Original article

Deep massage to posterior calf muscles in combination with neural

mobilization exercises as a treatment for heel pain: A pilot
randomized clinical trial
Bernice Saban
a,
*
, Daniel Deutscher
b
, Tomer Ziv
c
a
Physical Therapy Service, Maccabi Healthcare Services, Shpeigel 3, Petach Tikva, Israel
b
Physical Therapy Service, Maccabi Healthcare Services, Tel Aviv, Israel
c
Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
a r t i c l e i n f o
Article history:
Received 22 September 2012
Received in revised form
12 August 2013
Accepted 22 August 2013
Keywords:
Plantar heel pain syndrome
Deep massage
Neural mobilization
Functional status
a b s t r a c t
Background: Plantar heel pain syndrome (PHPS) is a common foot disorder; however, there is limited
clinical evidence on which to base treatment. Repeated clinical observations indicating heel pain during
heel rise and minisquat on the affected leg, involving activation of posterior calf muscles, formed the
basis of this study.
Objective: To compare deep massage therapy to posterior calf muscles and neural mobilization with a
self-stretch exercise program (DMS) to a common treatment protocol of ultrasound therapy to the
painful heel area with the same self-stretch exercises (USS).
Methods: Patients with PHPS were assigned to a program of 8 treatments over a period of 4e6 weeks in a
single-blind randomized clinical trial. Functional status (FS) at admission and discharge from therapy as
measured by the Foot & Ankle Computerized Adaptive Test was the main outcome measure.
Results: Sixty-nine patients were included in the trial (mean age 53, standard deviation (SD) 13, range 25
e86, 57%women), 36receivedDMStreatment and33withUSS. Theoverall group-by-timeinteractionfor the
mixed-model analysis of variance (ANOVA) was found statistically signicant (p 0.034), with a change of
(mean (condence interval, CI)) 15 (9e21) and 6 (1e11) FS points for the DMS and USS groups, respectively.
Conclusions: Data indicated that both treatment protocols resulted in an overall short-term improve-
ment, however, DMS treatment was signicantly more effective in treating PHPS than USS treatment.
2013 Elsevier Ltd. All rights reserved.
1. Introduction
Plantar heel pain syndrome (PHPS) encompasses a broad spec-
trum of pathologies. Several studies have hypothesized that certain
risk factors contribute to the development of this condition,
insinuating that the etiology of PHPS is multifactorial (Rome et al.,
2001; Irving et al., 2006; Yi et al., 2011). Approximately 10% of the
general population will experience PHPS during their lifespan, ac-
counting for 15% of all adult foot complaints requiring professional
care in both athletic and nonathletic populations (Rome et al.,
2001; Irving et al., 2006).
Treatment is usually conservative with a few intractable cases
referred to surgery (Taunton et al., 2002; DiGiovanni et al., 2003).
Though, to date, there is limited clinical evidence on which to base
treatment practice for PHPS (Crawford & Thomson, 2003; McPoil
et al., 2008), thus provoking the motive for further research.
Increased heel pain on a single stance heel rise and single stance
minisquat was observed by the authors in a large proportion of
patients diagnosed with PHPS, a nding supported by Rome et al.
(2001) in 53% of 36 athletic patients with this syndrome. These
two movements affect the foot by unloading heel weight bearing
and, theoretically, would be expected to cause a decrease in pain
level. Inspection by manual palpation of plantar exor muscles in
the posterior calf, that are actively involved in these movements,
detected incompliant and painful soft tissue in isolated or multiple
sites on the affected leg in patients with PHPS. Identication of
painful muscle tissue by manual palpation has been shown to have
good inter-tester reliability (Lucas et al., 2009). Areas of painful calf
muscle tissue in PHPS have been recorded (Nguyen, 2010; Renan-
Ordine et al., 2011), and are similar to myofascial trigger points
(Travell and Simons, 1983).
Lack of evidence regarding effective care for patients seeking
treatment for PHPS, and personal clinical observations described,
led to the proposal of a treatment procedure directed to the
* Corresponding author. Tel.: 972 39333712; fax: 972 39392613.
E-mail address: saban_b@mac.org.il (B. Saban).
Contents lists available at ScienceDirect
Manual Therapy
j ournal homepage: www. el sevi er. com/ mat h
1356-689X/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.08.001
Manual Therapy 19 (2014) 102e108
posterior calf muscles. The aim of this study was to compare this
approach to a more common protocol of treatment directed to the
heel area. The hypothesis was that deep, soft tissue massage
(Cyriax, 1984) to posterior calf muscles with neural mobilization
combined with stretching exercises (DMS) would lead to increased
pain relief and improved function compared to local ultrasound
therapy combined with the same stretching exercise program(USS)
for patients with PHPS.
2. Methods
2.1. Design and participants
This study was a parallel-group, prospective, single, blind, ran-
domized clinical trial. Consecutive patients over the age of 18
referred by an orthopedic surgeon to an outpatient physiotherapy
clinic (Maccabi Healthcare Services, Petach Tikva, Israel) for treat-
ment of PHPS were enrolled in the study. The Consolidated Stan-
dards of Reporting Trials guidelines were utilized in the study to
improve reporting standards (Moher et al., 2001).
Inclusion criteria comprised pain consistent with PHPS, opera-
tionally dened as plantar heel pain with increased pain on initial
weight bearing after a period of rest, lessening with continued
activity (McPoil et al., 2008). Exclusion criteria included systemic
disease, tumor, fracture, prolonged history of steroid use, severe
vascular disease, prior lower leg surgery, possibility of referred pain
to the heel (excluding the calf muscles), or inability to comply with
the treatment schedule. Eligible patients undergoing other treat-
ments for heel pain prior to the study were requested to stop
treatments one month before entering the study. Participating
patients, all volunteers, signed an informed consent. This study was
approved by the Institutional Review Board for the Protection of
Human Subjects, Maccabi Healthcare Services, Israel (serial number
2006031).
2.2. Sample size
A sample size of 56 patients was chosen to provide 80% power to
detect a difference of 10 points between treatment groups after 8
treatments. This calculation is based on using an independent t-test
at a 2-sided p-level of 0.05 and assumes a previously published
within-group standard deviation (SD) at admission of 13 points
(Hart et al., 2005).
2.3. Therapists
One author (BS), who did not provide treatment and was not
involved in the randomization, conducted physical examinations at
admission and discharge. After initial examination, patients were
assigned to receive treatment by one of the staff members. Fifteen
physiotherapists participated in the study (mean age 36 years, SD 9
years, range 27e54 years, mean clinical experience 11 years, SD 10
years; range 1e30 years).
2.4. Randomization and interventions
Randomization was conducted after initial examination by the
patients who chose a sealed opaque envelope containing either
DMS or USS protocol. All patients were treated 1e2 times a week,
receiving a total of 8 treatments over a 6-week period. All partici-
pating physiotherapists underwent practical training sessions on
manual techniques and exercises included within each treatment
protocol, including clarications of study procedures and opera-
tional denitions, before commencement of the trial and ongoing
as required.
2.4.1. Deep massage therapy
Patients lay in a prone position with their shins resting on a
pillow and their feet hanging over the edge of the bed. Relevant
painful areas of the muscles were identied by deeply palpating the
entire muscle group (Fig. 1), a technique that has been shown to
have good inter-rater reliability (k range, 0.57e1.00) (Lucas et al.,
2009). Deep massage therapy consisted of 10 min of forceful soft
tissue massage mobilization techniques, described by Cyriax
(1984), directed to the incompliant and painful areas of the pos-
terior calf muscle group. The technique was applied across the
muscle bers both medially and laterally, with sufcient sweep and
depth (Cyriax, 1984) until obtaining a pain response to the pressure.
Fig. 1. Technique of deep muscle massage.
B. Saban et al. / Manual Therapy 19 (2014) 102e108 103
The therapist could choose to work with thumbs or another other
body parts, i.e. elbow (Fig. 2), to enable sufcient force to reach
deeper muscle areas.
2.4.2. Ultrasound therapy
No evidence has been found as to the use of therapeutic ultra-
sound (Crawford and Thomson, 2003; McPoil et al., 2008) for
reducing pain in individuals with PHPS. Yet, therapeutic ultrasound
continues to be a commonly used intervention (Crawford and
Snaith, 1996; Deutscher, 2002; Cleland et al., 2009). Reviews of
therapeutic ultrasound have failed to identify a dose-response
relationship, though intensities from 0.5 W/cm
2
to 3 W/cm
2
have
been advocated (van der Windt et al., 1999; Robertson and Baker,
2001).
Ultrasound parameters matched customary procedures used in
the clinic, a frequency of 1 MHz and intensity of 1.0 W/cm
2
,
continuous dose. Ultrasound, at each session, was applied to the
painful area of the heel for 3 min (Watson, 2000) using Enraf
Nonius Sonoplus 492, ENRAF, Netherlands (coupling gel: Aqua-
sonic, USA). Slowcircular movements were applied over the painful
area of the heel using a transducer head of 5 cm
2
.
2.4.3. Stretching exercise protocol
Several studies have demonstrated that calf muscle stretching is
effective in management of PHPS at short- and long-term follow-
ups (Porter et al., 2002; Cleland et al., 2009). All patients were
instructed in self-stretching techniques directed at the posterior
calf muscles 3 times per day with 5 repetitions for each stretch,
using intermittent stretching of 20 s followed by 10 s of rest (Young
et al., 2001; Porter et al., 2002). Self-stretching of the calf muscles
was performed in a standing position, the affected foot furthest
away from the wall and both feet positioned on a line. To focus
stretch on the gastrocnemius muscle the knee on the affected side
was kept in full extension (Fig. 3a), whereas to focus stretch on the
soleus muscle the knee on the affected side was bent (Fig. 3b).
While holding these positions, patients leaned forward keeping the
heels on the oor until a stretch in the calf and/or the Achilles
tendon regionwas felt. In addition to verbal instruction, all subjects
received an illustrated instruction sheet with details of the required
daily program.
2.4.4. Neural mobilization
The DMS group was instructed to perform one additional ex-
ercise, a passive straight leg raise combined with dorsiexion using
a long belt (SLR&DF) (Fig. 4), with the same regime as for calf
stretches. The proposed rationale for this exercise was to increase
stretch on neural structures (Butler, 2000; Meyer et al., 2002).
2.5. Measures
2.5.1. Demographic information
Information was collected at initial examination using a stan-
dardized questionnaire tailored-made for this study. Data included
Fig. 2. Deep massage to calf muscles using elbow.
Fig. 3. Calf stretching exercises.
Fig. 4. Straight leg raise with dorsiflexion exercise using a belt.
B. Saban et al. / Manual Therapy 19 (2014) 102e108 104
age, gender, body mass index, duration of symptoms in weeks,
work activity, sports participation and previous treatments for
PHPS.
2.5.2. Outcome measures
Functional status (FS) outcomes were quantied using the Foot
& Ankle Computerized Adaptive Test (CAT) (Hart et al., 2005) and
dened as the main outcome measure. Development, simulation
and use of the CAT have been previously described (Hart et al.,
2005; Deutscher et al., 2008), as well as validity, sensitivity to
change and responsiveness as assessed by utilizing minimal
detectable change and minimal clinical important change (MCIC)
(Hart et al., 2008a). The Foot & Ankle CAT was developed as a body
part specic CAT (Millsap and Everson, 1993; Hart et al., 2005),
and represents the item response theory conceptualization of the
Lower Extremity Functional Scale (LEFS) (Binkley et al., 1999). FS
scores ranged from 0 (low) to 100 (high functioning), with a MCIC
of 8 points determined by Wang et al. (2009). Before imple-
menting the Foot & Ankle CAT into Maccabi Health Services clinics,
items were translated from the original English version into He-
brew, Russian and Arabic following published procedures (Lewin-
Epstein et al., 1998; Hart et al., 2009). The knee CAT (Hart et al.,
2008b, 2009) Hebrew and Russian translations, using the same
items from the LEFS as the Foot & Ankle CAT was found valid with
negligible differential item functioning (Hart et al., 2009;
Deutscher et al., 2010) and strong known groups construct val-
idity (Deutscher et al., 2011). A customized version of Patient In-
quiry software developed by FOTO, Inc.
1
has been fully integrated
into Maccabis electronic health record system (Swinkels et al.,
2007; Deutscher et al., 2008).
Description of pain felt on taking rst steps in the morning was
assessed with a 10 cmvisual analog scale (VAS) used as a secondary
outcome measure. The VAS has been previously described
(Woodforde and Merskey, 1972) and found to be reliable (Ferraz
et al., 1990; Hawker et al., 2011) and valid (Downie et al., 1978;
Price et al., 1983; Hawker et al., 2011) for measuring pain. A MCIC
of 1.4 cmhas been determined for a 10 cmpain VAS inpatients with
rotator cuff disease evaluated after 6 weeks of non-operative
treatment (Tashjian et al., 2009).
2.6. Statistical analysis
Patient demographic characteristics and outcome measures at
baseline were compared between the two treatment groups to
estimate quality of randomization. Frequency distributions were
used to describe categorical data and means and standard de-
viations to describe continuous data. The KolmogoroveSmirnov
test was used to determine a normal distribution of continuous FS
and VAS outcome variables (p >0.05). Students t-test was used
for comparisons of normally distributed continuous variables;
ManneWhitney test for abnormally distributed data and c
2
test
for categorical variables. These tests were reapplied to compare
patients who had completed the treatment sessions to those who
had not.
All subjects were analyzed according to the intention-to-treat
principle, with imputation of data by the last outcome carried
forward. A multivariate mixed-model analysis of variance (ANOVA)
was used with time (pre-intervention, post-intervention) as a
within-subject variable and group (DMS, USS) as a between-subject
variable, to examine effects of interventions on FS and VAS. If the
interaction of time and treatment was found signicant, it was
followed by paired Students t-test for outcome measures
performed using baseline and discharge scores. Independent t-test
was performed for comparison of outcome measures between
groups before, and after intervention. All statistical tests were two-
sided, p-value <0.05 was considered statistically signicant.
Change scores were expressed as means and condence intervals
(CIs). The change in score within each group and between groups
was compared to the MCIC. Data were analyzed using the SPSS
version 15.
3. Results
Sixty-nine volunteer patients who fullled the eligibility criteria
and agreed to participate were recruited between September 2006
and March 2009 (mean age 53, SD 13, range 25e86, 57% women).
Participating patients were randomized into DMS (n 36) and USS
(n 33) groups. An additional 3 patients who had been assigned to
the USS group were excluded by the ethics committee after
randomization due to invalid consent forms (missing signatures).
Comparisons of patient demographic and clinical characteristics at
baseline between treatment groups (Table 1) resulted in no sig-
nicant differences (p >0.05). All participating physiotherapists
treated patients from both the DMS and USS groups, with the same
average number of patients per therapist in each treatment group
(3 patients (SD 2, range 1e7)).
Fifty-one patients completed the treatment program and
assessment at discharge, indicating a 74% completion rate, oper-
ationally dened as the percentage of episodes with FS intake
data and FS discharge data (Deutscher et al., 2009) (Fig. 5).
Completion rates for the DMS and USS groups were similar (72%
and 76%, respectively, p 0.738). Characteristics of dropouts in
each group were similar to those patients who remained in the
trial (Table 2). One patient in each group reported adverse reac-
tion to treatment.
The group-by-time interaction for the mixed-model ANOVA
was statistically signicant for change score of the main outcome
measure (FS) (p 0.034) (Table 3), which indicated a difference in
treatment effects. This remained signicant after controlling for
age, gender, body mass index (BMI) and chronicity (p 0.025).
The DMS group achieved a mean change of 15 points (CI 95% 9e
Table 1
Baseline patient characteristics by treatment group.
Variable DM
n 36
USS
n 33
p-Value
Age (years) 54 12 (32e81) 52 13 (25e87) 0.57
a
Female (% (N)) 47 (17) 67 (22) 0.10
b
BMI 30 5 (23e44) 30 6 (20e42) 0.98
a
Duration of pain at admission
(weeks)
19 19 (4e78) 25 21 (2e78) 0.23
a
Work condition e standing
most of the day (% (N))
17 (6) 21 (7) 0.63
b
No previous sports activity
(% (N))
67 (24) 67 (22) 1.00
b
Previous treatments (% (N)) 75 (27) 73 (24) 0.83
b
FS 47 13 (29e77) 50 13 (23e80) 0.38
a
Pain during 1st morning steps
(VAS)
6.8 3.0 (0e10) 7.0 2.7 (0e10) 0.71
a
Data presented as meanstandard deviation (SD) and (range) unless stated.
DMS e deep massage to calf muscles and self-stretch exercise treatment group, USS e
ultrasound therapy and self-stretchexercise treatment group; BMI ebody mass index;
Work condition e standing most of the day e the patient described standing as the
main activity during the day; No previous sports activity e no participation in sporting
activities; Previous treatment e patient reported having treatments of medication,
insole or night splint; FS e functional status; VAS e 10 cm visual analog scale.
a
t-Test.
b
c
2
test.
1
Focus On Therapeutic Outcomes, Inc, P Box 11444, Knoxville, TN 37919.
B. Saban et al. / Manual Therapy 19 (2014) 102e108 105
21), whilst the USS treatment group achieved a mean change of 6
FS points (CI 95% 1e11). Change in FS score within both groups
over time was statistically signicant (DMS p <0.001, USS
p 0.025).
Decrease in pain level with rst morning steps was signicant
for all participants after interventions (DMS p <0.001, USS
p <0.001), although the results were similar between groups
(p 0.921) (Table 4). The DMS group achieved a mean change
Fig. 5. CONSORT ow diagram for patient participation.
Table 2
Comparison of baseline patient characteristics by treatment adherence for each treatment group.
Variable DMS p-Value USS p-Value
Complete, n 26 Incomplete, n 10 Complete, n 25 Incomplete, n 8
Age (years) 53 11 (32e81) 56 14 (32e78) 0.52
a
51 15 (25e86) 55 8 (37e63) 0.47
a
Female (% (N)) 46 (12) 50 (5) 0.74
b
76 (19) 38 (3) 0.06
b
BMI 29 4 (23e42) 32 6 (26e44) 0.08
a
30 6 (20e42) 30 5 (24e39) 0.8
a
Duration of pain at admission (weeks) 15 11 (4e52) 30 27 (6e78) 0.17
c
24 22 (2e78) 26 18 (4e52) 0.86
a
Work condition -standing most of the day (% (N)) 15 (4) 20 (2) <0.01
b
** 24 (4) 13 (1) <0.01
b
**
No previous sports activity (% (N)) 62 (16) 80 (8) 0.05
b
64 (16) 75 (6) 0.06
b
Previous treatments (% (N)) 73 (19) 80 (8) 1.00
b
76 (19) 63 (5) 0.65
b
FS 46 12 (29e72) 52 15 (30e77) 0.18
a
51 13 (23e80) 46 12 (26e59) 0.34
a
Pain during 1st morning steps (VAS) 7 3 (0e10) 6 4 (0e10) 0.34
b
7 3 (0e10) 7.0 3 (0e10) 0.97
a
Data presented as mean standard deviation (SD) and (range) unless stated.
DMS e deep massage to calf muscles and self-stretch exercise treatment group; USS e ultrasound therapy and self-stretch exercise treatment group; BMI e body mass index;
Work condition e standing most of the day e the patient described standing as the main activity during the day; No previous sports activity e no participation in sporting
activities; Previous treatment e patient reported having treatments of medication, insole or night splint; FS e functional status; VAS e 10 cm visual analog scale.
*p <0.05; **p <0.01.
a
t-Test.
b
c
2
test.
c
ManneWhitney test.
B. Saban et al. / Manual Therapy 19 (2014) 102e108 106
of 2.4 cm on the VAS scale (CI 95% 1.4 to 3.4), and the USS
group achieved 2.5 cm (CI 95% 1.4 to 3.8).
4. Discussion
The basic premise for introducing deep massage treatment to
the calf was that contraction of the ankle plantar exor muscle
group generated heel pain. The DMS treatment targeted to calf
muscles demonstrated a greater improvement in functional abili-
ties compared to ultrasound treatment directed to the heel pain
area. The USS group achieved a statistically signicant change in
the FS score of 6 points at the end of treatment; however, this was
not clinically signicant as it did not reach the MCIC of 8 points.
Whereas the change in the FS score of 15 points in the DMS
treatment group was signicant both statistically and clinically. The
difference of 9 points (CI 95% 0.7e16) between the 2 groups also
surpassed the MCIC, although the lower bound estimate of this
value did not. All participants achieved a signicant improvement,
statistically and clinically, in their pain level with rst morning
steps, and results were similar in both groups (p 0.921).
The FS score displayed more variance between the two treat-
ment protocols than the pain VAS. This result could indicate that
morning pain level reects only one aspect of patients symptoms,
not necessarily representative of perceived functional abilities,
while the FS scale is more sensitive to various physical functions
that present a wider range of the patients ability as a result of PHPS.
Renan-Ordine et al. (2011) conducted a study using a similar
protocol and showed that treatment which included manual trigger
point therapy applied to calf muscles with self-stretching exercises,
resulted in a greater decrease of pain and greater improvement of
physical function, compared to stretching exercises alone. Trigger
point therapy techniques for PHPS were also suggested in a case
study by Nguyen (2010), recommending treatment to muscles of
the entire lower limb. These results support the nding that a soft
tissue massage mobilization treatment to calf muscles with a self-
stretching protocol is effective in improving function and
decreasing pain in patients with PHPS.
Some positive changes were expected in both treatment groups
based on results of previous studies including calf stretching ex-
ercises (Young et al., 2001; Porter et al., 2002). The exact mecha-
nismof stretching efcacy in the management of PHPS is unclear as
muscles of the posterior calf are attached to the posterior calcaneus,
and therefore not directly connected to the plantar heel area.
The fascia, connecting the calf to the heel area and foot, was
theorized to be released of strain during the clinical tests of heel
rise and squat thus not considered as a possible source of PHPS. In
addition, there is no consensus as to the possibility that stress on
fascia is a cause of increased pain perception (Herrington et al.,
2008).
It has been suggested that PHPS could originate from a
dysfunction of the tibial, plantar or calcaneal nerves (Jolly et al.,
2005; Alshami et al., 2008). The tibial nerve travels down the
posterior calf in-between the supercial and deep muscle groups. It
passes posterior to the medial malleolus and, after dividing into
medial and lateral branches, enters the foot area deep to the
abductor hallucis muscle at the medial process of the calcaneal
tuberosity (Warwick and Williams, 1973). These nerves supply the
skin of the heel and medial side of the sole of the foot. Rose et al.
(2003) recorded an abnormal sensitivity in both medial calcaneal
and medial planar nerves in 72% of patients with PHPS, thus sug-
gesting a proximal neural origin. This lead the authors to include
the SLR&DF exercise in the DMS group in order to promote mobility
of these neural structures (Butler, 2000; Meyer et al., 2002).
Signicant differences in patient characteristics between groups
at baseline were not found indicating a successful randomization
process. In addition, etiological factors associated with PHPS (Rome
et al., 2001; Riddle et al., 2003) were evenly distributed between
groups (Table 1).
This study had several limitations. All patients performed the
exercises during their treatment sessions; however there was no
record of daily self-exercise compliance, thus limiting our ability to
fully assess the impact on results. Furthermore, the DMS group
performed one additional exercise (SLR with DF), therefore intro-
ducing another variable into the trial. The massage techniques used
in this trial have not previously been assessed for reliability. The
results are appropriate only for the specic ultrasound parameters
used in this study. There could be some difference in the attention
allotted to patients between the groups, but it is difcult to gauge
this impact, as the treatments were also different in nature i.e.
painful massage for 10 min compared to non-painful ultrasound for
3 min. Missing data can bias the results, although dropout rates
were similar between groups (p 0.738), and similar to previous
reports (Deutscher et al., 2009; Wang et al., 2009; Bezalel et al.,
2010) and results supported no patient selection or participation
bias (Table 2). There was no true control group and the sample was
relatively small, thus this research is considered a pilot study.
Additionally, there was no follow up of patients, thus limiting our
ability to assess long-termresults of these two treatment protocols.
5. Conclusion
This study supports the use of a treatment protocol that is easily
implemented and is effective in individuals with PHPS. Deep
Table 3
Baseline, discharge and change in FS score over time by treatment group.
DMS
N36
USS
N33
Between groups
difference (CI 95%)
p-Value
Baseline 47 50 3 (9 to 4) 0.380
Discharge 62 56 6 (2 to 13) 0.140
Within-group change 15 6 11 (0.7e16) 0.034*
CI 95% for within-group
change
9e21 1e11
p-Value <0.001** 0.025*
p-Value assessed with t-test.
FS efunctional status; DMS edeep massage to calf muscles and self-stretch exercise
treatment group; USS e ultrasound and self-stretch exercise treatment group; CI e
condence interval.
FS scores (higher values indicate greater function) are expressed as mean and CI for
baseline, discharge and within-group change scores.
*p <0.05; **p <0.01.
Table 4
Baseline, discharge and change in rst morning pain, using VAS, over time by
treatment group.
DMS
N36
USS
N33
Between groups
difference (CI 95%)
p-Value
Baseline 6.8 6.9 0.1 (1.6 to 1.3) 0.879
Discharge 4.2 4.4 0.2 (1.9 to 1.5) 0.804
Within-group
change
2.4 2.5 0.1 (0.7 to 1.7) 0.921
CI 95% for
within-group
change
1.4 to 3.4 1.4 to 3.8
p-Value <0.001** 0.001**
p-Value assessed with t-test.
VAS e 10 cm visual analog scale; DMS e deep massage to calf muscles and self-
stretch exercise group; USS e ultrasound and self-stretch exercise group; CI e
condence interval.
VAS scores (lower values indicate less pain) are expressed as mean and CI for
baseline, discharge and within-group change scores.
*p <0.05; **p <0.01.
B. Saban et al. / Manual Therapy 19 (2014) 102e108 107
massage therapy to posterior calf muscles and neural mobilization
combined with stretching exercises had superior short-term FS
outcomes compared to ultrasound treatment with stretching ex-
ercises. Further research is recommended to assess and validate
this approach, and its rationale, for treatment of PHPS.
Acknowledgments
The authors are grateful to the management and staff of the
Physiotherapy Clinic, Maccabi Health Services, Petach Tikva, Israel.
A special dedication to Dr. Dennis L Hart (deceased), PT, PhD, for
his support of this project and for providing practical functional
status measurement tools.
The authors thank Mrs. Phyllis Curchack Kornspan for her
editorial services.
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