[ research report ]

ANAT SHASHUA, MPT1 • SHLOMO FLECHTER, MD, PhD2 • LIAT AVIDAN, BPT1
DANI OFIR, BPT1 • ALEX MELAYEV, BPT1 • LEONID KALICHMAN, PT, PhD3

The Effect of Additional

Ankle and Midfoot Mobilizations
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on Plantar Fasciitis:
A Randomized Controlled Trial

H
eel pain is a common phenomenon, occurring in approximately microscopic tears when it inserts into the
10% of the population over a lifetime,7,10,28 and the leading calcaneus. This condition is better re-
ferred to as fasciopathy or fasciosis.7,17,28
cause of treatment for foot and ankle pathologies.33 Of
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Plantar fasciitis is characterized by pain

the pathologies that cause heel pain, the most common at the bottom of the heel and along the
is plantar fasciitis (PF).33 To date, it has been demonstrated that medial border of the plantar fascia.7,28,33
this condition is not characterized by inflammation but rather by The pain is usually aggravated in the
noninflammatory degenerative changes of the plantar fascia that cause morning, with the first step after get-
ting out of bed or after prolonged sitting
(non–weight bearing).
TTSTUDY DESIGN: A single-blind randomized TTRESULTS: No significant difference was found
The literature suggests several hy-
controlled trial. between groups in any of the outcomes. Both
potheses as to the factors that may con-
TTOBJECTIVE: To evaluate the efficacy of ankle groups showed a significant difference in the
Journal of Orthopaedic & Sports Physical Therapy®

numeric pain-rating scale and Lower Extrem-

and midfoot mobilization on pain and function of
patients with plantar fasciitis (PF).
TTBACKGROUND: Plantar fasciitis is a degenera-
tive process of the plantar fascia, with a lifetime
prevalence of approximately 10%. Limited ankle
dorsiflexion is a common finding and apparently
acts as a contributing factor to the development
of PF.
TTMETHODS: Fifty patients with PF, aged 23
to 73 years, were randomly assigned to either
the intervention or control group. Both groups
received 8 treatments, twice a week, consisting of
stretching exercises and ultrasound. In addition,
the intervention group received mobilization of
the ankle and midfoot joints. Dorsiflexion range of
motion was measured at the beginning and at the
end of treatment. The results were evaluated by 3
outcomes: the numeric pain-rating scale, Lower
Extremity Functional Scale, and algometry.
ity Functional Scale. Both groups significantly
improved in dorsiflexion range of motion, with no
difference between groups.
TTCONCLUSION: The addition of ankle and foot
joint mobilization aimed at improving dorsiflex-
ion range of motion is not more effective than
stretching and ultrasound alone in treating PF. The
association between limited ankle dorsiflexion and
PF is most probably due to soft tissue limitations,
not the joints. Trial registered at ClinicalTrials.gov
(registration number NCT01439932).
TTLEVEL OF EVIDENCE: Therapy, level 1b. J Or-
thop Sports Phys Ther 2015;45(4):265-272. Epub 4
Mar 2015. doi:10.2519/jospt.2015.5155
TTKEY WORDS: ankle joint, dorsiflexion, joint
mobilizations, plantar fascia
tribute to PF, divided into external factors
(eg, as prolonged standing, inappropriate
footwear, previous injuries, and high-
load running) and internal factors (eg,
anatomical and biological characteristics
comprising limited first metatarsopha-
langeal joint movement, limited ankle
dorsiflexion [DF], asymmetric leg length,
thickening of the plantar fascia, foot hy-
perpronation, weakness of calf muscles,
spur, older age, and a high body mass
index).19
A number of studies have indicated
that limited ankle DF may be a factor
associated with PF,22,25,29,33 which may
cause, as a compensation, increased stress
on the plantar fascia. This hypothesis is
based on the theory that ankle DF of less

1
Bat-Yamon Physical Therapy Clinic, Clalit Health Services, Tel Aviv, Israel. 2Bat-Yamon Medical Center, Clalit Health Services, Tel Aviv, Israel. 3Department of Physical Therapy, The
Leon and Matilda Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. The study was approved
by the Helsinki Committee of Clalit Health Services and registered on the National Institutes of Health website ClinicalTrials.gov (registration number NCT01439932). The authors
certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the
article. Address correspondence to Anat Shashua, 10 Feldman Street, Nes-Ziona 74058 Israel. E-mail: Anatsh6@clalit.org.il t Copyright ©2015 Journal of Orthopaedic & Sports
Physical Therapy®

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 [ research report
than 10° during gait may cause abnormal
compensatory pronation of the subtalar
joint, which in turn may increase stress
on the plantar fascia.16,19 Three stud-
ies have specifically examined ankle DF
range of motion. Riddle et al29 found that
limited ankle DF significantly increased
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the risk of PF. The other 2 studies found
no significant difference between a case
group with PF and a control group with-
out PF.18,26,30 Therefore, additional stud-
ies are needed to evaluate the possible
association of ankle DF range of motion
with PF.
Treatment options for PF are contro-
versial.8,10,19,25 The Cochrane review from
201010 examined 19 randomized trials
that included treatment by steroid injec-
tions, shockwaves, night splints, orthot-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ics, and heel pads. Most of the treatment
options produced a marginal advantage
compared to no treatment or a control
treatment, such as stretching. Guide-
lines of the Orthopaedic Section of the
American Physical Therapy Association
from 200825 cited additional treatments
but also found no clear advantage to
these treatments compared to a placebo
Journal of Orthopaedic & Sports Physical Therapy®
or control treatment, and a lack of strong
evidence from randomized controlled tri-
als to support them.
Manual therapy for PF includes soft
tissue manipulation techniques, mobi-
lization, and manipulation of the ankle
and foot joints. A number of case series
have demonstrated rapid improvement
in pain and function following mobiliza-
tion and manipulation techniques to the
talocrural, subtalar, and first tarsometa-
tarsal joints, supporting further study in
randomized controlled trials.25
In a randomized controlled trial by
Renan-Ordine et al,28 manual tech-
niques for soft tissue release combined
with stretching exercises were compared
with stretching exercise alone. It was as-
sumed that the presence of myofascial
trigger points in the calf muscles would
create stiffness and therefore reduce the
effectiveness of the stretching exercises.
They used trigger point pressure-release
and neuromuscular techniques over the
266 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy
45-04 Shashua.indd 266
gastrocnemius muscle. The outcomes
showed improvement in both groups,
with significant improvement in the in-
tervention group in physical function
(measured by the Medical Outcomes
Study 36-Item Short-Form Health Sur-
vey quality-of-life questionnaire) and
pain intensity (measured by pressure
pain threshold).
Cleland et al7 compared manual ther-
apy and exercise with electrophysical
therapy and exercise. The control group
was treated by iontophoresis with dexa-
methasone and stretching exercises. The
intervention group received the same
stretching exercise protocol combined
with various manual techniques, includ-
ing soft tissue massage; mobilization;
and manipulation of the talocrural joint,
rearfoot complex, tibiofibular joint, and
intertarsal joint. When knee or hip joint
impairments were found, manual tech-
niques were performed. The outcome
measures included 2 patient self-report
questionnaires (the Lower Extremity
Functional Scale [LEFS] and the Foot
and Ankle Ability Measure) and a numer-
ic pain-rating scale (NPRS) for heel pain.
The manual therapy group demonstrated
a significant improvement in pain and
function outcomes. Due to the diverse
manual techniques (soft tissue as well
as joint mobilizations) and involvement
of joints distant from the foot (knee and
hip), it was difficult to conclude whether
the joint mobilizations applied on ankle
and foot joints had any therapeutic effect.
To date, studies have mainly report-
ed on soft tissue techniques to improve
range of motion in patients with PF. Pre-
vious studies found that ankle joint mobi-
lization and manipulation improved the
range of ankle DF.2 Despite the evidence
that limited ankle DF may be a contribut-
ing factor to PF,22,25,33 no interventional
study has examined the direct correlation
between increase in ankle DF following
treatment and decrease in PF symptoms.
The aim of this study was to evaluate
the effect of ankle, subtalar, and midfoot
joint mobilizations on pain and function
in patients with PF. We hypothesized that
]
mobilization of these joints, in addition
to conventional physical therapy, would
significantly improve pain and function
in patients with PF, as opposed to con-
ventional treatment alone.
METHODS
Design
A
n interventional, prospective,
single-blind randomized controlled
trial.
Setting
All study procedures were performed at
the Bat-Yamon Physical Therapy Clinic of
Clalit Health Services, Tel Aviv District,
Tel Aviv, Israel.
Sample
Recruitment occurred from October 2011
through December 2012 (a period of 15
months). The study participants were
enrolled and recruited from patients who
were receiving physical therapy treatment
and were diagnosed with PF or a calcane-
al spur. Inclusion criteria were as follows:
aged 18 to 75 years, pain at the bottom
of the heel generated by pressure, and an
increase in pain (NPRS, greater than 3)
in the morning on taking a few steps or
after prolonged non–weight bearing. Ex-
clusion criteria were as follows: tumors,
prolonged use of steroids, below-the-
knee fracture occurring during the last
year, prior foot surgeries, tarsal tunnel
syndrome, fat-pad syndrome, pregnancy,
and not being available in the coming
month. The study was approved by the
Helsinki Committee of Clalit Health Ser-
vices in Meir Hospital, Kfar Saba, Israel.
All patients signed an informed-consent
form prior to participation, and the rights
of the subjects were protected. The study
was registered at ClinicalTrials.gov (reg-
istration number NCT01439932).
Sample-Size Estimation
The sample-size calculation was per-
formed by using an online power/
sample-size calculator (http://stat.ubc.
ca/~rollin/stats/ssize/n2.html). Calcu-
3/18/2015 4:52:07 PM
 lations were based on the following pa-
rameters: 2-sided test, power of 0.80,
alpha of .05, a difference of 1.4 between
the average NPRS scores of the 2 groups,
and standard deviation of 1.5 (NPRS and
standard deviation data were taken from
a previous study).7 The effect size was
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0.93. The number of subjects in each
group, according to this calculation, was
20. Due to the possibility of dropouts, 50
participants were recruited to provide
approximately 25 participants per group.
Allocation
Participants were randomly assigned to
groups following a simple randomization
procedure. Fifty opaque, sealed envelopes
were prepared in advance, containing
cards with the name of the study group, of
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
which 25 were for the control group and
25 for the intervention group. All sealed
envelopes were thoroughly mixed. At the
end of baseline evaluation, the examiner
randomly picked up the consequent en-
velope and gave it to the physical thera-
pist who performed the treatment. Cards
with a group name were returned to the
examiner at the end of the study, after all
Journal of Orthopaedic & Sports Physical Therapy®
evaluations were completed. The exam-
iner was blinded to patient allocation.
Outcome Measures
Baseline and final assessments were per-
formed by a physical therapist (A.S., the
examiner) who was blinded to the study
group.
Baseline evaluation included demo-
graphic data collection, medical history,
and physical examination. Demographic
data included age, sex, weight, height,
body mass index (kg/m2), history, physi-
cal activity (participation, type of activ-
ity, and hours per week), occupation, and
general health of the patient. Physical
examination included observation of gait
pattern (categorized as normal, limp-
ing, toe touch, or other). Palpation was
performed for local heat or swelling and
for local pain at the medial calcaneal tu-
berosity. Participants with clinical symp-
toms of pain in the middle of the heel
that were aggravated by walking on hard
journal of orthopaedic & sports physical therapy | volume 45 | number 4 | april 2015 | 267
45-04 Shashua.indd 267
surfaces or with a history of heel trauma
were excluded for suspicion of fat-pad
syndrome.8,33 Three signs to differen-
tially diagnose tarsal tunnel syndrome
were assessed to exclude this pathology:
presence of numbness or burning pain,1
Tinel sign, and neurodynamic test. The
Tinel sign was found to be positive in tar-
sal tunnel syndrome and medial plantar
nerve entrapment by Schon and Baxter
in 1990.32 The modified straight leg raise
test with ankle DF/eversion was found to
be a valuable tool to differentiate plan-
tar heel pain of neural origin from other
common conditions such as PF.1,23 Be-
cause none of these tests can provide an
accurate answer, any participant with a
positive test of tarsal tunnel syndrome
was excluded.
Dorsiflexion range of motion was
measured in both legs (FIGURE 1). Mea-
surement was performed in the lunge
position. The patient stood against the
wall with the measured leg in front and
toes pointing to the wall. The patient was
asked to maximally bend the knee toward
the first toe without lifting the heel. An
inclinometer was placed on the anterior
aspect of the tibia, and the recorded angle
to the vertical was the ankle DF. The high
reliability (intraclass correlation coeffi-
cient [ICC] = 0.96-0.99) of this method
has been previously demonstrated, with
a minimal clinically important difference
(MCID) of 3.7° to 3.8°.24
Finally, the 3 outcome measures—the
NPRS, LEFS, and algometry—were con-
ducted. The NPRS is a valid and reliable
tool for assessing pain intensity20,21,27 and
is a common outcome in PF studies.7,13,34
Pain score according to the NPRS (0-10),
taken during the first steps in the morn-
ing, was the primary outcome (0 as “no
pain” and 10 as “very severe pain”). The
MCID has been shown to vary between
1.7 points14 and 2 points31 for chronic
musculoskeletal pain. Pain score was
measured 4 times during the study: at
baseline, after 4 sessions, at the end of all
treatment sessions, and after a 6-week
follow-up.
The LEFS consists of 20 questions in-
FIGURE 1. Methods of ankle dorsiflexion evaluations.
volving everyday functional activities and
is used to assess lower extremity disor-
ders. The questionnaire was developed by
Binkley et al in 19994 and found to have
high reliability and validity (test-retest
reliability, 0.94; 95% lower-limit con-
fidence interval [CI]: 5.89 and correla-
tion with the quality-of-life questionnaire
Medical Outcomes Study 36-Item Short-
Form Health Survey, 0.8; 95% lower-
limit CI: 5.73). The maximum score
indicating a high functional level was 80,
and the MCID was 9 points (90% CI).4
The questionnaire was translated into
Hebrew and validated as part of a com-
puterized adaptive evaluation system.11,12
The LEFS score was measured 4 times
during the study: at baseline, after 4 ses-
sions, at the end of all treatment sessions,
and after a 6-week follow-up.
Algometry measures the minimum
pressure required to produce pain and
consists of a flat, 1-cm2 disc connected
to a manometer. The disc was placed
vertically on the point of pain, with the
therapist increasing the pressure inten-
sity until the initial pain appeared (when
the feeling of pressure became painful).
The score was determined by averaging
3 repeated measurements, with a 30-sec-
ond break between each. Algometry fa-
cilitates an objective assessment of pain
3/18/2015 4:52:08 PM
 [ research report ]
during our study: at baseline and at the
Subjects with PF screened for end of all treatment sessions.
eligibility, n = 78
Intervention
Treatments were performed by 3 physi-
Subjects excluded, n = 25 cal therapists at the Bat-Yamon Clinic.
• Absence of pain at first steps The physical therapists had at least 3
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in the morning, n = 7 years of experience and appropriate

• Language difficulties, n = 6
• Unavailability, n = 5
• Age, n = 3
• Previous foot fracture/
surgery, n = 2
• Health condition, n = 2
Subjects meeting the inclusion
criteria, n = 53
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
training. In the present study, partici-
pants in both groups received 8 sessions
over a 4-week period. Both groups re-
ceived explanations and training as to
stretching exercises for the plantar fascia
and triceps surae muscles. Throughout
the study, patients were asked to perform
2 sets, lasting 30 seconds, 3 times a day
for each exercise, as recommended by
previous studies7,25 (APPENDIX A, available
at www.jospt.org). All patients received

information and guidance for practice

Agreed to participate and signed at home.
informed consent, n = 50 Participants in both groups received
therapeutic ultrasound over the most
tender area. Despite lack of randomized
controlled trials and weak evidence sup-
Randomization
porting therapeutic ultrasound efficacy in
the management of PF, clinicians contin-
ue to use this therapy. It is a popular and
Control group, n = 25 Intervention group, n = 25
Journal of Orthopaedic & Sports Physical Therapy®

common treatment among physical ther-

Midterm evaluation (after 4
sessions), n = 23
• Dropped out due to
dissatisfaction, n = 2
End-of-treatment evaluation, n = 23
6-wk follow-up evaluation, n = 23
FIGURE 2. Flow diagram of subject recruitment and retention. Abbreviation: PF, plantar fasciitis.
in addition to the NPRS, a subjective
assessment. Algometry was found to be
valid and reliable in repeated measure-
ments (interrater, intrarater) over normal
muscles in healthy people, with an MCID
Midterm evaluation (after 4
sessions), n = 24
• Dropped out due to family
problem, n = 1
End-of-treatment evaluation, n = 23
• Dropped out due to health
problem, n = 1
6-wk follow-up evaluation, n = 23
of 14.71 to 19.61 N/cm2.15 Chesterton et
al6 found high reliability when the 3 re-
peated measures were averaged: ICC =
0.91 (95% CI: 0.82, 0.97); MCID, 17.39
N/cm2. Algometry was measured twice
apists worldwide7 and in the Clalit Health
Services, the largest health care provider
in Israel (Clalit internal statistics). The
following parameters were used: frequen-
cy of 1 MHz, 1.5 W/cm2, 50% pulses for 5
minutes. Dosage was calculated based on
previous studies, the manufacturer’s pro-
tocol, and guidelines published at www.
electrotherapy.org.
In addition, the intervention group re-
ceived a number of manual techniques,
including anterior/posterior talocrural
joint mobilization under both weight-
bearing and non–weight-bearing condi-
tions, for improving DF range of motion,
subtalar joint mobilization for eversion
and inversion, and mid-tarsal mobiliza-
tion for pronation and supination of the
midfoot. Each technique was executed for
1 to 1.5 minutes (a total of 5 minutes per
manual treatment) (APPENDIX B, available
at www.jospt.org). At the end of all treat-
ment sessions, all patients underwent

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45-04 Shashua.indd 268 3/18/2015 4:52:09 PM

 reassessment, which included symptom
behavior, gait pattern, DF range of mo- TABLE 1 Demographic and Baseline Characteristics*
tion, and the 3 outcome measures. The
NPRS morning score and LEFS ques-
tionnaire were carried out after 4 sessions Variables Intervention Group (n = 25) Control Group (n = 25)
and by telephone 6 weeks after cessation Sex, n (%)
of treatment.
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Female 18 (72) 17 (68)

In patients with bilateral PF, only
Male 7 (28) 8 (32)
the more painful foot was used for this
Age, y 54.16  13.04 48.48  11.68
study. The other foot received standard
treatment, and data on this foot were not BMI, kg/m2 29.00  4.79 30.36  4.42
collected. Symptom duration, mo 5.28  4.54 6.54  5.69
Dorsiflexion RL, deg 39.88  8.96 39.68  6.14
Statistical Analysis Dorsiflexion OL, deg 39.88  9.63 41.80  5.99
Statistical analysis was performed using
NPRS (0-10) 7.76  2.03 8.12  1.72
SPSS Version 17 for Windows (SPSS Inc,
LEFS (0-80) 40.00  16.48 48.16  17.06
Chicago, IL). The outcome variables and
DF range of motion were compared us- Algometry, Pa 423.17  176.42 365.52  200.65
ing a repeated-measures approach for Abbreviations: BMI, body mass index; LEFS, Lower Extremity Functional Scale; NPRS, numeric
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

pain-rating scale; OL, other leg; RL, reference leg.

the main effect of time and the group-
by-time interaction. Comparisons to pa-
tients with limited DF were performed
with the Mann-Whitney U test for non-
parametric variables due to the small
number of subjects in each group. All
statistical analysis was conducted us-
ing the intention-to-treat approach. The
missing-completely-at-random test con-
Journal of Orthopaedic & Sports Physical Therapy®
*Values are mean  SD unless otherwise indicated.
found in other baseline characteristics
between dropouts and other participants.
Thirty-six patients attended all 8 sessions
(18 patients from each group), 4 patients
attended 7 of 8 sessions (2 patients from
each group), 4 other patients attended
No significant correlation was found
between improvement in DF range of
motion and improvement in NPRS and
LEFS scores (P = .395 and P = .066,
respectively). For the within-group
comparison, NPRS and LEFS scores

firmed that data were missing at random,
and the missing values were replaced by
predicted values using the expectation
maximization technique.
RESULTS
6 of 8 sessions (2 patients from each
group), and 2 other patients attended 5
of 8 sessions (1 patient from each group).
The reasons for not attending all sessions
were unavailability, satisfactory improve-
ment, or lack of improvement.
Initially, baseline data were compared,
improved significantly in both groups
(P<.001 and P = .001, respectively). No
difference was found in algometry in both
groups. Dorsiflexion range of motion was
measured twice during the study, before
intervention and at the end of all treat-
ment sessions. Both groups significantly

S
eventy-eight patients with PF
were screened during the study pe-
riod. Twenty-five did not meet the
inclusion criteria and 3 refused to partici-
pate. Fifty patients (15 men, 35 women;
age range, 23-73 years; mean  SD age,
and no differences were found between
groups in all baseline characteristics
(TABLE 1).
In the group-by-time interaction, no
significant difference was found in any of
the 3 outcomes, as well as in DF range of
improved in DF range of motion in the
reference leg (intervention group, 2.16°;
P = .006; control group, 2.96°; P = .023).
DISCUSSION

51.32  12.58 years) met the inclusion
criteria and were included in the study.
Duration of symptoms ranged from 1
to 24 months (mean  SD, 5.91  5.13
months). Forty-six patients completed
the study and 4 dropped out (1 man and 1
woman from the intervention group and
2 women from the control group) (FIGURE
2). The age range of the dropouts was
29 to 45 years (younger on average than
other participants). No differences were
motion (TABLE 2).
In the comparison between patients
whose DF range of motion was initially
limited (less than 35°) and patients with
a DF range of motion of 35° or greater,
a significant difference was found in the
relative change of the DF range of mo-
tion in favor of the limited patients (P
= .021). No difference was found in the
relative change in NPRS and LEFS scores
between these subgroups.
M
obilization of the ankle, sub-
talar, and midfoot joints, in
conjunction with conventional
physical therapy, did not improve pain
and function more than conventional
treatment alone in patients with PF. Both
the NPRS and LEFS showed continuous
improvement throughout all measure-
ment points in both groups, with no
difference between them. Although the
intervention group demonstrated greater

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 [ research report ]

TABLE 2 Summary of Findings for Group-by-Time Interaction*

Mean Difference Group-by-Time Main Effect

Baseline After 4 Sessions End of Treatment 6-wk Follow-up Between Groups† Interaction‡ of Time‡
NPRS (0-10) 0.09 (–1.14, 1.32) P = .490 (0.051) P<.001 (0.502)
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Intervention group 7.76  2.03 7.16  2.36 5.6  3.3 4.68  3.38
Control group 8.12  1.77 6.68  1.89 5.28  2.88 4.76  3.41
LEFS (0-80) 5.89 (–3.69, 15.47) P = .161 (0.105) P<.001 (0.508)
Intervention group 40.00  16.48 43.12  18.47 47.6  19.38 55.96  19.45
Control group 48.16  17.06 51.88  17.35 52.32  19.69 57.88  18.03
Algometry, Pa 61.74 (–42.71, 166.18) P = .828 (0.001) P = .072 (0.069)
Intervention group 423.17  176.43 ... 461.74  184.98 ...
Control group 365.52  200.66 ... 395.92  198.94 ...
Dorsiflexion, deg§ 0.2 (–4.03, 4.43) P = .573 (0.007) P = .001 (0.216)
Intervention group 39.88  8.96 ... 42.04  8.83 ...
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Control group 39.68  6.14 ... 42.64  7.09 ...

Abbreviations: LEFS, Lower Extremity Functional Scale; NPRS, numeric pain-rating scale.
*Values are mean  SD unless otherwise indicated.
†
Values in parentheses are 95% confidence interval.
‡
Values are P value (effect size). Significant at P<.05.
§
Refers to the reference leg.

improvement in LEFS scores, no statis- in some patients with PF the pain area effect of mobilization on pain and func-
tical or clinical differences were found; may slightly vary, algometry might not be tion outcomes in patients with PF and
therefore, we assume that the lower the an applicable outcome for PF. found that patients treated with joint
Journal of Orthopaedic & Sports Physical Therapy®

baseline functional score, the greater the
potential for improvement favoring the
intervention group in this case.
In algometry, which also measured
pain intensity, no difference was found
between or within groups. This finding
is not consistent with a previous study of
PF that found an association between im-
provement in algometry and in the Medi-
cal Outcomes Study 36-Item Short-Form
Health Survey quality-of-life score.28 Pos-
sible reasons for this finding may be due
to difficulty in focusing on the specific
pain point of the patient.
In the present study, according to the
patient’s subjective report, the most pain-
ful point occurred at the medial anterior
heel, near the medial calcaneal tuberos-
ity. It is possible that in some patients, the
sensitivity at that point decreased during
treatment and the second measurement
was performed at a different point. In
addition, we used a 1-cm2 pressure disc,
which required a precise point. Because
Out of 46 patients who completed the
study, 29 improved in pain intensity and
18 improved in function. These findings
are consistent with previous studies dem-
onstrating the effectiveness of this conven-
tional treatment, stretching exercises, and
therapeutic ultrasound in treating PF.7,25,28
Previous studies (mainly case-control
designs) have found an association be-
tween DF range of motion and PF.19,29
Because the temporal relationship be-
tween DF range of motion and PF was
not examined, it is unclear whether their
findings of limited DF were a cause or
consequence. On the other hand, to our
knowledge to date, no study has assessed
the outcome effect of increased DF range
of motion on pain and function of pa-
tients with PF. Though stretching ex-
ercises—a common treatment in many
studies—can affect DF range of motion,
a correlation between this effect and the
change in outcome measures was not ex-
amined.7,25,28 Cleland et al7 examined the
mobilization had a positive outcome;
however, due to the abundance of tech-
niques and joints involved, they could not
determine which technique was superior
and which joint was the most relevant.
In the present study, we chose to fo-
cus on mobilization of the ankle and foot
joints, based on the assumption that lim-
ited DF is a contributing factor. Dorsi-
flexion range of motion increased in both
groups. Because there was no difference
between the groups, we assume that the
mobilizations did not affect DF range of
motion.
Bennell et al3 defined limited DF in
the lunge position as less than 35°. Ac-
cording to this definition, 10 patients in
this study had limited DF range of mo-
tion and 40 had normal DF range of mo-
tion at baseline. In independent-sample
t tests, the NPRS, LEFS, and DF range
of motion showed a significantly greater
improvement in the patients with lim-
ited DF. A significant difference was also

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45-04 Shashua.indd 270 3/18/2015 4:52:11 PM

 found in the relative change of DF in fa-
vor of the limited subgroup (P = .021). In
the limited DF subgroup, 6 patients were
from the intervention group and 4 were
from the control group. Using the Mann-
Whitney U test, a significant difference
was found in the relative change in NPRS
Downloaded from www.jospt.org at UCSF Lib & CKM/RSCS Mgmt on April 1, 2015. For personal use only. No other uses without permission.
in favor of the control group (P = .013).
No significant difference was found in
other parameters. Hence, no benefit was
achieved in patients with limited DF
who received mobilization versus those
who did not. However, due to the small
number of subjects, it is difficult to draw
a definite conclusion.
No significant correlations were found
between the relative change of DF range
of motion and the relative change of
NPRS and LEFS scores.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
There is conflicting evidence as to the
association between limited DF and heel
pain. In a systematic review by Irving et
al,18 the association between chronic heel
pain and possible etiological factors was
examined. No conclusive proof was found
to support the association between lim-
ited DF and PF. Only 1 of the 3 studies
included in the review found a significant
Journal of Orthopaedic & Sports Physical Therapy®
correlation.
In 2008, McPoil et al25 published
guidelines for treating heel pain. They
identified limited DF as one of the risk
factors for PF, based on the isolated study
of Riddle et al,29 who examined risk fac-
tors using a matched case-control design.
In that study,29 the experimental group in-
cluded 50 patients with unilateral PF and
the control group included 129 age- and
sex-matched subjects without PF. The au-
thors found that the risk for PF increased
as DF range of motion decreased; however,
due to the study design, causality (whether
limited DF caused PF or PF caused lim-
ited DF) could not be established.
Kibler et al22 examined strength and
flexibility in calf muscles of runners with
and without PF, comparing 3 groups:
a control group of runners without
symptoms, an experimental group of
runners with symptomatic PF (a symp-
tomatic leg), and the same group with
an a­symptomatic leg. A significantly lim-
journal of orthopaedic & sports physical therapy | volume 45 | number 4 | april 2015 | 271
45-04 Shashua.indd 271
ited range of motion in the symptomatic
leg of the experimental-group partici-
pants was found compared to the other
2 groups when measuring DF with the
knee extended. In the 2 aforementioned
studies, DF was measured with the knee
extended.
In contrast, Irving et al19 performed
a matched case-control study evaluating
the association between different risk
factors, including DF range of motion
measured in weight bearing, and heel
pain. No correlation was found between
limited DF and heel pain; moreover, DF
was significantly higher in the subjects
with heel pain compared with those in
the control group. This is in contrast to
previous studies in which individuals
with PF had limited DF. A possible ex-
planation for this contradiction may be
that in previous studies9,22,25,29 DF was
measured in non–weight bearing with
the knee extended. Thus, full dynamic
range of motion at the ankle joint could
not be achieved due to gastrocnemius
tension, which limits movement. There-
fore, it may be assumed that muscular
tension of the gastrocnemius, rather than
joint stiffness or muscular tension of the
soleus, contributed to DF limitation in
individuals with PF.
In the present study, we measured
DF with the knee flexed to prevent ten-
sion from the gastrocnemius muscle and
evaluate the full range of motion of the
joint. No correlation was found between
the relative change of DF range of mo-
tion and the relative changes in pain and
function outcomes. Furthermore, no
benefit was found using joint mobiliza-
tion techniques for improving this range
of motion. Therefore, we assume that the
joint stiffness is not associated with PF.
A recent study by Bolívar et al5 found
that subjects with contracture of the
posterior leg muscles (hamstrings, gas-
trocnemius, soleus) were more likely
to develop PF. This finding reinforces
our assumption that the main factor in-
volved in PF is muscle tension and not
joint stiffness.
We suggest that the association be-
tween limited DF and PF found in
previous studies originates from the
shortening of the gastrocnemius muscle
and not the limited ankle joint range of
motion. Therefore, treatment should be
focused on soft tissue techniques rather
than on foot and ankle joint mobilization.
Limitations
The reliability of the DF measurement
was not tested in the current study and
the parameters of this measurement were
based on the literature. For convenience,
follow-up examinations of the NPRS and
LEFS were performed by phone.
CONCLUSION
A
nkle and foot joint mobiliza-
tion aimed at improving DF range
of motion is not more effective than
ultrasound and stretching alone in treat-
ing PF. The association between limited
DF and PF most probably is based on calf
muscle shortening (mainly of the gastroc-
nemius) and not on ankle or foot joint
limitation. t
KEY POINTS
FINDINGS: A combination of stretching
exercises and therapeutic ultrasound (1
MHz, 1.5 W/cm2, 50% pulses for 5 min-
utes) was effective in decreasing pain
and improving function in patients with
PF. The addition of ankle and foot joint
mobilizations did not change the out-
come of the treatment.
IMPLICATIONS: The addition of ankle and
foot joint mobilizations should not be
implemented in standard physical treat-
ment of PF.
CAUTION: The reliability of DF measure-
ment was not tested in the current
trial. Follow-up examinations were
performed by phone call and could have
caused outcome bias.
ONLINE APPENDICES
Descriptions, dosages, and illustrations
of the exercise program and mobilization
techniques used in the study intervention
are available online at www.jospt.org.
3/18/2015 4:52:11 PM
 [ research report
ACKNOWLEDGEMENTS: The authors would like
to thank Oded Lewinsky, Director, Bat-Yamon
Physical Therapy Clinic, and Rafi Cohen, Di-
rector, Physical Therapy Services, Tel Aviv
District, Clalit Health Services, for support
and encouragement, the entire staff of physical
therapists at the Bat-Yamon Physical Therapy
Downloaded from www.jospt.org at UCSF Lib & CKM/RSCS Mgmt on April 1, 2015. For personal use only. No other uses without permission.
Clinic for assistance in the enrollment and re-
cruitment process, and Mrs Phyllis Curchack
Kornspan for her editorial services.
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 APPENDIX A

EXERCISE PROGRAM
Exercise Description Dosage Illustration
Gastrocnemius muscle stretch Step position against the wall with the refer- 2 stretches for 30
ence leg behind and the knee and foot facing seconds each,
straight forward. Lean forward toward the wall 3 times a day
while keeping the knee straight and the heel
on the floor until you feel tension at your calf
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Soleus muscle stretch Step position against the wall with the refer- 2 stretches for 30
ence leg behind and the knee and foot facing seconds each,
straight forward. Lean forward toward the wall 3 times a day
while keeping the knee bent and the heel on
the floor until you feel tension at your calf
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Plantar fascia stretch Sitting, put your reference leg across the other 2 stretches for 30
leg. Hold the toes with one hand and pull seconds each,
toward your shin until you feel tension along 3 times a day
your foot
Journal of Orthopaedic & Sports Physical Therapy®

APPENDIX B

MOBILIZATION TECHNIQUES
Mobilization Description Illustration
Non–weight-bearing AP The patient lies prone, the reference leg in 90° of knee flexion. The therapist
ankle joint mobilization stands at the reference leg’s side while one hand stabilizes the tibia and fibula
behind the ankle toward the malleoli and the second hand grasps the midfoot
and performs AP movement. If the patient cannot lie prone, the technique will
be performed supine, with the foot out of bed. The therapist stabilizes the tibia
and fibula behind the ankle toward the malleoli with one hand while the other
hand grasps around the talus and performs AP movement

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Mobilization
Weight-bearing AP ankle
joint mobilization
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Eversion/inversion of
subtalar joint
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Pronation/supination of
mid-tarsal joints
Journal of Orthopaedic & Sports Physical Therapy®
Abbreviation: AP, anterior/posterior.
A2 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy
45-04 Shashua.indd 2
APPENDIX B
Description Illustration
The patient stands in front of a chair while the reference leg is placed on it, with
the knee bent. The therapist stands in front of the patient and stabilizes his
foot toward the AP direction. A padded belt is placed around the patient’s
distal posterior calf and the therapist’s pelvis. The patient performs active
dorsiflexion while the therapist leans back and performs posterior/anterior
movement with the belt
First option: the patient lies prone, the reference leg in 90° of knee flexion. The
therapist stands at the reference leg’s side, grasps the foot around the cal-
caneus, and performs inversion and eversion movements by moving the calf
close and away while maintaining the foot parallel to the ceiling
Second option: the patient lies on the reference leg’s side while the foot, distal to
the talus, is out of bed. The therapist stabilizes the distal calf with one hand
and with the other hand grasps around the calcaneus and performs eversion
and inversion by movements toward the floor and the ceiling
The patient lies prone, the reference leg in 90° of knee flexion. The therapist
stands at the reference leg’s side and stabilizes the calcaneus and talus with
one hand while the other hand twists the mid-tarsal joints toward pronation
and supination
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