Myofascial trigger point therapyThe immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial
Introduction
An adequate ankle range of motion (ROM) is considered a necessary component for functional activities such as running, ascending and descending stairs and normal gait (Cavanagh, 1990, Donatelli, 1996, Brukner and Khan, 2006). A disturbance of ankle ROM, resulting from muscle tightness during gait, may affect not only the ankle-foot complex, but also the remaining joints of the lower extremities (You et al., 2009). Chronic myofascial pain in the calf muscles has been documented to cause a biomechanical abnormality of gait, resulting in an excessive knee flexion angle during the stance phase of gait (Wu et al., 2005). Adequate ankle dorsiflexion (>10°) is required in midistance for the tibia to advance over the foot and allow forward body movement (Norkin and White, 2003). If this ankle ROM is restricted by tight musculature, compensation may occur in the form of genu recurvatum, early knee flexion, early heel lift or excessive pronation at the subtalar joint (Prior, 1999). These compensatory mechanisms put undue stresses on structures and may lead to foot pathologies such as plantar fasciitis, achilles tendonitis and metatarsalgia (Hill, 1995). Increased subtalar joint pronation has also been identified as a “remote” contributing factor in patellofemoral pain (Crossley et al., 2006).
A commonly used description of myofascial trigger points is that by Travell and Simons (1992) and Simons et al. (1999), who define MTrPs as hyperirritable areas within taut bands of skeletal muscle or fascia. Within the literature, MTrPs have been classified as active or latent. Active MTrPs refer pain at rest or with muscular activity, whereas latent MTrPs are normally pain free unless direct pressure is applied to them (Travell and Simons, 1992, Simons et al., 1999). Latent MTrPs often cause stiffness and restricted ROM without pain and are far more common that active MTrPs (Simons et al., 1999).
MTrPs refer pain along a limb or body part and are found regionally, for example the neck, back, shoulder and lower limb. This muscular pain disorder is termed a myofascial pain syndrome (MPS) (Simons et al., 1999). MTrPs are considered a hallmark finding of MPS and within clinical practice are claimed to be a common source of musculoskeletal pain and dysfunction, in people presenting for manual therapy (Friction, 1990, Blanco et al., 2006).
Travell and Simons (1983) originally termed compression of a MTrP as “ischaemic compression”. Clinical evidence and the nature of MTrPs indicate that when applying digital pressure to inactivate a MTrP there is no need to exert sufficient pressure to produce ischaemia, as the core of the MTrP is already suffering from severe hypoxia (Travell and Simons, 1999). Therefore “ischaemic compression” has been replaced by “trigger point pressure release” which, according to Simons et al. (1999) is less vigorous, equally or more clinically effective and employs the barrier release concept advocated by Lewit (1999). TrP pressure release applied downward on a MTrP tends to lengthen sarcomeres and can be effective in increasing ROM and reducing muscle tension (Simons, 2004).
The need to include ROM measurements in future studies on the efficacy of manual therapy in MTrPs has been recommended as myofascial pain is characterised by restricted ROM (Fernández de las Peñas et al., 2005). Physiotherapists, particularly in orthopaedic practice, have traditionally focused on the measurements of impairments such as pain, range of motion and muscle strength (Abrams et al., 2006).
There is limited clinical evidence on the efficacy of manual therapy on MTrPs/MPS in the lower limb. A systematic review of the literature on the effectiveness of non invasive treatments for active MTrP pain, found twenty of the twenty-three included trials assessed the treatment of MTrPs in the neck and/or upper trapezius region (Rickards, 2006).
Although the available literature suggests that MTrPs may cause restricted joint ROM (Travell and Simons, 1983, Travell and Simons, 1992, Simons et al., 1999, Lucas et al., 2004, Fernández de las Peñas et al., 2005; Blanco et al., 2006), there is a scarcity of research suggesting that TrP pressure release may be an effective intervention for restriction in ankle ROM. It has been proposed that soleus MTrPs specifically relate to a restriction of dorsiflexion of the ankle (Travell and Simons, 1992).
The primary aim of this pilot study was to investigate the immediate effect of a single treatment of TrP pressure release of soleus on restricted active ankle dorsiflexion ROM. The secondary aim is to assess the methodological design quality of the pilot study and identify areas for improvement in future research.
Section snippets
Participants
Twenty-eight healthy undergraduate physiotherapy and sports therapy students volunteered for this study. During the screening process, 20 participants (5 men and 15 women; mean age 21.7 ± 2.1) were included as they met the inclusion criteria, namely unilateral restriction in active ankle dorsiflexion (<10°) and at least one identifiable MTrP within the soleus muscle. The exclusion criteria were: under 18 years old, diagnosis of Fibromyalgia Syndrome (FMS), inability to lie prone or flex the knee
Results
The groups appear relatively comparable in age but not gender, with the intervention group bias towards females. Group Characteristics in Table 1
The descriptive data for the pre- and post-ROM measurements, including the mean values and standard deviations (SD) obtained for the control and intervention group are presented in Table 2. The independent t-test at baseline indicates no statistically significant difference between the groups for pre-ROM measurements (p = 0.93). In relation to ankle ROM
Discussion
The results of this present study demonstrate that statistically a single treatment of TrP pressure release to the soleus has an immediate effect on restricted active ankle dorsiflexion ROM. A moderate treatment effect size was established in the intervention group, suggesting that the results are clinically meaningful. Statistical significance does not necessarily equate to clinical importance (Gemmell et al., 2008). Jacobson and Traux (1991) highlight a limitation in the use of statistical
Limitations and methodological considerations
The secondary aim of this pilot study was to critique aspects of the methodological design quality, identify limitations and propose areas for improvement in future research evidence.
Conclusion
This study has indicated that a single treatment of TrP pressure release has shown an immediate significant increase in active ankle dorsiflexion. Although the overall treatment effect size of ankle ROM is smaller than may be clinically significant, this study may have clinical relevance to the clinician treating a patient with reduced ankle dorsiflexion.
It is hoped that the main findings, including the identified limitations and methodological considerations in this pilot study, will inform
Acknowledgements
The authors would like to thank Dr Shea Palmer (University of the West of England) for statistical advice.
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Final year physiotherapy students at time of data collection.