












































CLINICAL OUTCOMES RESEARCH 

 

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Copyright © by Indiana State University                                                                              Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

Graston Technique® as a Treatment for Patients with Chronic Plantar 
Heel Pain  
Troy R. Garrett, EdD, LAT, ATC, EMT1 & Peter J. Neibert, PhD, LAT, ATC2 

1University of Northern Iowa, Cedar Falls, IA; 2Dixie State University, St. George, UT  
 

 
ABSTRACT 

Use of Instrument-Assisted Soft Tissue Massage has 
increased in popularity, and the plantar fascia is a 
superficial tissue that may benefit from this treatment. The 
objective of this study was to determine the effectiveness of 
Graston Technique® (GT) for decreasing pain and 
increasing function in participants with chronic plantar heel 
pain over a six-week period. A single blind, pretest-posttest 
control/comparison group design, with a sample of 22 
adults (5 males, 17 females) was utilized. Participants were 
assigned to three groups: GT/stretching, 
effleurage/stretching, and stretching only. After completion, 
effleurage/stretching and stretching only groups were later 
offered GT with posttest scores recorded. Participants were 
pretested/posttested using the Foot Health Status 
Questionnaire (Foot Pain, Foot Function, and General Foot 
Health), McGill Pain Questionnaire, and Visual Analog 
Scale. A posttest Kruskal-Wallis analysis between the three 
groups demonstrated a significant difference of the Visual 
Analog Scale between the GT/stretching and 
effleurage/stretching groups. From pre to posttest, 
Wilcoxon Test resulted in GT/stretching group significantly 
improving in 4 out of 5 variables, with effleurage/stretching 
significant in 1 out of 5, and stretching only demonstrating  
significance in 3 out of 5. Friedman’s Test for effleurage 
and stretching only groups resulted in significant differences 
in all the variables when GT was later administered. The 
mean differences between pre and posttest for the groups 
demonstrated a minimal important difference of 4 out of 4 
variables for GT/stretching, 2 out of 4 variables for 
effleurage/stretch, 2 out of 4 variables for the stretching 
only group. Participants improved in variables measured 
over a six week treatment of GT. This was both shown to be 
not only statistically significant, but clinically significant 
utilizing minimal important difference. 

Key Phrases 
Instrument assisted soft tissue massage, chronic plantar heel 
pain, manual techniques  
 
Correspondence 
Dr. Troy Garrett, University of Northern Iowa, 2351 Hudson 
Road – HPC 008A, Cedar Falls, IA 50614-0244 
Twitter: @tgarrettatc 
 
Full Citation 
Garrett TR & Neibert PJ. Graston Technique® as a 
treatment for patients with chronic plantar heel pain. Clin 
Pract Athl Train. 2019;2(3):22-34. 
https://doi.org/10.31622/2019/0003.4.     

Submitted: August 8, 2019 Accepted: October 18, 2019 
 

INTRODUCTION 

Chronic plantar heel pain (CPHP), previously 

referred to as “plantar fasciitis”, is one of the most 
common causes of heel pain, accounting for 
approximately 11-15% of all foot disorders.1 
CPHP typically results from repetitive micro 
trauma or excessive overload to the fascia.1 
Individuals most prone to this condition are 
middle-age women,2 and those with high body 
mass index.2 CPHP has been shown to have a 
negative impact on foot health and overall quality 
of life resulting in functional disabilities.3  
 
Historically, CPHP has been described as a 
painful heel with inflammation of the plantar 
fascia at its origin.1 In recent years, research has 
suggested that plantar heel pain is rather a non-
inflammatory degenerative fasciosis.4 Snider et. 
al, 5 conducted histological examinations of 
surgical biopsy specimens and found 
degenerative tissue markers such as collagen 
necrosis, angiofibroplastic hyperplasia, chondroid 
metaplasia, and matrix calcification. Others 
observed similar findings on histological 
examination such as, “marked thickening and 
fibrosis,”6 and “fiber fragmentation in association 
with myxoid degeneration.”4 However, no 
markers for inflammation were found in these 
studies.  
 
Numerous interventions have been utilized for 
treatment of CPHP, which include, heat,7 
cryotherapy,7 non-steroidal anti-inflammatory 
drugs,7 heel pads/cups,8 night splints,9 low-dye 
arch taping,10 plantar fascia specific stretching,11 
calf stretching,12 steroid injection,13 extra-
corporeal shock wave therapy,14 platelet-rich 
plasma injection,13 and myofascial trigger point 
therapy.15 Unfortunately, not all patients 

https://doi.org/10.31622/2019/0003.4


Graston Technie® as a Treatment for Patients with Chronic Plantar Heel Pain 
 

 

 
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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

experience a resolution of symptoms following 
these treatment interventions. 
 
In recent years instrument assisted soft tissue 
massage (IASTM) has grown in popularity and 
usage among clinicians working with active 
populations.16-21 It has been hypothesized, for 
degenerative tissue conditions such as tendinosis 
and fasciosis, that IASTM reinitiates the 
inflammatory response by creating controlled 
microtrauma in the affected tissues.16,22 It has 
been further hypothesized that this controlled 
microtrauma to degenerated tissue ultimately 
results in tissue maturation and remodeling.16,17,23-

26  
 
While numerous case studies have been published 
regarding the GT (Indianapolis, IN) with chronic 
degenerative disorders, 16,18-21 there is only one 
case series study of plantar heel pain on multiple 
participants.23 The effectiveness of IASTM on 
CPHP has not, to our knowledge, been studied in 
a randomized group design. Therefore, the 
purpose of our study was to determine the 
effectiveness of instrument-assisted soft tissue 
mobilization, specifically the GT (GT), for the 
treatment of patients suffering from CPHP. We 
hypothesized that GT would be more effective at 
decreasing foot pain and increasing foot function 
with patients suffering from chronic plantar heel 
pain when compared to a placebo and stretch 
only protocol. 
 
PARTICIPANTS  

Following Institutional Review Board approval, 
volunteers were recruited for a period of 10 
months. Of the 44 patients screened, 28 met the 
inclusion criteria and agreed to participate 
(Figure 1). Overall, 7 men and 21 women with 
CPHP symptoms (age = 46.45 ± 12.5 years, 
Body Mass Index = 30.45 ± 6.13) were 
enrolled. Four participants discontinued 
intervention, due to scheduling conflicts (n=2) and 
due to not tolerating the GT (n=2). Also, two 
participants (n=2) were later excluded from the 

analysis because they were later diagnosed with 
a pathological bone spur of the calcaneus, 
therefore, they were deemed ineligible for 
inclusion in the study. Of the remaining 22 
participants, 7 were assigned to the 
GT/stretching group (2 males and 5 females, 
48.5 ± 13.8 years), 7 were assigned to the 
effleurage/stretching group (2 males and 5 
females, 44.6 ± 13.3), and 8 were assigned to 
the stretching only group (1 male and 7 females, 
46.1 ± 10.4 years). 

Individuals were included in the study if they had 
a physician (M.D., D.O., or D.P.M.) clinical 
diagnosis of CPHP that resulted in pain and 
discomfort for at least 3 months; with no 
corticosteroid injections within 30 days of 
participation. Individuals were excluded from 
participation if they reported having a history of 
diabetes; pathological bone spurs of calcaneus; 
any past plantar fascia release surgery; or any 
acute plantar fascia injuries. Cancer, burn scars, 
rheumatoid arthritis, polyneuropathies, chronic 
regional pain syndrome, or other conditions 
known to be contraindications to GT also resulted 
in exclusion from the study.22  

INTERVENTIONS 

Carey et al22 states that the basic components of 
the GT are: (1) 3-5 minutes of active warm-up, 
(2) 8-10 minute GT treatment, and (3) 
specifically targeted tissue stretches. For the 
warm up, the participants were placed on a 
stationary bike, then asked to cycle for 5 
minutes, at a comfortable pace appropriate to 
their level of fitness prior to the treatment 
intervention. Participants then removed the shoe 
and sock of the involved foot and assumed a 
prone position on the treatment table. A drapery 
was attached to wires hanging from the ceiling 
between the levels of the waist to mid-thigh to 
ensure visual blinding to the treatment (Figure 
2A). 



Graston Technique® as a Treatment for Patients with Chronic Plantar Heel Pain 

 

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Copyright © by Indiana State University                                                                              Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

Figure 2: (A): Blinding of the participant during interventions. (B) GT instrument #4. (C) GT instrument #2. 
(D) GT instrument #3. (E) Plantar Fascia Sp ecific Stretching as defined by DiGiovanni et. al.1

  



Graston Technie® as a Treatment for Patients with Chronic Plantar Heel Pain 
 

 

 
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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

The knee of the involved foot was flexed to 90°, 
while the investigator supported the ankle 
proximal to the malleoli, maintaining the ankle in 
a neutral position. GT emollient (Indianapolis, IN) 
was applied to the plantar surface of the foot 
for all participants. For the GT/stretching group, 
one of three certified athletic trainers (ATC) level 
M1 certified Graston Technique® providers 
(years of GT experience = 4.17 ± 2.02) 
performed a predetermined protocol of: 4 
minutes of GT instrument #4 (Figure 2B), the 
large convex instrument; 3 minutes of GT 
instrument #2 (Figure 2C), the medium concave 
instrument; and 3 minutes of GT instrument #3 
(Figure 2D), the small convex instrument, for a 
total of 10 minutes. All certified providers were 
instructed to provide pressure to the participants 
comfort level, while performing sweeping strokes 
from anterior to posterior and posterior to 
anterior22 from the calcaneus to the metatarsal 
heads of the plantar surface. Participants were 
monitored and encouraged to report if the 
treatment was too painful or caused a high level 
of discomfort. Treatment was focused on areas 
where adhesions were discovered through the 
GT instruments. When using GT instruments, if 
adhesions are detected, a vibratory sensation is 
felt by the clinician.22  

The effleurage/stretching group participants 
were placed in the same prone position following 
the warm-up. However, after the emollient was 
applied, the investigator provided light touch 
effleurage with the fingertips, from the calcaneus 
to the metatarsal heads, for 8 minutes. 
Investigators were instructed that the effleurage 
was to be very light for sensory effects and not 
deep enough to cause mechanical effects to the 
tissue. For the stretching only group, participants 
were placed in the same position. Emollient was 
lightly applied for 10 seconds, the ankle was 
held in the same neutral position for 8 minutes 
without any additional contact to the plantar 
surface. A towel was used to remove the 

emollient at the end of the timed treatment for 
each group. 

Each session, for all participants regardless of 
treatment group, was concluded with plantar 
flexion specific stretching as described by 
DiGiovanni et al.11 The participant assumed a 
seated position, crossed the involved foot over 
the uninvolved leg, stabilized the calcaneus with 
the contra-lateral hand, and stretched the 
plantar fascia by forcibly extending the toes at 
the metatarsal heads with the ipsilateral hand 
(Figure 1E). The investigator confirmed successful 
stretching by verifying tautness of the medial 
plantar fascia. Participants performed 10 
stretches holding each for 10 seconds.11 
Participants were scheduled for 11 more sessions 
(2 per week, not on consecutive days). All the 
participants were instructed not to perform any 
additional plantar fascia specific stretching 
outside of their scheduled treatment sessions. This 
information was repeated after each treatment 
session. In addition, patients were told there 
were no restrictions in physical activity or 
activities of daily living.  

At the end of the 12th session all participants 
completed posttest survey instruments of the Foot 
Health Status Questionnaire, McGill Pain 
Questionnaire, and Visual Analog Scale. 
Participants of the effleurage/stretching and 
stretching only groups were offered the 
investigative GT treatment for another 12 
sessions as the GT/stretching group, with 12 out 
of 15 eligible participants electing to receive the 
treatment. Of the three that declined, two had no 
interest in receiving GT, one later voluntarily 
discontinued. This group of (n=12) received a 
second round of posttest survey outcome 
measurement after the 12th GT session. 

PROCEDURES/OUTCOME MEASURES 

This study was a single blind, randomized 
pretest-posttest control/comparison group 



Graston Technie® as a Treatment for Patients with Chronic Plantar Heel Pain 
 

 

 
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Copyright © by Indiana State University                                                                              Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

design, in which individuals with CPHP were 
randomly assigned to one of three interventions: 
(1) GT of plantar fascia plus plantar fascia 
specific stretching (Graston/stretching); (2) 
effleurage of the plantar surface of the foot plus 
plantar fascia specific stretching 
(effleurage/stretching); (3) and the only 
stretching group (received no treatment) plus 
plantar fascia specific stretching (stretching only). 
Participants underwent 2 treatment sessions a 
week (not on consecutive days) for 6 weeks, 
totaling 12 sessions. The Foot Health Status 
Questionnaire, McGill Pain Questionnaire, and 
Visual Analog Scale were administered before 
and after the 6 week intervention for all 3 
groups. After the posttest, the 
effleurage/stretching and stretching only groups 
were offered the investigative treatment in the 
same manner as the Graston/stretching group 
for an additional 6 weeks. The independent 
variable was treatment type, with gender being 
controlled by randomization. The dependent 
variables were foot function, foot pain, and 
general foot health (from the Foot Health Status 
Questionnaire) and also foot pain of two other 
instruments (McGill Pain Questionnaire and Visual 
Analog Scale). 

Participants were recruited from local podiatry 
clinics and by a university-wide online 
advertisement. Four local podiatry clinics with 8 
doctors of podiatry provided letters of support 
for this study. Patients with a clinical diagnosis of 
CPHP were given an envelope with an enclosed 
recruitment flyer including the contact information 
of the investigators. Potential participants were 
instructed to contact the investigators if they 
were interested in participation. Upon making 
contact, a telephone interview was conducted to 
determine if inclusion and exclusion criterion 
were met.  

Following the telephone interview, participants 
were scheduled to meet an investigator at the 
athletic training research laboratory, where the: 

consent form, list of contraindications, and a 
medical release form (to verify CPHP diagnosis) 
were signed. Specific information such as 
treatment interventions, full design of the study, 
and to which group assigned was withheld from 
the participants during the screening process and 
throughout the treatment intervention phase of 
the study. Initial pretesting survey outcome 
instruments consisting of the Foot Health Status 
Questionnaire, McGill Pain Questionnaire, and 
Visual Analog Scale were completed.  

Foot Pain, Foot Function, and General Foot 
Health were utilized. Foot Health Status 
Questionnaire scores were calculated using the 
Foot Health Status Questionnaire Data Analysis 
Software© (Version 1.03). Numerous sources 
have shown strong content validity and 
reliability, with Cronbach α ranging from .85 to 
.8828 with appropriate factorial structure and 
high internal consistency and test-retest 
reliability, ICCs ranging from .74 to .92,28,29 with 
specific sensitivity to patients with CPHP.  

The McGill Pain Questionnaire long form consists 
of 20 groups of words describing pain, with the 
participant circling the word in each subsection 
that best applies and then an ordinal ranking 
score is tabulated.30 The range of the total 
McGill Pain Questionnaire score is 0 for “no 
pain” and 76 being the maximal score for the 
“worst pain”. Test-retest reliability of multiple 
studies report a correlation of r > .70.31  

The Visual Analog Scale is a 10 cm line that 
states “No Pain” on the left, and “Worst Pain 
Imaginable” on the right. Participants are 
instructed to make a vertical mark on the scale 
best describing their pain within the last 24 
hours. The score is measured from the distance 
from the left border to the vertical mark in 
millimeters. Visual Analog Scale scores were 
tabulated by an individual independent of the 
study measuring the distance from the left (no 
pain) to the vertical mark made by the subject in 



Graston Technie® as a Treatment for Patients with Chronic Plantar Heel Pain 
 

 

 
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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

millimeters. Test-retest reliability has been 
reported as high as r=.94, with correlations 
ranging from .61 - .92 when compared to pain 
scales using words for validity.32  

Landorf and Radford33 examined the minimal 
important difference (MID) which is defined as 
the amount of improvement needed that was 
deemed important to the patient, for the Foot 
Health Status Questionnaire and Visual Analog 
Scale, specifically for patients with ‘plantar 
fasciitis.’ For the Foot Health Status 
Questionnaire, the minimal important differences 
were reported as: 14 for Foot Pain, 7 for Foot 
Function, and 9 for General Foot Health. For the 
Visual Analog Scale, 9 millimeters of 
improvement was reported as the minimal 
important difference.33 MID data for the McGill 
Pain Questionnaire has not been reported in the 
literature. 

Statistical Analysis  

Non-parametric tests were utilized to analyze 
the data. A Kruskal-Wallis test was conducted to 
determine differences between the three 
treatment groups at pretest, and later at 
posttest. Any significant differences was 
analyzed with a Mann-Whitney U test.  Within 
group differences between pretest and posttest 
for each of the five variables was calculated 
utilizing Wilcoxon Signed Ranks Test.  
Effleurage/stretching and stretching only group 
was computed together from pretest to posttest 
to post GT with Friedman’s Test. Alpha was set at 
P<0.05 for all tests, with Post Hoc for Friedman’s 
test having Bonferroni correction set at 0.0167.34 
All data were analyzed on IBM SPSS Statistics 
24 (Chicago, IL).  

RESULTS 

To test for homogeneity between the groups, a 
Kruskal-Wallis test was conducted to analyze the 
pre test scores. There were no significant 
differences between the groups on all the 

dependent variables: Foot Pain H(2) = 2.73, p = 
0.25, r = .58, Foot Function H(2) = 1.16, p = 
0.55, r = .24, General Foot Health H(2) = 0.95, 
p = 0.62, r = .20, McGill Pain Questionnaire 
H(2) = 1.47, p = 0.47, r = .31, and Visual 
Analog Scale H(2) = 1.90, p = 0.36, r = .40. A 
posttest analysis between the three groups 
resulted in a significant difference with Visual 
Analog Scale H(2) = 8.78, p = 0.012, r = 1.87. 
Post Hoc Mann-Whitney test demonstrated a 
significant difference for Visual Analog Scale 
between the GT/stretching and 
effleurage/stretching groups (p=0.011).  

Within groups significance was measured 
utilizing the Wilcoxon Signed Ranks test and are 
displayed in Table 1. Four of the five variables 
of the GT/stretching group were found to be 
significant. One out of 5 variables were 
significant for the effleurage/stretching group. 
The stretching only group was significant on 3 out 
of 5 variables. Mean differences within groups 
from baseline to posttest along with 95% CI and 
MID data are reported in Table 2. 

The effleurage/stretching and stretching only 
groups were offered GT after the initial posttest, 
and 12 out of 15 participants received the 
treatment. Data for the two groups were 
combined, and Friedman’s test was conducted 
between pretest (baseline), post effleurage or 
stretching only, and following the administration 
of GT. Data for Friedman’s test is displayed in 
Table 3, as the combined effleurage/stretching 
and stretching only groups demonstrated 
significant differences after GT, utilizing the 
Bonferroni Correction level of significance.   

DISCUSSION 

The purpose of this study was to determine the 
effectiveness of instrument-assisted soft tissue 
mobilization, specifically the GT, for the 
treatment of patients suffering from CPHP. The 
results showed significant Kruskal-Wallis posttest  



Graston Technique® as a Treatment for Patients with Chronic Plantar Heel Pain 

 

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Table 1: Within Groups Baseline to Post Test Wilcoxon Signed Ranks Results. 
 Graston/stretching Effleurage/stretching Stretch only 
 Baseline Post Sig Effect Baseline Post Sig Effect Baseline Post Sig Effect 
Variable mean±SD mean±SD  Size mean±SD mean±SD  Size mean±SD mean±SD  Size 

Foot Pain 41.0±14.1 75.2±13.6 *0.028 0.58 27.5±16.3 40.3±32.0 0.173 0.36 47.4±27.7 59.2±27.0 0.26 0.28 
Foot 
Function 58.9±23.6 91.9±8.6 *0.018 0.63 41.1±37.4 50.8±34.0 *0.042 0.54 53.9±21.6 72.6±27.1 *0.011 0.63 

General 
Foot Health 40.0±28.2 65.4±26.4 0.058 0.5 26.8±39.2 31.1±39.4 0.414 0.21 38.1±33.1 29.1±29.5 0.144 -0.36 

MPQ 29.6±10.3 13.4±9.7 *0.043 0.54 22.8±11.7 24.0±12.0 0.866 -0.04 28.8±18.1 15.5±11.5 *0.012 0.63 

VAS 47.8±20.0 13.9±10.2 *0.018 0.63 63.1±18.7 63.7±31.6 0.865 -0.04 51.4±25.8 24.1±16.2 *0.017 0.59 
* = p<0.05 
Foot pain, foot function, and general foot health are categories of the Foot Health Status Questionnaire, where 100 equals optimal foot health. 
MPQ=McGill pain questionnaire is scored with 0 being no foot pain and 76 as maximal foot pain. 
VAS=Visual analog scale is scored with 0 being no foot pain and 100 as maximal foot pain. 

 

Table 2- Mean Differences and 95% Confidence Intervals Between Baseline and Post-Test. 

  Foot Pain Foot Function General Foot Health MPQ VAS 
Graston Technique® Mean 42.5 32.8 25 14.8 35 

 (95%CI) (11.9,58.1) (12.5,56.25) (-12.5,75.0) (-2,29) (13,54) 
Effleurage Mean 11.9 12.5 10.6 -0.75 -3.5 

 (95%CI) (-6.3,33.1) - - (-17.0,12.5) (-29,37) 
Stretch Only Mean 10.6 18.8 -16.3 13.3 27.3 

 (95%CI) (-12.5,39.1) (12.5,28.1) - (4.5,23.0) (7.5,46.5) 

MID33  14 7 9 NA 9 
MPQ=McGill Pain Questionnaire; VAS=Visual Analog Scale; MID=Minimal Important Difference. - = Calculation not 
possible due to small amount of differences between baseline and posttest (n<=5). 

 

 



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Table 3. Friedman Mean Ranks for Effleurage/Stretching and Stretching Only Groups with 
additional Graston/Stretching treatment (n=12). 

 Pre Test 1 Post Test 2 Post Test 3  

 post hoc  post hoc post hoc Freidman 
  1v2 2v3 1v3 sig 
Foot Pain 1.46 (0.068) 1.71(0.004)* 2.83 (0.003)* 0.001 
Foot Function 1.08 (0.001)* 2.08 (0.008)* 2.83 (0.003)* 0.000 
General Foot 
Health 1.71 (0.496) 1.50 (0.005)* 2.79 (0.008)* 0.001 

MPQ 2.75 (0.061) 2.17 (0.004)* 1.08 (0.002)* 0.000 
VAS 2.58 (0.069) 2.33 (0.003)* 1.08 (0.002)* 0.000 
*= Bonferroni Correction to 0.0167 level of significance. MPQ=McGill Pain Questionnaire; 
VAS=Visual Analog Scale 

differences between the GT/stretching and 
effleurage/stretching groups with the Visual 
Analog Scale. Within group pre- post-test 
comparison revealed significant differences with 
the GT/stretching group in 4 out of 5 variables. 
The effleurage/stretching group showed 
significant differences in 1 out of 5 variables, 
and stretching only was significant with 3 out of 
5 variables.  

Additionally, we found a bimodal response 
utilizing the Minimal Important Difference (MID) 
as reported by Landorf and Radford33, who 
report the MID of the scores for Foot Health 
Status Questionnaire and Visual Analog Scale for 
CPHP (14 points for Foot Pain, 7 points for Foot 
Function, 9 points for General Foot Health, and 9 
points with the Visual Analog Scale). The 
GT/Stretching group exceeded the MID in all 4 
variables that report MID data. 
Effleurage/Stretching group exceeded the MID 
with 2 out of 4 variables, and the Stretch only 
group also exceeded on 2 out of 4 variables.  

The unexpected positive effects for the 
effleurage/stretching and stretching only groups 
may be a result of the plantar fascia specific 
stretching which was performed for all three 
groups. The GT Manual22 recommends that a 
therapy session ends with a period of stretching 
the treated tissue. DiGiovanni11 has reported 
benefits with plantar fascia specific stretching 
compared to Achilles stretching during an eight 

week program, which therefore may explain the 
improvements among all three groups. However, 
the effleurage/stretching and stretch only groups 
improved significantly with all measured 
variables utilizing Friedman’s analysis (Table 3) 
after completing the GT regimen. Therefore, 
there appears to be a trend of improved 
outcomes when utilizing GT combined with 
plantar specific stretching for the treatment of 
CPHP. 

To date, only one study23 utilizing GT for CPHP 
with multiple participants, has been published. 
Their findings are similar to this current study, 
where they found significant improvement for 
pain and function from baseline to follow-up. 
However, due to the case series design and the 
lack of a control group, a cause-and-effect 
relationship could not be established. In addition, 
different outcome instruments, treatment 
durations, and stretches were used in the design 
of this study. Therefore, caution should be used 
when comparing Looney et.al.23 with our results 
due to methodology differences, and comparing 
a case series to randomized comparison group 
design.  

While there is limited published research using 
GT as a treatment intervention for CPHP, there 
are positive benefits16,18-21 for the treatment of 
other chronic disorders. Sevier et al19 reported 
improvements in function and pain when 
comparing a treatment intervention consisting of 



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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

transverse friction massage, phonophoresis, 
stretching, and cryotherapy with a GT 
intervention for the treatment of lateral 
epicondylitis. In a case report of a 40 year old 
patient presenting with chronic Achilles 
tendinopathy, Miners and Bougie21 reported 
improvements in self-reported pain and function 
following an 8 week intervention of GT, Active 
Release Techniques, eccentric exercise and static 
gastrocnemius/soleus stretching. One noticeable 
limitation of each of these case reports is the 
combination of several treatment modalities in 
the treatment of the patients. Therefore, it is 
difficult to determine if the GT was responsible 
for the improvements in pain relief and function. 
In a systematic review conducted by Cheatham 
et al35 looking at the efficacy of IASTM as an 
intervention to treat various pathologies, they 
similarly concluded that a lack of treatment 
protocol homogeneity makes it difficult to 
determine the effects of IASTM in general. 
Cheatham et al35 also report that no IASTM 
study has ever reported a significant difference 
between control or comparison groups and 
IASTM groups. In contrast, we found a post-test 
significant differences with the Visual Analog 
Scale between our GT/stretching and 
effleurage/stretching groups.  

Schaefer and Sandrey,18 examined the effects of 
GT in conjunction with a dynamic balancing 
treatment (DBT) program on outcomes associated 
with chronic ankle instability; they found no 
significant difference between the groups. The 
GT/DBT group demonstrated an increase in 
functional outcomes as did the other groups in the 
study. Thus, it appears that GT offers some 
benefit in the treatment of other chronic 
conditions in addition to this study with patients 
suffering from CPHP.  

This study was limited by the small sample size 
(n=22). In addition, it was also limited by a lack 
of a repeated-measures design, therefore only 
an immediate follow-up after the intervention. 

Therefore, no long term results are known for our 
study population, including the rates of 
recurrence or a need for any additional 
intervention. The sample population represented 
the group that is most susceptible to chronic 
plantar heel pain, consisting of people of middle 
age with elevated body mass index, so our 
results may not represent young healthy athletes, 
and not patients with acute plantar fascia injury. 
The participants represented a population with 
an average age in the mid 40’s with a body 
mass index averaging 28-30, which is above the 
obese range of greater than 25. It has been 
previously reported that a population of higher 
body mass index and over age 40 are more 
susceptible to suffering from CPHP.2 The 
participants were not monitored for activity 
levels during the duration of the intervention. This 
study was also limited by the inequality of males 
(n=5) to females (n=17) as participants. The 
methods of this study limited the GT treatment to 
the use of 3 instruments with basic sweeping 
strokes. Future research needs to be completed 
regarding different GT strokes, different foot 
and ankle positions, and the use of more 
advanced GT techniques. Future research should 
also incorporate more objective instruments, such 
as plantar fascia thickness via diagnostic 
ultrasound to supplement the subjective scales. 

CLINICAL APPLICATION 

To our knowledge, this study is the first 
randomized pretest-posttest control/comparison 
group design investigating the use of GT plus 
plantar-fascia specific stretching as an 
intervention for CPHP. Consequently, our findings 
shed light on the use of GT as a potential 
treatment of CPHP. It is our recommendation that 
clinicians take a multifaceted approach to 
treating patients with CPHP which includes GT 
along with Plantar Fascia Specific Stretching11 
and other traditional treatment methods.36 Future 
research should focus on multicenter randomized 



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Copyright © by Indiana State University                                                                              Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

controlled trials incorporating IASTM specifically 
regarding CPHP. 

The authors declare that no financial conflict of 
interest exists with the research comprised within 
this article. There is no commercial or proprietary 
interest with any materials used for this study. 

Acknowledgements 

The authors wish to thank Dawn Jacobson, MA, 
ATC, PES for her assistance with data collection, 
also Courtney Sheets, ATC for her assistance with 
data analysis.  The authors as well would like to 
thank Mark Jacobson of the UNI Statistical 
Consulting Center and Dr. Robin Lund, PhD for 
their assistance with statistical analysis. 

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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

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All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

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Copyright © by Indiana State University                                                                              Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

2014;44(11):A1-A23. 
https://doi.org/10.2519/jospt.2014.0303 

https://doi.org/10.2519/jospt.2014.0303



