Pain improvement after three weeks of daily self-executed cross-friction massage using a fascia ball in a patient with recent-onset plantar heel pain: a case report

ABSTRACT

Background

Plantar heel pain is described as sharp pain at the medial plantar aspect of the calcaneus and medial longitudinal arch of the foot. There are various treatment options that usually need a clinician or a therapist for application. The present case report aimed to describe the outcomes of self-executed cross-friction massage using a fascia ball in a patient with recent-onset plantar heel pain.

Case description

The patient was a 42-year-old man who reported plantar heel pain during the first steps in the morning along with decreased function of the foot and ankle lasting about three months. He was instructed to self-execute cross-friction massage using a fascia ball daily in the evening at home for six weeks.

Outcomes

Pain during treatment decreased from a Numeric Pain Rating Scale (NPRS)-score of 8/10 and from a Short-Form McGill Pain Questionnaire (SF-MPQ)-score of 34/60 at initial treatment to NPRS- and SF-MPQ-scores of 0/10 and 0/60, respectively, after about three weeks. The patient reported no pain and restored function after six weeks of treatment, and in the follow-up measurements.

Discussion

Daily self-executed cross-friction massage using a fascia ball may be a useful alternative intervention for treating recent-onset plantar heel pain.

Background

Plantar heel pain is commonly caused by plantar fasciitis [1], currently better called plantar fasciopathy [2], and is described as sharp pain at the medial plantar part of the calcaneus and medial longitudinal arch of the foot [3]. It can occur during standing, walking and running after prolonged inactivity [4,5]. As the plantar fascia assists the medial and lateral arches by distributing about 14% of forces throughout the surface of the foot sole, and supports propulsion of the body during terminal stance and toe-off phases of walking [6,7], combined high mechanical load and iterative microtrauma likely represent the predominant cause of the pathology [4]. Plantar heel pain is increasingly experienced during the first few steps in the morning and after long periods of non-weight-bearing [1]. Then, it usually decreases in the further course of walking with stretching of the fascia and metabolite dissemination. In the general population, a prevalence of 7% [8] to 10% [9] was reported for plantar fasciopathy or plantar heel pain, respectively. Commonly, middle-aged people are affected, with women more frequently than men [7,10].

Histologically, the underlying process of developing plantar fasciopathy is considered more degenerative, rather than inflammatory [11]. Causes are multifactorial, and risk factors involve continuous overuse of the plantar fascia, long-lasting weight-bearing, pes planus, restricted ankle dorsiflexion, sedentary lifestyle, and high body mass index (BMI) [5,7,10,12–15]. Plantar heel pain is considered recent-onset or acute if it has been present for less than six months and chronic if symptoms persist for six months or longer [16].

The list of non-operative treatment options is long and encompasses exercise, manual therapy, stretching, extracorporeal shockwave therapy (ESWT), anti-inflammatory injections, dry needling, low-level laser therapy, electrotherapy, phonophoresis, ultrasound, taping, rocker shoes, ankle-foot orthoses involving night splints, and education [3,5,17]. Most of these interventions need a clinician or therapist for application, and may have adverse effects. Cross or transverse friction massage is one of the manual therapy interventions [3] more commonly used to treat various musculoskeletal conditions, such as patellar [18], extensor carpi radialis brevis, supraspinatus or Achilles tendinopathy [19], and plantar fasciopathy [3]. Thereby, mechanical pressure is applied transversely to the reorganizing collagen of the tissue to soften the adhesion [20], to cause a traumatic hyperemia [21], to break down scar tissue [3], to improve pain, and to aid the healing process [22]. For the treatment of plantar heel pain, the therapist applies cross-friction massage at the insertion of the plantar fascia using a reinforced index finger [3]. The motion of the finger is employed back and forth across the fibers of the most painful area of the tissue. Duration of cross-friction massage, the amount of pressure, and time between sessions are reported to depend on the type of tissue, stage of injury (acute or chronic), and severity of pain [22,23], however, recommendations are predominantly anecdotal [20,22,23], and need revision [22]. Considerable troubles of manually applied cross-friction massage are that it strains the therapists‘ hands intensively [24,25], and that the given pressure may not be sufficient to evoke the required morphological and histological effects [26,27]. Meanwhile, alternative options for applying cross-friction massage, such as instrument assisted soft-tissue mobilization [28], may exist for the treatment of plantar heel pain, which is considered important for successful management, including pain improvement and aiding healing progress [22]. One option may be the use of a fascia ball to self-execute cross-friction massage. A successful treatment using a lacrosse ball, which is similar to a fascia ball, in an adolescent athlete with chronic achilles tendinopathy was reported in literature [29]. Furthermore, using a lacrosse ball to induce a self-myofascial release of the plantar surface of the foot, led to improvements in sit-and-reach test performance in healthy college students [30]. This case report followed the CARE guidelines for case reports [31] and aimed to describe the outcomes of self-executed cross-friction massage at the plantar heel using a fascia ball, representing a simple non-operative therapeutic option to help patients improve their recent-onset plantar heel pain.

Case description

A 42-year-old man (body height: 1.88 m; body mass: 89 kg; body mass index: 25.2 kg/m²) presented to the university and reported that he had been experiencing plantar heel pain in his right foot for almost three months. He could not remember a traumatic injury or infection that may have triggered complaints; however, he assumed that onset of pain began after regularly wearing a pair of sneakers with a flat sole for about two weeks. Although he removed the sneakers, pain remained. Furthermore, he felt recurrent slight stiffness in the triceps surae muscle of his right leg, usually 24 to 48 hours after performing recreational sport activities, such as running, mountainbiking, or playing football.

In the past, he experienced three sprains at the right ankle joint during playing football, with the third ankle sprain occuring about 20 years ago. He did neither report a feeling of ankle instability nor any events of giving way. Typically, he described diffuse moderate pain in the right heel with the first steps in the morning, with prolonged standing, and with walking after prolonged standing. Furthermore, he reported discomfort at the heel when loading the heel to stabilize the foot while pressing the accelerator pedal during motoring. The plantar heel pain influenced his quality of life, by frequently thinking and worrying about it. The patient reported no family history of symptoms or diseases associated with chronic pain conditions. His work was predominantly sedentary and he usually performed sport activities recreationally about one to two times per week. He did not yet consult a physician and did not take any medications. At initial evaluation, his primary goal was to reduce typical symptoms and intensity of his plantar heel pain. No Institutional Review Board approval was required for a single case report. The patient gave approval for his participation in this case report.

Examination

At initial examination, the patient reported a varying pain intensity ranging from 2/10 to 5/10 on the Numeric Pain Rating Scale (NPRS) at the plantar heel during the course of the day. Pain was worst during the first steps in the morning (5/10) and improved with walking and cycling (2/10). The NPRS is an 11-point pain-rating scale with 0 representing no pain and 10 representing worst imaginable pain [29,32]. It has been commonly used for the evaluation of plantar heel pain [17]. Saphenous nerve neuropathy was excluded, because the patient did not clearly describe burning or shooting pain sensations [33]. The straight leg raise test (SLR) and the slump test were performed on both the left and right sides, which did not reveal any pain or neural tension deficits of the sciatic nerve or movement limitations that could indicate nerve root compression [34]. In addition, the modified SLR (SLR_TIBIAL), where the foot is dorsiflexed in combination with an eversion prior to hip flexion to raise the leg with the knee extended, was performed and also showed no pain, ruling out a neurogenic plantar heel pain due to the tibial nerve [35]. There was no swelling at the medial calcaneal tubercle, but there was tenderness on palpation at the medial plantar part of the calcaneus compared to the contralateral side. As the patient showed no pain at the matched contralateral remote site [36] and no signs of hyperalgesia or allodynia [37] during all examinations, altered nociceptive central pain processing was excluded and not further quantified by pressure algometry [38].

Outcomes and assessments

The NPRS was used to continuously monitor daily progress of patient’s pain perception during treatment. Moreover, the Short-Form McGill Pain Questionnaire (SF-MPQ) [39–41] was used during treatment to determine daily development of perception and extent of pain [3]. The SF-MPQ consists of five scores [42]. The first score includes the sensory (Ia) and the second score the affective (Ib) dimensions of pain. In the sensory dimension of pain (Ia), the patient is asked to rate 11 words, that characterize pain perception, from 0 = no pain to 3 = severe pain. In the affective dimension Ib the patient has to rate 4 words, that describe pain perception, from 0 = no pain to 3 = severe pain, as well. Taken the sensory (Ia) and the affective (Ib) scores together, the maximum score is 45 points, representing the third score of the questionnaire. In the fourth score of the SF-MPQ, the patient rates the overall pain experience on a scale ranging from 0 = no pain to 5 = excruciating. In the fifth score, the patient rates his perceived pain on a visual analogue scale (VAS) from 0 = no pain to 100 = worst imaginable pain. In the present study, the NPRS (0 = no pain to 10 = worst imaginable pain) was used, instead. The ratings from the third to fifth scores are then summarized to a total score, with higher scores representing worse pain. In the present study, the maximum score was 60. The patient was asked to complete the assessments manually at home daily after each treatment session in the evening at a similar time (about 10 p.m.) and to report the results to the therapist (MA) by telephone. He was instructed to return to the university if his pain perception was ‘much better’ (>40% reduction) [43], i.e. <5 points on the NPRS for at least one week. This time frame was individually defined by the patient, who felt that a week of such pain relief would be personally meaningful [44]. If symptoms remained unchanged or worsened (NPRS ≥8/10) after three weeks of treatment [3], he was instructed to return to the university for reevaluation and redirection of therapy.

Measurement of physical function of the foot and ankle

The Foot and Ankle Ability Measure (FAAM), a validated self reported measure of physical function for the foot and ankle, was used to register functional performance level [45] in the morning of the first day of treatment, and then in the morning after each five days of treatment for six weeks. The FAAM has two subscales. The first is a 21 item subscale to determine problems with activities of daily living (FAAM-ADL), and the second subscale is a 8 item subscale to measure problems during sport activities (FAAM-Sport). The result of each item of the respective subscale is summed up (maximum score of the activities of daily living subscale = 84; maximum score of the sport activities subscale = 32). The sum is divided by the maximum score and then multiplied with 100. A resulting maximum score of 100 represents no functional limitation in each subscale. In patients with chronic ankle instability, FAAM-ADL-, and FAAM-Sport-scores of < 90 and < 80, respectively, are considered to represent a disability of function [46].

After manual testing, the lower leg movements (active and passive range of motion) of the affected side were not restricted compared to the unaffected side. Therefore, goniometric measurements were not performed. The patient demonstrated a neutral foot posture [47]. During the finger to floor distance measurement (FFD), he could not reach the floor with a mean distance of 13.5 (±1.5) cm from three trials, indicating a possible deficit of hamstring extensibility along with pelvic girdle and/or lumbar spine flexibility [48]. A limitation of hamstring flexibility was found in patients with plantar heel pain, previously [49]. The FFD is considered to be a reliable test for detecting total mobility when bending forward in standing position with intra- and inter-tester reliability scores of the intraclass-correlation coefficient (ICC) = 0.99 [50]. The patient did not show any strength deficits in dorsiflexion, plantarflexion, eversion, and inversion at the right and left ankle joints after using manual muscle testing (5/5) [29]. Furthermore, he could easily perform 25 single-leg heel raises on each leg, which is considered normal [51].

Intervention

Early phase

Two days after initial examination, the patient began to apply the cross-friction massage using the fascia ball (crane®, ALDI Sued, Germany) daily at home in the evening [52], while sitting in a relaxed upright position [47] on the couch. The fascia ball had a diameter of 8 cm and consisted of robust cork, unable to squeeze it. It was placed underneath the heel at the most painful aspect of the tissue (Figure 1). The patient was barefoot, with the toes slightly dorsiflexed actively to allow for slight stretching of the plantar fascia [3]. He was instructed to press the heel against the ball until pain was felt, and then to roll over the ball anterior-posterior and medial-lateral approximately within an inch [3] using self-selected, but steady, speed and treatment duration. Initially, no specification of duration was given because patients are most likely to adhere to their preferred treatment [53]. As mentioned above, the patient was instructed to call the therapist (MA) if symptoms changed significantly. Accordingly, no pain elicited with palpation of plantar fascia, and significant improvements in NPRS and SF-MPQ scores were observed at the second visit on post-treatment day 19 (Figure 2). He reported a treatment duration of approximately two hours per day, including self-selected breaks.

Figure 1.

Foot placement on the fascia ball during self-executed cross-friction massage.

Figure 2.

Line graph illustrating daily short-form McGill pain questionnaire-scores during six weeks of treatment; red line: sensory component (ia) of pain, orange line: affective component (ib) of pain, gray line: total sensory and affective pain score, yellow line: average pain intensity (Numeric Pain Rating Scale [NPRS]), blue line: current pain intensity, green line: total score of pain.

Second phase

For the second phase of treatment, which began after day 19, he was then asked to reduce the treatment time to 5 to 10 minutes and to reduce heel pressure. The reason for this was that the intensive treatment chosen by the patient was no longer necessary due to the significant reduction in pain. In addition, he was instructed to perform approximately 10 maximal isometric contractions of the quadriceps and tibialis anterior muscles for at least 5 seconds and breaks of 10 seconds with the knee fully extended and the foot maximally dorsiflexed in a supine, sitting, or standing position whenever he felt slight discomfort in the heel and/or triceps surae muscle in daily life, in order to relax the posterior leg muscles, especially the triceps surae muscle, as a result of decreased neural activity and increased inhibition of proprioceptive structures [54–56]. On days 23, 29 to 31, 33, 35, and 40, mild pain recurred (Figure 2). He was then instructed to increase the treatment duration and heel pressure during the treatment according to his pain tolerance.

Treatment was completed six weeks after the beginning of treatment. The patient continued his usual activities during the treatment period. In follow-ups two and four weeks, as well as six months after the final treatment day, pain and function were assessed again to determine persistence of outcomes. The sequence of examinations and interventions is presented in Table 1.

Table 1.

Sequence of examinations and interventions.

Sequence	Examination/intervention	Procedures
1 (first visit)	Initial examination	Anamnesis; physical examination; patient reported outcomes and assessments
2 (two days after first visit)	Beginning of treatment	Self-executed cross-friction massage using the fascia ball daily at home in the evening for about two hours
3 (second visit on day 19 of treatment)	Evaluation of treatment	Patient reported outcomes and assessments
4 (first day after second visit)	Adaptation of treatment	Reduction of treatment time to 5 to 10 minutes with reduced heel pressure; performance of approximately 10 maximal isometric contractions of the quadriceps and tibialis anterior muscles for at least 5 seconds and breaks of 10 seconds
5 (third visit six weeks after the beginning of treatment)	End of treatment	Physical examination; patient reported outcomes and assessments
6 (two weeks after the end of treatment)	Follow-up 1	Patient reported outcomes and assessments
7 (four weeks after the end of treatment)	Follow-up 2	Patient reported outcomes and assessments
8 (six months after the end of treatment)	Follow-up 3	Patient reported outcomes and assessments

Outcomes and follow-up

During the first self-treatment session the patient rated his pain intensity at 8/10 on the NPRS and at 34/60 on the SF-MPQ total score (Figure 2). In the morning before the first treatment session, the patient‘s FAAM-ADL-score was 73.8 and his FAAM-Sport-score was 71.9 (Figure 3). There was a considerable pain reduction to a SF-MPQ total score of 8 and a NPRS score of 2 after one week of treatment. Moreover, the FAAM-scores increased to 94 (ADL) and 84.4 (sport) (Figure 3). The following two days, pain increased again to a SF-MPQ total score of 21 (Figure 2) and a NPRS score of 5. From then, pain decreased continuously to 0 in both scores at day 18 (Figure 2) and the FAAM-scores ADL and sport improved to 100, respectively (Figure 3). In the following three weeks, pain improvement maintained with a few episodes experiencing mild pain (Figure 2). At the follow-up measurements after two and four weeks, the patient demonstrated no pain (NPRS = 0/10; SF-MPQ = 0/60) and full function (FAAM-ADL = 100/100; FAAM-Sport = 100/100). At 6-month follow-up, the patient reported maintenance of these scores.

Figure 3.

Physical function of the foot and ankle measured in the morning of the first day of treatment (measurement 1), and then in the morning after each five days of treatment for six weeks (measurements 2 to 8) using the Foot and Ankle Ability Measure (FAAM). ADL: Activities of Daily Living.

Discussion

The main finding was, that the patient experienced a considerable improvement of pain and function after about three weeks of daily treatment. Furthermore, after six weeks of treatment and in the follow-ups after two and four weeks as well as six months, the patient demonstrated persisting positive outcomes, showing that improvement of plantar heel pain and restoration of physical function maintained.

Acute and persistent effects during and after treatment

During the first five days of treatment, the patient felt no significant improvement of pain, which may have been caused by the targeted repetitive loading of the connective tissue, potentially leading to a tensile stress, inducing a collagen remodeling process [57]. After one week of treatment, the patient reported a considerable pain relief, similar to previous findings [3]. This may be explained by the acute numbing effect of cross-friction massage, that usually sets in after at least 10 minutes of treatment [58]. Consequently, the typical analgesic effect over the treatment area may have emerged [23,26,58].

In the following course of treatment, pain continuously decreased to nearly zero or even zero in both scores. The regular application of cross-friction massage with the fascial ball applied to the painful area of the plantar heel may have increased arterial perfusion [59] and increased fascial layer sliding [60], which may have contributed to the improved outcomes after treatment, similar to findings from foam rolling research [59,60]. After approximately three weeks of considerable pain improvement, treatment was limited to 5 to 10 minutes at a pain-adjusted pressure. Thereby, the mechanical stimulation may have aided collagen remodeling [61].

Comparable to the findings of the present study, significant and clinically meaningful pain and functional improvements were achieved by aggressive soft tissue mobilization directed to the insertion of the plantar fascia at the medialcalcaneal tubercle [62,63]. Thereby, improvement of pain intensity (NPRS 0/10) and duration of treatment were similar [63]. However, treatment in these studies included other manual interventions, such as joint glide mobilizations, manipulation, or stretching. The intense rolling of the medial plantar surface of the affected foot over the hard fascia ball may have caused slight mobilization of the many small joints of the hindfoot and midfoot, contributing to the improvement in pain.

Pain reduction may also be explained by a cascade of neurophysiological responses from the peripheral and central nervous systems, rather than being solely mechanical [64]. It was reported, that cross-friction massage using the reinforced index finger in combination with stretching of the gastrocnemius-soleus muscle complex or in combination with mobilization and manipulation of the ankle and foot or in combination with both alternative interventions leads to significant improvements of heel pain and function of the foot and ankle, with cross-friction massage combined with stretching being superior for pain reduction [3]. In addition, there is strong evidence that combined interventions of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions improve pain at six weeks and one year [65]. In the present study, education, resistance training, stretching, and neurodynamic interventions were not used; however, because of the continuous improvement in pain and function as measured by the NPRS, SF-MPQ, and FAAM over the course of treatment, the patient may have increased physical activity and lower extremity loading, which may have resulted in improved neuromuscular function. Because the patient did not show deficits in the outcome measures of muscle function and neurodynamics at initial examination, possible adaptations were not assessed after the intervention and at follow-ups.

Pain and functional improvements were maintained to the end of treatment at six weeks and at follow-ups. This may have indicated that after rapid tissue adaptations, a reduction in plantar fascia thickness occurred along with a reduction in plantar heel pain sensitivity [66]. However, this could not be investigated in the present study.

Technique and duration of applying cross-friction massage

It was stated that cross-friction massage must be applied transversely to the certain tissue [26] and that the therapist’s fingers and patient’s skin must be shifted consistently to avoid blister formation or subcutaneous bruising [23]. During rolling the heel over the fascia ball, consistent movement of the ball’s surface and the skin could not be controlled; however, previous recommendations of cross-friction massage techniques are anecdotal [22,58], and therefore, could also not guarantee a standardized external mechanical stimulation and skin movement. The same applied for duration and intensity of cross-friction massage application. It was proposed that friction massage should be applied for 10 minutes, and that pain during treatment is commonly the result of a wrong indication, a wrong technique, or an unfamiliar level of pressure [58]. The patient in the present study performed the cross-friction massage about two hours daily, using a painful, but tolerable, pressure during the first three weeks of treatment with a successful outcome, challenging the previous guidelines.

There were limitations in the present case report. Conclusions about a cause and effect relationship with the treatment and the patient’s successful outcomes cannot be inferred. Moreover, physiological explanations of pain reduction and plantar fascia adaptations remain not clarified. Information from studies supporting the use of a fascia ball for treating plantar heel pain lacks. Therefore, applying the cross-friction massage using the fascia ball, including pressure, frequency, and duration, was based on primarily anecdotal evidence [22]. No other recommended treatment options, such as stretching, shockwave therapy, or custom orthoses [17], were used with this patient. Therefore, it is unknown if similar outcomes would have been achieved using those interventions. In normal practice, it may not be possible to treat a patient for approximately two hours daily under the supervision of a therapist due to time constraints. However, to be effective, it is important that patients adhere to therapy [67], and therefore, self-administered treatment with a fascia ball at home with this frequency and duration may be a realistic option, as demonstrated in this case report.

Conclusion

The present case report described the successful treatment of a patient with recent-onset plantar heel pain. The patient reported that daily self-administered cross-friction massage using a fascia ball was a useful and practical treatment for his condition. Therefore, it may be an alternative intervention in the management of recent-onset plantar heel pain that needs to be further investigated in controlled clinical trials.

Biography

Martin Alfuth is a physiotherapist and sports scientist. Since 2014, he has been a full professor of therapeutic sciences at the Faculty of Health Care at the Niederrhein University of Applied Sciences in Krefeld, Germany. He has also been teaching sports physiotherapy at the German Sport University Cologne for 12 years. His research focuses on the investigation of sensorimotor function and strength in patients with load-dependent impairments of the musculoskeletal system, the biomechanical and ICF-oriented analysis of the effectiveness of insoles and orthoses in the context of therapy management in patients with musculoskeletal and neurological impairments, and the evaluation of therapy programs in rehabilitation. Martin is the author of national and international publications and a speaker at congresses.

Disclosure statement

No potential conflict of interest was reported by the author(s).