Instrument assisted soft tissue mobilization versus dynamic oscillatory stretch technique in females wearing high heels; a randomized clinical trial

Abstract

Background: Prolonged and frequent use of high-heeled footwear has been associated with musculoskeletal maladaptation and impairments. These include calf tightness, reduced ankle dorsiflexion range of motion (ROM), and altered gait mechanics. Over time, these changes may compromise the functional mobility of the lower extremity.

Objective: to compare the instrument-assisted soft tissue mobilization and dynamic oscillatory stretch technique on ankle ROM and Lower Extremity Functions among high-heeled users.

Method: This single-blinded, randomized Controlled Trial was carried out at Begam Akhtar Memorial Trust Safari Hospital from August 2023 to January 2024. A total of n=54 females aged between 20-40 years with <17 degrees dorsiflexion, wearing high heels of at least 2 inches, for 5 hours/day, for more than 3 days/week, and > one year included in the study. The sample was divided into group A, which received Graston mobilization (IASTM), and group B received the dynamic oscillatory stretch technique (DOST) for gastrocnemius and soleus muscles. For lower limb functions, ankle ROM goniometer and Pain were assessed through lower extremity functional status, goniometer, and numeric pain rating scale.at baseline and after the 12th session.

Results: The Results showed significant improvement (p<0.001) in the IASTM group as compared to the DOST group with respect to ankle ROM, pain reduction, and LEFS showed equal (p=0.303) improvements for both groups.

Conclusions: IASTM is more effective than DOST in improving ankle ROMs and decreasing pain in female high heel users. However, both techniques showed similar improvements in lower extremity functional status.

Clinical trial registry: NCT06086600

INTRODUCTION

Over the past few decades, high-heeled (HH) shoes have become an essential part of contemporary fashion and business attire for women worldwide, causing biomechanical problems in lower limbs[1,2,3]. with high prevalence reported in institutional and clinical settings ranging from 39% to 78, among those 46% exhibited poor functional activities[4,5]. Musculoskeletal injuries are caused by overuse and poor foot posture causing both mechanical and functionally changes[6].

A high heeled shoe is normally 10cm tall, but a flat-soled shoe is 0-4cm tall and consist of stiff heel cap and thin toe holder that anteriorly protrudes with exaggerated plantar curve that encourages continuous plantarflexion in the ankle joint, [5] which can cause calf muscle tendon unit (MTU) shortening[6]. The gastrocnemius muscle can be shortened by 5% by elevating the heel by 13 cm,[7] resulting in simultaneous rigidity of these muscles. Stiffness in these muscles results in development of trigger points in muscles. Myofascial trigger points are hyperirritable zones in muscles that are identified by reduced vasculature[3,6]. Thus, wearing high heels on a daily basis would cause shortening of the gastrocnemius muscular fascicles, reduced triceps surae muscle extensibility, increased Achilles tendon stiffness and reduced ankle joint ROM. High heel wearers demonstrated reduced dorsiflexion and eversion and increased ankle ROM in Plantarflexion and inversion when compared to flat shoe (FS) wearers. The high heel wearers also reported pain in dorsiflexion, when walking in flat shoes[7]. Function of lower extremity also get effected due to alteration in mechanical characteristics of the Achilles' Tendon, which in turn cause gastrocnemius strain, Achilles tendinitis, and plantar fasciitis [5].

Physical therapists are employing a broader range of therapies to prevent dysfunction and deformities brought on by muscular contractures, maintain and improve flexibility, and lessen joint stiffness. This includes using wet heat pads, applying ultrasound therapy, engaging in Muscle energy techniques (MET), continuous passive motion (CPM), stretching or mix these techniques[8]. Stretching and Kinesiotaping of calf muscle are frequently advised to improve ankle joint dorsiflexion or lessen symptoms of these conditions[9,10]. In response to the increased knowledge of these concerns, interventions i.e. IASTM and DOST have developed as viable techniques to address the negative effects of excessive heel usage on calf muscles.

Overuse of muscles can cause excessive tension leading to soft tissue injuries. After injury, fibrosis and scar tissue formation can occur in the injured tissue which reduces the tissue elasticity and forms adhesions that can results in pain and diminished function of soft tissues. When using IASTM with appropriate pressure and shear force on specific area, inflammation along with capillary and micro vascular haemorrhage can be the result. This inflammation removes the scar tissue and release adhesions thus initiating the healing response. It also increases the nutrient and blood supply to the effected injured area and migration of fibroblasts. At last, new collagen is formed and realigned that regenerate the injured tissues[11]. Dynamic oscillatory stretch technique proves better than static stretch in increasing hamstring flexibility and stretch threshold effects in increasing joint range of motion[12].

Literature shows the effects of interventions only on ankle movements i.e., dorsiflexion and inversion in regular high heel wearer[5,7]. The current study observed effect in both the ankle and sub-talar joints including all range of motion dorsiflexion, inversion, eversion and Plantar flexion of ankle joint and functional status of lower limbs. Both techniques (IASTM and DOST) seem to be effective in improving ROM, reduce fascia tightness, muscle tightness and release of trigger points in sports populations however its effects on shortened calf muscle–tendon unit (MTU), thicker and stiffer Achilles tendon and muscle fatigue in female wearing high heels has not been done before. This study seeks to bridge the gap by performing an organized study of the effects of IASTM and DOST on calf muscles in females who wear high heels on a daily basis so this study might add effective treatment in literature. The current study is planned to compare the effects of IASTM and DOST in Pain, ankle ROM and on functional status in females wearing high heel.

METHODOLOGY

Study design & setting: It was a Randomized Control Trial (RCT # NCT06086600) with and. After taking the ethical approval from Research ethical committee (Ref: Riphah/RCRAHS-ISB/REC/MS-PT/01610) the data was collected from Begham Akhter Rukhsana Memorial Trust, Safari Hospital. Study duration was 6 months from August 2023 to January 2024.

Participants: The participants age was 20-40 years having <17^O dorsiflexion, wearing ≥2 inches high heel for 5 hrs/ day, more than 3 days/week and for more than 1 year. The participants with DVT, malignancy, infection, Eczema, MSK injury or surgery of lower limb, Sciatica or other Neuropathy/Neurological disorder, acute cardio-respiratory disorder or any medical co-morbidities [13] were excluded from the study. All participants provided written informed consent following the Declaration of Helsinki guidelines.

Sample size: Sample size was n=54 calculated through G-power with priori effect size of 0.25, alpha 0.95 and power 80% and number of measurements was set at 2.the sample was collected through convenience non-probability sampling.

Randomization & Blinding: The randomization was done through random number generator and the allocation concealment was done through sealed envelope method. Author FN did the allocation in groups and MN did the intervention. The research was Single blinded study; outcome assessor was unaware of the patient’s allocation in groups to reduce bias.

Figure 1: CONSORT diagram

Intervention: Each participant took part in 12 treatment sessions spread over four weeks, with three sessions scheduled per week. Evaluations were carried out at the beginning of the study and again after the final (12th) session. Alongside their assigned interventions, participants in both groups also received standard conventional treatment throughout the study period. The participants in both groups received a passive warmup using a hot pack applied to the calf muscles for 10–15 minutes before intervention. Participants in Group A received IASTM using the Graston Technique with a stainless steel, S-shaped Tai-Chi knife (GT-2 tool). The treatment targeted the gastrocnemius and soleus muscles in prone position with feet overhanging the plinth. The therapist stood at the side of the plinth and applied moisturiser before intervention. after that gentle stroke using the tool in a proximal to distal direction to identify trigger points or taut bands. after localisation, strokes were applied in multiple directions at a 30° to 60° angle with minimal pressure for 40 to 120 seconds. Group B participants received DOST targeting both the gastrocnemius and soleus muscles. The total stretching time was 60 seconds per set (2 second stretches×10 repetitions×3 sets). The gastrocnemius was stretched in Supine lying with full knee extension. The therapist passively dorsiflexed the ankle to the first point of stretch and applied slow oscillations for 2 seconds each at the end range and repeated 10 time per set in 3 set total, increasing the range progressively with every set. While soleus muscle was stretched in supine as well but with 15° knee flexion having the foot flat on the table. The therapist than dorsiflexed the ankle after stabilising the lower leg to the initial stretch point than applied oscillatory passive stretches at end range for 2 seconds[13]. All participants received 10 repetitions, 2 sets stretching exercises for the gastrocnemius and soleus muscles using a seated calf stretch with a resistance. To conclude every session, a cold pack was then applied to the calf muscles for 5 minutes. (Figure 2)

Figure 2: Stretching Techniques to Manage Calf Muscles

Outcome measures: numeric pain rating scale (NPRS), an 11-point subjective measure for pain intensity ranging from least pain (0) to unbearable pain (10) was used [14]. To measure the ROMs including ankle dorsiflexion, plantarflexion, inversion, eversion, the goniometer was used universally. The ROMs measurements were taken thrice to ensure reliability[15]. Lower extremity functional scale (LEFS) was used to assess functional abilities with lower extremity impairments, containing 20 questions, with five options that range from (0) unable to perform to (4) able to perform without difficulty. The LEFS covers a wide range of activities, including basic mobility tasks such as walking and standing, as well as more complex activities like running, jumping, and climbing stairs. It assesses the patient's ability to perform these activities both with and without assistive devices. The score ranges from 0-80, a higher score indicate better function[16].

Statistical analysis: The outcome measures were taken at baseline and on last treatment session (12th session). Data analysed through Statistical Procedure of Social Sciences (SPSS)). Normality was calculated of all variables which concluded that and all variables were non-parametric. For between group analyses Maan Whitney U-Test was applied. Wilcoxon Signed Rank Test was applied for within group analysis.

RESULTS

The total of n=54 samples was analysed, mean age of all participants were 29.33± 5.76 years. And the mean heel height was 3.04 ±0.870 inches. Further among the participants, n=36(66.7%) individuals reported wearing high heels three times per week, while n=18(33.3%) individuals reported wearing them five times per week.

Independent sample T test was applied for between group A and B analysis. There was significant difference in both groups according to mean and standard deviation in all variables, including ankle dorsiflexion, ankle plantar flexion, ankle inversion, ankle right eversion, NPRS and LEFS (p<0.05) except left ankle eversion. Detailed description given in table 2.

Paired sample T test was applied for within group analysis of groups with respect to outcome measures. Both groups showed significant improvement (p<0.001) in all variable i.e. in ankle ROMs, NPRS, and LEFS as shown in table 3.

Table 1: Between group comparison independent sample t test

Table 2: Within group comparison using paired sample t test

DISCUSSION

The purpose of the study was to compare the effects of Instrument assisted soft tissue mobilization and Dynamic oscillatory stretch technique on females wearing high heels. The findings show that IASTM and DOST are effective strategies for improving ankle ROMS and lower limb functional status. When compared to DOST, the inter-group study indicated that IASTM is far more effective at improving range of motion, and pain levels however it has no advantage with respect to left foot eversion and lower limb functional status.

Ikeda N, et.al conducted research on effects of instrument assisted soft tissue mobilization applied on gastrocnemii, soleus, and tibialis posterior muscles; overlying deep fascia; and Achilles tendon in healthy individuals and concluded that IASTM showed significant improvement in Dorsiflexion-ROM and reduction in ankle stiffness[17]. Another study conducted by Carrie A Rowlett et al compared of Instrument assisted soft tissue mobilization and traditional stretching on the gastrocnemius-soleus complex in healthy participants and concluded that both IASTM and stretching demonstrably increased ankle dorsiflexion RO [18]. Another study comparing IASTM with stretching in pronated dominant foot individuals shows significant results in IASTM with respect to ankle range of motion, foot posture, foot function and dynamic balance. In the present study, IASTM significantly improve ankle range of motion and foot pain in women wearing high heels as compared to dynamic oscillatory stretch[19]. The superior effects of IASTM in improving ankle ROM and reducing foot pain may be attributed to its ability to target deeper myofascial restrictions and stimulate mechanoreceptors, enhancing tissue extensibility and neuromuscular responses. Unlike dynamic oscillatory stretching, IASTM provides controlled microtrauma, promoting localized inflammation and tissue remodelling, which may result in more sustained improvements, especially in chronically stressed structures like those affected by prolonged high heel use

Bhurchandi compared the IASTM with ultrasound on ankle pain and function and found that IASTM outperform in alleviating heel pain and discomfort[20]. Another study conducted by shows the effectiveness of IASTM as compared to static stretching in decreasing pain caused by delayed onset of muscle soreness (DOMS) in young healthy females[21]. Jooyoung Kim et al. conducted a study that concluded, IASTM considerably reduces pain levels which supports the notion of current research that IASTM significantly reduce pain in both right and left leg. Increased blood flow to effected area might be the reason of pain reduction. IASTM induces localized microtrauma and inflammation, which restarts the healing process by promoting fibroblast activation and collagen synthesis. This facilitates removal of scar tissue, improves vascularity, and enhances oxygen and nutrient delivery to the area. These effects help clear pain-mediating substances and reduce mechanical irritation, leading to significant pain relief over time[11].

Jahnvi T. Shah, compared Active release technique and Instrument assisted soft tissue mobilization on the gastro soleus muscles in high heels concluded that IASTM is a more effective trigger point release intervention since it increases ankle dorsiflexion range of motion[13] which support current research findings.

Heejun Kim, showed that the application of instrument assisted soft tissue technique on medial and lateral gastrocnemius and tibilalis anterior in patient with limited ankle dorsiflexion syndrome showed improvement in ankle mobility and muscle activation however there were no changes on foot pressures[22]. A pilot study of a doctoral project showing that no significant difference in effects of the IASTM combined with dynamic stretching and dynamic stretching alone on lower extremity dynamic strength after 48 hours in healthy volunteers with > 90% limb symmetry index[23]. Reason probably is it consists on single session and healthy volunteer’s with >90% symmetry. IASTM might have more effects if the individual have < 90% asymmetry. The dynamic oscillatory muscle stretch technique has no available data up to my knowledge in ankle mobility. Kanza et al concluded that DOST is more effective in improving hamstring flexibility in asymptomatic healthy individuals[24].

Current study aimed at the comparison of impact of IASTM and DOST on pain, lower extremity functional status as well as all ankle ROMS. The inter-group analysis concluded that IASTM is more effective in improving ROM, lower extremity functional status and NPRS, hence it can be used in clinical practice. The study has the limitation that BMI was not considered in outcomes, that may act as the confounder with the high heel. Future studies should focus on objective measurement of stroke intensity of instrument assisted soft tissue mobilization and measure the effects on muscle strength.

CONCLUSION

Instrument assistive soft tissue manipulation (IASTM) is more effective than Dynamic Oscillatory stretch technique (DOST) in improving ankle range of motion and decreasing pain in female high heels user. However, both techniques showed similar improvements in lower extremity functional status.

DECLARATIONS & STATEMENTS

Author’s Contribution

MN: substantial contributions to the conception and design of the study, acquisition of data for the study, and drafting the work.
RT: substantial contributions to the conception and design of the study, methodology development, formal analysis, supervision, and project administration.

FN: acquisition of data for the study and critical revision of the work for important intellectual content.

MS: substantial contributions to the conception and design of the study and drafting the work.

AR: drafting, editing, critical revision for important intellectual content, and final review.

MN, RT, FN, MS, and AR: final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.

Ethical Statement

The study was approved Riphah Human Research Ethics Committee of Riphah international university (approval number: Riphah/RCRAHS-ISB/REC/MS-PT/01610), where it was performed and subjects gave informed consent to the work.

AI Use Statement

The author use the Al tools like Grammarly, endnote, G power, Turnitin for the drafting, referencing, and sample size calculation and plagiarism checking.

Consent Statement

Informed written and verbal consent was taken from the patients for using the clinical data and pictures, hiding their identity, anonymously to be used in publication.

conflict of interest

None to declare.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Acknowledgments

None to declare.

Funding Sources

The authors received no financial support for this article to declare

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