Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

Original Research Article Allied sciences

International Journal of Pharma and Bio Sciences ISSN

0975-6299

EFFECTIVENESS OF CYRIAX FRICTION MASSAGE ALONG WITH

ULTRASOUND THERAPY IN PATIENTS WITH
PLANTAR FASCITIS.
ANNA JACQUELINE ABIGAIL1 AND KAMALAKANNAN.M1 *
1
Saveetha College of Physiotherapy, Saveetha University, Chennai, India.

ABSTRACT
Plantar fasciitis, a repetitive strain injury of the medial arch and heel, is one of the most common causes
1
of foot pain. Aim is to determine the effectiveness of cyriax transverse friction massage with ultrasound
therapy in the management of plantar fasciitis. Objective is To determine the effectiveness of ultrasound
therapy with cyriax transverse friction massage on pain and functional ability in patients with plantar
fascitis. Methodology: 30 Individuals were selected according to the inclusion and exclusion criteria.
Participants were randomly assigned into two groups group A and group B. Pain was measured with
Numerical Pain Rating Scale (NPRS), Foot function index (FFI) used to measure quality of life. Results:
The post-test mean value of NPRS in Group-A is 3.47(SD 0.74) and post-test mean value of NPRS in
Group-B is 1.40 (SD 0.63), this shows that Group-A is greater than Group-B with the P value (0.001),The
post-test mean value of FFI in Group-A is 93.00 (SD 1.65) and post-test mean value of FFI in Group-B is
88.3 (SD 1.29), this shows that Group-A is greater than Group-B with the P value (0.001). It has been
concluded that Cyriax tranverse friction massage with ultrasound therapy (Group B) is more effective than
(Group A) in decreasing painand improving the functional ability.

KEYWORDS: plantarfascitis, Ultrasound therapy, footpain, heel pain,cyriax friction.

KAMALAKANNAN.M*
Saveetha College of Physiotherapy,SaveethaUniversity,Chennai,India.

Received on : 08-03-2017
Revised and Accepted on : 17-04-2017
DOI: http://dx.doi.org/10.22376/ijpbs.2017.8.2.b841-848

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INTRODUCTION documented thermal effects. Ultrasound therapy helps

in tissue repair and wound healing according to various
Plantar fasciitis, a repetitive strain injury of the medial clinical trials. It has been a treatment of choice in soft
arch and heel, is one of the most common causes of tissue injuries. The high frequency sound stimulates the
1
foot pain. Plantar fasciitis is usually a repetitive local tissues and increases the blood flow to the area
9,10,11
microtrauma overload injury of the attachment of the alleviating inflammation.
1,2
plantar fascia at the inferior aspect of the calcaneus.
Occasionally, plantar fasciitis occurs as part of an MATERIALS AND METHODS
2
inflammatory arthropathy or spondylarthropathy. The
function of the plantar fascia is in twofold: statically, it Study Design: Experimental study,
stabilizes the medial longitudinal arch and dynamically it Study Setting: Saveetha Medical College & Hospital
restores the arch and aids in reconfiguring the foot for Physiotherapy Outpatient Department Saveetha
efficient toe-off. When this tissue becomes damaged, University, Sampling
pain and/or weakness may develop in the area. Some of Method: Simple Random Sampling technique, Sample
the risk factors involved are sports activities, being Size: 30.
overweight , prolonged standing, increased subtalar Scientific and Ethical clearance was obtained from
pronation accompanying flat feet, and limited ankle Saveetha University.
1,3
dorsiflexion, wearing faulty shoes/slippers. Plantar Inclusion Criteria: Both gender,Age group between 30-
fasciitis is a common and often disabling complaint and 50years,Patients with plantar fascitis (plantar stretch test
is estimated to account for up to 15% of all foot positive), NPRS score not more than 7, Patients with
3
symptoms in adults. It has been estimated that it affects heel pain for >3 weeks.
as much as 10% of the general population over the Exclusion Criteria: Radiological evidence showing
4
course of a lifetime. The condition is bilateral in up to calcaneal spur, Patients with bilateral foot pain, Clinical
one-third of cases and two third of cases are unilateral. disorders where therapeutic ultrasound/friction massage
Incidence reportedly peaks in people between the age is contraindicated such as infective conditions of foot,
5
of 40 to 60 years in general population. The plantar tumor, dermatitis, calcaneal fracture, metal implant
,12,13
aponeurosis or fascia consists of 3 bands: lateral, around the ankle. , Impaired circulation to lower
14
medial, and central. the most common site of pain in extremities , Neurological disorders, Corticosteroid
persons with plantar fasciitis is near the origin or injection in heel for the past six months.
enthesis of the central border of the plantar aponeurosis Materials Required: Therapeutic Ultrasound
at the medial tubercle of calcaneum, individuals also equipment, Coupling Medium (aquasonic gel),
complain of pain over the mid portion of the central Treatment Couch.
band. The symptoms of plantar fasciitis includes pain Procedure: 30 Individuals were selected according to
over the medial part of the calcaneum, pain during the the inclusion and exclusion criteria. Detailed procedure
6
first few steps after rest. Cyriax deep transverse friction was explained to the patients in colloquial terms about
massage is a technique popularized by Dr. James the safety and simplicity of the procedure and informed
Cyriax for pain and inflammation relief in consent was obtained from those who were interested.
musculoskeletal conditions. Deep friction massage is a Participants were randomly assigned into two groups.
technique that attempts to reduce abnormal fibrous Pain was measured with Numerical Pain Rating Scale
adhesions and make scar tissue more mobile in acute, (NPRS), Foot function index (FFI) used to measure
sub- acute and chronic inflammatory conditions by quality of life.
realigning the normal soft tissue fibers. This is carried
out by fingertip or by the thumb. According to Cyriax, Group - A (Control Group)
Deep Transverse Friction causes traumatic hyperemia Ultrasound therapy was given to the patient, with patient
which results in increased blood flow and decrease in positioned in a comfortable position preferably in prone
7
pain. The Cyriax deep friction massage is deep and lying with pillow/towel roll supported in anterior part of
must be applied transversely to the specific tissue ankle and therapy was given by placing the transducer
involved which enhances circulation. Cyriax's goals are head over the medial plantar aspect of the heel/painful
two-fold: to provide movement to the tissue itself and to region using coupling medium, parameters are given in
8
produce traumatic hyperemia. Transverse friction (Table:1)
massage (TFM) is a specific type of connective tissue
massage applied precisely to the soft-tissue structures. Group - B (Experimental Group)
The aim of the TFM is to stretch and mobilize fibrous Ultrasound therapy (Table:1) is followed by Cyriax deep
adhesions and tight scar tissue. The frictions should be transverse friction massage. Patient was positioned in
applied by manual pressure directly to the origin of the supine lying , the patient’s foot is held by the therapist
plantar fascia using a repetitive back-and-forth motion, in such a way that the plantar fascia is in stretched
transversely across the affected structure with adequate position and deep transverse friction massage was
sweep to cover the affected area and sufficient depth to given using bilateral thumb across the affected
produce mechanical stretching of the underlying fibersover the medial plantar aspect of the heel for a
9
structure. Therapeutic ultrasound has been used duration of 8 mins.(Table:2)
extensively to treat a variety of conditions because of its

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Table1
TREATMENT PROTOCOL for Ultrasound therapy

Frequency 3MHZ
Intensity 1.5w/ cm2
Duration 7 minutes
Mode pulsed
Treatment was given for 10 days(5days/week for two weeks)

Table 2
TREATMENT PROTOCOL for Friction massage

Frequency 5 days / week for 2 weeks

Duration 8 minutes
Treatment was given for 10 days(5days/week for two weeks)

Figure 1
Ultrasound Therapy

Figure 2
Cyriax Transverse Friction Massage

Outcome measures
15,16
Numerical Pain Rating Scale (NPRS) for pain
The NPRS is ascale consisting of numbers 0 to 10, it helps to find the pain threshold of the patient subjectively, in
which 0 refers to no pain and 10 refers to worst imaginable pain.

15,16
0 indicates no pain Foot function index
1-3 indicates mild pain This questionnaire is used to evaluate the effect of foot
4-6 indicates moderate pain pain in every day life. For the following questions the
7-10 indicates severe pain subject will be asked to score each question on a scale
from 0 (no pain/no difficulty/none of the time) to 10

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(worst pain imaginable/so difficult activity cannot be STATISTICAL ANALYSIS

done/all of the time)theirfoot pain over the past week.
Patient is explained/asked to read each question and The collected data were tabulated & analyzed using
circle a number from 0-10.It includes three subscales descriptive & inferential statistics. To all parameters
namely : pain subscale, disability subscale, activity mean & standard deviation (SD) was been used. Paired
limitation subscale under which the questions are asked. t-test will be used to analyze significant changes
Outcome measures were taken before intervention and between pre-test & post-test measurements. Unpaired t-
at the end of 10 days treatment for both the groups and test was been used to analyze significant changes
considered as pre & post values respectively. between two groups.
Statistically, results were obtained.

Table 3
Pre test –Post test values of group – A

Group A Mean Standard deviation t value p value

Numerical Pain Rating Scale (NPRS) Pre test 6.13 0.64 14.2701 <0.001
Post test 3.47 0.74
Foot Function Index (FFI) Pre test 97.87 2.53 11.4810 <0.001
Post test 93.00 1.65
The data from the above table shows the pre-test and post-test values of Numerical Pain Rating Scale
(NPRS) and FootFunction Index (FFI) in Group-A subjects.

The pre-test mean value of NPRS is 6.13 (SD 0.64) and of FFI is 97.8 (SD 2.53 ) and the post -test mean value
post-test mean value is 3.47(SD 0.74) this shows that is 93.00 (SD 1.65) this shows that FFI scores are
NPRS scores are gradually decreasing with the P value gradually decreasing with the P value (0.001)
(0.001) statistically significant. The pre-test mean values statistically significant.

Graph 1
Showing Pre and Post Test Values of NPRS in Group-A

Graph 2
Showing Pre and Post Test Values of FFI in Group-A

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Table 4
Pre test –Post test values of group - B

Group B Mean Standard deviation t value p value

Pre test 6.07 0.59 <0.001
Numerical Pain Rating Scale (NPRS) Post test 24.9727
1.40 0.63
Foot Function Index Pre test 98.13 2.67
10.8163 <0.001
(FFI) Post test 88.33 1.29
The data from the above table shows the pre-test and post-test values of Numerical Pain Rating Scale
(NPRS) and Foot Function Index (FFI) in Group-B subjects.

The pre-test mean value of NPRS is 6.07(SD 0.59) and of FFI is 98.13 (SD 2.67) and the post -test mean value
post-test mean value is 1.40 (SD 0.63) this shows that is 88.33 (SD 1.29) this shows that FFI scores are
NPRS scores are gradually decreasing with the P value gradually decreasing with the P value (0.001)
(0.001) statistically significant. The pre-test mean values statistically significant.

Graph 3
Showing Pre and Post Test Values of NPRS in Group-B

Graph 4
Showing Pre and Post Test Valuesof FFI in Group - B

Table 5
Comparison between the post test values Group A&B

Parameter Post Test Values ‘t’ test Signifi-cance

Group A Group B
Mean Standard deviation Mean Standard deviation
Numerical Pain Rating Scale (NPRS) 3.47 0.74 1.40 0.63 8.2018 <0.001

Foot Function Index 93.00 1.65 88.3 0.33 8.6351 <0.001

(FFI)
Post test measure of mean and standard deviation for Numerical Pain Rating Scale (NPRS) and Foot Function
Index (FFI )in group A and group B in respect with ‘t’ value (student ‘t’ test)

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The data from above table shows the post-test values of with the P value (0.001) The post-test mean value of FFI
Numerical Pain Rating Scale (NPRS) and Foot Function in Group-A is 93.00 (SD 1.65) and post-test mean value
Index (FFI) in Group-A and Group-B. The post-test of FFI in Group-B is 88.33 (SD 1.29), this shows that
mean value of NPRS in Group-A is 3.47(SD 0.74) and Group-A is greater than Group-B with the P value
post-test mean value of NPRS in Group-B is 1.40 (SD (0.001)
0.63), this shows that Group-A is greater than Group-B

Graph 5
Showing Post Test - Post Test Values of NPRS inGroup-A & Group-B

Graph 6
Showing Post Test - Post Test Values of FFI inGroup-A & Group-B

RESULTS arch and heel, is one of the most common causes of

16
foot pain. Plantar fasciitis is usually a repetitive
From the statistical analysis made with the quantitative microtrauma overload injury of the attachment of the
data revealed statistically significant difference between plantar fascia at the inferior aspect of the calcaneus.
the Group A and Group B, and also within the group. Plantar fasciitis has been reported as the leading cause
The post-test mean value of NPRS in Group-A is for heel pain. It is a common and often disabling
3.47(SD 0.74) and post-test mean value of NPRS in complaint and is estimated to account for up to 15% of
17
Group-B is 1.40 (SD 0.63), this shows that Group-A is all foot symptoms in adults. It has been estimated that
greater than Group-B with the P value (0.001) The post- it affects as much as 10% of the general population over
18
test mean value of NPRS in Group-A is 93.00 (SD 1.65) the course of a lifetime. Standley hasstated that injury
and post-test mean value of FFI in Group-B is 88.3 (SD strains fibroblasts and fascia in negative ways and in
1.29), this shows that Group-A is greater than Group-B contrast manual muscle treatment strains
with the P value (0.001) Statistical Analysis of post test, fibroblasts/fascia in curative ways. Both injury and
Numerical Pain Rating Scale (NPRS) and Foot Function manual muscle treatment increases the number of
Index (FFI) revealed that there is high statically fibroblasts in fascia with injury creating pro-inflammatory
significant difference seen between Group A and Group mediators and manual muscle treatment healing by
B. increasing anti-inflammatory mediators. Geoff Formosa,
Gordon Smith concluded in their study that the friction
massage applied by the using the thumb of one hand to
DISCUSSION impart the frictions while stretching the plantar fascia
with the other hand by maintaining toe dorsiflexion. This
Plantar fasciitis, a repetitive strain injury of the medial
one-handed technique resulted in considerable effort on

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the part of the operator to maintain depth during the along with ultrasound therapy in treatment of plantar
treatment session. This may have resulted in a non- fascitis.
uniform application of the technique during the ten-
minute sessions. Suggested the preferable use both Limitations
thumbs to apply the Transverse Friction Massage (TFM) 1. Small sample size.
and stabilize the heel with the rest of the fingers in order 2. Equal attention to all the patients could not be given
to impart a deeper and more controlled pressure. In this as the procedure was done by single therapist.
study TFM is given using bilateral thumb , which was 3.Therapist fatigue is a major problem encountered
found to be effective though therapist fatigue was during the study due to the hands on technique which is
inevitable. The aim of this study was to determine the cumbersome
effectiveness of cyriax transverse friction massage
along with ultrasound therapy in treatment of patients Future Recommendations
with plantar fascitis. 30 subjects fulfilling the inclusion A studywith large sample size is recommended and Use
criteria were assigned to this study by randomization of massaging probe can be considered in order to avoid
technique. The subjects were divided into 15 subjects fatigue
each. Informed consent was taken from the subjects
and the procedure was explained. Group A (n=15) were CONCLUSION
receiving ultrasound therapy over a period of 2weeks, 5
days/week. Group B (n=15) were receiving Cyriax From the result, it has been concluded that
transverse friction massage and ultrasound therapy Cyriaxtranverse friction massage with ultrasound
therapy over a period of 2weeks, 5 days/ week. therapy (Group B) is more effective and befifiting the
Numerical pain rating scale (NPRS) and Foot Function patients than giving only ultrasound therapy (Group A) in
Index(FFI) was used to as the tools for analysis. The decreasing pain and improving the functional ability. In
nd
Outcome measures were been taken at the end of 2 this study it has found that when cyriax friction massage
week. n the present study, the subjects were chosen is given along with ultrasound therapy for a patiens with
from age group 30-50 years. The data obtained from the foot pain is reduces the foot pain and improves the
study was statistically analyzed using paired and activities of daily living for the patients suffering with foot
unpaired t-test. The result of the study revealed that pain (plantarfascitis).
there was decrease in pain and an improvement in the
functional ability. Decrease in pain measured by NPRS
in both groups, A and B after the respective protocol.
CONFLICT OF INTEREST
Hence, the result of this study proves that, there will be
Conflict of interest declared none.
beneficial effect of Cyriax transverse friction massage

REFERENCES
1. Geoff Formosa, Gordon Smith.Transverse 7. Gail J. Chamberlain.A Review Cyriax's Friction
frictional massage for plantarfasciitis: a clinical Massage.The journal of orthopaedic and sports
pilot trial. International Musculoskeletal physical therapy.1982 3(15):32-35.
Medicine.2011 33(3): 55-60. 8. Young SR and Dyson M. Clayton’s
th
2. RachelleBuchbinder.Case study on Plantar Electrotherapy.9 edition.Delhi:A.I.T.B.S
Fasciitis.The New England journal of medicine. Publishers and distributors; 1996.
2004 May; 20(4): 28-30. 9. Gerald T. Kuwada.A. Prospective Randomized
3. Daniel L.Riddle , Matthew Pulisic, Peter Pidcoe, Trial Using Four Treatment Modalities for the
Robert E. Johnson. Risk factors of plantar Treatment of Plantar Fasciitis. The Foot and
fasciitis; a matched case control study. The Ankle Online Journal. 2011 August; 5(15):30-35.
journal of bone and joint surgery. 2003 85(5): 10. Amelia Williamson, Barbara Hoggart. Pain: A
872-877. review of three commonly used pain rating scales.
4. ShashwatPrakash, AnandMisra.Effect of manual Journal of Clinical Nursing.2014 14(6): 798–804.
therapy vs conventional therapy in patients with 11. John T. Farrar, James P. Young Jr, Linda
plantar fasciitis- a comparative study.International LaMoreaux, John L. Werth, R. Michael
Journal of Physiotherapy and Research. 2014 Poole.Clinical importance of changes in chronic
2(1): 55-62. pain intensity measured on an11-point numerical
5. Thomas G. Heel pain plantar fasciitis: Clinical pain rating scale. International Association for the
Practise Guidelines. The journal of Orthopaedic & Study of Pain. 2001 5(15):30-35.
Sports Physical Therapy.2008 14(5): 72-77. 12. Budiman-Mak E,Conrad, K. J,&Roach, K. E. The
6. H. B. Shivakumar, ChanappaT. S, Pradeep Foot Function Index: a measure of foot pain and
Kumar Reddy, JayashreeDey. A comparative disability. Journal of Clinical Epidemiol.1991
study between the efficacies of ultrasound 44(6):561-570.
therapy with cryokinetics with soft tissue massage 13. Shih-Huey Wu, Huey-Wen Liang, Wen-Hsuan
(deep friction massage) in acute supraspinatus Hou, Reliability and Validity of the Taiwan
tendinitis.Journal of Evolution of Medical and Chinese Version of the Foot Function Index.
Dental Science.2014 April; 3(15):30-35. Journal of Formos Med Association 2008
107(2):38-40.

This article can be downloaded from www.ijpbs.net

B-847
 Int J Pharm Bio Sci 2017 Apr; 8(2): (B) 841-848

14. Agel J.Reliability of the Foot Function Index. A taping for Plantar Fasciitis. Journal of
report of the AOFAS Outcomes Committee. Musculoskeletal Pain. 2010; 18(1):55-65.
Journal of sports science. 2005 Nov; 26(11):962- 18. Mark W. Cornwall, Thomas G. McPoil.Plantar
967. Fasciitis: Etiology and Treatment .Journal of
15. Sivasankar. P.Effect of Ultrasound Therapy and Orthopedic & Sports Physical Therapy.1999
Myofascial Release on Pain and Function in December; 29(12):40-45.
Patients with Plantar Fascitis. International journal 19. Wearing S, Smeathers J. The pathomechanics of
of scientific research. 2014; August: 3(8):25-30. plantar fasciitis. Journal of sports medicine. 2006;
16. Suman Kuhar, Khatri Subhash, JebaChitra. 36(7):585-611.
Effectiveness of Myofascial Release in Treatment 20. Brosseau L, Casimiro L, Milne S, Robinson VA,
of Plantar Fasciitis: A RCT. Indian Journal of Shea BJ,Tugwell P, et al. Deep transverse friction
Physiotherapy and Occupational Therapy.2007; massage for treating tendinitis. Cochrane
1(3):58-65. Database Systemic Review 2002; 5(3):68-70.
17. Chien-Tsung Tsai, Wen-Dien Chang Jen-Pei Lee.
Effects of Short-term Treatment with Kinesio

This article can be downloaded from www.ijpbs.net

B-848