The Effectiveness of Acupuncture on Myofascial Trigger Points Versus Traditional Chinese Medicine Acupoints for Treating Plantar Fasciitis With Low Back Pain: A Study Protocol for a Randomised Clinical Trial [Letter]

Plantar fasciitis is a painful condition that affects the plantar fascia, a fibrous structure located on the sole of the foot that connects the heel to the toes. This condition causes intense pain, especially in the first steps in the morning or after prolonged periods of rest. Frequently, patients with plantar fasciitis also develop low back pain due to changes in gait to compensate for the foot pain. Acupuncture has emerged as a promising therapeutic option for these conditions, but there is an important scientific debate about which approach is more effective: treatment at myofascial trigger points or the use of traditional points of Traditional Chinese Medicine.

Chinese researchers from Gansu University of Traditional Chinese Medicine published a scientific letter commenting on a study comparing these two acupuncture approaches for treating patients suffering simultaneously from plantar fasciitis and low back pain. Myofascial trigger points are specific areas of muscle tension that, when pressed, cause localized pain and may radiate to other regions of the body. Traditional Chinese acupuncture points, on the other hand, are specific locations along the energy meridians, selected according to ancient principles of Eastern medicine. Although both approaches use needles, they are based on distinct theories about how the body works and how healing occurs.

The original study being commented on proposed to investigate which of these two acupuncture techniques would be more effective for patients presenting with both plantar fasciitis and low back pain. The methodology involved a randomized clinical trial, which is considered the gold standard for medical research, as it allows comparing different treatments in a controlled and scientific manner. However, the authors of the letter identified several important limitations in the study design that may affect the reliability and applicability of the results.

One of the main concerns raised was the fact that the study recruited participants from only one hospital in Guizhou province, China. This means that all patients shared similar regional and ethnic characteristics, which may limit the application of the results to other populations. Genetic and environmental factors, such as climate, lifestyle, and physical characteristics specific to the region, were not considered in the analysis. The researchers suggest that future studies should include multiple research centers, encompassing populations from different regions, climates, and lifestyles, to ensure that results can benefit people from diverse backgrounds.

Another methodological aspect questioned was the difficulty of fully standardizing acupuncture treatments. Because acupuncturists cannot be "blinded" during the procedure — that is, they know which technique they are applying — there is inherent subjectivity in the treatment. Parameters such as needle depth, stimulation intensity, and needle manipulation techniques may vary between treatment groups, introducing biases in the results. In addition, the study did not include a control group with sham acupuncture or conventional treatments such as physical therapy, making it difficult to distinguish between the specific effects of acupuncture and the placebo effect.

The researchers also criticized the exclusive reliance on subjective pain scales as the primary outcome measure. Although these scales are widely used in medicine, they are influenced by patients' emotions, perceptions, and individual differences, which may affect the stability of the results. The absence of objective measures, such as imaging studies or biological markers, makes it difficult to verify real changes in tissue structure or physiological functions caused by acupuncture treatment.

For future research, the authors suggest significant improvements in study design. They recommend the inclusion of magnetic resonance imaging to quantify the degree of tissue inflammation and the measurement of inflammatory markers in blood, such as interleukins and C-reactive protein, providing a more objective basis for assessing treatment efficacy. They also propose the use of sham acupuncture as a control, using needles that do not penetrate the skin or that are applied at locations distant from recognized points, to minimize placebo effects.

Despite the limitations identified, the researchers recognize the value of the original study as an important framework for investigating the use of acupuncture in the treatment of plantar fasciitis with low back pain. They emphasize the need for interdisciplinary collaboration and exploration of individualized treatment parameters, aligned with the principles of precision medicine. The ultimate goal is to generate high-quality scientific evidence that can support the inclusion of acupuncture in international clinical guidelines, improving pain management and functional rehabilitation of patients.

This scientific discussion demonstrates how medical research evolves through constructive debate among specialists, always seeking to refine methods to offer the best possible treatments to patients suffering from complex painful conditions such as plantar fasciitis associated with low back pain.