Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the Candidate

& Address

SANJAY PAUL

S/O SUSHIL KUMAR PAUL

BSNL QTR COMPLEX T3 B7 RM 4

RYNJAH SHILLONG 793006

MEGHALAYA

2 Name of the Institution

DAYANANDA SAGAR COLLEGE OF

PHYSIOTHERAPY, BANGALORE

3 Course of study and subject

MASTER OF PHYSIOTHERAPY

(Musculoskeletal disorders & Sports

physiotherapy)

4 Date of admission to course July 2013

5 TITLE OF THE TOPIC

“THE EFFECTIVENESS OF LOW DYE TAPING AND MYOFASCIAL RELEASE

TECHNIQUE VERSUS LOW DYE TAPING AND STRETCHING IN PATIENTS

WITH PLANTAR FASCIITIS. A COMPARATIVE STUDY. ”

6 Brief resume of the intended work :

6.1 INTRODUCTION

Plantar heel pain is one of the most commonly occurring foot complaints treated by health

care professionals.[1] Plantar heel pain is thought to be most commonly associated with the

plantar fascia - when the term plantar fasciitis is commonly adopted. Plantar fasciitis is the

most common cause of inferior heel pain. The word ‘fasciitis’ assumes inflammation is an

inherent component of this condition. [2]

The plantar fascia is a thick, fibrous, relatively inelastic sheet of connective tissue

originating from the medial heel, where it then passes over the superficial musculature of

the foot and inserts onto the base of each toe. The plantar fascia is the main stabilizer of the

medial longitudinal arch of the foot against ground reactive forces, and is instrumental in

reconfiguring the foot into a rigid platform before toe-off. [3, 4]

Plantar fasciitis can be defined as: An inflammation of the plantar fascia.( also referred as

Plantar heel pain syndrome, or Painful heel syndrome) The injury itself is an enthesopathy

(an abnormality or injury at the site of attachment of a ligament or tendon to bone) of the

origin of the plantar fascia at the medial tubercle of the calcaneum due to excess traction .[5,

6,7,8,9]

The chief initial complaint is typically a sharp pain in the inner aspect of the heel and arch

of the foot with the first few steps in the morning or after long periods of non-weight

bearing. Usually, after walking approximately ten to twelve steps the plantar fascia becomes

stretched and the pain gradually diminishes. However, symptoms may resurface as

throbbing, a dull ache, or a fatigue-like sensation in the medial arch of the foot after

prolonged periods of standing, especially on unyielding cement surfaces. Generally, pain is

most significant when weight bearing activities are involved. [10, 11, 12, 13]

Plantar fasciitis affects about 10% of the population at least in one moment in life, being

obese women at menopause age most affected,(14) In the non athletic population, it is most

frequently seen in weight bearing occupations, 65% of non sports demographics are

overweight, with unilateral involvement most common in 70% of cases. Second major

distribution of plantar fasciitis is in the athletic population, 10% of all running athletes.

Basket ball, tennis, football, long distance runner and dance have all noted high frequency

of plantar fasciitis .[15,16]

Under normal conditions, the plantar fascia performs this function appropriately without

incurring injury. Some risk factors of plantar fasciitis include faulty mechanics of the foot

due to structural abnormalities, age-related degenerative changes, overweight, training

errors, and occupations involving prolonged standing; those falling into this category

include teachers, construction workers, cooks, nurses, military personnel, and athletes

training for long distance running events.[3,4,,10,17,19] In the presence of these risk factors,

excessive tensile forces may cause micro-tears in the plantar fascia. Repetitive trauma to the

plantar fascia exceeding the fascia’s ability to recover may lead to degenerative changes and

an increased risk of injury. [7, 18 ]

Plantar fasciitis has been reported across a wide sample of the community. The etiology of

plantar fasciitis is unclear diagnosis is usually based on clinical signs including plantar heel

pain during weight-bearing after a period of non-weight-bearing, pain eases within but then

increases with further use as the day progresses, and pain on palpation. [19,20]

Various physiotherapy treatment protocols have been advocated in the past such as rest,

taping, stretching, orthosis / night splint, Silicon heel cups. Electrotherapy modalities in the

form of ultrasound, phonophoresis, laser, microwave diathermy, iontophoresis, cryotherapy,

contrast bath have been given in past. [21].Treatments for plantar fasciitis are varied and

research findings supporting their use are sometimes conflicting.

Myofascial release is a soft tissue mobilization technique. it has been considered as one of

the physical therapy treatments in the chronic conditions that cause tightness and restrictions

in the soft tissues like fibromyalgia, post polio syndrome, asymmetrical muscle weakness

due to peripheral neuropathy, non flexible rib cage due to chronic respiratory disease and

also plantar fasciitis[22]

If symptoms are treated in chronic stage, they will be alleviated. Myofascial release

techniques stem from the foundation that fascia, a connective tissue found throughout the

body, reorganizes itself in response to physical stress and thickness along the lines of

tension. [23] By myofascial release there is change in the viscosity of the ground substance to

more fluid state which eliminates that fascia’s excessive pressure on the pain sensitive

structure and restores proper alignment.[24] Myofascial techniques have been shown to

stimulate fibroblast proliferation, leading to collagen synthesis that may promote healing of

plantar fasciitis by replacing degenerative tissue with a stronger and more functional tissue.

Hence this technique is proposed to act as a catalyst in the resolution of plantar fasciitis.[25]

Plantar fasciitis taping technique can help the foot to get the rest it needs by supporting the

plantar fascia and allowing healing to take place. It significantly reduces the pain associated

with plantar fasciitis.[26]

Low dye taping is an orthopaedic strapping technique of the foot involving the application

of tape 5 to 6 inches above the malleoli to provide support to both the talo-crural joint and

subtalar joint .It helps to raise the medial longitudinal arch and bring the subtalar joint closer

to its neutral position. [27]

Low dye taping is used primarily to reduce strain on the plantar fascia and medial arch

structures to help control excessive pronation [28,29,30]. It has been found to be a useful adjunct

in common “overuse syndromes” that present with excessive or prolonged pronation.

The purpose of taping is to distribute forces away from the plantar fascia and decrease the

stress that activity or weight bearing on it, low dye taping helps patients with the pain of the

“first step” in standing or getting out of the bed.[31]. Supportive tape reduces the symptoms of

plantar heel pain by reducing strain in the plantar fascia during standing and ambulation.[32]

Low dye taping provides an anti pronation and reduces the pressure exerted through the

medial side of the foot.[33]

Stretching is a general term used to describe any therapeutic maneuver designed to increase

the extensibility of soft tissues, thereby improving flexibility by elongation of the shortened

structures. Stretching exercise programs play an important role in treatment of plantar

fasciitis and can correct weakness of intrinsic foot muscles. [34]

Ultrasound is the electrotherapy modality used in treating pain in plantar fasciitis.

Ultrasound is a high frequency sound wave with an affinity for the tendons and ligaments

(highly organized, without high water content). Ultrasound enhances to increase chemical

activity in tissues, increase cell membrane permeability, deform molecular structures, and

alter diffusion and protein synthesis rates, all potentially affecting the speed of tissue repair.[35] A study conducted by Hana Hronkova on plantar fasciitis in which a group received

ultrasound for plantar fasciitis showed significant reduction in pain [36,37]

6.2 Need for the study :

Plantar fasciitis is a common musculoskeletal, occupational or sport-related repetitive strain

injury and is one of the most common causes of heel pain .The term plantar fasciitis itself

has been responsible for considerable confusion, since the condition usually presents as a

combination of clinical entities, rather than the discrete diagnosis of plantar fasciitis.

Despite its wide distribution in the sporting and general communities, there remains

widespread debate on its etiology and dissatisfaction with a lack of reliable treatment

outcomes. Treatments for plantar fasciitis are varied and research findings supporting their

use are sometimes conflicting. Literature indicates that plantar fasciitis may be successfully

treated using a conventional approach. Implementation of a conventional treatment and

preventative protocol has been shown to be effective in resolving or reducing the symptoms

associated with plantar fasciitis. Myofascial release technique, Low Dye Taping procedures

and stretching are frequently utilized as a conventional treatment for plantar heel pain.

However, none of the reviews have focused specifically upon effect of low dye taping and

myofascial release technique comparing low dye taping interventions and stretching, , in

patients with plantar fasciitis along with conventional physiotherapy on pain and functional

status for people.

Hypothesis :

Null hypothesis (H0): There will be no significant difference in the results between low

dye taping and myofascial release technique, or low dye taping and stretching with

conventional physiotherapy in reducing pain in plantar fasciitis.

Experimental hypothesis (H1): There will be a significant difference in the results

between low dye taping and myofascial release technique compared to low dye taping and

stretching, with conventional physiotherapy in reducing pain in plantar fasciitis.

6.3 Review of Literature:

PLANTAR FASCIITIS

Bartold S J 2004 , described that the second major occurrence of plantar fasciitis, is in the

athletic population. He states that plantar fasciitis accounts for 10% of all reported injuries

in runners irrespective of the training distance. As there is an accepted prevalence of plantar

fasciitis in the 5th decade, middle aged runners represent the most common demographic in

the athletic population[38]

Dunn J E et al 2004,conducted a study in US, claimed that seven percent of adults aged 65

years or older have been found to have plantar heel pain. This disorder is thought to be

multi-factorial in origin with factors such as obesity, excessive periods of weight bearing

activity and decreased ankle range of motion commonly suggested to be involved[39]

Riddle D L et al 2003,stated that plantar fasciitis commonly causes inferior heel pain and

occurs in up to 10 percent of the US population. Plantar fasciitis accounts for more than

600000 out patients visits annually in the United States. The condition affects active and

sedentary adults of all ages. Plantar fasciitis is more likely to occur in persons who are

obese, who spend most of the day on their feet, or who have limited ankle flexion[40]

May T et al 2002 , concluded that plantar fasciitis is repetitive stress injury of the medial

arch and heel. It is one of the most common causes of foot pain. Plantar fasciitis was found

to be a common occupational or sport related repetitive strain injury[41]

Intervention:

MYOFASCIAL RELEASE TECHNIQUE

Renan-Ordine R, Alburque-Sendin F et al , 2011 Conducted a randomized control trial

study to check out effectiveness of Myofascial release therapy for treating heel pain (plantar

fasciitis). 4 treatment sessions given each week for total 4 weeks and result concluded that

incorporation of Myofascial release technique before static Stretching is superior to isolated

stretching for improving function and decreasing pain in patients with plantar fasciitis.[42]

Paloni John 2009, in a study review Of Myofascial Release as an Effective Massage

Therapy Technique, supports the usage of Myofascial Release Technique for the treatment

of Myofascial pain. Myofascial pain can present in clinical settings and can mimic other

conditions. Literature relies on palpation, symptoms, and patient’s history as key to the

diagnosis of this condition . According to literature, applying an appropriate myofascial

technique can be a very effective therapy for myofascial pain. Results have shown a

decrease in pain, and an increase in range of motion for the joint acted by the affected

muscle.[43]

Suman Kuhar et al , 2007 Performed a randomized control trial study to check out

effectiveness of Myofascial Release in Treatment of Plantar Fasciitis using 30 subjects

randomly allotting into two groups. Group A received therapeutic ultrasound , contrast bath,

foot intrinsic muscles strengthening exercise , plantar fascia stretching exercise and Group B

received conventional treatment as group A added with myofascial release for 15 minutes

for 10 consecutive days and results concluded that myofascial release is an effective

therapeutic option in the treatment of plantar fasciitis.[44]

Adelaida Maria Castro sanchez, Guillermo A. Mataran-Penarrocha, Jose Granero-

Molina et al, 2007,in a study Benefits of Massage- myofascial Release therapy on pain ,

anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia and

concluded that myofascial release therapy reduces the sensitivity to pain at tender points in

patients with fibromyalgia, improving their pain perception[45]

Harlapur M A, Vijay B, Basavaraj Chandu 2007, in a study , Comparison of myofascial

release and positional release therapy in plantar fasciitis- A clinical trial stated that both

MFR and PRT along with ultrasound therapy for chronic plantar fasciitis showed

improvement following 10 days of treatment as per significant decrease in pain (VAS) and

improvement in functional ability as per FFI which can be effective treatment regime in

participants with chronic plantar fasciitis[46]

LOW DYE TAPING

Damien Nolan et al, 2009 conducted a study on 12 subjects with plantar fasciitis, low dye

taping was applied and exercise was done i.e. walking for 10 minutes at a normal pace and

concluded that low dye taping continues to have effect on medial forefoot even after 20

minutes exercise and use of low dye tape as an intervention for reducing excessive

pronation at subtalar joint[47]

Joel a Radford et al; 2006 concludes that Low-Dye taping is effective for the short-term

treatment of the common symptom of 'first-step' pain in patients with plantar heel pain.

Low-Dye taping could be used as an inexpensive short-term treatment for plantar heel pain

while patients wait for longer-term treatments, such as foot orthoses.[48]

Hyland MR , Webber - Gaffney A et al; 2006 . This study states that Calcaneal taping was

shown to be a more effective tool for the relief of plantar heel pain than stretching, sham

taping, or no treatment.[49]

Anne-Maree Keena et al, 2005 conducted a comparative a study on 105 participants to find

the effectiveness of low dye taping for the short term management of plantar fasciitis and

they concluded that in the short term, low dye taping significantly reduces the pain

associated with plantar fasciitis[50]

J. Saxelby, R. F, Betts et al; 1997 This small study suggests that Low-Dye taping has a

beneficial effect on the symptoms of plantar fasciitis but still larger study is required to

prove its efficacy.[51]

Stretching

David Sweeting et al; 2011 concluded that Inclusion of stretches directly to the plantar

fascia may provide better short-term pain relief than stretching the Tendo-Achilles alone.[52]

Joel A Radford* et al; 2007This study concluded that when used for the short-term

treatment of plantar heel pain, stretching for two weeks provides no statistically significant

improvements in 'first-step' pain, foot pain, foot function and general foot health.[53]

Digiovanni BF ,   et al;2006 This study supports the use of the plantar fascia-stretching  as

the key component of treatment for plantar fasciitis. Long-term benefits of the stretch

include a marked decrease in pain.[54]

Therapeutic Ultrasound

Robertson VJ, Baker KG (2001). They performed a systematic review of randomized

controlled trials in which ultrasound was used to treat people in conditions like

musculoskeletal injuries and soft tissue lesions. Each trial was assigned to investigate the

contributions of active and placebo ultrasound to the patient’s outcome measured. Thirty-

five randomized clinical trials were published. 10 of the 35 RCTS were judged to acceptable

methods using criteria based on those developed by Sackett et al. of these RCTS, the results

of two trials suggested that therapeutic ultrasound is more effective in treating some clinical

problems than placebo ultrasound, and the results of 8 trial suggest that it is not and

concluded there is little evidence that active therapeutic ultrasound is more effective than

placebo ultrasound for treating people with pain /a range of musculoskeletal injuries/ or for

promoting soft tissue healing.[55]

Outcome measures

Visual Analogue scale and foot function index

Boonstra AM et al ,2008, Performed a study to determine the reliability and validity of the

visual analogue scale for disability in patients with chronic musculoskeletal pain and they

concluded that the reliability of the VAS for disability is moderate to good and a strong

correlation with the VAS for pain.[56]

Mc Cormac HM, Horne DJ, Sheather S. (1998). In their study of critical review of

clinical application of visual analogue scale stated that visual analogue scale is established

as valid and reliable in range of clinical and research application[57]

Wu SH, Liang HW, Hou WH. 2008, Performed a study to evaluate the reliability and

validity of foot function index among patients with plantar fasciitis and the results

concluded the foot function index to be a very reliable and valid outcome measure to assess

pain and disability among patients with plantar fasciitis.[58]

Budiman Mak E, Conrad KJ, et al. [1991] Develop to measure the impact of foot

pathology on function in terms of pain, disability and activity restriction. The self

administered index consisting of 23 items divided into 3 sub- scales, were both total and

Sub – scales scores are produced and was examined for test – retest reliability internal

consistency, and construct and criterion validity. Strong correlation between the FFI total

and sub- scale scores and clinical measures of foot pathology supported the criterion validity

of the index.[59]

6.4 Objective of the study :

To study the effectiveness of low dye taping and Myofascial release technique

compared to low dye taping and stretching, to reduce pain in patients with plantar

fasciitis

7. Materials and Methods:

7.1 Source of data :

Physiotherapy Clinic, Dayananda Sagar college of Physiotherapy, Kumaraswamy

Layout, Bangalore

Sagar Hospital, Jayanagar, Bangalore

Sagar hospital, Banshankari, Bangalore

7.2 Method of collection of data: Population :Subjects diagnosed with plantar fasciitis

Sample design :Convenience sampling.

Sample size :50

Type of Study : Experimental with pre- post test design (Comparative study)

Duration : 6 months

7.3 INCLUSION CRITERIA:a. Clinically diagnosed cases of chronic plantar fasciitis

b. Age group = 18– 55 years

c. Both genders included in the study

7.4 EXCLUSION CRITERIA:a. Previous surgical history for plantar fascia

b. History of pathologies around ankle /foot

c. History of recent fractures around ankle/ foot

d. History of surgery ankle/ foot

e. History of auto immune or systemic inflammatory disorders

f. Subjects with fixed deformities of foot/ ankle and knee joint.

g. Subjects with impaired circulation to lower extremities, peripheral neuropathies, etc.

h. Subjects with neurological disorders leading to impaired balance and coordination.

i. Subjects with fragile thin healing skin or tissue that is susceptible to stress injury.

j. Corticosteroids injection in heel preceding 3 months

7.5 Materials required :

Adhesive tape

Spirit

Cotton

Scissors

Pillow

Therapeutic Ultrasound

Ultrasound Gel

Towels

Treatment couch

Hot pack

Pen and Paper

MEASURING TOOLS: Visual Analog Scale (VAS)

Foot Function Index (FFI)

7.6 METHODOLOGY

Intervention to be conducted on participantsSubjects who fulfill the inclusion and exclusion criteria will be randomly divided into two

Groups by simple random sampling, Group A and Group B. Informed consent will be taken

from each of the subjects prior to participation. Instructions will be given to the subjects

about techniques performed.

This will be followed by Subjective as well as Objective assessment of the involved foot for

tenderness, temperature, swelling, pain and its intensity in terms of the Visual Analog Scale

(VAS). In addition to this functional assessment will be carried out using Foot Function

Index (FFI).

A total of 50, Group A (n=25) and Group B (n=25). Group A will receive myofascial

release technique with low dye taping along with therapeutic ultrasound and Group B will

receive myofascial release technique and therapeutic ultrasound.

Before & after intervention pain assessment will be taken by Visual Analogue scale (VAS)

every day. Functional assessment will be taken by using Foot Function Index (FFI)

Testing procedure:

Group A:  

Will receive therapeutic ultrasound, Myofascial release technique and low dye taping

Therapeutic Ultrasound : Ultrasound with the output of 1W/cm2 for 7 minutes using

a pulsed mode 1: 1 ratio with frequency of 1MHz for 5 times a week for 2 weeks.

Myofascial Release Technique : For myofascial release technique, the patient is

asked to lie down prone on a couch with their feet out of the couch. A pillow will be

placed under their feet for support and comfort. The area of the treatment will be

cleaned and dried. The therapist will evaluate the area of treatment. The therapist will

stand near the foot end of the patient. Sustained gentle pressure in the line with the

fibres of the platar fascia from calcaneum towards the toes, using the thumb will be

given This pressure will be held for 90 seconds. This myofascial release technique

will be given for 15 minutes per session with 1 minute of rest interval for 5 days per

week. the total treatment period will be for 2 weeks.[60]

Low Dye Taping : The patient will be made to lie down in supine position with the

talocrural joint placed in neutral position over the end of the couch. The patient will

be instructed to slightly supinate the subtalar joint of the affected foot and maintain

the position during the procedure. The skin will be cleaned with alcohol, and the tape

was applied directly to the skin. The adhesive tape will be applied just proximal to the

lateral aspect of the fifth metatarsal head and wrapped around the posterior aspect of

the calcaneum, and attached just proximal to the medial aspect of the first metatarsal

head. The two additional strips of adhesive tape will be applied in the same direction

as the first, overlapping the initial tape strip by one-quarter inch. Later the medial

longitudinal arch of the foot will be filled with three to four strips of the adhesive

tape, the initial strip will be placed just proximal to metatarsal heads on the lateral

side of the foot and passing under the medial longitudinal arch to the dorsum of the

foot and the last strip ending just distal to the tendon of the anterior tibialis. [61]The

tape may remain in place 1-3 days before next application.[62]

Group B:  

Will receive therapeutic ultrasound, stretching and low dye taping

Therapeutic Ultrasound : Ultrasound with the output of 1W/cm2 for 7 minutes using

a pulsed mode 1: 1 ratio with frequency of 1MHz for 5 times a week for 2 weeks.

Stretching: Stretching is given specific to plantar fascia. the patient is asked to lie

supine and made comfortable. the therapist supports the patient’s ankle with his one

hand. with the other hand he dorsiflexes the toes , holding the metatarsophalengeal

joint and stretches to the plantar fascia, till the patient feels the stretch on the plantar

fascia the stretch is checked by palpating tension over plantar fascia. the stretch is

hold for 30 seconds each for 10 times[63]

Low Dye Taping : The patient will be made to lie down in supine position with the

talocrural joint placed in neutral position over the end of the couch. The patient will

be instructed to slightly supinate the subtalar joint of the affected foot and maintain

the position during the procedure. The skin will be cleaned with alcohol, and the tape

was applied directly to the skin. The adhesive tape will be applied just proximal to the

lateral aspect of the fifth metatarsal head and wrapped around the posterior aspect of

the calcaneum, and attached just proximal to the medial aspect of the first metatarsal

head. The two additional strips of adhesive tape will be applied in the same direction

as the first, overlapping the initial tape strip by one-quarter inch. Later the medial

longitudinal arch of the foot will be filled with three to four strips of the adhesive

tape, the initial strip will be placed just proximal to metatarsal heads on the lateral

side of the foot and passing under the medial longitudinal arch to the dorsum of the

foot and the last strip ending just distal to the tendon of the anterior tibialis. [61] The

tape may remain in place 1-3 days before next application.[62]

All the subjects will be advised to use soft heel foot wear, not to stand for long time and not

to walk bare foot. Subjects will be put on home exercise program.

Outcome Measures:

Visual Analog Scale

Foot Function Index

Statistics:

Statistical analysis will be performed by using SPSS software for windows (version

17) & probability value (p value) will be set as 0.05

Descriptive statistics will be used to find out mean, standard deviation for

demographic & outcome variable.

Wilcoxon Signed Rank test will be used to find out the significant difference for

ordinal scale within the groups.

Mann-Whitney U test will be used to find out the significant difference for ordinal

scales between the groups.

Microsoft word, excel will be used to generate graphs & tables, etc.

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9 Signature of Candidate :

10 Remarks of the Guide :

11 Name and Designation of

11.1 Guide : DR. MATHEW ANAND

11.2 Signature :

11.3 Co-Guide : DR. SRIHARI SHARMA K.N

11.4 Signature :

11.5 Head of Department : DR ANIL T. JOHN

11.6 Signature :

12 12.1 Remarks of the Chairman & Principal:

12.2 Signature :

DAYANANDA SAGAR COLLEGE OF PHYSIOTHERAPY

THE INSTITUTIONAL ETHICAL COMMITTEE

ETHICAL CLEARENCE CERTIFICATE

The Institutional Ethical Committee of Dayananda Sagar College of Physiotherapy has

reviewed the research proposal of Mr. Sanjay Paul, MPT student, Dayananda Sagar College

of Physiotherapy, Kumaraswamy layout, Bangalore –78, certificates that the research proposal is

ethically satisfactory.

Reference: Ethical guide lines for biomedical resource on human Council Of Medical

Research.

New Delhi- 2000

CHAIR PERSON SECRETARY

Basic medical scientists:

1)

2)