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Tuesday, June 6, 2023

Trigger Point Release with Stretching Improved Plantar Heel Pain Better than Stretching Alone

Brent Brookbush

Brent Brookbush


Research Review: Trigger point release with stretching improved plantar heel pain better than just stretching alone

By Stefanie DiCarrado DPT, PT, NASM CPT & CES

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Renan-Ordine, R., Alburquerque-Sedin, F., De Souza, E.P.R., Cleland, J.A., Fernandez-De-La-Penas, C. (2011) Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: A randomized controlled trial. Journal of Orthopaedic & Sports Medicine. 41(2) 43-50 - ARTICLE

Lower Extremity TrP's
From top to Bottom: Lateral Gastrocnemius, Solues, Flexor Hallucis Longus

Why is this relevant?: Plantar fasciitis is one of the most commonly reported foot/ankle injuries, resulting in various levels of disability. The authors of this study cite research suggesting that the pain associated with plantar fasciitis may not be due to an inflammatory process, as the name suggests, but instead the result of degenerative changes in the plantar fascia itself. This may imply more research is needed exploring the source of dysfunction; with the intent of preventing further disruption of the plantar fascia tissue (As opposed to, researching interventions aimed at simply reducing or interrupting the inflammatory process). The authors cited various studies noting a reduction in pain post trigger point release, or stretching protocols. At the time of publication, no study looked at trigger point release combined with stretching. This article compares trigger point release & self-stretching (TPR) to self-stretching alone (SS) and its affect on plantar heel pain.

Study Summary

Study DesignRandomized Controlled Trial (RCT)
Level of EvidenceLevel II: Evidence from an RCT
Subject Demographics
  • Age: 44 + 10 years
  • Gender: 45 female, 15 male
  • Characteristics: unilateral heel pain
  • Inclusion Criteria: 18-60 y.o., unilateral heel pain with insidious onset of sharp pains on plantar surface of heel during weight bearing after a period of non-weight bearing. Increased pain in the morning during first steps followed by decreased symptoms with slight levels of activity like walking
  • Exclusion Criteria: any condition would cause manual therapy to be contraindicated (tumor, fracture, rheumatoid arthritis, osteoporosis, severe vascular disease), fibromyalgia, previous manual therapy interventions
Outcome Measures
  • Measured at baseline and at final treatment session (4 weeks later)
    • Physical function and bodily pain domains of the SF-36 self-administered questionnaire
    • Pressure pain threshold (PPT): the least amount of pressure that results in pain

  • Greater improvement on SF-36 and reduced PPT values in TPR group vs SS group
    • SF-36: Physical Function & Bodily Pain at final treatment session (higher value = more improvement)
      • Physical Function
        • SS: 11.6 point increase
        • TPR: 20.9 point increase

      • Bodily Pain
        • SS: 13.0 point increase
        • TPR: 20.8 point increase

    • PPT at final treatment session (higher = improvement)
      • Gastrocnemius
        • SS: 0.5 more kg/cm³ tolerated
        • TPR: 1.4 more kg/cm³ tolerated

      • Soleus
        • SS: 0.3 more kg/cm³ tolerated
        • TPR: 1.1 more kg/cm³ tolerated

      • Posterior Calcaneus
        • SS: 0.3 more kg/cm³ tolerated
        • TPR: 1.5 more kg/cm³ tolerated

ConclusionsBoth stretching alone and the combination of trigger point release and stretching, can alleviate plantar heel pain consistent with a differential diagnosis of plantar fasciitis. The addition of trigger point release into a stretching protocol provides greater pain relief and improvements in function than stretching alone.
Conclusions of the ResearchersThe addition of trigger point release techniques to a self stretching program produced greater short term pain relief than self stretching alone in those with plantar heel pain.

Review & Commentary:

The strengths of this study include the authors' strict subject selection, congruence between hypothesis, protocols and measures, and the standardized methodology that ensured the validity of those measures. The authors specified the problem being addressed (plantar heel pain and related disabilities). They reviewed the body of evidence on conservative (non-surgical) treatment of plantar heel pain (calf and foot stretching) and noted that it was inconclusive, seeming to have only moderate effectiveness in the short term.

The researchers developed clear inclusion and exclusion criteria to ensure appropriate subject selection. Based on calculations, the study needed 27 subjects per group to demonstrate a minimally clinically important difference between protocols. Each group in this study contained 30 subjects. They explained that outcome measures were chosen with the intent of focusing on function (i.e. the use of the physical function portion of a questionnaire), alluding to greater clinical relevance.

The study involved a highly standardized, and therefore, strong methodology. The authors provided a description on every device and/or questionnaire used with enough detail to ensure reproducibility. The researchers randomized subjects into two groups (self stretching - SS; and trigger point release with self stretching - TPR), and described the software system used for randomization. The qualifications of the examiner were listed, and the examiner was blinded to reduce the potential for bias. Both groups performed self-stretching techniques for 4 weeks; the TPR group also received manual trigger point release. Manual release was chosen over self-administered techniques to reduce the chance that individual variance in treatment application would affect outcomes. Future studies should implement a self-administered trigger point release and stretching protocol as a home exercise program to investigate if such a program can assist in long-term relief from symptoms. The authors' chose the same self stretching exercises that were found to have moderate effect in reducing plantar heel pain in previous research. The authors clearly described the stretching positions and dosage (20s holds with 20s rest for a total of 3 minutes, 2x per day), and provided images. Each session with the exmainer included a review of the the stretches with corrections administered as needed. The authors clearly described the clinical presentation of trigger points and assessment used to determine manual intervention, and supplied citations to support the methodology used. All subjects within the TPR group demonstrated active trigger points; therefore, all patients were appropriate for the intervention applied.

The authors provided details of their statistical analysis, as well as confidence intervals to investigate results of the groups over time, results between subjects within the same group, and results between the groups.

The authors mentioned several limitations of this study. Their was no true control/sham group. The was also potential for an attention bias with the TPR group, as they received a larger dose of attention and "touch" from the therapist. This implies that future studies should compare the SS and TPR protocols to a group receiving no therapy, but that the control and SS groups need to include sham manual treatments to reduce the chance that placebo, and/or touch have influenced outcome measures. Further, the use of objective measurements may add validity to finding, such as goniometry or muscle strength tests. The authors did mention the use of a device to record the amount of pressure before the onset of pain, but most of the data was gathered using a questionnaire which left room for subjectivity.

It was acknowledge that the study focused on short term results (4 week intervention), and that future studies should investigate long term changes. Further, future research may consider the comparison of various trigger point techniques to help identify which protocols are most effective. One issue with that must be overcome in manual therapy studies, is the impact "skill of the practitioner" has on outcomes. Finally, the authors felt future studies should use a more specific lower extremity questionnaire (exp: Lower Extremity Functional Scale - LEFS) rather than the general SF-36. Despite these limitations, this study provides helpful information toward the treatment of a common foot/ankle dysfunction.

Why is this study important?

This study demonstrates the importance of an integrated approach to addressing muscular dysfunction. Although stretching may be an effective means for lengthening soft tissue, trigger points may hinder the adaptations associated with stretching. Applying trigger point release techniques prior to stretching techniques may reduce the impact trigger points have on lengthening tissue, augment the results of stretching, and enhance outcomes.

How does it affect practice?

Practitioners may consider the inclusion of palpation for assessment, and specific interventions for trigger points in musculature presumed to be adaptively shortened, over-active and/or tight. Based on the result of this study, the inclusion of trigger point release prior to lengthening techniques may augment results.

How does it relate to Brookbush Institute Content?

Release techniques prior to lengthening are advocated as part of the Brookbush Institutes model for Corrective Intervention/Rehabilitation: Release, Lengthen, Mobilize, Activate, Integrate. Further, studies by Halperin et. al. (2014), Sullivan et.al (2013), Skarabot et al. (2015), Mohr et al. (2014) demonstrated that release techniques can improve joint range of motion without decreasing force output of the target muscle; implying that trigger point release may be an ideal choice for an integrated warm-up preceding activity requiring explosive power or maximum strength. This study focuses on trigger point release, prior to stretching in the gastrocemius and soleus muscles, both of which are noted as having a propensity toward over-activity and adaptive shortening in the Brookbush Institute predictive model of Lower Leg Dysfunction (LLD) . Recommended in this model is release, mobilization of the ankle joint when necessary, and stretching of the calf complex (along with intervention for all other affected structures). The videos below demonstrate static and active release techniques of the gastroc /soleus complex, self-administered ankle joint mobilization and static, active and dynamic calf stretching techniques.

Gastrocnemius and Soleus Static Release (Self-administered)

Gastrocnemius and Soleus Active Release (Self-administered)

Ankle Mobilization (Self-administered)

Static Calf Stretch

Active Calf Stretch

Dynamic Calf Stretch


  1. Review: Healey, K.C., Hatfield, D.L., Blanpied, P., Dorfman, L.R., and Riebe, D. (2014). The effects of myofascial release with foam rolling on performance. Journal of Strength and Conditioning Research. 28(1). 61–68
  2. Review: Pearcy, G.E.P., Bradbury-Squires, D.J., Kawamoto, J., Drinkwater, E.J., Behm, D.G., Button, D.C. (2015) Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. Journal of Athletic Training. 50(1): 5-13
  3. Review: Macdonald, G.Z., Button, D.C., Drinkwater, E.J., Behm, D.G. (2014) Foam rolling as a recovery tool after an intense bout of physical activity. Medicine & Science in Sports & Exercise 46(1): 131-142
  4. Review: Sullivan, K.M., Silvey, D.B.J., Button, D.C., Behm, D.G. (2013). Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments. International Journal of Sports Physical Therapy 8(3) 228-236.
  5. Review: Halperin, I., Aboodarda, S.J., Button, D.C., Andersen, L.L., Behm, D.G. (2014). Roller massager improves range of motion of plantar flexor muscles without subsequent decreases in force parameters. The International Journal of Sports Physical Therapy. 9(1): 92 -102
  6. Review: Skarabot, J., Beardsley, B., Stim, I. (2015). Comparing the effects of self-myofascial release with static stretching on ankle range of motion in adolescent athletes. International Journal of Sports Phyiscal Therapy. 10(2): 203-212
  7. Review: Mohr, A. R., Long, B. C., & Goad, C. L. (forthcoming 2014). Foam Rolling and Static Stretching on Passive Hip Flexion Range of Motion. Journal of sport rehabilitation. Currently in press.

© 2015 Brent Brookbush

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