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Effect of aquatic exercises on pain and functional performance in plantar fasciitis
*Corresponding author: Sandeep Shinde, Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, Krishna Vishwa Vidyapeeth, Deemed to be University, Karad, Maharashtra, India. drsandeepshinde24@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Aphale SR, Shinde S. Effect of aquatic exercises on pain and functional performance in plantar fasciitis. J Musculoskelet Surg Res. 2025;9:482-9. doi: 10.25259/JMSR_225_2025
Abstract
Objectives:
Plantar fasciitis (PF) is a prevalent cause of heel pain, especially in middle-aged and older adults. Non-invasive treatments such as physiotherapy and exercise are essential for relief. Aquatic exercises (AQEs), with their low-impact nature, may offer functional and analgesic benefits. This study evaluated the impact of a structured AQE program on pain and function in PF.
Methods:
A total of 116 participants with chronic PF, bilateral heel pain lasting over a month, normal or overweight body mass index, morning pain, and a positive windlass test were included in the study. Exclusion criteria included lower limb fractures, recent surgery, malignancy, skin disorders, pregnancy, or aquaphobia. Participants were randomly assigned to Group A (land-based) or Group B (AQEs). Pre- and post-intervention assessments included the visual analog scale (VAS), range of motion, manual muscle testing (MMT), ultrasonographic evaluation, and the foot function index (FFI).
Results:
Both groups showed significant improvements across all outcomes; however, the group subjected to aquatic training demonstrated superior results (P < 0.0001) compared to the land-based group. The reduction in pain during activity surpassed the minimal clinically important difference (MCID) of 2.0 on the VAS with a mean difference of 4.37. Improvements in dorsiflexion, MMT, FFI scores, and plantar fascia thickness also exceeded those of Group A. The AQE group exceeded established MCID thresholds across all the outcome measures.
Conclusion:
Although both exercise approaches effectively alleviate symptoms, AQEs produced more notable improvements in pain relief and functional performance in patients with PF.
Keywords
Hydrotherapy
Joint mobility
Musculoskeletal disorders
Pain reduction
Plantar fasciitis
Rehabilitation
INTRODUCTION
The plantar fascia is a dense connective tissue band originating from the medial tubercle of the calcaneus and dividing into five bands near the forefoot. With limited elasticity (4%), it plays a key role in foot biomechanics. It is frequently implicated in plantar fasciitis (PF), a common cause of heel pain, also referred to as “plantar fasciopathy” due to minimal inflammatory signs.[1,2] Clinically, PF presents with heel pain, burning sensation during weight-bearing, morning stiffness that eases with movement, and pain recurrence with activity.[3]
A hallmark diagnostic feature is plantar fascia thickening, often increasing by approximately 2.16 mm, as seen on ultrasonography.[4,5] Contributing factors include increased body mass index (BMI), which adds mechanical load, and prolonged standing or ambulation, which heightens microtrauma risk.[6,7] Biomechanical limitations – such as restricted ankle dorsiflexion or reduced first metatarsophalangeal joint motion – further elevate fascial stress, disrupting foot pressure distribution and increasing injury risk.[8,9] The Figure 1 illustrates the etiological factors contributing to plantar fasciitis, classified as intrinsic (age, high BMI, foot deformities, weak musculature), extrinsic (prolonged standing, inappropriate footwear, high heels, overuse), and biomechanical (abnormal gait, restricted ankle mobility, poor shock absorption) determinants. Collectively, these factors predispose individuals to excessive plantar fascia loading and symptomatic manifestations.
- Risk factors for planter fasciitis. BMI: Body mass index.
Aquatic therapy, or hydrotherapy, is an effective treatment for musculoskeletal conditions. It involves therapeutic exercises in a temperature-controlled pool, offering a buoyant, low-impact environment ideal for individuals with joint pain, muscle weakness, or limited mobility. Water’s properties – buoyancy, viscosity, hydrostatic pressure, and warmth – help reduce pain, improve mobility, and enhance functional recovery.[10]
In addition to physiotherapy, other interventions for PF include injection therapies. A randomized comparative study comparing platelet-rich plasma (PRP) and corticosteroid injections found that PRP provided long-lasting pain reduction and greater patient satisfaction with treatment.[11]
Aquatic therapy reduces joint stress through buoyancy, making it suitable for conditions such as osteoarthritis, post-surgical recovery, and chronic back pain. Unlike traditional resistance training, water offers adjustable, uniform resistance that allows safe, progressive exercise without overloading tissues. It is especially helpful for those with limited strength or mobility. Studies support its role in improving pain, mobility, and quality of life in musculoskeletal conditions.[12,13] Studies such as Abedian et al. have shown the benefits of aquatic exercise (AQE) for managing pain in PF.[14] However, methodological limitations reduce their clinical relevance. The absence of comparison with land-based interventions limits conclusions about relative effectiveness. In addition, outcome measures focused only on pain and balance, excluding important factors such as range of motion (ROM), muscle strength, foot function, and plantar fascia thickness.[14] Other limitations include poor generalizability, lack of long-term follow-up, and limited access to aquatic therapy.
Hence, the present study aimed to assess the impact of an AQE program on pain levels and functional performance in individuals with PF.
MATERIALS AND METHODS
Study design
A total of 116 participants from the local region, aged 30– 50 years and diagnosed with PF by an orthopedic surgeon, were selected for the study. During the trial, eight participants withdrew, leaving 108 who completed the study. This single-blinded randomized controlled trial blinded participants and used allocation concealment through sequentially numbered, opaque, and sealed envelopes with group assignments generated in the Statistical Package for the Social Sciences (SPSS) version 26. An independent researcher prepared the envelopes, opened only at allocation to prevent selection bias. Participants were randomly assigned to an experimental group (n = 54) and a control group (n = 54).
Sample size was calculated using this formula: n = z2pq/L2, where n = number of participants, Z 1.96, p estimated proportion of population, q 100-p, L allowable error.
The study included male and female participants within the specified age range who experienced bilateral heel pain for over 1 month and had a normal or high BMI. Pain typically radiated from the central heel pad or medial calcaneal tubercle along the plantar fascia to the medial longitudinal arch. Participants rated pain based on the more symptomatic foot. Inclusion required typical PF symptoms, such as morning pain with initial steps and a positive windlass test, where dorsiflexion of the toes reproduces heel pain by tightening the plantar fascia, elevating the arch, and aiding propulsion. Only clinically diagnosed cases of bilateral PF were included in the study. This ensured a consistent symptom profile across participants for accurate assessment of intervention effects.
Exclusion criteria ruled out individuals with a history of lower limb fractures in the past 10 years, recent lower extremity surgeries, malignancies, dermatological issues, pregnancy, or aquaphobia. Individuals with diagnosed rheumatological diseases, chronic systemic conditions such as diabetes mellitus, thyroid dysfunction, or uncontrolled hypertension, were excluded from the study. Participants were instructed to discontinue any analgesic or anti-inflammatory medications at least 2 weeks before clinical assessment.
Procedure
The demographic details of all participants were recorded, and each was informed about the study’s purpose. All outcome measures, including visual analog scale (VAS), ROM measured with a goniometer, manual muscle testing (MMT), ultrasonographic evaluation, and the foot function index (FFI), were assessed at 2 time points. Assessments were done at baseline and during the final week of the 6-week intervention. No home program was given. Pre-assessment values were obtained using VAS, ROM, MMT, ultrasound, and FFI. All participants received a paraffin wax bath and ultrasound (0.8 W/cm2, 7 min) at the start of each of the 24 sessions (4 sessions/week), applied uniformly to reduce confounding.
Treatment protocol
Group A
Group A participants received land-based exercises (LE), including warm-up, whole-body activation exercises, active exercise training, and cool-down [Table 1].
| Group A (Land-based) | Group B (Aquatic) | ||
|---|---|---|---|
| Exercise protocol | Repetitions/duration | Exercise protocol | Repetitions/duration |
| Warm-up | Warm-up | ||
| Deep breathing techniques - pursed lip breathing, thoracic expansion exercises | 3 min | Same as group A | |
| Whole-body activation exercises | Whole body activation exercises | ||
| Wall push-ups | 5 sets -5 s holds | Same as group A | 5 sets -5 s holds |
| Arm circles | 10 repetitions | Underwater arm circles | 10 repetitions |
| Sit-ups | 5 repetitions | Cross-country ski | 5 repetitions |
| Curling of toes | 10 repetitions | Same as group A | 10 repetitions |
| Forward walking | 3 min | Same as group A | 3 min |
| Backward walking | 3 min | Same as group A | 3 min |
| Sideway walking | 3 min | Same as group A | 3 min |
| Exercise regimen (0–3 weeks) | Exercise regimen (0–3 weeks) | ||
| ATMs | 10 repetitions | Marching on spot | 10 repetitions |
| Rolling by tennis ball underfoot | 10 repetitions | Tandem walking | 3 sets |
| Towel curls | 10 repetitions | Single-leg stance while catching and throwing a ball | 5 repetitions -2 sets |
| Isometrics -hamstrings and quadriceps | 5 repetitions -10 s, hold | One leg standing with leg swing (eyes open and closed) | 5 repetitions -2 sets |
| Three-way kicks using the chair | 5 repetitions -2 sets | One leg standing with eyes open and then eyes closed. | 5 repetitions -2 sets |
| Short foot exercise | 10 repetitions | Double-leg calf raises | 3 repetitions – hold 5 s |
| Bilateral heel raises | 10 repetitions | Short foot exercise | 10 repetitions |
| Mini squats | 10 repetitions | Mini squats (With the help of noodles) | 10 repetitions |
| Tandem walking | 3 sets | Deep water walking | 5 min |
| Exercise regimen (3–6 weeks) | Exercise regimen (3–6 weeks) | ||
| Jumping jacks | 10 repetitions | Same as group A | 10 repetitions |
| Lunges | 10 repetitions | Water jog | 3 min |
| Double-leg calf raises | 10 repetitions -5 s. hold | Same as group A | 10 repetitions -5 s. hold |
| Resistance flutter kicks | 10 repetitions | Same as group A | 10 repetitions |
| Ball kicking in multiple directions | 10 repetitions | Alternate leg bounds with weight cuffs | 10 repetitions |
| One leg standing (eyes open and then eyes closed) | 10-s hold -5 sets | Same as group A | 10-s hold -5 sets |
| Tandem stance | 10-s hold -5 sets | Lunges | 10 repetitions |
| Dorsiflexion-plantarflexion of the ankle with the help of a resistance band | 10 repetitions -2 sets | Deep water walking | 10 min |
| Cool down | Cool down | ||
| TA and plantar fascia stretch | 10-s hold – 3 sets | Same as group A | |
| Toe walking | 3 sets (10 m/set) | ||
| Walking on heels | 3 sets (10 m/set) | ||
| Relaxation regimen | 5 min | ||
ATMs: Ankle toe movements, TA: Tendo Achilles
Group B
AQE was conducted in the hospital’s hydrotherapy pool, 4 times weekly for 6 weeks (30–40 min/session). Water temperature was maintained at 32–36°C, with depth up to mid-sternum level. Hydrotherapy equipment included aquatic weight cuffs and noodles. A licensed physiotherapist supervised all sessions, prioritizing participant safety over exact exercise execution [Table 1]. Exercise intensity was modified in real time based on participant tolerance and clinical judgment.
Outcome measures
VAS
The VAS provides a simple, sensitive, and reproducible method for quantifying pain, making it suitable for clinical evaluation and monitoring of treatment effects over time.[15]
ROM
Ankle joint mobility – specifically dorsiflexion and plantarflexion – was assessed using a universal goniometer. Accurate ROM assessment is essential for tracking improvements in flexibility and joint function following rehabilitation interventions.[16]
MMT
Ankle dorsiflexion and plantarflexion strength were assessed using MMT, which applies resistance to joint movements and grades muscle strength on a 0–5 scale. MMT is a practical tool for evaluating motor function and identifying weakness in neuromuscular and musculoskeletal conditions.[17,18]
FFI
It is a validated outcome that is used to evaluate the impact of foot disorders on daily life. It evaluates three subdomains: Pain, disability, and limitations in daily life activities. The tool has high internal consistency (0.70–0.96). It is considered reliable for both clinical and research purposes.[19]
Ultrasonography
Ultrasonographic imaging was used to check the plantar fascia thickness, which is an objective marker in diagnosing and monitoring PF. Its reliability showed as intraclass correlation coefficients typically exceeding 0.85, with reported intra-rater values between 0.77 and 0.98 and inter-rater values from 0.76 to 0.98.[20]
Statistical analysis
Data analysis was performed using IBM SPSS Statistics version 26. Pre- and post-assessments of the group were calculated using a paired t-test. Between-group analysis was conducted using an unpaired t-test. The level of confidence interval was 95%. For all measured variables, the mean and standard deviation were obtained.
RESULTS
Demographic data revealed a balanced distribution between the experimental and control groups, each with 54 participants. The age groups included 30–40 years (n = 42) and 40–50 years (n = 66), which were equally represented. BMI classification revealed 52 participants with normal BMI and 56 as overweight, evenly distributed. The sample comprised 40 males and 68 females, equally assigned. Occupationally, 60 participants had prolonged standing jobs, and 48 held sedentary roles. The types of footwear included flat chappals (n = 50), shoes (n = 28), sandals (n = 18), and heels (n = 12), with a uniform distribution across both groups [Table 2].
| Demographic parameters | Number of subjects % | Group A | Group B |
|---|---|---|---|
| Age | |||
| 30–40 years | 42 (38.88) | 21 | 21 |
| 40–50 years | 66 (61.11) | 33 | 33 |
| Body mass index | |||
| 18.5–24.9 kg/m2 | 52 (48.14) | 26 | 26 |
| 25–29.9 kg/m2 | 56 (51.85) | 28 | 28 |
| Sex | |||
| Males | 40 (37.03) | 20 | 20 |
| Females | 68 (62.96) | 34 | 34 |
| Type of working | |||
| Prolonged standing | 60 (55.55) | 30 | 30 |
| Sedentary | 48 (44.44) | 24 | 24 |
| Type of footwear used daily | |||
| Flat chappals | 50 (46.29) | 25 | 25 |
| Shoes | 28 (25.92) | 14 | 14 |
| Sandals | 18 (16.66) | 09 | 09 |
| Heels | 12 (11.11) | 06 | 06 |
The values mentioned in the brackets are percentages of number of subjects respectively.
Both groups showed statistically significant improvements across all outcome measures; however, the AQE group (Group B) consistently demonstrated superior outcomes in Table 3. Notably, greater reductions in VAS scores were observed at rest and during activity, with Group B achieving the minimal clinically important difference (MCID) threshold for rest (1.54 cm) and exceeding it during activity (4.37 cm). While both groups improved in ankle ROM and muscle strength, only Group B reached clinically meaningful changes (≥3 °–5° for ROM and ≥1 grade in MMT), particularly in dorsiflexion, plantarflexion, and inversion. Functional outcomes, measured by FFI, improved substantially in both groups, with Group B showing a greater and clinically significant reduction. Finally, plantar fascia thickness, where a reduction of approximately 0.9 mm or more is considered clinically important, decreased notably in Group B (1.03 mm on the right and 1.00 mm on the left), confirming a meaningful structural change. Group A did not meet this threshold, while Group B consistently exceeded MCID values, supporting its efficacy.
| Outcome measures | Group A | Group B | Minimal clinically important difference values | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Pre- ssessment values (Mean±SD) | Post-assessment values (Mean±SD) | Mean difference | P-value (with 95% Confidence interval) | Pre-assessment values (Mean±SD) | Post-assessment values (Mean±SD) | Mean difference | P-value (with 95% confidence interval) | ||
| VA | |||||||||
| At rest | 1.59±1.12 | 0.66±0.47 | 0.93 | <0.0001 | 1.98±0.85 | 0.44±0.50 | 1.54 | <0.0001 | ≥1.5–2.0 cm |
| On activity | 5.09±1.193 | 1.87±1.229 | 3.22 | <0.0001 | 4.98±1.87 | 0.61±0.83 | 4.37 | <0.0001 | ≥1.5–2.0 cm |
| ROM | |||||||||
| Dorsiflexion right side | 13.53±0.50 | 13.66±0.47 | −0.13 | 0.0069 | 13.51±0.72 | 16.92±0.69 | −3.41 | <0.0001 | ≥3°–5° |
| Dorsiflexion left side | 13.48±0.50 | 13.85±0.70 | −0.37 | 0.0326 | 13.53±0.52 | 16.98±0.76 | −3.45 | <0.0001 | ≥3°–5° |
| Plantar flexion right side | 35.92±0.26 | 36.16±0.35 | −0.24 | 0.0061 | 34.27±0.45 | 37.57±0.49 | −3.3 | <0.0001 | ≥3°–5° |
| Plantar flexion left side | 34.94±0.23 | 35.07±0.26 | −0.13 | 0.0069 | 34.46±0.55 | 38.68±0.42 | −4.22 | <0.0001 | ≥3°–5° |
| Inversion right side | 26.48±0.56 | 26.75±0.43 | −0.27 | 0.0177 | 25.51±0.63 | 28.59±0.49 | −3.08 | <0.0001 | ≥3°–5° |
| Inversion left side | 26.42±0.49 | 26.79±0.40 | −0.37 | 0.0014 | 25.92±0.88 | 29.03±0.86 | −3.11 | <0.0001 | ≥3°–5° |
| Eversion right side | 17.57±0.49 | 17.86±0.35 | −0.29 | 0.0059 | 16.85±0.81 | 18.85±0.87 | −2.00 | <0.0001 | ≥3°–5° |
| Eversion left side | 17.61±0.49 | 17.87±0.33 | −0.26 | 0.0069 | 16.56±0.71 | 18.98±0.68 | −2.42 | <0.0001 | ≥3°–5° |
| MMT | |||||||||
| Dorsiflexors right side | 2.94±0.59 | 3.11±0.31 | −0.17 | 0.0112 | 2.81±0.39 | 3.34±0.91 | −0.53 | 0.0055 | ≥1 grade |
| Dorsiflexors left side | 3.25±0.48 | 3.53±0.50 | −0.28 | 0.0239 | 3.44±0.50 | 4.87±0.49 | −1.43 | <0.0001 | ≥1 grade |
| Plantar flexors right side | 3.27±0.45 | 3.52±0.50 | −0.25 | 0.0181 | 3.29±0.46 | 4.37±0.48 | −1.08 | <0.0001 | ≥1 grade |
| Plantar flexors left side | 3.57±0.49 | 3.83±0.37 | −0.26 | 0.0119 | 3.44±0.51 | 4.64±0.48 | −1.2 | <0.0001 | ≥1 grade |
| FFI | 70.64±0.48 | 31.16±0.74 | 39.48 | <0.0001 | 71.90±1.45 | 26.98±1.89 | 44.92 | <0.0001 | ≥7–12 points improvement |
| Plantar fascia thickness | |||||||||
| Right side | 5.03±0.51 | 4.94±0.50 | 0.09 | 0.0014 | 5.02±0.47 | 3.97±0.14 | 1.03 | <0.0001 | ≥0.9 mm reduction |
| Left side | 5.01±0.48 | 4.87±0.49 | 0.12 | 0.0009 | 5.01±0.50 | 4.01±0.13 | 1.00 | <0.0001 | ≥0.9 mm reduction |
VAS: Visual analog scale, ROM: Range of motion, MMT: Manual muscle testing, FFI: Foot function index, SD: Standard deviation
Post-intervention results demonstrated statistically significant improvements in all outcome measures for both groups, with the AQE group consistently showing superior outcomes in Table 4. Greater pain reduction was observed in Group B at rest and during activity. Ankle ROM improvements were more pronounced in the AQE group. Muscle strength gains, especially in dorsiflexors and plantar flexors, were also higher in Group B. Functional performance, as measured by the FFI, improved more substantially in the AQE group. In addition, ultrasonographic assessment revealed a greater reduction in plantar fascia thickness in Group B. Overall, the AQE intervention resulted in more significant improvements across all measured domains compared to the control group.
| Outcome measures | Parameters | Post values (Group A: Mean±SD) | Post values (Group B: Mean±SD) | Effect size between the Post values of groups A and B | P-value (With 95% confidence interval |
|---|---|---|---|---|---|
| VAS | At rest | 0.66±0.47 | 0.44±0.50 | −0.22 | 0.0012 |
| VAS | On activity | 1.87±1.22 | 0.61±0.83 | −1.26 | <0.0001 |
| ROM | Dorsiflexion (Right) | 13.66±0.47 | 16.92±0.69 | 3.26 | <0.0001 |
| Dorsiflexion (Left) | 13.85±0.70 | 16.98±0.76 | 3.13 | <0.0001 | |
| Plantarflexion (Right) | 36.16±0.35 | 37.57±0.49 | 1.41 | <0.0001 | |
| Plantarflexion (left) | 35.07±0.26 | 38.68±0.42 | 3.61 | <0.0001 | |
| Inversion (Right) | 26.75±0.43 | 28.59±0.49 | 1.84 | <0.0001 | |
| Inversion (left) | 26.79±0.40 | 29.03±0.86 | 2.24 | <0.0001 | |
| Eversion (Right) | 17.86±0.35 | 18.85±0.87 | 0.99 | <0.0001 | |
| Eversion (Left) | 17.87±0.33 | 18.98±0.68 | 1.11 | <0.0001 | |
| MMT | Dorsiflexors (Left) | 3.53±0.50 | 3.34±0.91 | −0.19 | <0.0001 |
| Dorsiflexors (Right) | 3.11±0.31 | 4.87±0.49 | 1.76 | <0.0001 | |
| Plantar flexors (Right) | 3.52±0.50 | 4.37±0.48 | 0.85 | <0.0001 | |
| Plantar flexors (Left) | 3.83±0.37 | 4.64±0.48 | 0.81 | <0.0001 | |
| FFI | 31.16±0.74 | 26.98±1.89 | −4.18 | <0.0001 | |
| Plantar fascia thickness | Right Side | 4.94±0.50 | 3.97±0.14 | −0.97 | <0.0001 |
| Left Side | 4.87±0.49 | 4.01±0.13 | −0.86 | <0.0001 | |
VAS: Visual analog scale, ROM: Range of motion, MMT: Manual muscle testing, FFI: Foot function index
DISCUSSION
The results demonstrated that both groups experienced significant improvements in pain, ROM, muscle strength, and functional performance. However, Group B consistently showed greater improvements across all parameters, including VAS scores, ROM, MMT, FFI, and plantar fascia thickness.
PF can significantly affect ankle ROM and the strength of intrinsic foot muscles through biomechanical and neurophysiological mechanisms. Chronic inflammation of the plantar fascia causes pain and stiffness, leading to altered weight-bearing and compensatory gait patterns. These, such as reduced heel strike or limited dorsiflexion during gait, further restrict ankle mobility, especially dorsiflexion. Over time, these adaptations may lead to disuse atrophy and weakening of the intrinsic foot muscles and extrinsic foot muscles, resulting in recurrent symptoms of PF due to improper muscle and joint function during walking, which are essential for maintaining medial longitudinal arch stability and toe flexion strength.[21]
AQE offers balance benefits comparable to LE, particularly in adults over 65. Its low-impact, supportive environment reduces injury risk while enhancing postural stability, muscle activation, and proprioception, key for improving balance and mobility in those with musculoskeletal issues.[22] Aquatic therapy has also shown effectiveness in knee osteoarthritis. A study on postmenopausal women found that high-intensity aquatic resistance training improved gait speed and reduced fat mass. These gains, due to water’s supportive and resistive properties, may translate to PF by enabling safe movement and early functional training, suggesting similar rehabilitative benefits for lower limb conditions.[23]
Another trial by Rathleff et al. highlighted the efficacy of strength training with high loading in managing PF; their findings showed tissue remodeling and collagen synthesis, resulting in long-term improvements in pain and function through loading on the fascia.[24] High-load strength training may therefore be a viable primary treatment approach, either alone or combined with other interventions.[24]
Recent evidence suggests reconsidering conventional strategies for managing foot pain, particularly the reliance on orthotic insoles. Tedeschi (2024) argues that while orthotics may offer temporary relief, footwear design more effectively addresses biomechanical deficits, improves proprioception, and redistributes plantar pressure. This supports the use of therapeutic footwear modifications, alone or with orthotics, to promote sustained pain relief and functional improvement.[25]
Another study highlights the crucial role of proper shoe fit –not just aesthetics – in maintaining foot health. Their scoping review found that appropriately sized and width-fitted footwear significantly reduced callus formation and plantar pressure, and educational interventions led to better shoe choices in older adults.[26]
Supporting aquatic therapy for PF, Abedian et al. conducted an 8-week intervention showing significant post-treatment pain reduction.[14] Their findings emphasized how water’s physical properties help relieve symptoms, reinforcing AQE as a safe, non-invasive strategy. However, broader studies with longer follow-up are needed to refine and validate aquatic intervention protocols.[14]
In clinical practice, aquatic-based rehabilitation can benefit individuals with PF by reducing discomfort and improving adherence. This approach may enhance outcomes and, when integrated into routine physiotherapy, offers a versatile, patient-centered option, particularly valuable for managing chronic PF.
In this study, AQEs demonstrated greater effectiveness than LE in reducing pain and enhancing functional performance among patients with PF.
Strengths
A key strength of this study is the use of aquatic-based rehabilitation, which reduces mechanical load on the plantar surface, a crucial factor in PF management. The water environment likely improved participant compliance and satisfaction, as reported in feedback, due to reduced discomfort compared to traditional LE programs.
Limitations
The study focused only on short-term outcomes, limiting insight into the long-term effects of AQE. Although the sample size was sufficient for initial analysis, it may limit the generalizability of the findings. Dropout analysis was not conducted, and the lack of follow-up data limits understanding of recurrence rates and sustained benefits.
CONCLUSION
This study shows that a 6-week AQE program is more effective than LE in reducing pain and improving ROM, muscle strength, and foot function in PF. Water’s low-impact environment supports early recovery while reducing plantar fascia stress. These findings highlight the potential of aquatic therapy as an effective component of comprehensive rehabilitation strategies for lower extremity musculoskeletal conditions.
Recommendations
Future studies should include longer follow-up to assess lasting benefits and recurrence prevention, with larger sample sizes for stronger statistical power. Comparing various aquatic protocols can help optimize treatment for PF across populations. Incorporating blinded assessors and carefully controlling confounding variables will enhance methodological rigor.
Authors’ contributions:
SA was involved in the conception and design of the study, data collection, data analysis, and interpretation, and SS performed the manuscript drafting and subsequent revisions. All authors have thoroughly reviewed and approved the final version of the manuscript and take full responsibility for its content and the similarity index.
Ethical approval:
The research/study approved by the Institutional Review Board at Institutional Ethical committee, number 023/2023-2024, dated October 17, 2023.
Declaration of patient’s consent :
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Conflicts of interest:
There are no conflicting relationships or activities.
Financial support and sponsorship: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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