2

Scholle

Positive Outcomes from Pelvic Assessment leading to MET and Kinesio Taping Interventions for a Woman Diagnosed with Plantar Fasciitis: A Case Report

Lauren L. Scholle

Abstract

A pelvic alignment assessment is an important component to evaluating patients with various conditions. This examination tool is particularly essential when examining patients with impairments in the ankle or the foot. This assessment may guide treatment interventions when an asymmetry is found. A 49-year-old female patient, with an active lifestyle, was diagnosed with bilateral plantar fasciitis. This patient had unsuccessful results from a surgical release of the plantar fascia in her right foot, as well as from strengthening and stretching interventions. A pelvic assessment of the patient indicated a hypomobile left innominate as well as a sacroiliac joint (SIJ) dysfunction. Treatment interventions involved Muscle Energy Technique (MET), soft tissue mobilization with the Graston Tool, and kinesiotape (KT). The patient’s home exercise program (HEP) involved isometric exercises to maintain the MET corrections. Positive outcomes from six weeks of treatment included decreased pain, increased activity and participation levels, and improved Lower Extremity Functional Scale (LEFS) and Fear Avoidance Belief Questionnaire (FABQ) scores.

This case study illustrates the importance of conducting a pelvic assessment for every patient that has a lower extremity impairment, particularly in the foot or ankle. This study demonstrates how positive outcomes were facilitated with the utilization of MET and KT for a patient with plantar fasciitis. Further research is needed to investigate relationships between foot and ankle impairments and pelvic asymmetry, as well as how MET and KT interventions may be effective in treating patients with foot and ankle restrictions, when a pelvic malalignment or SIJ dysfunction is found. This manuscript word count is 3,481 words.

Background and Purpose.

The importance of conducting a pelvic alignment assessment during the examination of patients, especially those with low back pain, has been well documented in recent years.1,2.3 Research indicates the effectiveness of utilizing a pelvic alignment assessment for patients with conditions involving restrictions in the pelvis, hips, thighs and knees.4,5 Less research has been published on the significance of the pelvic alignment assessment in patients with lower extremity conditions further down the kinetic chain to the ankle and foot.6 This case report demonstrates the value of conducting a pelvic assessment with every patient presenting with a lower extremity condition, including those involving the ankle and foot, as it may guide treatment with positive outcomes.

This case report involves the observations found in managing a patient’s plantar fasciitis with a multimodal program that includes pelvic alignment and KT. The patient diagnosed with chronic plantar fasciitis did not find relief from prior interventions involving stretching and a surgical release. This condition is an overuse syndrome that may become chronic, if gone untreated.6 Repeated stress on the plantar fascia may occur from imbalances in the muscles, or in the skeletal alignment.7 If corrections are not made to these imbalances, and the healing process is not given adequate time to resolve the condition, further damage and failure may result in the bone alignment, muscle balance, and ligament integrity.6 This case report demonstrates that one of the effective treatments for the patient’s plantar fasciitis was pelvic alignment using MET, as the patient’s pelvic asymmetry was contributing to the impairments in her feet.

The effectiveness of MET interventions has been well researched over the past few decades. Many studies have documented how interventions involving MET methods contribute to improvements in joint function, corrections in musculoskeletal imbalances, and diminishments in patients’ pain.7,8 However a gap in the literature was found in addressing the impact of MET performed on patients with pelvic asymmetries in alleviating ankle and foot impairments, including plantar fasciitis. One study found significant decreases in patients’ pain from plantar fasciitis, as compared to the control group, after receiving MET to improve gastro-soleus complex flexibility.7 The patient in this case study would not have been included in this particular study, as her restrictions did not include gastro-soleus tightness. However, this patient did improve from MET interventions focusing on pelvic and hip muscle imbalances.

KT is an intervention used for various conditions to facilitate or inhibit muscle activity.11 KT can provide support to damaged tissue without restricting range of motion. Research has identified improvements in the mobility of the lymphatic and venous flow with the use of KT.12 KT has been reported to have a positive effect on the fascia, while reducing pain, increasing muscle performance and decreasing susceptibility of a micro-trauma.12 A study comparing KT with other treatments in patients with plantar fasciitis found improvements in both pain and foot function in the KT group, as compared to the other groups.11 This study found a significant reduction in the plantar fascia thickness, measured by ultrasound, at the insertion site on the calcaneus in the KT group.11 This case report demonstrates positive outcomes in the patient’s pain level and mobility from use of KT. Further research is needed to assess the impact KT has in the recovery of patients with plantar fasciitis.

The International Classification of Functioning, Disability and Health (ICF) framework was used as a guide in the clinical decision making process during the evaluation, diagnosis and prognosis for this patient.13 This model is used in conjunction with the patient’s presentation, evidence based research and the practitioner’s experience. This case report explores how the ICF guided the evaluation of a patient diagnosed with plantar fasciitis with critical findings of a pelvic malalignment that impacted treatment decisions.13 Treatment choices, including MET and KT, are discussed as they relate to the positive outcomes for the patient, and can guide other therapists in their treatment choices for patients with similar presentations. The purpose of this case report is to report observations of managing plantar fasciitis with a multimodal program that includes pelvic alignment and KT. This case report illustrates the need for more research to be conducted to assess the effectiveness of implementing MET and KT interventions in patients with ankle or foot restrictions, when an asymmetry in the pelvis is identified.

Case Description: Patient History and Systems Review.

A 49-year-old, Caucasian, female patient was referred to outpatient physical therapy for a diagnosis of plantar fasciitis. The patient had intermittent symptoms for two years starting in 2013. The patient had received physical therapy for this condition. The patient reported that previous physical therapy focused on stretching and strengthening exercises. Her symptoms did not resolve. The patient had an endoscopic plantar fasciotomy in her right foot. This surgical intervention was unsuccessful in resolving her symptoms. The patient described her foot pain as tight and sharp at the heels of both feet. The pain was worse in the morning.

The patient presented with no other medical conditions. The patient reported no diseases in her family health history. The patient had no other major surgeries. The patient has no allergies. The patient takes 10 mg of Busipirone, as needed, to treat occasional anxiety. The patient reports that her anxiety is chronic.

The patient lives in a two-story home with her family. The patient is a nurse. She stands or walks during her workday. Her condition and pain restricted her participation in work and recreation. The patient’s goals for therapy included decreasing her pain to increase work efficacy and participation in recreational activities. The patient is a kinesthetic learner. The patient did not identify any cultural or learning barriers.

Clinical Impression #1.

The primary problem the patient experienced was bilateral foot pain. Using the numeric rating scale (NRS), the patient rated her bilateral foot pain as seven out of ten when first stepping out of bed and after long runs.14 Pain when first stepping out of bed is consistent with symptoms from plantar fasciitis.7,17 The patient’s history of running is also consistent with this condition of overuse.7 It is more common that plantar fasciitis occurs unilaterally, however it may occur bilaterally.7,14 This is particularly true if the patient has a gait deviation or an asymmetry somewhere up the kinetic chain that causes stress and strain to the plantar fascia.7 The patient’s low back pain after giving birth was revealing.2,14 A pelvic malalignment may be present.4 Compensations in her gait may cause more stress and strain on her plantar fascia.5,17

Potential differential diagnoses for the patient’s condition include intrinsic foot muscle strain or tightness, calcaneal neuritis or stress fracture, fat pad syndrome, tarsal tunnel syndrome, neuropathic pain, an instability or a pelvic malalignment.6,14 Additional information was requested from the patient after the review of systems. The patient reported no history of ankle, knee or hip injury. The patient denied night pain. The patient denied constant pain. The patient reports wearing supportive foot-ware with a built in arch. The patient noted a difficult pregnancy with low back pain after giving birth. The patient did not receive any treatment for this pain, as she learned to manage it. The patient further explained positions that she often assumes during work.17

The additional information provided by the patient involving her difficult pregnancy and subsequent low back pain was crucial in the analysis of the potential diagnoses and prognosis of the patient’s condition.3,17 The ICF model guided the decision making process in making a diagnosis and prognosis.13 This framework assisted in organizing the patient’s identified problems as well as restrictions in activities and participation. The patient’s current bilateral foot pain along with her previous low back pain were used to make a diagnosis.14 The environmental and personal factors were used to make a prognosis.13

The plan for the examination involves assessing the patient’s sensation, passive range of motion (PROM), joint mobility, quality of movement, manual muscle testing (MMT), palpation, joint play and deep pressure applied to the foot and ankle.18 Timed up and go (TUG) and gait analysis will be administered.17 A pelvic alignment assessment will be conducted to note any asymmetries.4,14

The patient was chosen for the case report as she had gone through previous unsuccessful interventions, including physical therapy and a surgical release. The positive outcomes from the chosen assessment tools and interventions may guide research studies. The patient’s motivation to find effective treatment was strong, as too her compliance to her HEP.

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Figure 1.1 ICF Model

Health Condition/Pathology: Bilateral Foot Pain

Functional Activities/Tasks:

1. difficulty at work

2. difficulty walking

3. difficulty running

4.

5.

6.

Body Structures/Function:

1. bilateral foot pain

2. previous low back pain

3.

4.

5.

6.

Participation:

1. mother and wife

2. friend

3. golfer

3.

4.

5.

6.

Environmental Factors:

Demanding work as a nurse, family support

Personal Factors:

Propensity to anxiety, motivated, athletic

The ICF Model was used to organize information about the patient’s condition, restrictions and internal and external factors. This was used to guide the evaluation, diagnosis, prognosis and ultimately the plan of care.13

Examination.

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Table 1.1 Examination

This table establishes an overview of the examination tests and measures utilized, the method used, the findings, reliability and validity.

Test

Method

Findings

Reliability and Validity

Sensory testing was conducted.

Upper and lower dermatomes were assessed with the patient’s eyes closed in a seated position.14 A light touch with the practitioner’s second digit was used.14 The patient noted where she felt the light touch on her body.

No deficits were noted. All dermatomes were intact.

In a study evaluating test-retest reliability and inter-observer reliability of quantitative sensory testing, for both test-retest reliability high correlations, r = 0.80 to 0.93 at the affected test area.21

The patient’s lower extremity active and PROM was assessed.

The patient was assessed according to the methods delineated by Magee in the supine position.14 In the supine position a half foam bolster was placed under the patient’s knee to place the gastro-soleus complex on slack, avoiding any passive insufficiency.17

The patient’s PROM was within functional limits (WFL) for the hip, knee, and ankle. All end feels of bilateral ankle joints were firm. The patient’s quality of movement was fluid in movement. The patient had a willingness to move. No pain was elicited in any of the active or PROM testing.

According to a study done by Schneiders and Karas, the interrater reliability for measuring ankle PROM with a goniometer is .92, indicating a high reliability.15 Validity was not found.

MMT was performed to assess the strength of the patient.

MMT was performed as detailed by Magee.14 The patient was in a seated position with upper and lower extremities tested to note any muscle weakness or imbalance.14

All muscles tested were WFL.

More than one hundred studies for MMT were reviewed. The research found good reliability and good validity for MMT in patients with musculoskeletal conditions.16

The TUG was performed to identify any fall risk.17

While sitting in a chair, the patient was instructed to stand up, walk the marked 10 feet, turn and walk back to sit in the chair.

The patient’s TUG score was 6 seconds, indicating no fall risk.17

Interrater and intrarater reliability for the TUG is 0.99.17 Validity is not found for the patient’s age group.

Palpation and joint play was utilized to assess the soft tissue and joint mobility.17,18

The patient was seated with her feet elevated from the floor. Joint play was performed according to Magee.14 Deep pressure was applied to the posterior medial aspect of the calcaneus, along the insertion of the plantar fascia.

Nothing remarkable was found upon joint play. Bumps were noted upon palpation of the plantar fascia. Upon deep pressure to the calcaneus the patient noted discomfort and tenderness in both feet.14

Intraclass-correlations, based on various examinations performed varied. The range of reliability was from 0.98 to 0.58 depending on the examination performed.22 Concurrent and predictive validity ranged from fair to good.22

The plantar fascia stretch test was performed to note any elicitation of the patient’s familiar symptoms.18

The patient was in a seated position with the plinth elevated. The patient’s great toe was extended passively.18 This test was performed bilaterally.

The stretch test elicited pain along the plantar fascia in both feet.

The reliability of this test is .96.18 The validity is not found. However, the test is useful in noting if pain is elicited when stretching the plantar fascia.

The patient completed the LEFS.

The LEFS was completed by the patient using the directions given by the measure.

The patient’s score indicated a 30% disability, indicating minimal disability.

The LEFS has a reliability of .93.19 It is valid in assessing group and individual change and has large responsiveness.19

The patient completed the FABQ.

This is a self-report measure that focuses on how the patient’s fear and avoidance about physical activity may affect her bilateral foot pain.

The patient’s score placed her in the low disability category with a 20% disability.

Interrater Reliability for the FABQ is .94 and validity for this measure is .9.20

A gait analysis was performed with the use of observation.

The patient walked barefoot for twenty meters, turned and walked back three times, as the therapist observed from a posterior, anterior and medial view.14

The patient has bilateral pes cavus. She remains in supination in both feet, with decreased toe off and decreased heel strike.

Test-retest reliability and validity is good in observational gait analysis.17

The key findings from the exam that reproduced the patient’s familiar symptoms included the plantar fascia stretch test in both foot. The patient’s familiar symptoms were also provoked with deep pressure applied to the posterior medial aspect of the calcaneus, along the insertion of the plantar fascia of both feet.14

Key findings from the exam also involved a pelvic alignment assessment. The standing forward bend test (SFBT) was performed by palpating the patient’s posterior superior iliac spine (PSIS) while standing. The patient was instructed to bend forward to touch the floor. If the SIJ is in dysfunction, the PSIS translates superiorly earlier on one side than on the other. The patients left PSIS translated higher than her right PSIS, indicating a possible SIJ dysfunction with a left hypomobile side. The stork test was also performed. The patient pulls one leg into the chest while standing. The therapist assesses if the PSIS on that side drops inferiorly. The test was performed on the opposite leg to compare. The patient’s left PSIS did not move inferiorly, as the right had done. This also indicated a potential hypomobile left innominate.

The squish test was performed with the patient in supine position. The therapist places their hands on the patient’s right and left ASIS. The therapist then directs a force at a forty-five degree angle towards the plinth backward and medially to stress the SIJ on that side. This was repeated on both sides to determine if one side is less mobile. The patient’s left side was less mobile. The reliability and validity of these tests has not been documented. These tests were used due to the experience and positive outcomes the therapist experienced in using these assessments and guiding treatment sessions to align pelvic asymmetries and SIJ dysfunctions.

Clinical Impression #2.

Using the ICF Model as a guide along with the findings from the examination, the initial impression of the patient’s chief complaint is confirmed in the second impression.13 The key findings that lead to the diagnosis of plantar fasciitis included bilateral foot pain during the stretch test, and when deep pressure was applied to the calcaneus, at the insertion of the plantar fascia. This overuse condition did not resolve with traditional therapy or with a surgical release. Another key finding suspected to be contributing to the patient’s pain includes a pelvic malalignment, as well as a potential SIJ dysfunction.

The plan for action is to educate the patient on the findings and inform her of the plan of care, and if the patient agrees, proceed with interventions.17 This will involve further assessment of the pelvis along with MET to make corrections of asymmetries. The patient’s symptoms will be monitored to assess if the corrections are reducing her pain. Other interventions will involve KT for support and healing of the plantar fascia. The KT will also be used to provide feedback for the patient during ambulation to correct deviations that cause strain.11 Outcome measures including the NRS for pain and the pelvic alignment tests will be used with every session to assess the patient’s progress and make any necessary modifications. The LEFS and FABQ will be used at the end of treatment to assess if the patient’s functional disability score and fear avoidance rating decreased.19,20

The patient is an appropriate candidate for the case report as her common condition has different symptoms that may be related to pelvic asymmetries. This case may lead to further research in the pelvic assessments performed on patients with foot and ankle conditions. It may also lead to more research on how the interventions of MET and KT can provide positive outcomes for patients with plantar fasciitis.

Interventions.

The evaluation identified an SIJ dysfunction that was addressed first in the treatment. The squish test, SFBT, stork and tug test indicated a left hypomobile innominate. The left pubic bone was higher than the right found during a pubic alignment assessment with the patient prone. The left leg was found to be longer than the right, with a leg length test administered with the patient supine after bridging. The treatment chosen to correct this malalignment was MET.

Patient education was provided to explain the reasoning and evidence supporting the treatment. When an asymmetry is present in the pelvic alignment, muscles length tension relationship with bones is compromised.7,8 MET is used to reset the balance of the muscles to enable symmetry.10 With the patient supine, the left side of the patient’s buttocks was half over the side of the plinth. The therapist grasped the left medial ankle with her left hand. The left forearm of the therapist rested on the medial knee and tibia of the patient. The right thumb of the therapist rested on the superior left pubic bone to monitor the barriers of movement in the pelvis. The therapist then took the left leg of the patient to the barriers of extension, abduction and external rotation in the left hip. The therapist then backed off from these barriers.9

The patient was instructed to produce a contraction of one pound of pressure into adduction, against the therapist’s elbow.7 The patient held this pressure for eight to ten seconds. The patient was instructed to stop the contraction and relax the hip. The therapist cued, “allow your leg to be dead weight.”10 The patient was then instructed to take a deep breath for two to three seconds. This sequence was repeated for three to five cycles.8 The patient was then re-evaluated for symmetry.7,8

After a correction the patient was instructed to walk and note any difference in pain.10 If the patient noted decreased pain in her feet, the correction was appropriately administered. Stabilization exercises were taught to the patient with education on the importance of performing them.7,9 After the MET is performed, the imbalanced muscle spindles may revert back to their previous tension.10 The stabilization exercises are used to prevent this from occurring.10 The patient was educated to avoid strenuous exercise that may recruit strong muscles to pull the hip back into asymmetry.7,10 The patient was instructed on gentle isometrics to hold the corrections.7,10 The patient was instructed on pelvic bridges, abductor and adductor isometrics. The patient was given a green Thera-band placed around her knees and tied for moderate resistance. A ball was placed between the patient’s knees. The patient gently rolled the knees out against the band for ten seconds, then inward against the ball for ten seconds. The patient rested for ten seconds. The patient was instructed on the frequency needed to perform the exercises as ten reps, and perform three sets each day.8,10

Treatment included a deep soft tissue mobilization with the Graston tools. The number three tool was chosen with the broad side used to strip the patient’s bilateral plantar fascia. Moderate pressure was applied with the patient’s tolerance as a guide for modifications. This was performed for six minutes on each foot. KT was applied to provide support, decrease pain, lift the dermis to facilitate healing and provide feedback for the patient during ambulation.11 The tape was cut into an I strip. Moderate tension was pulled on the tape with the middle of the strip applied horizontally, perpendicular to the fascia.12 The two ends were laid down up either side of the ankle with minimal tension. The ends finished distal to each malleolus. The patient ambulated after the tape was applied and noted increased support. Verbal cues were given for the patient to increase heel strike and toe off. The patient was given instruction and education on how to remove, and reapply the tape as needed.11 The patient was instructed to wear the KT during long shifts at work, when running and playing golf and to increase heel strike and toe off during gait.12

Outcomes.

The patient experienced positive outcomes from the interventions provided. Using the NRS, the patient had a consistent decrease in pain from ratings of seven out of ten at evaluation to four out of ten after two weeks of therapy. At discharge the patient reported zero to one out of ten pain in both of her feet. The plantar fascia stretch test was performed at discharge. The test was negative in both feet. The patient completed the LEFS again at discharge. The patient’s score indicated no disability.19 The patient reported increased participation in running and playing golf, due to decreased pain. The patient completed the FABQ at discharge. The patient’s score placed her in the no disability category.20 The patient had decreased fear avoidance in participation of activities due to decreased pain in her bilateral feet

A pelvic alignment assessment was conducted at each treatment session. Improvements were noted with each session in the SFBT with the left innominate having increased mobility. Upon discharge, the SFBT was performed, no hypomobility was noted. The stork test was also performed upon discharge and indicated no hypomobility. The squish test was performed at discharge. The test was negative, indicating no SIJ dysfunction. Upon gait analysis, the patient had increased heel strike and toe off during ambulation. The patient demonstrated increased balance between supination and pronation during the appropriate times of the gait cycle, instead of staying in supination throughout.

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Figure 1.2 Pain and Participation Outcomes

The NRS was used every session to record the patient’s pain. Patient participation level was recorded each session with the patient rating her percentage of activity engagement. This figure illustrates the decrease in the patient’s pain level from seven out of ten at evaluation to one out of ten at discharge. The figure demonstrates the relationship between the decrease in pain level with the patient’s reported increase in participation level. The patient reported an increase in recreational and work activities from the baseline of 30% to the discharge level of 90%.

Discussion.

This case report illustrates the observations of managing plantar fasciitis with a multimodal program that includes pelvic alignment and KT. This report demonstrates how the interventions of MET and KT may have assisted in addressing the patient’s pain and functional limitations.23 Using the ICF model, it was evident that the patient had restrictions in functional activities and in participation of various roles.13 The first clinical impression was founded on research, the clinician’s experience, and the patient’s values. This impression guided the examination to include assessment of plantar fasciitis with the stretch test and deep palpation, as well as a gait analysis and a pelvic assessment.24 The key findings from the examination involved a positive indication of plantar fasciitis along with a pelvic asymmetry and SIJ dysfunction.

Problem solving skills were utilized to assess how pelvic asymmetry and SIJ dysfunction may have been adversely impacting the patient’s gait and stress on her bilateral feet.25 Muscle imbalances at the hip may have caused the patient to overcompensate during ambulation, leading to stress and strain on her compromised plantar fascia.26 The discovery of a pelvic asymmetry and SIJ dysfunction guided treatment sessions to focus on evidence-based methods to correct these imbalances.27 The intervention techniques of MET and KT were chosen based on their strength and success in the literature.28,29 They were used due to the effectiveness the clinician has experienced using these methods with other patients with similar presentations. These interventions were also selected due to the patient’s values of independence and recreational activity.

Positive outcomes were noted throughout the six-week treatment of the patient. The patient had decreased pain from her plantar fasciitis symptoms after treatments involving MET and KT.25 The patient had increased heel strike and toe off during ambulation and noted decreased pain with ambulation.26 The patient noted increased participation in her roles at work, as well as recreational activities such as running and playing golf, throughout the treatment period, due to decreased pain and stiffness.26 This case report demonstrates that one of the effective treatments for the patients with plantar fasciitis may include pelvic alignment using MET, if a pelvic asymmetry is found.

Other studies have shown the effective use of MET on SIJ dysfunctions and pelvic malalignment.24 Research has shown a decrease in pain when MET was appropriately used on patients with pelvic malalignment and SIJ dysfunction.26 MET has been supported by evidence as a safe and successful treatment for muscle pain and somatic dysfunction.23 Most studies have examined the use of MET in increasing range of motion.25,26 The literature also supports the effective use in KT in the treatment of patients with ankle and foot impairments.29,30 These studies have focused on the increase of support and stability with the KT, while also providing healing effects and feedback for the patient’s quality of movement.30

The implications for this study may include the increased practice of conducting a pelvic assessment for every patient that has a lower extremity impairment, particularly in the foot or ankle. There may also be an increased utilization of MET and KT for patients who have plantar fasciitis or other foot dysfunctions that may be related to pelvic asymmetry or an SIJ dysfunction. Further research is needed to investigate relationships between foot and ankle impairments and pelvic asymmetry or SIJ dysfunction. Research is also needed to examine how MET interventions may be effective in treating patients with foot and ankle restrictions, when a pelvic malalignment or SIJ dysfunction is discovered. Research on the impact of KT on plantar fasciitis can also be further explored to assess the most effective methods of this intervention in treating plantar fasciitis and other foot and ankle impairments.

References

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2. Chaléat-Valayer E, Mac-Thiong J, Paquet J, Berthonnaud E, Siani F, Roussouly P. Sagittal spino-pelvic alignment in chronic low back pain. European Spine Journal [serial online]. September 3, 2011;20:634-640. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 24, 2017.

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7. Tanwar R, Moitra M, Goyal M. Effect of Muscle Energy Technique to Improve Flexibility of Gastro-Soleus Complex in Plantar Fasciitis: A Randomised Clinical, Prospective Study Design. Indian Journal Of Physiotherapy & Occupational Therapy [serial online]. October 2014;8(4):26-30. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 23, 2017.

8. Iqbal A, Ahmed H, Shaphe M. Efficacy of Muscle Energy Technique in Combination with Strain-counterstrain Technique on Deactivation of Trigger Point Pain. Indian Journal Of Physiotherapy & Occupational Therapy [serial online]. July 2013;7(3):118-123. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2017.

9. Dhinkaran M, Arora A. Comparative analysis of muscle energy technique and conventional physiotherapy in treatment of sacroiliac joint dysfunction. Indian Journal Of Physiotherapy & Occupational Therapy [serial online]. October 2011;5(4):127-130. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 22, 2017.

10. Geiser M. Modification of traditional muscle energy techniques for treatment of backward sacral torsion in women with clinical hypermobilty [sic]: a novel approach...AAOMPT Conference, 2009. Journal Of Manual & Manipulative Therapy (Journal Of Manual & Manipulative Therapy) [serial online]. September 2009;17(3):182. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 23, 2017.

11. WHAT IS THE CURRENT EVIDENCE FOR THE USE OF KINESIO TAPE? A LITERATURE REVIEW. Sportex Dynamics [serial online]. October 2012;(34):24-30. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2017.

12. Morris D, Jones D, Ryan H, Ryan C. The clinical effects of Kinesio® Tex taping: A systematic review. Physiotherapy Theory & Practice [serial online]. May 2013;29(4):259-270. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 24, 2017.

13. Fairbairn K, May K, Yang Y, Balasundar S, Hefford C, Abbott, JH. Mapping Patient-Specific Functional Scale (PSFS) Items to the International Classification of Functioning, Disability and Health (ICF). Physical Therapy. February 2012. 92(2), 310-317. Accessed April 06, 2016. http://dx.doi.org/10.2522/ptj.20090382.

14. Magee DJ. Orthopedic Physical Assessment, 6th ed. Philadelphia, PA: WB Saunders; 2014.

15. Schneiders A, Karas S. The accuracy of clinical tests in diagnosing ankle ligament injury. European Journal Of Physiotherapy [serial online]. December 2016;18(4):245-253. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2017.

16. Cuthbert SC, Goodheart GJ. On the reliability and validity of manual muscle testing: a literature review. Chiropractic & Osteopathy. 2007;15:4. doi:10.1186/1746-1340-15-4.

17. Wise CH. Orthopaedic Manual Physical Therapy: From Art to Evidence. 7th ed. Philadelphia, PA: F.A. Davis Company; 2015.

18. Budiman-Mak E, Conrad KJ, Mazza J, Stuck RM. A review of the foot function index and the foot function index – revised. Journal of Foot and Ankle Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579714/table/T11/. Published 2013. Accessed May 22, 2017.

19. Yeung TS, Wessel J, Stratford P, Macdermid J. Reliability, validity, and responsiveness of the lower extremity functional scale for inpatients of an orthopaedic rehabilitation ward. The Journal of orthopaedic and sports physical therapy. https://www.ncbi.nlm.nih.gov/pubmed/19487822. Published June 2009. Accessed May 21, 2017.

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Patient Outcomes

Reported painBaseline2 weeks 4 weeks 6 weeks (discharge)7.04.03.01.0Participation levelBaseline2 weeks 4 weeks 6 weeks (discharge)3.05.07.09.0