In
accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.
56   J. J. FRASER ET AL.

Figure 1. Study selection process and search results with outcome measures of concern.

recommendation grading of ‘E,’ indicating theoretical or and Web of Science databases utilizing the search
foundational evidence to support the use of this inter- terms: ((groups[TIAB] OR trial[TIAB]) OR randomly[TIAB]
vention in the treatment of PF patients [18]. In just 6 OR placebo[TIAB] OR randomized[TIAB] OR Controlled
years, the updated and most recent CPG published in clinical trial[pt] OR Randomized controlled trial[pt]) AND
2014 now recommends MT in the care of PF patients (((((‘Fasciitis’[Mesh] AND ‘Foot Diseases’[Mesh]) OR (‘planter
with a grade of ‘A,’ indicating a strong recommendation fasciitis’[All Fields] OR ‘plantar fasciosis’[All Fields] OR
based on a multitude of level I and II studies in the liter- ‘Fasciitis, Plantar’[Mesh] OR plantar fascia[text word] OR
ature [19]. Utilization of MT by physical therapists in the plantar fasciae[text word] OR plantar fascias[text word]
care of patients with PF has progressively increased in OR plantar fasciopathy[text word] OR plantar fascitis[text
recent years and appears to result in decreased cost and word]) OR (calcaneodynia[text word] OR ‘calcaneal per-
length of care [3]. The mechanism of effectiveness of MT iostitis’[text word] OR enthesopathy[text word] OR ‘heel
is multifactorial and encompasses mechanical, neuro- spur’[text word])) OR ((pain[text word] OR inflammation
physiological, and psycho-emotional effects [20], all of [text word] OR inflammatory[text word] OR inflame[text
which may benefit patients with PF. Despite growth of word] OR inflamed[text word]) AND (plantar[text word] OR
evidence for the use of MT in the care of patients with PF, (heel[text word] OR heels[text word]) OR foot[text word] OR
the authors are unaware of any systematic reviews that feet[text word] OR arch[text word] OR arches[text word])))
have compared MT to other interventions in this patient AND ((manual[tw] OR physical[tw] OR manipulate[tw]
population. The purpose of this systematic review was OR manipulation[tw] AND therapy[tw] OR therapies[tw]
to compare randomized control trials (RCTs) of MT, to OR therapeutic[tw] OR physiotherapy[tw]) OR ((joint
include soft tissue mobilization and joint mobilization [text word] OR mobility[text word] OR mobile[text word]
or manipulation, with control interventions on the out- OR mobilization[text word] OR ‘joints’[MeSH Terms] OR
comes of patient-reported pain, patient-reported func- ‘joints’[All Fields] OR soft tissue[tw]) AND (manipulate[tw]
tion, and pressure-pain thresholds (PPT) measured by OR manipulation[tw])))) AND ‘humans’[MeSH Terms]) AND
algometry in patients with PF. English[lang].

Methods Study selection criteria

This systematic review was registered in PROSPERO Studies were included if they were an RCT that employed
(CRD42016038379) and can be accessed at https://goo. a form of MT in the experimental group for the treatment
gl/f296V2. of patients with PF. Inclusion criteria was non-specific for
the treatment setting, the type of MT utilized, the disci-
pline of the treating clinician, or the comparison inter-
Search strategy
vention utilized in the design. MT interventions, which
A medical research librarian assisted in the development included both soft tissue mobilization and joint mobiliza-
of a systematic search of PubMed, CINAHL, Cochrane, tion or manipulation, were often employed conjunctively
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY   57

with another treatment such as self-stretching exercises. Patient-reported pain

To be included in this review, MT had to be a focal inde-
Six studies reported patient-reported pain as an out-
pendent variable in the study design. Outcome measures
come [23–26,28,29]. Of these studies, two utilized the
of interest included patient-reported pain, PPT during
visual analog scale (VAS) [26,28], three utilized the
algometric testing, and patient self-reported function. In
Numeric Pain Rating Scale (NPRS) [23,24,29], and one
the case of studies that did not provide statistical meas-
utilized the Bodily Pain subscale of the SF-36 [25] to
ures of mean and variance, the corresponding author
assess patient-reported pain. ES point estimates and the
was contacted. Studies were excluded if the correspond-
associated 95% CI for comparisons of treatment effect on
ing author was unable to provide this information. See
patient-reported pain are illustrated in Figure 2. With the
Figure 1 for details of the study selection process.
exception of three studies [25,28,29], there were no con-
clusive differences in patient-reported pain between MT
Assessment of methodological quality and the comparison groups at 2 weeks through 6 months
post treatment. A large and conclusive ES favoring MT
The methodological quality of the included studies was
and routine care (consisting of stretching, strengthening,
assessed using the PEDro scale, a 10 item assessment of
and ultrasound) over routine care alone for the NPRS at
quality of RCTs, with a score of 10 representative of the
3 and 6 week time points [29]. Patients who received
highest quality study and 0 representative of the lowest
MT, in addition to self-stretching, demonstrated moder-
[21]. Three of the authors scored the included studies
ate ES with 95% CI that did not cross zero on the SF-36
independently and came to a consensus on the final
Bodily Pain subscale at 4 weeks post treatment [25]. In
PEDro score for each study. In the event a consensus
a comparison of corticosteroid injection with Grade I-II
could not be achieved, the fourth and most senior author
joint mobilizations and calf and plantar fascia stretching,
would independently make the final determination of
patients who received the injection had better outcomes,
quality for the disputed study.
as demonstrated by large ES, at 3 weeks, 6 weeks, and 3
month time points, but fared no better at 12 months [28].
Data extraction and statistical analysis
Study design, sample population, setting, experimen- Algometry
tal and comparison interventions, and group means
Three studies reported algometric PPT as an outcome
and standard deviations for patient-reported pain and
[23,25,27]. Of these studies, one utilized the location of
function and algometric PPT were extracted for each
the most tender spot on the plantar foot to assess the
reported time point in the included studies (Table 1).
PPT [23]. The other two studies utilized three standard-
Post-intervention means and standard deviations were
ized points on gastrocnemius, soleus, and the posterior
calculated for studies that reported baseline means,
calcaneus to assess PPT [25,27]. The details of the subject
pre-post change scores, and variance. Statistical analy-
characteristics, treatment rendered, and assessment time
sis was performed by calculating Cohen’s d effect sizes
points are summarized in Table 1. ES point estimates and
(ES) and associated 95% confidence intervals (CI) [22]. ES
95% CI for comparisons of PPT are illustrated in Figure
were interpreted using the scheme proposed by Cohen
4. When assessed with algometry, patients treated with
[22]:<0.2 equates to a trivial ES, 0.2–0.49 small, 0.5–0.79
MT had conclusively better outcomes than controls
moderate, and ≥0.8 large. When the ES point estimates
at 4 weeks and 3 months with large ES in two studies
and 95% CI were plotted, the treatment effect was inter-
[25,27], but were equivalent at 4 weeks in the third study
preted as being conclusively advantageous over the
[23]. The trend of the ES point estimates for algometry
other when the 95% CI did not cross zero. Meta-analysis
appears to favor groups treated with MT.
was not performed due to the heterogeneity of MT and
comparison interventions and outcome measures used
across the reviewed studies. Patient-reported function
Seven studies reported patient-reported function as
Results an outcome [23–29]. Of these, three studies utilized
the Lower Extremity Functional Scale (LEFS) [23,24,29],
Our search strategy yielded seven RCTs [23–29] that com-
three utilized the Foot and Ankle Ability Measure (FAAM)
pared MT interventions to comparative interventions.
[24,28,29], one utilized the functional subscales of the
The details of the subject characteristics, treatment ren-
SF-36 [25], one utilized the Functional Scale derived from
dered, and assessment time points are summarized in
Foot & Ankle Computerized Adaptive Test (FS) [26], and
Table 1. Details of the methodological quality assessment
one utilized the Foot Function Index (FFI) [27] to assess
are provided in Table 2. PEDro scores for the included
patient-reported function. The details of the subject
studies ranged from 6 to 9. The most common PEDro
characteristics, treatment rendered, and assessment time
items that were not addressed involved blinding of the
points are summarized in Table 1. ES point estimates and
patient or the treating clinician.
 58 

Table 1. Characteristics of the seven Randomized Control Trials (RCT) comparing manual therapeutic interventions with control interventions in patients with plantar fasciitis.

Author Year Outcomes and assess- PEDRO

Design Sample population Inclusion criteria Groups/intervention Experimental mean, SD Control mean, SD ment time points score
Ajimsha 2013 Adults (n = 67; 49 Insidious onset of sharp pain under Manual therapy group (n = 33): FFI: BL 63.01 ± 4.44 FFI: BL 61.38 ± 5.22 4wks FFI, Algometry: 4wks, 9
RCT females/17 males) with the plantar heel surface upon Myofascial release of the gastroc- 4wks17.39 ± 4.02 12wks 56.85 ± 6.91 12wks 60.15 ± 8.11 12wks
unilateral heel pain weight bearing after a period nemius (gastroc) X 5-min, soleus X 24.81 ± 3.98
treated at a nonprofit of non- weight bearing, Plantar 5-min, plantar fascia 2 X 5-min, 3/wk
 J. J. FRASER ET AL.

research foundation heel pain that increases in the X 4-wks

clinic morning with the first steps Control group (n = 32): Sham ultra- PPT: Gastroc BL 1.8 ± 0.44 4wks PPT: Gastroc BL 2.0 ± 0.22 4wks
after waking up, and symptoms sound 2.9 ± 0.82 12wks 2.6 ± 0.54 2.2 ± 0.51 12wks2.1 ± 0.32 Sole-
decreasing with slight levels of Soleus BL 2.0 ± 0.48 4wks us BL 2.2 ± 0.52 4wks 2.2 ± 0.31
activity 3.1 ± 0.91 12wks 2.7 ± 0.65 12wks 2.1 ± 0.72 Calcaneus BL
Calcaneus BL 2.1 ± 0.38 2.3 ± 0.77 4wks 2.5 ± 0.67 12wks
4wks3.4 ± 0.95 12wks 2.4 ± 0.48
3.1 ± 0.78
Celik 2015 RCT Adults (n = 43; 23 females, Patients with a point of maximal Manual therapy group (n = 19): Grade I VAS: BL 7.8 (1.6), 3wk 5.4 (2.8), VAS: BL 7.7 (1.5), 3wk 1.8 (2.1), 6wk VAS, FAAM; 3wks, 6wks, 7
20 males) with PF treated tenderness on clinical examina- & II subtalar traction and lateral glide; 6wk 5.0 (2.3), 12wk 4.9 (2.4) 1.2 (1.4), 12wk 1.5 (1.9) 12mo 3mos, 12 mos
in an ortho and trauma tion over the medial tubercle of talocrural post glide; 1st TMT dorsal 12mo 2.7 (3.2) 3.3 (3.2)
clinic the calcaneus, pain with palpa- glide; gastroc and plantar fascia
tion of the proximal insertion stretching 3/wk X 3-wks
of the plantar fascia, heel pain Injection group (n = 20): Administered FAAM: BL 55.2 (18.4), 3wk 60.6 FAAM: BL 45.5 (17.6), 3wk 80.7
during weight-bearing activity, a 1 cc 40 mg methyl-prednisolone & (14.4), 6wk 70.2 (17.5), 12wk (19.4), 6wk 85.7 (11.2), 12wk
negative tarsal tunnel test, and a 4 mL 2% prilocaine to the PF 69.4 (16.8), 12mo 86.7 (21.9) 83.5 (14.6), 12mo 83.4 (17.3)
positive windlass test
Cleland 2009 Adults (n = 60; 42 females, Heel pain, LEFS ≤ 65 Manual therapy group (n = 30): Soft tis- NPRS: BL: 4.8 (1.9) Mean change NPRS: BL: 4.6 (1.6) Mean change NPRS, LEFS, FAAM; 8
RCT 18 males) with primary sue mobilization of triceps surae and (CI) 4wks: −1.4 (−0.8, −2.2) (CI) 4wks: −1.4 (−0.8, −2.2) 6wks: 4wks, 6mos
heel pain in 2 outpt plantar fascia, foot X 5-min, Grade 6wks: −2.8 (−1.9, −3.7) −2.8 (−1.9, −3.7)
ortho clinics III-V ankle, knee, hip mobilizations as
needed) and exercise 2/wk X 2-wks
1/wk X 2wks
Control group (n = 30): Electrophysio- LEFS: BL: 47.8 (14.3) Mean LEFS: BL: 51.1 (10.8) Mean
logical agents and exercise change (CI) 4wks: 21.0 (15.1, change (CI) 4wks: 7.5 (3.1, 12.0)
26.9) 6wks:22.8 (15.6, 30.1) 6wks:12.9 (7.8, 18)
FAAM: 57.2 (16.4) Mean change FAAM: 57.3 (12.2) Mean change
(CI) 4wks: 22.2 (15.1, 29.4) (CI) 4wks: 8.9 (3.6, 14.3) 6wks:
6wks: 31.6 (22.2, 41.1) 17.9 (12.9, 23.1)
Ghafoor 2016 Adults (n = 60; 48 females, Diagnosis of plantar fasciitis, Manual therapy group (n = 30): Soft NPRS: BL: 5.1 (1.3) Mean change NPRS: BL: 4.8 (1.7) Mean change NPRS, LEFS, FAAM; 6
RCT 12 males) referred from LEFS ≤ 65 tissue mobilization of triceps surae 3wks: 1.9 (0.2), 6wks: 3.5 (0.1) 3wks: 0.4 (0.2), 6wks: 1.6 (0.2) 3wks, 6wks
orthopedics with plantar and plantar fascia, Gr II & IV rearfoot
heel pain mobilizations X 5-min, strengthen-
ing, stretching, ultrasound X 8-visits FAAM: BL: 54.4 (3.0) Mean FAAM: BL: 54.0 (5.0) Mean change
change 3wks: 15.1 (0.7), 6wks: 3wks: 1.8 (1.2), 6wks: 6.2 (1.2)
26.6 (0.6)
Control group (n = 30): Strengthening, LEFS: BL: 54.9 (6.2) Mean LEFS: BL: 50.1 (4.7) Mean change
stretching, ultrasound change 3wks: 11.7 (0.9), 6wks: 3wks: 1.5 (0.8), 6wks: 9.3 (0.8)
17.0 (0.9)
Renan-Ordine Adults (n = 60; 45 Primary report of unilateral plantar Manual therapy group (n = 30): Trigger PF: BL 44.3 ± 16.86 4wks PF: BL 41.2 ± 16.2 4wks 52.8 ± 19.4 Physical function and 6
2011 RCT females/15 males) with heel pain of insidious onset, point manual therapy to gastroc 3 X 65.2 ± 12.2 Mean Change Mean Change 11.6 (CI 8, 15) bodily pain domains
a dx of plantar heel pain sharp pain under the plantar 90-s, self-stretching protocol, 4/wk 20.9 (CI16.5, 25.2) of the SF-36 ques-
treated in a PT clinic heel surface upon weight bear- X 4-wks tionnaire; Algometry:
ing after a period of non-weight Baseline, 4wks
bearing, pain that increases in
the morning with the first steps
after waking up and symptoms
decreasing with slight levels of
activity
PR: BL 30.3 ± 31.6 4wks PR: BL 29.6 ± 34.7 4wks 50.9 ± 32.9
63.5 ± 27.63 Mean Change Mean Change 21.3 (CI 8.2, 34.3)
3.2 (CI 22.2, 44.1)
BP: BL 35.3 ± 18.25 4wks BP: BL 31.7 ± 18.4 4wks 44.7 ± 17.5
56.1 ± 13.8 Mean Change Mean Change 13 (CI 9.4, 16.5)
20.8 (CI 16.6, 25.0)
GH: BL 54.6 ± 17.3 4wks GH: BL 54.1 ± 15.9 4wks
60.8 ± 12.2 Mean Change 6.2 54.9 ± 16.2 Mean Change .8
(CI 2.1, 10.3) (−2.6, 4.2)
Vit: BL 1.1 ± 18.4 4wks Vit: BL 36.5 ± 18.5 4wks 44.1 ± 19
52.1 ± 15.7 Mean Change Mean Change 7.6 (3.7, 11.4)
11.0 (CI 2.7, 13.3)
Control group (n=30): Instruction in in SF: BL 52.7 ± 24.6 4wks SF: BL 46.2 ± 28.5 4wks 57 ± 17.8
a self-stretching protocol 68.3 ± 18.8 Mean Change Mean Change 10.8 (2.9, 18.6)
15.6 (CI 9.2, 22.0)
ER: BL 47.6 ± 36.7 4wks ER: BL 40.8 ± 39.6 4wks 51.9 ± 32.5
78.6 ± 27.5 Mean Change Mean Change 11.1 (0.8, 21.5)
31.0 (CI 18.3, 43.6)
MH: BL 55.3 ± 18.0 4wks MH: BL 51.1 ± 25.7 4wks
62.0 ± 19.8 Mean Change 6.7 60.1 ± 22.2 Mean Change 9 (3.3,
(CI 1.2, 12.3) 14.9)
Algometry: Gastrocnemius Algometry: Gastrocnemius BL:
BL: 1.3 ± 0.5 4wks 2.7 ± 0.6; 1.8 ± 0.7 4wks 2.3 ± 0.5; Soleus
Soleus BL: 1.9 ± 0.6, 4wks: BL: 2.1 ± 0.5, 4wks: 2.4 ± 0.5;
3.0 ± 0.9; Calcaneus BL Calcaneus BL 2.3 ± 1.1, 4wks:
1.7 ± 0.8, 4wks: 3.2 ± 1.3 2.6 ± 0.9
Saban 2014 RCT Adults (n = 69) with plantar Plantar heel pain with increased Manual therapy group (n = 36): Deep VAS: BL: 6.8 (3.0) Mean change VAS: 7.0 (2.7) Mean change (CI) VAS, FS: 4–6wks 7
heel pain treated in an pain on initial weight bearing massage X 10-min to posterior calf (CI) 4–6wks: −2.4 (−1.4, −3.4) 4–6wks: −2.5 (−1.4, −3.8)
outpt PT clinic after a period of rest, lessening muscles and neural mobilization
with continued activity with a self-stretch exercise program
X 8 visits
Control group (n = 33): Ultrasound FS: BL: 47 (13) Mean change (CI) FS: BL: 50 (13) Mean change (CI)
therapy to the painful heel area with 4–6wks: 15 (9, 21) 4–6wks: 6 (1, 11)
the same self-stretch exercises
(Continued)
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 
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 60   J. J. FRASER ET AL.

95% CI for comparisons of patient-reported function are

Notes: Outpt = Outpatient, PT = Physical Therapy, Ortho = Orthopaedic, Dx = Diagnosis, Post = Posterior, BL = Baseline, wks = weeks, mos = months, VAS = Visual Analogue Scale, FAAM = Foot and Ankle Ability Measure, NPRS = Numeric Pain

36, GH = General Health scale of the SF-36, Vit = Vitality scale of the SF-36, SF = Social Function scale of the SF-36, ER = Emotion role scale of the SF-36, MH = Mental Health scale of the SF-36, FFI = Foot Function Index, PPT = Pressure-pain
Rating Scale, LEFS = Lower Extremity Functional Scale, FS = Functional Status of the Foot & Ankle Computerized Adaptive Test, PF = Physical Function scale of the SF-36, PR = Physical Role scale of the SF-36, BP = Bodily pain scale of the SF-
PEDRO
score
illustrated in Figure 3. There was a trend of improved

8
function that favored patients who received MT from 3
Outcomes and assess- weeks to 6 months with moderate to large ES. Patients
NPRS, LEFS 2wks, 4wks, who received a corticosteroid injection to the plantar
ment time points

fascia had improved function with large ES from 3 weeks

Algometry: 4wks
to 3 months, but no better than those treated with MT
at 12 months (Figure 4).
10wks

Discussion
6.68 ± 1.89 4wks: 5.28 ± 2.88

Patients who received MT interventions in combination

Control mean, SD

2wks 51.88 ± 17.35 4wks

NPRS: BL: 8.12 ± 1.77 2wks

with stretching or strengthening exercises generally

365.52 ± 200.66 4wks:
52.32 ± 19.69 10wks:
LEFS: BL 48.16 ± 17.06

had greater improved self-reported function and PPT

10wks 4.76 ± 3.41

Algometry Pain: BL

395.92 ± 198.94 thresholds during algometric assessment when com-

57.88 ± 18.03

pared to patients treated with stretching, strengthen-

ing, or modalities alone. It is important to qualify that
group means for reported pain in the included studies
improved following treatment, regardless of the inter-
Algometry: BL: 423.17 ± 176.43

vention received.
Experimental mean, SD

2wks: 43.12 ± 18.47 4wks:

7.16 ± 2.36 4wks 5.6 ± 3.3
Manual therapy group (n = 25): Anterior/ NPRS: BL: 7.76 ± 2.03 2wks:

Only one study demonstrated large ES that favored

4wks: 461.74 ± 184.98
LEFS: BL: 40.00 ± 16.48

the inclusion of MT (joint and soft tissue mobilization)

47.6 ± 19.38 10wks:
10wks: 4.68 ± 3.38

in routine care (stretching, extrinsic plantarflexion and

55.96 ± 19.45

intrinsic foot strengthening, and ultrasound) over rou-

tine care alone in reducing both self-reported pain and
improving function [29]. While the superior improve-
ments observed in the MT group are likely attributed
stretching, exercises, and ultrasound X

to the multimodal treatment approach utilized in this

posterior talocrural (weight-bearing
and non–weight-bearing), subtalar

pronation/supination joint mobili-

zations X 1–1.5-min each, midfoot
eversion/inversion, and midtarsal

study, these results should be interpreted with caution.

Control group (n = 25): stretching
Groups/intervention

Because this study did not employ any blinding (patient,

exercises and ultrasound

treating clinician, or assessor administering the outcome

measures), there is a risk of bias that may have influenced
the outcomes. Administration bias is a concern when uti-
lizing patient-reported outcome measures, especially in
8 sessions)

MT research and practice [30].

The effect of MT on self-reported pain was equiva-
lent to comparison interventions in two studies despite
than 3) in the morning on taking

improvements in self-reported function at the same

increase in pain (NPRS, greater
generated by pressure, and an

a few steps or after prolonged

Pain at the bottom of the heel

time points [23,24]. It is likely that patients who had

Inclusion criteria

improvement in self-reported function as a response to

non–weight bearing

treatment may also have increased pain associated with

increased activity. One study demonstrated moderate ES
that favored MT for patient-reported pain was assessed
utilizing the bodily pain scale (BPS) of the SF-36 [25]. The
SF-36 BPS is a two-item scale that asks the patient to not
only rate pain intensity, but also how pain impacts func-
tion. It is plausible that the NPRS and VAS, both of which
females/15 males) with
Sample population

do not have qualifiers of impact of pain on function or

Adults (n = 55; 35

quality of life, may not have the same responsiveness

plantar pain

as the SF-36 BPS in detecting change in symptoms in

patients with PF. Another plausible explanation may be
Table 1. (Continued).

attributed to differences in effectiveness between type

of MT intervention provided to these patients. This was
the only study to utilize trigger point MT as an interven-
Shashua 2015

thresholds.
Author Year

tion [25]. The application of focused manual force over a

Design

painful, taut band of muscle may have palliative effects

RCT
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY   61

Table 2. PEDro scoring for studies included in analysis.

Ajimsha Cleland Ghafoor Renan- Saban Shashua
  (2013) Celik (2015) (2009) (2016) Ordine (2011) (2014) (2015)
1. Eligibility criteria? Y Y Y Y Y Y Y
2. Random allocation? Y Y Y Y Y Y Y
3. Allocation concealed? N Y Y N N Y Y
4. Groups similar? Y Y Y Y Y Y Y
5. Subject blinding? Y N N N Y N N
6. Therapist blinding? Y N N N N N N
7. Assessor blinding? Y N Y N Y Y Y
8. 85% subjects completed? Y Y Y Y N N Y
9. Allocation maintained or intention to Y Y Y Y N Y Y
treat?
10. Between group statistical comparisons? Y Y Y Y Y Y Y
11. Point and variability measures reported? Y Y Y Y Y Y Y
PEDro Score 9/10 7/10 8/10 6/10 6/10 7/10 8/10

Figure 2. Effect sizes and 95% CIs of patient-reported outcome measures of pain comparing manual therapy with control interventions
in patients with plantar fasciitis.

that other milder interventions, such as massage, may specifically joint mobilization of the talocrural, subtalar,
not elicit. and midfoot joints, demonstrated equivalent ES at 4
Underlying mechanical disruption or inflammation of weeks post treatment when PPTs were measured at the
the plantar fascia may sensitize local cutaneous receptors most tender spot on the plantar foot [23]. PPT utilizing
and contribute to symptom severity. Basic research has a site that is most painful is more likely an assessment
demonstrated decreased cutaneous hypersensitization of tissue reactivity, compared to a measure of central
following ankle joint mobilization as a result of spinal level sensitization. Hence, discretion should be used when
neurochemical mechanisms [31,32]. Methodological dif- interpreting these results.
ferences in studies utilizing PPT outcomes may explain Large ES for PPTs were observed at 4 weeks and 3
the observed results. Specifically, the equivalent ES esti- months post intervention in studies of PF patients treated
mate found in the Shashua (2015) study [ES = 0.33, 95% with myofascial release [27] or trigger point MT [25] when
CI (−0.23, 0.89)] is likely associated with the proximity of algometric PPT was measured at standardized test sites
the algometric test site to the mechanical or inflamma- on the calcaneus, soleus, and gastrocnemius. It is possible
tory pain generator. Patients who were administered MT, that greater effects of MT in these studies are a result of
62   J. J. FRASER ET AL.

Figure 3.  Effect sizes and 95% CIs of patient-reported outcome measures of function comparing manual therapy with control
interventions in patients with plantar fasciitis.

Figure 4. Effect sizes and 95% CIs of algometry/pressure-pain thresholds comparing manual therapy with control interventions in
patients with plantar fasciitis.
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY   63

intervention and algometric assessment in regions remote Limitations

to the pain generator, but share common cutaneous
Heterogeneity of design, specifically delimitations and
innervation. PPT testing remote to a pain generator has
experimental and control interventions employed, may
previously been recommended as a method of assessing
amplify or mute the observed treatment effects. While all
spinal level sensitization [33]. The areas assessed in these
reviewed RCTs employed plantar heel pain as an inclu-
studies are innervated by branches of the tibial nerve and
sion criterion, there was a wide range of delimitations
dermatomes L5-S2, the same as the plantar fascia. Pain
utilized. Multiple potential pain generators contribute
generation in the PF may facilitate central sensitization of
to symptoms in PF [5,7,8], which adds complexity when
the afferent fibers of the tibial nerve and therefore have a
diagnosing and managing this condition. While less
secondary hypersensitization effect in the sural nerve as
stringent inclusion criteria may improve generalizabil-
well. Interestingly, the improvement in PPTs in the study
ity of study findings, intervention group response to
conducted by Ajimsha and colleagues [27] persisted for
treatment may be muted due to variability in this heter-
at least 3 months post treatment. These findings are sur-
ogeneous condition. While most studies compared MT
prising for a neurophysiologic response to MT. Aboodarda
in conjunction with exercise to exercise alone, Ajimsha
and colleagues [34] found improvements in PPT in the
and colleagues [27] used sham ultrasound as a control
triceps surae following local and non-local massage, but
intervention. This study also demonstrated much larger
that the effects were transient and short-lived.
effect sizes for patient reported function than other
The observed ES may be attributed to heterogeneity
studies illustrated in Figure 3 [27]. Heterogeneity of
of control interventions studied. Shashua and colleagues
outcome measures, differences in instrument respon-
[23] prescribed stretching exercises and therapeutic
siveness, and study design in MT may also contribute
ultrasound for their control group. This is in stark con-
to bias. Differences in MT techniques utilized across the
trast to the placebo ultrasound utilized with the control
reviewed studies preclude us from making a recommen-
group in the study conducted by Ajimsha and colleagues
dation to any one specific form of MT. It is expected that
[27]. Regardless, Renan-Ordine and colleagues [25] also
this limitation will resolve as the body of evidence grows
observed large ES when MT and self-stretching was com-
and encompasses trials comparing similar forms of MT.
pared to self-stretching alone.
Patients who received a corticosteroid injection to the
plantar fascia demonstrated more immediate improve- Conclusion
ments in self-reported pain and function up to 3 months,
but not at 12 months when compared to patients treated Based on the seven RCTs that met our criteria for review,
with stretching and MT [28]. Compared to stretching and we conclude that inclusion of MT in a treatment plan
joint mobilization, patients may benefit from PF injection improves PPT and function more effectively than com-
earlier in the treatment course. Decreased pain associ- parison interventions in patients with PF. The inclusion
ated with PF injection may allow patients to tolerate of MT interventions in a comprehensive rehabilitation
stretching and strengthening exercises earlier in the plan of care appears to yield greater improved function
rehabilitation course. There are risks associated with PF from 3 weeks to 6 months and PPT when compared
injection, such as rupture of the fascia [35]. Clinicians to interventions such as stretching and strengthening
must weigh the short-term benefit of PF injection with exercises or modalities. MT techniques for the ankle-foot
the risks associated with the intervention. complex utilized in the studies included both joint mobi-
Regarding clinical effectiveness, it is unclear whether lizations (Grade V proximal tibiofibular anterior glide,
there is any one MT technique that is superior in Grade III–IV posterior fibular glides, Grade I–V rearfoot
improving pain and function in patients with PF. It is distraction, Grade I–IV subtalar lateral glides, Grade I–V
recommended that clinicians consider use of both joint talocrural posterior glides in non-weight-bearing and
mobilization of the ankle and foot and soft tissue mobili- weight-bearing, Grade V cuboid dorsal glide, Grade III–
zation techniques to include trigger point therapy, deep IV intertarsal mobilizations, Grade I–II first tarsometatar-
massage, and myofascial release in conjunction with sal dorsal glides, and Grade II & IV unspecified rearfoot
stretching and strengthening when treating patients mobilizations) and soft tissue techniques (trigger point
with PF. Clinicians should continue to exercise sound mobilization of the gastrocnemius, deep massage to the
clinical judgment and provide MT intervention based triceps surae, myofascial release to the gastrocnemius,
on physical examination findings. For future research, soleus, and plantar fascia, and unspecified soft tissue
the authors encourage more superiority trials where MT mobilizations to the plantar fascia) applied for 1.5–10-
combined with standard care, such as stretching and min in 6–16 treatment sessions. Based on the low risk
strengthening exercises, is compared to standard care. and the potential benefits of improved self-reported and
Parallel group RCTs that compare different types of MT clinically measured pain and function, it is recommended
interventions would also be of great value in determin- that MT be included in a comprehensive rehabilitation
ing clinical effectiveness of specific techniques in the program, including stretching and exercise, in the treat-
treatment of patients with PF. ment of patients with PF.
64   J. J. FRASER ET AL.

Disclosures   [2] Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom

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