EFFECT OF MUSCLE ENERGY TECHNIQUE VERSUS CONVENTIONAL EXERCISE ON PAIN AND FUNCTIONAL OUTCOME IN SUBJECTS WITH PLANTAR FASCIITIS

ABSTRACT Background: The plantar fascia develops a degenerative disease called plantar fasciitis. The most prevalent cause of inflammation in the inferior heel is plantar fasciitis. Excessive stretching can develop plantar fasciitis, an inflammatory disorder of the plantar fascia that can cause ripping and inflammation of the fascia. Plantar fasciitis is considered the etiology of 11% to 15% of foot complaints that need medical attention. Plantar fasciitis affects two million people, resulting in one million outpatient visits per year. The aim of this study is to find out the effect of Muscle Energy Technique versus Conventional exercise on pain and functional outcome in subjects with Plantar Fasciitis. Methods: Subjects with plantar fasciitis were included based on the selection criteria. The plantar fasciitis pain/disability scale was used to calculate pre and post-test results. The subjects were randomly assigned into, Muscle Energy Technique group (n=30) followed by post isometric relaxation and reciprocal inhibition and received muscle energy technique and to Conventional exercise group(n=30) received stretching of calf muscle and plantar fascia and strengthening the intrinsic foot muscles followed by ultrasound for 15 minutes. Result: According to the statistical analysis, both groups had a statistically significant improvement between their pre and post values (p<0.0001). There was significant variation in postexercise results between the two groups (p<0.0001), indicating that muscle energy technique is more effective than conventional exercise. Conclusion: Muscle energy technique has been shown to be more effective than Conventional exercise at relieving pain and improving functional outcome. Keywords: Conventional; Muscle energy technique; Plantar fasciitis; Ultrasound. Abbreviations: MET – Muscle Energy Technique, PF- Plantar fasciitis, PFPS-Plantar Fasciitis Pain/Disability Scale, PIR- Post Isometric Relaxation, RI- Reciprocal Inhibition. A K, varshini- [email protected]

Background: The plantar fascia develops a degenerative disease called plantar fasciitis. The most prevalent cause of inflammation in the inferior heel is plantar fasciitis. Excessive stretching can develop plantar fasciitis, an inflammatory disorder of the plantar fascia that can cause ripping and inflammation of the fascia. Plantar fasciitis is considered the etiology of 11% to 15% of foot complaints that need medical attention. Plantar fasciitis affects two million people, resulting in one million outpatient visits per year. The aim of this study is to find out the effect of Muscle Energy Technique versus Conventional exercise on pain and functional outcome in subjects with Plantar Fasciitis. Methods: S ubjects with plantar fasciitis were included based on the selection criteria. The plantar fasciitis pain/disability scale was used to calculate pre and post-test results. The subjects were randomly assigned into, Muscle Energy Technique group (n=30) followed by post isometric relaxation and reciprocal inhibition and received muscle energy technique and to Conventional exercise group(n=30) received stretching of calf muscle and plantar fascia and strengthening the intrinsic foot muscles followed by ultrasound for 15 minutes. Result: According to the statistical analysis, both groups had a statistically significant improvement between their pre and post values (p<0.0001). There was significant variation in postexercise results between the two groups (p<0.0001), indicating that muscle energy technique is more effective than conventional exercise. Conclusion: Muscle energy technique has been shown to be more effective than Conventional exercise at relieving pain and improving functional outcome. Keywords : Conventional; Muscle energy technique; Plantar fasciitis; Ultrasound. Abbreviations : MET – Muscle Energy Technique, PF- Plantar fasciitis, PFPS-Plantar Fasciitis Pain/Disability Scale, PIR- Post Isometric Relaxation, RI- Reciprocal Inhibition.

A tough aponeurosis with fibrils called the plantar fascia. It emerges from the calcaneus plantar tuberosity, divides into three bands, then attaches into the proximal phalanges bases 11 . A taut bundle of connective tissue called the PF serves as a windlass to support the foot’s arch. An enthesopathy, plantar fasciitis arises at the closest connection and is defined as the interface between the tendon or ligament attachment and the bony surface (periosteal). The flexor digitorum brevis muscle, on the other hand, is located deep inside the plantar fascia and connects to the calcaneus proximally through a tendon enthesis 14 . The plantar fascia develops a degenerative disease called plantar fasciitis (PF) as a result a recurrent stress in the area where it originates on the calcaneus 9 . This is the most typical reason why the inferior heel irritates. The discomfort and suffering brought on by this ailment can significantly reduce one’s physical mobility 13 . Forceful contraction of the gastrocnemius and soleus muscles pulls the Achilles tendon onto the calcaneum, exerting pressure on the bone. This pressure leads to inflammation of the plantar fascia, causing plantar fasciitis 3 . Plantar fasciitis and medial heel pain result from inflammation and degeneration in the plantar fascia, primarily at its origin on the heel’s medial side. The plantar fascia is essential for arch support, weight transfer, energy conservation, and shock absorption during walking 16 . Plantar fasciitis, often termed ”policeman’s heel” typically impacts middle-aged or older individuals, especially women aged 40 to 70, who have higher body weight, flat feet, extremely high arches, or stiff Achilles tendons. 14 Plantar fasciitis accounts for approximately 11percent to 15percent (around 2 million cases) of foot complaints requiring medical attention. Plantar fasciitis typically starts with intense stabbing pain in the heel when first getting out of bed or after prolonged sitting, easing with weight bearing. Later in the day, a dull ache may spread to the forefoot or arch. Physical examination reveals persistent tenderness in the medial plantar heel and pain during passive foot and toe flexion (windlass test) 12 . The windlass mechanism is activated by dorsiflexion of the toes, particularly the hallux, which raises the longitudinal arch in the medial direction and passively stretches the plantar fascia 17 . During walking pushoff, dorsiflexion of the toes tightens the plantar fascia like a windlass, raising the arch by bringing the heel closer to the toes. This mechanism highlights the importance of addressing mechanical dysfunction alongside inflammation management in plantar fasciitis rehabilitation 6 . Muscle Energy Technique is said to be efficient for a variety of objectives, comprising stretching and increasing myofascial tissue extensibility, boosting the ROM of a limited joint, building muscle, and functioning as lymph or vascular pumps to help with the drainage of fluid on RI and PIR are the two basic modifications utilized in Muscle Energy Technique group 19 . MET is a technique in which the subject makes active use of muscles up against a unique opposing force from a controlled orientation and in a particular direction. Isometric contractions are included in PIR. In other words, the antagonist is restrained, and the intra-fibral space is extended by the agonist 2 . Only a few fibers are activated when resistance is applied with little effort (isometric contraction);the rest are inhibited. Stretching exercises effectively restore and enhance the muscle tendon units and attain the range of motion and flexibility needed for desirable functional activities 4 . Targeting symptomatic and at risk populations with strength training therapies can help alleviate plantar fasciitis and increase the strength of the intrinsic foot muscles 15 . Stretching the gastrocnemius muscle and plantar fascia can alleviate discomfort in cases of plantar fasciitis 7 .Techniques for gradually extending the plantar fascia and intrinsic foot muscles have been demonstrated to lessen plantar fasciitis discomfort 8 . However, PIR involves contracting the afflicted muscle, which is believed to be more beneficial in treating stiffness in the calf muscles. One of the main stays of treatment for plantar fasciitis is thought to be stretching the calf muscle and plantar fascia. Since the calf muscles and plantar fascia both insert onto the calcaneus, the purpose of a stretching programme is to release the tension that is placed on the plantar fascia, either by the calf muscles tightening the fascia or by the fascia itself being tight 5 . The high-frequency mechanical wave known as therapeutic ultrasound, delivers energy through vibration. Continuous mode is possible indicator when treating chronic plantar fasciitis 1 .

In this study, a group of 60 subjects diagnosed with plantar fasciitis was selected using convenient sampling from the Saveetha Institute of Medical and Technical Sciences. The study was approved by 01/033/2023/ISRB/SR/SCPT. The study was conducted on 60 subjects with plantar fasciitis for age 30-50 years and above include both male and female diagnosed with plantar fasciitis and subjects include positive windlass test and pain should last for 4 weeks and subjects were excluded having recent fracture or trauma to lower limb, Ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis and gout, Tarsal tunnel syndrome, Club foot, Calcaneal spur, Flat foot, Retrocalcaneal bursitis.These 60 participants were allocated into 2 groups. Participants in Group A performed Muscle Energy Technique along with ultrasound, while Group B performed Conventional exercises along with ultrasound. The treatment duration for both groups was given for thrice a day for two weeks. All the subjects underwent Pretest measurement with plantar fasciitis pain/ disability scale. The same was repeated for the posttest after 2 Weeks. INTERVENTION MUSCLE ENERGY TECHNIQUE GROUP: 30 subjects with plantar fasciitis were assigned with Muscle Energy Technique along with Ultrasound for 45 minutes per day.Two effective MET for plantar fasciitis: PIR and RI Post Isometric Relaxation: PIR for gastrocnemius, the subjects were in supine and the foot extended over the edge of the couch keeping the knee in full extension Subject’s ankle joint was dorsiflexed by the therapist’s hand until a resistance or discomfort was felt. This position was held and subject was asked to exert effort (isometric contraction using approximately 20% of force) towards plantar flexion for a period of 5 to 7 seconds with appropriate breathing, then resistance was slowly released and relaxation for a period of 10 seconds was given, during this relaxation period, ankle was passively dorsiflexed to a new barrier (gastrocnemius stretch =60seconds). PIR for soleus, same as gastrocnemius but the knee slightly in flexed position. Reciprocal Inhibition: The therapist places the subject’s foot support while they are in a supine position then the subject actively contracts the calf muscles by attempting to push the foot downward (plantarflexion) against the therapist’s resistance. After 5-7secs of contractions, the subject rest for 10 seconds, and the therapist assists in gently stretching the calf muscles (60seconds) by dorsiflexing the foot. MET group was given for 20 minutes with 10 minutes rest interval. Followed by the ultrasound therapy with the subject in prone position with the foot out of the couch. The parameter of 1 MHz frequency, 1.5 W/cm 2 intensity for 15 minutes of continuous mode was delivered to the subject. CONVENTIONAL EXERCISE GROUP: 30 subjects with plantar fasciitis were assigned with conventional exercise along with Ultrasound for 45 minutes per day. The stretching exercise includes calf muscles stretch and plantar fascia stretch and strengthening exercises include heel raise, towel curls, toe spread and dome, tennis ball exercise. Conventional exercise was given for 20 minutes (10 minutes stretching and 10 minutes strengthening) = 20 repetitions (2 sets) then 10 minutes rest. Followed by the same ultrasound therapy procedure. The treatment duration for both groups was given for thrice a week for two weeks.

The statistical analysis of quantitative data of the Muscle Energy Technique group and conventional exercise groups, as well as within the groups, showed a statistically significant variation. Table 1.1 shows the baseline characteristics of Muscle Energy technique group and Conventional exercise group. In Table 1.2, the statistical analysis of pre and post test of Muscle Energy Technique group Conventional group using PFPS, pre and post test values of mean 79.37 and 38.67, SD value of 11.36 and 14.20, P In Table 1.3, the statistical analysis of pre and post test of conventional exercise Conventional group using PFPS, pre and post test values of mean 79.70 and 42.20, SD value of 10.30 and 14.27, P In Table 1.4, the statistical difference of the Muscle Energy Technique group and conventional exercise subjects was evaluated by post values of PFPSand comparison of post test of MET group and conventional exercise test of mean 38.67 and 42.20 and;SD value of 14.20 and 14.27 and P value is equal to 0.3404. These values were considered to be extremely statistically significant. These differences indicated that the subjects received Muscle Energy Technique group, was highly effective in reducing plantar fasciitis.

”Plantar fasciitis” is the term for aggravation of the plantar fascia near the bottom of the foot’s origin, in contrast to pain that results from recurrent stress along the fascia’s length. Gastrocnemius equinus is a well-studied exacerbating medical condition for plantar fasciitis. It is known that the soleus and tight gastrocnemius muscles can change (Rabadi D et al., 2022) 15 . Muscle Energy Technique involve active patient participation to improve muscle function, range of motion, and reduce pain as well as subject bears the responsibility for the dosage that is administrated. MET can target specific muscles, lengthen tight muscles, and improve circulation. It can be applied to any area with voluntary movement. The patient’s effort can range from a slight twitch to a maximum contraction, lasting from milliseconds to seconds. Most individuals with plantar fasciitis recover with conservative treatment, which involves stretching and modifying or avoiding uncomfortable activities. The Plantar Fasciitis Pain/Disability Scale (PFPS) is a 19 item questionnaire that assesses pain severity and functional limitations in plantar fasciitis. It uses a 100-point scale and focuses on questions specific to plantar fasciitis pain and its impact on daily activities. This tool may be useful in diagnosing and evaluating plantar fasciitis pain Willis et al., (2009) 19 . According to Grieve R, et.al, in (2017)Physiotherapists adhered to investigation principles for plantar fasciitis but didn’t consistently use recommended outcome measures. The most reported care techniques were calf/hamstring stretches, counseling,and self therapy. However, due to potential response bias, uncertain response percentages, and a small sample size, it was difficult to determine if this method truly reflected clinical practice across the UK 7 . According to V.Chitara, et.al (2015) Impact of Muscle Energy Technique group on Pain and Lower Limb Functional Activity in Subjects with Planter Fasciitis Compared to Myofasial Release They found that the Muscle Energy Technique group and Myofasial Release were useful in reducing pain, raising PPT, and improving lower limb function in subjects with plantar fasciitis. Both treatments successfully decreased pain, boosted lower limb function, and improved PPT 3 . According to DH Kamonseki, et.al (2016) The study findings suggest that regular checkups led to improvements in discomfort, activity levels, and lower limb stability for subjects with plantar fasciitis across all three exercise regimens examined. Daily stretching was found to be effective, while combining stretching with strengthening did not yield significantly greater effects compared to stretching alone 9 . Tanwar R, et.al (2014) determines with their study that MET showed high rate of improvement in reducing pain and improving foot function index 18 . Hence the study compared the effect of Muscle Energy Technique group versus conventional exercise reduces pain and improves functional outcome in subjects with plantar fasciitis. The study concluded that Muscle Energy Technique group and conventional exercise are effective but Muscle Energy Technique group is more significantly effective.

This finding led to the conclusion that Muscle Energy Technique group along with ultrasound and conventional exercise along with ultrasound has effectiveness on reducing pain, improving functional outcome in subjects with plantar fasciitis, but the significant effectiveness was seen in Muscle Energy Technique group along with ultrasound.

AND RECOMMENDATIONS

The study was done in a short time with a small number of subjects and no proper follow up data was collected. RECOMMENDATIONS: To make the study more valid and long term with large sample size is recommended. Further studies are recommended to analyze the effects of other modified exercise regime. Regular follow up should be done. More outcome measures can be added. CONFLICT OF INTEREST: The author’s declared no conflict of interest. FUNDING: No Funding

1. Al-Siyabi, Z., Karam, M., Al-Hajri, E., Alsaif, A., Alazemi, M., Aldubaikhi, A. A., & Al-Hajri, E. S. (2022). Extracorporeal shockwave therapy versus ultrasound therapy for plantar fasciitis: a systematic review and meta-analysis. Cureus, 14(1). DOI: 10.7759/cureus.20871 2. Baidya, P., Prabhakar, R., & Wadhwa, M. (2018). Efficacy of muscle energy technique and contract relax with mulligan’s mobilization with movement technique in subacute ankle sprain. MOJ Yoga Physical Ther, 3(1), 7-12.DOI: 10.15406/mojypt.2018.03.00036 3. Chitara, V. (2017). To compare the effectiveness of muscle energy technique versus myofasial release in pain and lower limb functional activity in subjects having planter fasciitis-A randomized control trial. International Journal of Science and Research (IJSR), 6(3), 2094-2099.DOI: 10.21275/ART20172019. 4. Digiovanni, B. F., Nawoczenski, D. A., Malay, D. P., Graci, P. A., Williams, T. T., Wilding, G. E., & Baumhauer, J. F. (2006). Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinical trial with two-year follow-up. JBJS, 88(8), 1775-1781.DOI: 10.2106/JBJS.E.01281 5. Fouda, K. Z., Ali, Z. A., Elshorbagy, R. T., & Eladl, H. M. (2023). Effect of radial shock wave and ultrasound therapy combined with traditional physical therapy exercises on foot function and dorsiflexion range in plantar fasciitis: a prospective randomized clinical trial. European Review for Medical & Pharmacological Sciences, 27(9). doi: 10.26355/eurrev_202305_32287. 6. Greve, J. M. D. A., Grecco, M. V., & Santos-Silva, P. R. (2009). Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis. Clinics, 64(2), 97-103.https://doi.org/10.1590/S1807-59322009000200006 7. Grieve, R., & Palmer, S. (2017). Physiotherapy for plantar fasciitis: a UK-wide survey of current practice. Physiotherapy, 103(2), 193-200. https://doi.org/10.1016/j.physio.2016.02.002 8. Gupta, R., Malhotra, A., Masih, G. D., Khanna, T., Kaur, H., Gupta, P., & Kashyap, S. (2020). Comparing the role of different treatment modalities for plantar fasciitis: a double blind randomized controlled trial. Indian journal of Orthopaedics, 54, 31-37. DOI: 10.1007/s43465-019-00038-w 9. Kamonseki, D. H., Gonçalves, G. A., Yi, L. C., & Júnior, I. L. (2016). Response to Letter to the Editor: Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Manual therapy, 23, e13–e14. https://doi.org/10.1016/j.math.2016.02.003 10. Kashif, M., Albalwi, A., Alharbi, A., Iram, H., & Manzoor, N. (2021). Comparison of subtalar mobilisation with conventional physiotherapy treatment for the management of plantar fasciitis. J Pak Med Assoc, 71(12), 2705-2709.DOI: https://doi.org/10.47391/JPMA.1049 11. League, A. C. (2008). Current concepts review: plantar fasciitis. Foot & ankle international, 29(3), 358-366. https://doi.org/10.3113/FAI.2008.0358 12. Neufeld, S. K., & Cerrato, R. (2008). Plantar fasciitis: evaluation and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 16(6), 338-346. DOI: 10.5435/00124635-200806000-00006 13. Okamura, K., Egawa, K., Okii, A., Oki, S., & Kanai, S. (2020). Intrinsic foot muscle strengthening exercises with electromyographic biofeedback achieve increased toe flexor strength in older adults: a pilot randomized controlledtrial. ClinicalBiomechanics, 80,105187.https://doi.org/10.1016/j.clinbiomech.2020.105187 14. Orchard, J. (2012). Plantar fasciitis. Bmj, 345. https://doi.org/10.1136/bmj.e6603 15. Rabadi, D., Seo, S., Wong, B., Chung, D., Rai, V., & Agrawal, D. K. (2022). Immunopathogenesis, early Detection, current therapies and prevention of plantar Fasciitis: A concise review. International immunopharmacology, 110, 109023. https://doi.org/10.1016/j.intimp.2022.109023 16. Sandhu, T. B., Jamil, A., & Arslan, S. A. (2023). COMPARATIVE EFFECTS OF MUSCLE ENERGY TECHNIQUE AND COUNTERSTRAIN TECHNIQUE ON PAIN, FUNCTION STATUS AND SATISFACTION LEVEL IN PLANTER FASCIITIS PATIENTS. Journal of Medical Sciences, 31(4), 270-275. https://doi.org/10.52764/jms.23.31.4.3 17. Schwartz, E. N., & Su, J. (2014). Plantar fasciitis: a concise review. The Permanente Journal, 18 (1), e105 DOI: 10.7812/TPP/13-113. 18. Tanwar, R., Moitra, M., & Goyal, M. (2014). Effect of muscle energy technique to improve flexibility of gastro-soleus complex in plantar fasciitis: a randomised clinical, prospective study design. NATIONAL EDITORIAL ADVISORY BOARD, 8(4), 26. 19. Willis, B., Lopez, A., Perez, A., Sheridan, L., & Kalish, S. (2009). Pain scale for plantar fasciitis. Foot Ankle Online J, 2(3). doi: 10.3827/faoj.2009.0205.00. Supplementary Material File (pictures.docx) - Download - 231.21 KB Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Metrics & Citations Metrics Article Usage 383views 78downloads Citations Download citation varshini A K. EFFECT OF MUSCLE ENERGY TECHNIQUE VERSUS CONVENTIONAL EXERCISE ON PAIN AND FUNCTIONAL OUTCOME IN SUBJECTS WITH PLANTAR FASCIITIS. Authorea. 26 February 2025. DOI: https://doi.org/10.22541/au.174054801.12727731/v1 DOI: https://doi.org/10.22541/au.174054801.12727731/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.