Comments on: Effect of aquatic exercises on pain and functional performance in plantar fasciitis

Dear Editor,

I read with great interest the randomized controlled trial by Aphale and Shinde evaluating the effects of aquatic exercises on pain and functional performance in individuals with plantar fasciitis.^[1] I also acknowledge the correspondence commenting on the study, as well as the subsequent authors’ response, and recognize their observations regarding the limitation of short-term follow-up when interpreting the durability of the reported intervention effects.^[2,3]

However, beyond the limitations discussed in the correspondence and response, additional statistical and interpretative considerations remain that may further strengthen the methodological quality and clinical interpretation of the findings. Specifically, the study evaluated multiple outcome measures, including pain intensity, ankle range of motion, manual muscle testing (MMT), the Foot Function Index, and plantar fascia thickness, without clearly specifying a primary outcome or applying appropriate adjustments for multiple comparisons. In clinical trials involving numerous endpoints, the absence of multiplicity control increases the risk of type I error and may lead to overestimation of treatment effects.^[4] Clear pre-specification of a primary outcome, along with appropriate statistical adjustment, would enhance internal validity and improve interpretability.

In addition, both intervention groups received adjunctive therapies, such as paraffin wax bath and therapeutic ultrasound, before the exercise sessions. As these modalities are known to independently influence pain perception and soft-tissue characteristics, their inclusion introduces potential confounding and limits the ability to attribute observed improvements solely to the exercise interventions. Future studies may benefit from isolating the effects of exercise or analytically accounting for co-interventions to strengthen causal inference.

Although statistically significant differences were reported and minimal clinically important differences were mentioned, reliance on p-values alone provides limited insight into clinical relevance. Reporting effect sizes and confidence intervals alongside clinically meaningful thresholds would allow readers to better evaluate the magnitude and precision of treatment effects beyond statistical significance. Finally, greater clarity regarding the intervention protocol would improve reproducibility. The manuscript refers to “ankle manual muscle testing” within the exercise program; however, MMT is an assessment method rather than a therapeutic intervention. A clearer description of the specific strengthening exercises performed would facilitate accurate interpretation and clinical translation.

Overall, Aphale and Shinde’s study^[1] provides clinically useful evidence supporting low-impact aquatic exercise for plantar fasciitis, demonstrating symptom improvement within a reduced-load environment and highlighting its role within a graded physiotherapy rehabilitation approach. Consideration of the statistical, methodological, and reporting aspects discussed here, together with those raised in the accompanying correspondence, may further enhance the clinical applicability of these findings.