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Randomised control trial to compare the efficacy of traditional Thai massage and ultrasound therapy for treating plantar heel pain

BMC Complementary Medicine and Therapies volume 25, Article number: 42 (2025) Cite this article

Abstract

Background

Massage is suggested to be an effective treatment for chronic plantar heel pain (PHP). There is, however, no scientific evidence to support this claim. In the present study Traditional Thai Massage (TTM) has been compared with Ultrasound therapy (US) for treating PHP.

Methods

Sixty PHP patients with a Myofascial Trigger Point (MTrP) present in the calf were randomly assigned to receive a 40-minute single treatment of either US or TTM. Pain Intensity (VAS), Pressure Pain Threshold (PPT), Ankle Dorsiflexion Range of Motion (DROM), and Foot Skin Temperature (FST), were measured before, immediately after, and 24 h after treatment.

Results

Compared to baseline, both groups showed a significant reduction in pain intensity immediately (CVAS) and 24 h after treatment (MVAS24) (p < 0.01), as well as a significant increase in PPT of the heel immediately after treatment (p < 0.05). However, only the US treatment group showed an increase in PPT in the calf immediately after treatment (p < 0.05). Furthermore, only the US group showed a significant increase in DROM immediately and 24 h after treatment (p < 0.001). The reduction in CVAS and increase in DROM immediately (p < 0.05) and 24 h after treatment (p < 0.01) were significantly greater in the US than the TTM group.

Conclusions

The significant efficacy of US with stretching for providing pain relief in the treatment of PHP is confirmed. For the first time, TTM has also been demonstrated to be effective in providing pain relief for patients with PHP and may have a potentially useful complementary role, in treating PHP.

Trial registration

TCTR20210909001 (First Submitted Date: September 2021).

Highlights

To compare the efficacy of TTM with US, when applied with a hot pack, both in combination with passive stretching, for treating PHP.

Ultrasound therapy, a commonly used physical therapy treatment modality, has shown good efficacy for providing pain relief for PHP. However, TTM has also demonstrated similar effectiveness. This suggests that TTM could be a complement to physical therapy and, in some instances, serve as an alternative treatment for PHP.

Peer Review reports

Introduction

Plantar Heel Pain (PHP) is the most common pain symptom of the foot and exacerbations typically last for weeks or months. Common causes of PHP are plantar fasciitis, heel spur syndrome and plantar fasciosis which often occur together. Pain is usually greatest on the bottom of the foot near the heel, and is usually worst when taking the first few steps after waking and can decrease in response to continued walking and other activities. Risk factors associated with PHP are age (patients are commonly aged between 40 and 60 years), certain types of exercise (e.g. long-distance running), foot mechanics (e.g. structural abnormalities such as pes planus, pes cavus, unequal leg length and calf and intrinsic foot muscle tightness), as well as foot spurs [1], obesity (BMI > 30 kg/m2), lifestyle and occupation (e.g. walking or standing for a long time) [2,3,4]. The prevalence of PHP in the adult population varies widely, ranging from 2.7 to 17.5% [5]. Among athletes, particularly runners, PHP prevalence is reported to range from 5.2 to 17.5% [6].

In both the acute and chronic phases, inflammatory signs such as swelling, redness and heat may be detected in patients with PHP. However, there have been several reports that most patients with PHP do not show signs of inflammation [7]. The so-called windlass effect theory has been proposed as a possible mechanism for explaining the development of PHP. The theory is that weight-bearing of the foot combined with dorsiflexion of the metatarsophalangeal joints, produces a tensile stress on plantar fascia and most especially in the area of the enthesis calcaneus [2, 4, 8, 9] which leads to repeated fascia injury and failure of the healing response [8, 9]. Healthy tissue may be replaced by angiofibroblastic hyperplastic tissue, resulting in an increase in fascia thickness, decrease in fascial tissue length and elasticity and restricted range of motion [10]. This leads to development of PHP which can interfere with normal daily living. For example, to relieve pain patients may develop abnormal patterns of walking which can result in foot, knee, hip or back problems. Indeed, a major clinical hallmark of PHP is abnormal weight-bearing which is likely to be associated with excessive muscle contraction of intrinsic foot muscles as well as of more proximal muscles. Patients with PHP may frequently also develop Myofascial Trigger Points (MTrPs), for example, the calf muscles.

Myofascial trigger points (MTrPs) are considered a significant contributor to pain in patients with PHP. First described by Simons et al. 1999 [12], MTrPs are hyperirritable spots within a taut muscle band. Active MTrPs cause spontaneous and referred pain, while latent MTrPs produce pain upon stimulation, such as with applied pressure. They are commonly associated with increased muscle stiffness, reduced flexibility, and limited range of motion. Frequently found in the gastrocnemius muscle [12], treatments targeting MTrPs may help alleviate pain in PHP patients.

The treatment of PHP is dependent on how long the condition has been present. Initially (i.e. first 6 weeks) anti-inflammatory drugs or corticosteroid injection may be prescribed and subsequently a multi-modality approach may be advised comprising immobilization, padding and strapping, stretching exercise, arch support/heel cup, shoe recommendations, custom orthotics and night splinting. If PHP has persisted for more than 6 months, the patient may be referred for Physical Therapy (PT) such as US or for complementary alternative treatments such as Massage [10, 11], and which in Thailand is most likely to be Traditional Thai Massage (TTM).

In giving US therapy special attention is paid to the presence and location of MTrPs and in the present study both US and TTM were administered as localized treatments. The most common US-based protocol for treating PHP is US combined with application of a hot pack and assisted stretching [11]. Massage treatment of chronic PHP, especially when MTrPs are present, may comprise Myo-Fascial Release (MFR) [13] and deep massage therapy applied to posterior calf muscles and neural mobilization with a self-stretch exercise program (DMS) [14]. As mentioned, in Thailand TTM is frequently applied to treat PHP, and comprises application of pressure massage along so called Sen Sib lines together with passive muscle stretching. Specifically, deep massage may be performed in the region of the MTrPs [15,16,17].

The aim of both US and TTM is to stimulate blood circulation within affected muscles, which may promote the removal of pain sensitizing substances, and mechanical stimulation of muscle fibers, with the aim of reducing pain intensity, relieving muscle tension and reducing muscle stiffness. However, there is no scientific evidence regarding which treatment may be the most effective. Therefore, in the present study a Randomised Control Trial (RCT) was performed to compare the efficacy of a well-established Physical Therapy protocol which uses US with TTM for treating PHP. US is predicted to show significant treatment effects. If TTM is also shown to have efficacy, the low cost and wide availability of TTM could make it a valuable adjunct to US for clinical management of PHP.

Methods

Study design

A prospective RCT involving parallel treatment groups, was carried out in the Physical Therapy/Rehabilitation Department, Banlueam Hospital, Nakhon Ratchasima, Thailand. The study was approved by the Human Research Ethics Committee of Khon Kaen University, Thailand (protocol number HE 602332), was conducted in accordance with the Declaration of Helsinki and each patient gave fully informed written consent of their willingness to participate. The study protocol adheres to the CONSORT 2010 guidelines and the trial is registered with the Thai Clinical Trials Registry (TCTR20210909001).

Participants recruitment/ sample size calculation

The patients who all had PHP were aged between 18 and 60 years and recruited during October 2021 to -September 2022 by a general practitioner working in the outpatient department at Banlueam Hospital, Nakhon Ratchasima, Thailand. Sample size was calculated based on a previous study of morning pain intensity in patients with PHP in which the pooled standard deviation of a numeric pain-rating scale (NPRS) was 2.80 and the mean difference of 2 was considered to be clinically significant. A total of 60 participants (30 per group) would need to be recruited to detect a difference in the effect of the two treatments (active vs. shame US) with a 2-sided t-test, power of 0.8, and α = 0.05 [11].

Inclusion criteria were (i) tender point on the plantar aspect of the heel at the medial calcaneal tuberosity, (ii) history of the pain being worse in the morning when the patient takes the first few steps after waking up or after long period sitting, (iii) tightness or limited ankle dorsiflexion range of motion (evaluated by passive stretching), (iv) active or latent MTrPs in the gastrocnemius or soleus muscle of the calf identified by manual palpation. Exclusion criteria were (i) red flag to manual therapy such as tumor, fracture, rheumatoid arthritis, severe vascular disease or thrombophlebitis, (ii) evidence of neurologic deficit, bilateral plantar heel pain, prior surgery in the lower extremity, diagnosis of fibromyalgia syndrome and (iii) if the patient had received any therapy for their foot pain within the past month. A total of 60 patients were recruited who had PHP affecting either one or both legs.

Protocol for study, randomization, and allocation concealment

Figure 1 shows the protocol of this study, after screening the demographic characteristics of the recruited participants were recorded by a general practitioner together with baseline values of the outcome measures. A stratified block randomization approach, with three age groups (18 to 30 years, 31 to 45 years and 46 to 60 years) of both female and male participants, was used to ensure that there were no biases in terms of age or sex when patients were allocated to either US or TTM treatment groups. Random assignment was based on a scheme using sealed envelopes (http://www.sealedenvelope.com) which were prepared by a researcher who assistant but was not directly involved in the study.

Fig. 1
figure 1

Flow diagram of participant recruitment

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Interventions

Ultrasound (US) treatment group

The US treatment which lasted 40 min administered by a physical therapist with over 7 years of work experience. The treatment comprised ultrasound followed by passive stretching (Fig. 2; US1-4). Ultrasound therapy was performed using a Sonopuls 492 system (Enraf-Nonius, Rotterdam, The Netherlands) set to operate in continuous mode, with a frequency of 1 Hz and intensity of 1.5 W per cm2. The ultrasound probe was positioned on the skin directly above the MTrP which had been identified as being located in either gastrocnemius or soleus muscle of the calf and which was likely to produce the referred pain in the heel during standing and walking. After an interval of 5 to 10 min the system was changed to intermittent mode, frequency of 1 MHz and intensity of between 0.5 and 1.0 W per cm2 and the treatment was applied with the new settings to the painful site on the heel for 3 min [18]. After resting for 5 min the patient lay down in a supine position and passive stretching of the calf muscle was performed with the knee in both non-flexed (i.e. leg extended) and flexed positions for a total of 15 min. The static stretching was similar to that used in TTM (see below) and comprised 15 s of stretching followed by 20 s rest with 5 repetitions per set for 2 sets, and with a 10-minute break between the two-stretching positions [14, 19].

Fig. 2
figure 2

Ultrasound and Tradition Thai Massage treatment protocols. The US protocol comprised four steps. With the patient in prone position (A) US was administered to the calf (US1) and heel (US2) and then with the patient in supine position (B) passive stretching of the calf was performed with the knee in extension (US3) and flexion (US4). The TTM protocol comprised nine steps. Four steps (TTM1-4) were performed with the patient in supine position (A), two (TTM5-6) in side lying (B), two (TTM7-8) in prone position (C), and finally stretching (TTM9) of the calf and foot muscles was performed with the patient in supine position (D). Sen Seb lines are denoted by (---> ). TTM1 = Close-open wind gate (Femoral artery occlusion) denoted by (o); TTM2 = Anterior of upper/lower leg; TTM3 = outer lines of upper/lower leg; TTM4 = Inner lines of upper/lower leg; TTM5-6 = The signal points of leg or “San-yan points” at outer and inner sides of a painful leg denoted by (•); TTM7 = Plantar surface of foot; TTM8 = Back lines of upper/lower leg; and TTM9 = Calf or gastrocnemius-soleus muscle stretching

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Traditional Thai massage (TTM) treatment group

Traditional Thai Massage (TTM) treatment was also given in a single 40 min session by a certified and licensed massage therapist. The TTM protocol comprised 9 steps (see Fig. 2; TTM1-9) and was applied specifically to the painful foot and leg, with 35 min devoted to manual massage and 5 min to passive stretching. The massage began with femoral artery occlusion, sometimes referred to as opening the wind gate, lasting 30 to 45 s (Fig. 2; TTM1), and which was followed by gentle massage using thumb and palm with pressure applied at sub-pain levels for 5 to 10 s at points regularly spaced along the relevant Sen Sib lines (Fig. 2; TTM2-4, TTM7-8), with the massage of each line repeated 3 to 5 times [14]. A number of major signal points (San Yan points) were encountered on each line and in these places the pressure was applied for an increased time of 30 to 45 s (Fig. 2; TTM5-6) [20]. Finally, passive stretching of the calf muscle was performed with the leg in an extended position for a total of 5 min (Fig. 2; TTM9), and comprised static stretching for 15 s follow by 20 s rest with 5 repetitions per set for 2 sets [19].

Outcome measures / recording / blinding

The following outcome measures were recorded by a physical therapist with work experience of 10 years and who was blinded to the treatment that the participant received.

Primary outcome

Current pain intensity (CVAS)

Current pain intensity (CVAS) is the pain patients reported experiencing when asked during the assessment and was measured by using a 10 cm Visual Analogue Scale (VAS) divided into 10 equal intervals and with 0 corresponding to no pain and 10 to the worst pain imaginable. In previous studies this method of measuring pain (CVAS) has been reported to have high intra-rater repeatability with ICC of 0.99 [21] and high concurrent validity [22].

First-step pain intensity (MVAS24)

Patients were additionally asked to rate the pain intensity they experienced when taking their first steps after waking or rising from bed in the morning (MVAS24).

Pressure pain threshold (PPT)

Pressure Pain Threshold (PPT) was measured by using a Commander TM Algometer and Digi Track (JTECH Medical, Salt Lake City, Utah, USA). The algometer comprises a rubber tipped plunger with area of 1 cm2 which was placed against the skin at the recording site and participants reported when the applied force which increased at a rate of 1 kg per second changed to a feeling of pain. The procedure was repeated three times at 2-minute intervals and the average value was recorded in units of pounds per cm2. The recording sites corresponding to the tender point on the heel of the affected foot and a prominent MTrP in the calf of the same leg were identified by manual palpation and were marked on the body using an ink pen. In previous studies the algometer has been shown to have high repeatability (r = 0.99) [23].

Secondary outcome

Ankle dorsiflexion range of motion (DROM)

In order to measure ankle Dorsiflexion Range of Motion (DROM) the participant stood next to a wall and made a weight bearing lunge movement with the leg on the same side as the affected foot. The distance from the wall to the big toe (cm) was recorded using a tape measure. This procedure was repeated three times at 10 s intervals and the mean value was recorded. Intra-rater repeatability of the measurement of DROM has been studied with ICC reported as 0.99 for the left and 0.98 for the right leg [24].

Foot skin temperature (FST)

Measurements of Foot Skin Temperatures (FST) were obtained by using Infrared (IR) Thermography. The camera that was used was a Ti10 Fluke Thermal Imaging Camera (Fluke Corporation, Washington, USA) set to operate in the spectral band of 7.5–14.0 μm. Imaging was performed in a quiet room with the temperature set to 25 °C and with an average relative humidity of 38%. Participants lay in a supine position on the examination table with their feet placed on a pillow, and prior to taking the measurements the affected foot was cleaned with a dry towel. The camera was positioned at a distance of 80 cm from the foot and three images were obtained and the average value of FST in the painful area of the heel was recorded. IR Thermography has been reported to have high intra-rater repeatability with ICC of between 0.62 and 0.92 [25].

All outcome measures were recorded at baseline, immediately after treatment, and 24 h after treatment, with the exception of pain intensity, which was measured only at baseline (CVAS) and 24 h after treatment (MVAS24), for the side of the body corresponding to the painful heel. In addition, the pain intensity that each patient experienced when taking their first steps after rising from bed in the morning of the day following treatment was recorded (MVAS24).

Statistical analysis

Statistical analysis was performed by using SPSS Version 26 (IBM, Armonk, New York, USA). Intra-rater repeatability of the PPT and DROM outcome measures was assessed. by using the Intra-class Correlation Coefficient (ICC). A two-way repeated measures Analysis of Variance (ANOVA) was performed to evaluate the main effect and potential interaction effects (3 times x 2 treatment groups). If there was an interaction effect, pair-wise comparisons were performed by using post-hoc tests (Bonferroni) to determine the within group effects in each treatment group. In addition, an analysis of co-variance (ANCOVA) was performed to compare post-treatment data between groups using the baseline value as a covariate [26]. Partial Eta square (η2) for ANCOVA, 0.01 (small effects), 0.06 (medium effects) and 0.14 (large effects) were measured [27]. The study followed an intention-to-treat rule which meant that from the beginning until the end of the study, all patients remained in the group to which they were originally assigned.

Results

Demographic data corresponding to age, sex, weight, height, BMI, etc. for the two treatment groups are presented in Table 1.

Table 1 Demographic and baseline data for the US and TTM treatment groups
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There were no significant differences in any of the measures between the two groups (p > 0.05) with the exception that significantly more patients in the US group had prominent MTrPs in soleus muscle, while those in the TTM group had more prominent MTrPs in gastrocnemius muscle. The ICC values corresponding to the study of intra-rater repeatability in measuring PPT of heel and calf, DROM and FST are presented in Table 2 and all values are between 0.76 and 0.99 which corresponds to substantial agreement.

Table 2 Intra-class correlation coefficients and standard error of the measurement pre-treatment (n = 30)
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The average values of the outcome measures recorded at baseline, immediately after treatment and 24 h after treatment are shown in Table 3. Compared to baseline, both treatment groups exhibited a significant reduction in CVAS immediately after treatment. However, the US group showed an additional significant reduction in CVAS 24-hours after treatment. (p < 0.01). Moreover, both treatment groups displayed a significant decrease in MVAS24 pain intensity 24 h after treatment (p < 0.01). Both treatment groups also showed a significant increase in PPT of the heel immediately after treatment (p < 0.05), but only for the US treatment group was a significant increase in PPT of the calf muscle MTrP observed immediately after treatment (p < 0.05). No significant increase in PPT was observed for either the heel or the calf in either treatment group 24 h after treatment. However, the US group, but not the TTM group, showed significantly increased DROM both immediately and 24 h after treatment (p < 0.001).

Table 3 Comparison of outcome measures between baseline, immediate, and 24 h after treatment
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The statistical analysis performed to directly compare the US and TTM treatment groups (see Table 4), revealed that the US group showed a significantly greater reduction in CVAS and increase in DROM compared to the TTM group (p < 0.05) immediately following treatment (p < 0.05), and the increase in DROM was also significantly greater in the US than the TTM group 24 h after treatment (p < 0.01), with Partial Eta square (η2) values in the range 0.08 (i.e. medium) to 0.25 (i.e. large) for all the group comparisons.

Table 4 Comparison of US and TTM treatment groups, immediately and 24 h after treatment
Full size table

Within group, and between group (Table 4), analysis did not reveal any significant change, or differences, in FST immediately or 24 h after treatment.

Discussion

Ultrasound and TTM both showed efficacy for treating chronic PHP, producing a significant reduction in CVAS immediately after treatment as well as in MVAS24, recorded in the morning 24 h after treatment. In addition, both treatments also produced a significant increase in PPT of the heel immediately after treatment (p < 0.05), and for the US treatment group a significant increase in PPT of the calf muscle MTrP was also observed immediately after treatment (p < 0.05). No significant increase in PPT was observed for either the heel or the calf in either treatment group 24 h after treatment. However, the US group, but not the TTM group, showed significantly increased DROM both immediately and 24 h after treatment (p < 0.001). Interestingly, since the present study was designed and carried the American Physical Therapy Association have produced guidelines to the effect that US treatment is unlikely to be an effective treatment for PHP [28]. The results of the present study suggest that this recommendation may need to be reconsidered. In particular, as far as we are aware this is the first time PHP has been treated using a protocol in which US was applied to both the heel as well as a prominent MTrP that had been identified in either gastrocnemius or soleus muscle. The idea for this approach was taken from, Ajimsha et al. (2014) who used sham US delivered to plantar fascia, gastrocnemius and soleus as a control condition when investigating the effectiveness of myofascial release for treating PHP. The present study is the first in which such a procedure has been used as a real, as opposed to sham, treatment and has produced promising results.

Before discussing the findings of the present study in more detail it is important that acknowledgement is made of the fact that the 40 min US and TTM treatment protocols both included 15 min during which passive stretching of the patient’s leg was performed. Passive stretching is a well established component of TTM and as in the present study typically occupies about one quarter to one third of the treatment protocol. In the case of US passive stretching is sometimes included and sometimes omitted. In the present study, passive stretching was included in the US treatment protocol for a similar amount of time as in the TTM protocol. There is therefore a possibility that the effectiveness of US and TTM for treating PHP that has been demonstrated in the present study is in both cases due to the passive stretching that is included in both protocols. While considered unlikely, this possibility should be investigated in further research. The notable findings related to TTM are interesting, especially considering that the stretching component within the TTM protocol may have been less effective than that of the US protocol.

With regard to the analysis of DROM [29] the increase of 1.66 cm in the US group is higher than the change reported in a previous study for which the range was reported to be from 1.10 to 1.50 cm [24]. As discussed by Thomas et al. (2018), long static stretching is proven to improve joint and muscle flexibility. It is possible that the combination of US therapy and stretching of triceps surae (i.e. gastrocnemius and soleus) with the knee in both in extension in flexion in the US treatment may promote lengthening of both calf muscles, especially in soleus compared to TTM when stretching was only performed with the knee in flexion [30]. Moreover, the weight bearing lunge test for measurement of DROM has greater dependence on the extensibility of soleus [24, 31]. Another possible explanation is that demographic data show more patients in the US group had prominent MTrPs in the soleus muscle, while those in the TTM group had more prominent MTrPs in the gastrocnemius muscle. The significant difference in the relative location of prominent MTrPs in gastrocnemius and soleus between the two groups may have introduced a potential confounding factor in this study’s results. However, due to the small sample size, a subgroup analysis could not be performed to investigate the influence of the location of the prominent MTrP, and which would be interesting since as MTrPs in both muscles can contribute to heel pain [12]. The present study is the first to investigate the short-term effect of massage treatment (i.e. immediately and 24 h after treatment) in patients with PHP. There is therefore no study with which the results can be directly compared. However, the findings are consistent with the results of a previous study by Saban et al. (2018) who found both US and TTM treatments reduced the pain patients with PHP experienced when taking first steps in the morning 4 to 6 weeks after commencement of treatment [14]. In another study, Renan-Ordine et al. (2011) reported that 4 weeks of self-stretching and soft tissue trigger point manual therapy produced a greater increase in PPT than self-stretching alone [32].

Considering the minimal clinically important difference (MCID), the US group exhibited a greater reduction in pain intensity (CVAS) compared to the TTM group, with a difference of 1.07 cm at the 24-hour after treatment (p < 0.01). This difference corresponds to a moderate effect size (η2 = 0.071). However, when applying the MCID range of 1.8 to 5.2 cm as suggested by Sutton et al. (2019), the difference of 1.07 falls outside of that range [29].

The study has several limitations that should be acknowledged. Firstly, only the short-term and not the long-term effects of the US and TTM treatments were investigated. Secondly, in interpreting the results obtained from the measurement of foot skin temperature (FST) it should be noted that the data were collected during the summer season and even though temperature and humidity were well controlled in the room where recordings were made, patients may have been exposed to higher than usual outside temperatures between the baseline and subsequent measurements. Furthermore, the FST measurements were recorded after only a short rest period and may not be an equilibrium value.

In this study US treatment showed a longer lasting effect up until 24 h after treatment compared to TTM for some outcome measures. This may be due to differences in the mechanisms of US and TTM treatments [29]. In particular, the thermal effect produced by the ultrasound treatment may cause a lengthening of contracted muscle fibers within the MTrP. Ultrasound may also produce effects that are generally considered to be non-thermal in nature [33,34,35,36]. Taken together, the thermal and non-thermal effects of US have been suggested to transiently increase the flexibility of tendons, ligaments, and joint capsules, with consequent reductions in joint stiffness, pain and accompanying muscle spasm and temporarily increase in blood flow [35].

The improved blood circulation produced by acupressure massage and muscle stretching in TTM promotes removal of pain sensitizing substances (e.g. substance P, H + and lactic acid) [37, 38]. This may lead to reduction of muscle stiffness and increased flexibility. In addition, according to gate control theory stimulation of large nerve fibers (i.e. Aβ fibers) by TTM acupressure massage, and for which the conductance is higher than for small C fibers, may lead to inhibition in the conduction of pain signals in the substantia gelatinosa of the spinal cord and thus to the patient experiencing less pain [39]. Interestingly, PPT was only increased for the site of the MTrP in calf muscle as a result of US and not for TTM therapy.

There is evidence that treatment of Myofascial Pain Syndrome (MPS) with Ultrasound therapy relieves pain intensity in the upper trapezius muscles [40] The protocol comprising Ultrasound therapy, heat-pack and passive stretching that was used for the US treatment in the present study has previously been used by Aklinoglu and colleagues (2017) who reported that scores on an index of Foot Function was reduced in patients with PHP [41] The combination of thermal, non-thermal, mechanical and micro-massage effects produced by using Ultrasound in the PT treatment has the advantage of increasing levels of cellular activity and blood flow and both heals the inflammatory process while creating an analgesic effect [42].

Conclusions

Both US and TTM demonstrated similar efficacy for providing pain relief in the treatment of PHP. The finding with respect to US is consistent with several previous studies. However, the present study is the first in which TTM has been shown to be an effective treatment for PHP.

Data availability

We confirm that all data underlying our findings are fully accessible upon reasonable request by contacting the corresponding author.

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Acknowledgements

We wish to express our gratitude and appreciation to all the patients for their generosity and willingness to participate in this study. We gratefully acknowledge the staff of Outpatient clinic, Banlueam Hospital, Nakhon Ratchasima Province, Thailand for support in carrying out the study.

Funding

This work was supported by Research Center in Back, Neck, Other Joint Pain and Human Performance, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand.

Author information

Authors and Affiliations

  1. Physical Therapy/Rehabilitation Department, Banlueam Hospital, Nakhon Ratchasima, Thailand

    Supamas Somphai

  2. Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University (KKU), 123, Mitraphab Highway, Muang District, Khon Kaen, 40002, Thailand

    Wiraphong Sucharit, Punnee Peungsuwan & Uraiwan Chatchawan

  3. School of Physical Therapy, Faculty of Associated Medical Sciences (AMS), Khon Kaen University (KKU), Khon Kaen, Thailand

    Wiraphong Sucharit, Punnee Peungsuwan, Neil Roberts & Uraiwan Chatchawan

  4. Centre for Reproductive Health (CRH), Institute for Regeneration and Repair (IRR), University of Edinburgh, Edinburgh, United Kingdom, University of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom

    Neil Roberts

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Contributions

UC is the chief investigator and administrator of the project and was responsible for the conception and design of the study, acquisition and analysis of data, interpretation of the findings and drafting the article and revising it critically for important intellectual content. SS was responsible for acquisition and curation of the data. PP was responsible for the conception and design of the study. NR revised the article critically for important intellectual content and WS supported acquisition and analysis of data and reviewed the final version of the manuscript.

Corresponding author

Correspondence to Uraiwan Chatchawan.

Ethics declarations

Ethics approval and consent to participate

This study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki and the Good Clinical Practice Guideline. It was approved by the Human Research Ethics Committee of Khon Kaen University, Thailand (protocol number HE 602332) on January 14, 2017. Each patient provided fully informed written consent to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Somphai, S., Sucharit, W., Peungsuwan, P. et al. Randomised control trial to compare the efficacy of traditional Thai massage and ultrasound therapy for treating plantar heel pain. BMC Complement Med Ther 25, 42 (2025). https://doi.org/10.1186/s12906-025-04754-9

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Keywords

BMC Complementary Medicine and Therapies

ISSN: 2662-7671

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