Research Report

Plantar Fasciitis: Are Pain and Fascial

Thickness Associated With
SC Wearing, PhD, is Research Fellow,
Centre of Excellence for Applied
Arch Shape and Loading?
Sport Science Research, Queensland Scott C Wearing, James E Smeathers, Patrick M Sullivan, Bede Yates,
Academy of Sport, Queensland, Aus-
Stephen R Urry, Philip Dubois
tralia, and Institute of Health and Bio-
medical Innovation, Queensland Uni-
versity of Technology, corner of
Blamey St and Musk Ave, Kelvin Background and Purpose
Grove, Queensland 4059, Australia. Although plantar fascial thickening is a sonographic criterion for the diagnosis of
Dr Wearing also is Academic Fellow, plantar fasciitis, the effect of local loading and structural factors on fascial morphol-
HealthQWest, Bioengineering Unit,
University of Strathclyde, Glasgow,
ogy are unknown. The purposes of this study were to compare sonographic measures
Scotland. Address all correspondence of fascial thickness and radiographic measures of arch shape and regional loading of
to Dr Wearing at: s.wearing@qut. the foot during gait in individuals with and without unilateral plantar fasciitis and to
edu.au. investigate potential relationships between these loading and structural factors and
JE Smeathers, PhD, is Senior Lec- the morphology of the plantar fascia in individuals with and without heel pain.
turer, Institute of Health and Bio-
medical Innovation, Queensland Subjects
University of Technology.
The participants were 10 subjects with unilateral plantar fasciitis and 10 matched
PM Sullivan, BAppSci (Med Rad asymptomatic controls.
Tech), Grad Dip App Sci (Med
US), is Chief Sonographer,
Queensland X-ray, Mater Private
Methods
Hospital, South Brisbane, Queens- Heel pain on weight bearing was measured by a visual analog scale. Fascial thickness
land, Australia. and static arch angle were determined from bilateral sagittal sonograms and weight-
B Yates, BAppSci (Med Rad Tech), is bearing lateral foot roentgenograms. Regional plantar loading was estimated from a
Chief Radiographer, Queensland pressure plate.
X-ray, Mater Private Hospital, South
Brisbane, Queensland, Australia. Results
SR Urry, PhD, is Senior Lecturer, On average, the plantar fascia of the symptomatic limb was thicker than the plantar
Institute of Health and Biomedical fascia of the asymptomatic limb (6.1⫾1.4 mm versus 4.2⫾0.5 mm), which, in turn,
Innovation, Queensland Univer-
sity of Technology.
was thicker than the fascia of the matched control limbs (3.4⫾0.5 mm and 3.5⫾0.6
mm). Pain was correlated with fascial thickness, arch angle, and midfoot loading in
P Dubois, MB, BS, FRCR, FRACR, is the symptomatic foot. Fascial thickness, in turn, was positively correlated with arch
Chairman and CEO, Queensland
X-ray, Mater Private Hospital, South
angle in symptomatic and asymptomatic feet and with peak regional loading of the
Brisbane, Queensland, Australia. midfoot in the symptomatic limb.
[Wearing SC, Smeathers JE, Sulli-
van PM, et al. Plantar fasciitis: are
Discussion and Conclusion
pain and fascial thickness associ- The findings indicate that fascial thickness and pain in plantar fasciitis are associated
ated with arch shape and loading? with the regional loading and static shape of the arch.
Phys Ther. 2007:87:1002–1008.]

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1002 f Physical Therapy Volume 87 Number 8 August 2007


S
ince the pioneering work of
Hicks,1,2 in which tensile forces
within the plantar fascia of ca-
daveric limbs were related to foot
structure, the aspect ratio of the me-
dial longitudinal arch (ie, the height-
to-length ratio) has commonly been
implicated in the development of
plantar fasciitis. Low-arched foot
structures and foot pronation, in par-
ticular, have been suggested to in-
crease tensile load within the plantar
fascia, thereby increasing the risk of
microdamage.3,4 However, evidence
for the role of aberrant arch mechan-
ics in plantar fasciitis is equivocal.
Although there is some evidence
from radiographic studies that a
lower static arch shape is more fre-
quent in individuals with plantar fas-
ciitis than in those without plantar
fasciitis,5,6 studies using motion anal-
ysis techniques typically have shown
negligible differences in foot motion
or arch dynamics between subjects
with symptoms and pain-free con-
trols.7–9 As a consequence, we have
previously questioned the role of
arch mechanics in the etiology of
plantar fasciitis.7,10 However, the ma-
jority of research conducted to date
has failed to confirm the clinical di-
agnosis of plantar fasciitis via diag-
nostic imaging modalities, despite a
well-documented lack of specificity
of clinical signs and symptoms in di-
agnosing plantar fasciitis.11
Although no single imaging tech-
nique is comprehensive, sonography
provides an inexpensive method for
quantifying pathology of the plantar
fascia. In particular, thickening of
the plantar fascia has become a well-
established sonographic criterion for
the diagnosis of plantar fasciitis, and
a reduction in sagittal thickness has
commonly been reported with the
resolution of heel pain.12–14 How-
ever, recent research involving indi-
viduals with diabetes has indicated
that the morphology of the plantar
fascia also may be related to the re-
gional loading of the foot.
August 2007
Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading
In a series of experiments,
D’Ambrogi and colleagues15–17 dem-
onstrated that, although individuals
with diabetic neuropathy had a
thicker plantar fascia, similar to that
seen in plantar fasciitis, fascial di-
mensions were positively correlated
with the vertical force beneath the
forefoot during walking. The authors
speculated that the thickened fascia
effectively increased the stiffness of
the arch, resulting in greater plantar
pressures during gait. Although
there also is evidence that plantar
fasciitis is associated with altered re-
gional loading of the foot during
gait,18,19 the relationship between
fascial thickness and plantar loading
was evident only in individuals with
diabetes and not in control subjects
without diabetes. Whether the effect
represents a systemic change associ-
ated with diabetes, a local change
associated with mechanical factors,
or their combination is unclear.16
Moreover, it is unknown to what ex-
tent, if any, local mechanical factors
are related to the morphology of the
plantar fascia in individuals with
plantar fasciitis. It is particularly im-
portant to establish the effect of lo-
cal mechanical factors on the mor-
phology of the plantar fascia, given
that fascial dimensions often are
used to monitor the progression of
plantar fasciitis.20 –22 The aims of the
current investigation, therefore,
were to compare sonographic mea-
sures of fascial thickness and radio-
graphic measures of arch shape and
regional loading of the foot during
gait in individuals with and without
unilateral plantar fasciitis and to in-
vestigate potential relationships be-
tween these loading and structural
factors and the morphology of the
plantar fascia in individuals with and
without heel pain.
Materials and Methods
Subjects
Ten subjects (3 male and 7 female)
with unilateral plantar heel pain
Volume 87
([X⫾SD] age⫽48⫾12 years, height⫽
1.67⫾0.09 m, weight⫽79.3⫾10.2 kg)
and 10 asymptomatic control sub-
jects individually matched for age,
sex, and body weight (age⫽47⫾
12 years, height⫽1.68⫾0.11 m,
weight⫽81.6⫾10.6 kg) participated
in the study. Subjects with heel pain
had tenderness, localized to the cal-
caneal insertion of the plantar fascia,
which was exacerbated with weight
bearing following periods of rest.
Subjects were excluded if they had
diffuse or bilateral pain, evidence of
inflammatory arthropathy,23 or a his-
tory of trauma or foot surgery. The
mean (⫾SD) duration of heel pain
was 9⫾6 months. Subjects gave
written informed consent prior to
participation in the study, in ac-
cordance with university research
ethics policy.
Protocol
Prior to testing, the magnitude of
heel pain on return to weight bear-
ing following rest was measured
with a 10-cm visual analog pain
scale* anchored by the terms “no
pain” and “worst pain ever.” Non–
weight-bearing sagittal sonograms of
the fascial insertion of each foot sub-
sequently were acquired with a
variable-frequency 12-5 MHz linear
array transducer (HDI 5000†) and
coupling gel. Subjects were posi-
tioned prone with their ankle in neu-
tral (0° of dorsiflexion and plantar
flexion). The sagittal thickness of the
proximal insertion of the plantar fas-
cia was measured, to the nearest
tenth of a millimeter, at a standard
reference point 5 mm from the inser-
tion, at the anterior aspect of the
inferior border of the calcaneus
(Fig. 1). The bias and limits of agree-
ment for repeated measurements of
fascial thickness using this technique
are 0.01⫾0.06 cm.7
* Pain Relief Foundation, Clinical Sciences
Centre, University Hospital Aintree, Lower
Lane, Liverpool, United Kingdom L9 7AL.
† Advanced Technology Laboratories, Bothel,
WA 98011
Number 8 Physical Therapy f 1003
Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading

Following a familiarization period, a

23- ⫻ 44-cm EMED-SF pressure plat-
form§ with a spatial resolution of 4
sensors per square centimeter was
used to collect pressure data at a
sampling rate of 50 Hz. The pressure
platform provided an opportunity to
estimate site-specific or regional
forces within the foot.27 Subjects
completed 3 walking trials for each
limb at their preferred pace. Consis-
tency between trials was ensured by
monitoring the stance phase dura-
tion, which differed by less than 5%
between limbs. Trials were repeated
if footsteps did not fall entirely
Figure 1.
within the boundaries of the pres-
The thickness of the proximal insertion of the plantar fascia (d) was measured from
sagittal sonograms at a standard reference point 5 mm from the anterior, inferior border sure platform or if we observed gait
of the fascial insertion into the calcaneus (C). adjustments secondary to visual tar-
geting of the platform. Novel soft-
ware§ was used to calculate the peak
Weight-bearing lateral radiographic relative to the horizontal, using a cal- regional vertical force beneath the
projections of both feet were ob- ibration grid positioned within the rear foot, midfoot, forefoot, and dig-
tained during quiet bipedal stance.24 field of view.26 The calcaneal-first its using a standardized masking pro-
Radiographic images were saved to metatarsal (CMT1) angle, the angle cedure in which the length of the
a personal computer in DICOM subtended by the calcaneal inclina- footprint, excluding the toes, was di-
(Digital Imaging and Communica- tion and metatarsal declination an- vided into equal thirds.19 Peak re-
tions in Medicine) format and post- gles,25 subsequently was calculated gional forces have been shown to be
processed using MATLAB software.‡ using Euclidean geometry, in which more sensitive to gait anomalies as-
As depicted in Fig. 2, landmarks on the remaining angle of a triangle sociated with plantar fasciitis than
the inferior surface of the calcaneus (CMT1) is calculated from the 2 those derived from conventional
and the dorsum of the first metatarsal known angles.7 The root mean foot-ground reaction force curves.19
were manually digitized, and the cal- square error in determining the Peak regional ground reaction forces
caneal inclination and metatarsal CMT1 angle via this method is 0.2 were normalized to body weight and
declination angles were derived,25 degree, with the limits of agreement averaged over the 3 walking trials.
for repeated measures of ⫾0.5
‡The MathWorks Inc, 3 Apple Hill Dr, Natick, degree.26 Data Analysis
MA 01760-2048. The Statistical Package for the Social
Sciences (version 12)㛳 was used
for all statistical procedures.
Kolmogorov-Smirnov tests were
used to evaluate data for underlying
assumptions of normality. Because
all outcome variables were normally
distributed, means and standard de-
viations were used as summary sta-
tistics. Differences in each of the de-
pendent variables of interest (arch
shape, fascial thickness, and peak
vertical force beneath the rear foot,
Figure 2.
Illustration of the calcaneal-first metatarsal (CMT1) angle. The 4 points of reference (⫹)
represent the anterior, inferior aspect of the calcaneal tubercle, the anterior, inferior §Novel GmbH, Munich, Germany.
aspect of the calcaneocuboid joint, and the proximal and distal thirds of the dorsal 㛳
SPSS Inc, 233 S Wacker Dr, Chicago, IL
aspect of the shaft of the first metatarsal. 60606

1004 f Physical Therapy Volume 87 Number 8 August 2007

 Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading

midfoot, forefoot, and digits) were

compared between groups and
limbs using a 2-factor analysis of vari-
ance. The limbs of the control sub-
jects were individually matched to
the symptomatic and asymptomatic
limbs of the subjects with plantar
fasciitis, giving rise to nominally
termed symptomatic (Control S) and
asymptomatic (Control A) control
limbs. In each case, group (heel pain
and control) and limb (symptomatic
and asymptomatic) were treated as
within-subject factors, with the stan-
dard error adjusted for paired obser-
vations as outlined previously.28 Sig-
nificant group-limb interactions
were investigated using paired t
tests. Relationships among the mag-
nitude of pain, the sagittal thickness
of the plantar fascia, static arch
shape, and the average peak regional
loading of the foot were investigated
using scatter plots and Pearson
product-moment correlations. An al- Figure 3.
pha level of .05 was used for all uni- The average peak vertical force, expressed as a percentage of body weight, beneath the
variate tests of significance. rear foot, midfoot, forefoot, and digits of symptomatic, asymptomatic, and control
limbs. The mean value is included at the top of each bar. No statistically significant
difference was observed in the regional loading of the foot between limbs.
Results
There was a significant group ⫻ limb
interaction in the sagittal thickness of
the plantar fascia (F⫽43.8; df⫽1,9; limbs (128°⫾10° and 128°⫾8°, the symptomatic foot also was posi-
P⬍.05). The plantar fascia of the respectively). tively related to the maximum force
symptomatic limb (6.1⫾1.4 mm) was beneath the midfoot of the symp-
48% thicker than that of its asymptom- Table 1 demonstrates the relation- tomatic limb (r⫽.79, P⬍.05). No sig-
atic counterpart (4.2⫾0.5 mm) and ship between perceived pain on nificant correlations were found be-
75% to 79% thicker than the fascia of weight bearing and the sagittal thick- tween the sagittal thickness of the
the matched control limbs (3.4⫾0.5 ness of the plantar fascia, arch shape, plantar fascia and the arch shape and
mm and 3.5⫾0.6 mm). Similarly, the and regional loading of the symptom- peak regional loading in the control
plantar fascia of the asymptomatic atic foot. Significant correlations limbs (Tab. 2).
limb was significantly thicker than that were noted between the magnitude
of control limbs. of pain and fascial thickness (r⫽.68, Peak midfoot force was positively
P⬍.05), the magnitude of pain and correlated with CMT1 in both the
As demonstrated in Figure 3, there the CMT1 angle (r⫽.76, P⬍.05), and symptomatic (r⫽.93, P⬍.001) and
was no significant group ⫻ limb the magnitude of pain and midfoot asymptomatic (r⫽.64, P⬍.048)
interaction in the peak regional load- loading (r⫽.76, P⬍.05). limbs of the subjects with heel pain
ing of the foot. Similarly, there was but was not correlated in the
no significant group ⫻ limb inter- As shown in Table 2, the sagittal matched control limbs (r⫽⫺.281
action in the mean CMT1 angle be- thickness of the plantar fascia was and .47, respectively).
tween the symptomatic limbs positively correlated with the CMT1
(130°⫾7°) and asymptomatic limbs angle in the symptomatic feet Discussion
(126°⫾7°) of the subjects with (r⫽.89, P⬍.05) and asymptomatic Although sagittal thickening of the
heel pain and the matched control feet (r⫽.64, P⬍.05) of the subjects plantar fascia has been widely docu-
with heel pain. Fascial thickness in mented in people with plantar fasci-

August 2007 Volume 87 Number 8 Physical Therapy f 1005

Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading
itis,21,22,29 the present investigation is
the first to demonstrate that the
sonographic thickness of the symp-
tomatic fascia is positively related to
the severity of heel pain, as well as
the peak regional loading and static
shape of the arch of the symptomatic
foot.
In the current investigation, thicker
fascial structures were associated
with lower arched feet but only in
individuals with heel pain. Although
the shape of the medial longitudinal
arch, as measured by the CMT1, did
not differ between subjects with and
without plantar fasciitis, arch shape
accounted for approximately 80% of
the variance in the sagittal thickness
of the symptomatic fascia. Although
the strength of the relationship was
lessened in the contralateral limb
(r2⫽.41), the finding is consistent
with cadaveric models, in which fas-
cial tension has been directly linked
to the aspect ratio of the arch.1,2
However, fascial thickness was not
related to radiographic arch shape in
the control limbs. Thus, assuming
that fascial thickness reflects tensile
loading, it would appear that the
plantar fascia of individuals with heel
pain either are exposed to greater
internal loading, resulting in adap-
tive thickening, or are inherently
thickened but incapable of tolerating
normal tensile load, resulting in pain.
Given that both active (muscles) and
passive (plantar fascia and ligaments)
elements are important in the main-
tenance of the arch,30 it is possible
that muscular weakness, particularly
of the intrinsic foot muscles, may
result in a relatively greater internal
loading of the plantar fascia and
adaptive fascial thickening in people
with plantar fasciitis. Reduced
strength of the ankle and digital plan-
tar flexors has been documented in
individuals with plantar fasciitis,31,32
suggesting that the plantar fascia
may play a more pronounced role in
arch maintenance. Although such a
1006 f Physical Therapy Volume 87
mechanism would explain the fascial Table 1.
thickening noted in people with di- Pearson r Correlation Coefficients
abetic neuropathy,15–17 in which in- (P Value) Between Perceived Pain
on Weight Bearing and the Sagittal
trinsic foot muscle atrophy is com-
Thickness of the Plantar Fascia,
mon, the potential role of reflex Calcaneal-First Metatarsal (CMT1) Angle,
inhibition of musculature secondary and Regional Loading Beneath the
to heel pain cannot be discounted. Symptomatic Foot of the Subjects With
Heel Pain (n⫽10)
Similarly, it is equally plausible that Pain on Weight
plantar fasciitis may be characterized Bearing
by a systemic or degenerative fascial Fascial thickness .68a (P⫽.032)
thickening, comparable to that ob-
CMT1 angle .76a (P⫽.011)
served in tendon,33 which results in
a reduced capacity of the plantar fas- Rear-foot force ⫺.38 (P⫽.285)
cia to tolerate normal tensile load. In Midfoot force .76a (P⫽.011)
support of this hypothesis, reduced Forefoot force ⫺.09 (P⫽.799)
mechanical properties of tendon
Digital force ⫺.26 (P⫽.462)
with degenerative change has been
a
noted in animal models.34 As such, Statistically significant correlation (P⬍.05)
abnormal shape and movement of
the arch would not necessarily be
associated with plantar fasciitis, a toms within 12 months36 and that
finding consistent with the majority 40% of individuals with unilateral
of research conducted to date.7–9 Achilles tendinopathy develop symp-
Moreover, degenerative thickening toms in the contralateral limb.37 Al-
has been hypothesized to proceed though there is anecdotal evidence
asymptomatically in humans35 and that plantar fasciitis may progress in
would account for the increased fas- a similar manner,38 the clinical
cial dimensions observed in the course of plantar fasciitis remains
asymptomatic limb of individuals undocumented.
with heel pain. Prospective studies
have indicated that as many as 45% Previous investigators studying the
of thickened Achilles tendons effect of diabetes on the morphology
progress to develop clinical symp- of the plantar fascia have speculated
Table 2.
Pearson r Correlation Coefficients (P Value) Between the Sagittal Thickness of the
Plantar Fascia and the Calcaneal-First Metatarsal (CMT1) Angle and Regional Loading
Beneath the Foot in Symptomatic, Asymptomatic, and Matched Control Limbs
Fascial Thickness
Control (A) Control (S) Asymptomatic Symptomatic
CMT1 angle ⫺.14 (P⫽.707) ⫺.35 (P⫽.318) .64a (P⫽.047) .89a (P⫽.001)
Rear-foot ⫺.23 (P⫽.532) ⫺.32 (P⫽.367) ⫺.48 (P⫽.160) ⫺.46 (P⫽.182)
force
Midfoot ⫺.21 (P⫽.564) ⫺.09 (P⫽.809) .51 (P⫽.135) .79a (P⫽.007)
force
Forefoot .20 (P⫽.581) .12 (P⫽.738) ⫺.04 (P⫽.904) ⫺.14 (P⫽.696)
force
Digital ⫺.18 (P⫽.626) ⫺.26 (P⫽.472) ⫺.23 (P⫽.520) ⫺.10 (P⫽.790)
force
a
Statistically significant correlation (P⬍.05).
Number 8 August 2007

that thickening of the fascia in-
creased the stiffness of the foot and,
as a consequence, resulted in greater
load beneath the forefoot during
gait.15,16 The findings of the current
study, however, do not support such
a conclusion in plantar fasciitis.
Rather, in the symptomatic limb, the
sagittal thickness of the plantar fascia
was found to be correlated with
peak midfoot loading. Although it is
possible that greater midfoot loading
increases the internal compressive
stress at the calcaneal attachment
during mid-stance, resulting in pain
and adaptive thickening of the plan-
tar fascia,39 it may equally represent
an antalgic gait response in which
individuals with heel pain make gait
adjustments that specifically avoid
dynamic loading of the painful area,
as has been reported previously.18,40
Collectively, the findings of the cur-
rent investigation may suggest that,
although abnormal arch shape is not
characteristic of plantar fasciitis,
arch shape may influence midfoot
loading and modify the internal pres-
sure and level of pain at the fascial
insertion. However, it is unknown
whether the pain associated with
plantar fasciitis is influenced primar-
ily by external midfoot load, result-
ing in localized pressure near the fas-
cial enthesis, or by the tensile stress
borne directly by the plantar fascia as
a consequence of arch shape.
Similarly, how the greater fascial di-
mensions may relate to clinical
symptoms of heel pain is unclear. In
tendinopathy, tendon dimensions
have been shown to be positively
correlated with both the severity of
extracellular matrix disruption41 and
the level of tendon blood flow.42 Al-
though the role of collagen disrup-
tion in tendon pain has been ques-
tioned,43 recent research has shown
that pain levels associated with plan-
tar fasciitis are positively correlated
with hyperaemia, as determined by
power Doppler ultrasonography.44
August 2007
Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading
Although suggestive that pain may
be associated with neovascular in-
growth, as proposed in tendon,45,46
positive color flow and hypoechoge-
nicity are neither specific to nor con-
sistent findings in plantar fasciitis
and often are reported in asymptom-
atic limbs.20,44 It is likely, therefore,
that neovascularization is not the pri-
mary cause of pain in people with
plantar fasciitis. Although alternative
biochemical hypotheses involving
neurotransmitters, such as glutamate
and substance P, have been impli-
cated in tendon pain,47,48 the signif-
icance of these factors in plantar fas-
ciitis remains unknown.
As with all research, this study had a
number of limitations. Chiefly, it
should be remembered that this
study evaluated the relationship
among pain, fascial thickness, arch
shape, and regional loading of the
foot at the univariate level and, as
such, cannot account for potential
collinearity among variables. Given
the positive correlations found in the
current study among arch shape,
midfoot loading, and fascial thick-
ness, it is unknown which, if any, of
these variables is independently as-
sociated with heel pain. Moreover,
in light of the cross-sectional nature
of the current study, conclusions re-
garding cause-and-effect cannot be
made. Thus, it is unknown whether
arch shape and midfoot loading con-
tribute to the development of plantar
fasciitis or whether heel pain influ-
ences the shape and loading of the
foot during gait. Although the former
offers a therapeutic window for me-
chanical interventions, such as in-
soles, taping, and arch supports, the
latter would imply inherent limita-
tions to such an approach. We rec-
ommend, therefore, that future stud-
ies use a prospective study design in
which a multivariate modeling ap-
proach is used to estimate the re-
spective roles of fascial thickness,
arch shape, and regional loading in
the development of heel pain.
Volume 87
Summary
The findings of the current investiga-
tion suggest that the severity of pain
and fascial thickness associated with
plantar fasciitis are related to both
the regional loading and static shape
of the arch of the foot. Although the
effect is absent in individuals with-
out plantar fasciitis, it is unknown
whether these physical characteris-
tics contribute to the development
of plantar fasciitis or occur as a result
of gait adaptations secondary to heel
pain.
All authors provided concept/idea/research
design. Dr Wearing, Dr Smeathers, and
Dr Urry provided writing. Dr Wearing, Dr
Smeathers, and Mr Sullivan provided data
collection and analysis. Mr Yates and Dr Urry
also provided data collection. Dr Wearing
provided project management and subjects.
Mr Dubois provided facilities/equipment
and institutional liaisons. Dr Smeathers, Mr
Sullivan, Mr Yates, Dr Urry, and Mr Dubois
provided consultation (including review of
manuscript before submission).
Ethical clearance for the project was ob-
tained from the Queensland University of
Technology Human Research Ethics Com-
mittee (QUT Ref No. 2335H).
The study findings were presented at the
2004 EMED International Scientific Meeting
(Leeds, United Kingdom) and subsequently
were published in abstract form in Clinical
Biomechanics, 2005;20(9):S39.
This article was submitted May 12, 2006, and
was accepted April 2, 2007.
DOI: 10.2522/ptj.20060136
References
1 Hicks JH. The mechanics of the foot: the
plantar aponeurosis and the arch. J Anat.
1954;88:25–30.
2 Hicks JH. The foot as a support. Acta Anat.
1955;25:34 – 45.
3 Taunton JE, Ryan MB, Clement DB, et al.
Plantar fasciitis: a retrospective analysis of
267 cases. Physical Therapy in Sport.
2002;3(2):57– 65.
4 Viel E, Esnault M. The effect of increased
tension in the plantar fascia: a biomechani-
cal analysis. Physiother Theory Pract.
1989;5:69 –73.
5 Shama SS, Kominsky SJ, Lemont H. Preva-
lence of non-painful heel spur and its re-
lation to postural foot position. J Am Po-
diatry Assoc. 1983;73:122–123.
Number 8 Physical Therapy f 1007
Plantar Fasciitis: Pain, Fascial Thickness, Arch Shape, and Loading
6 Prichasuk S, Subhadrabandhu T. The rela-
tionship of pes planus and calcaneal spur
to plantar heel pain. Clin Orthop.
1994(306):192–196.
7 Wearing SC, Smeathers JE, Yates B, et al.
Sagittal movement of the medial longitudi-
nal arch is unchanged in plantar fasciitis.
Med Sci Sports Exerc. 2004;36:1761–1767.
8 Warren BL, Jones CJ. Predicting plantar
fasciitis in runners. Med Sci Sports Exerc.
1987;19:71–73.
9 Messier SP, Pittala KA. Etiologic factors as-
sociated with selected running injuries.
Med Sci Sports Exerc. 1988;20:501–505.
10 Wearing SC, Smeathers JE, Urry SR, et al.
The pathomechanics of plantar fasciitis.
Sports Med. 2006;36:585– 611.
11 Griffith JF, Wong SM, Li EK. Ultrasound
evaluation of plantar fasciitis. Scand
J Rheumatol. 2001;30:176 –177.
12 Genc H, Saracoglu M, Nacir B, et al. Long-
term ultrasonographic follow-up of plan-
tar fasciitis patients treated with steroid
injection. Joint Bone Spine. 2005;72:
61– 65.
13 Hammer DS, Adam F, Kreutz A, et al.
Ultrasonographic evaluation at 6-month
follow-up of plantar fasciitis after extracor-
poreal shock wave therapy. Arch Orthop
Trauma Surg. 2005;125:6 –9.
14 Kamel M, Kotob H. High frequency ultra-
sonographic findings in plantar fasciitis
and assessment of local steroid injection.
J Rheumatol. 2000;27:2139 –2141.
15 Giacomozzi C, D’Ambrogi E, Uccioli L, Ma-
cellari V. Does the thickening of Achilles
tendon and plantar fascia contribute to the
alteration of diabetic foot loading? Clin
Biomech. 2005;20:532–539.
16 D’Ambrogi E, Giurato L, D’Agostino MA,
et al. Contribution of plantar fascia to the
increased forefoot pressures in diabetic
patients. Diabetes Care. 2003;26:
1525–1529.
17 D’Ambrogi E, Giacomozzi C, Macellari V,
Uccioli L. Abnormal foot function in dia-
betic patients: the altered onset of Wind-
lass mechanism. Diabet Med. 2005;
22:1713–1719.
18 Katoh Y, Chao EY, Morrey BF, Laughman
RK. Objective technique for evaluating
painful heel syndrome and its treatment.
Foot Ankle. 1983;3:227–237.
19 Wearing SC, Smeathers JE, Urry SR. The
effect of plantar fasciitis on vertical foot-
ground reaction force. Clin Orthop.
2003;409:175–185.
20 Cardinal E, Chhem RK, Beauregard CG,
et al. Plantar fasciitis: sonographic evalua-
tion. Radiology. 1996;201:257–259.
21 Gibbon WW, Long G. Ultrasound of the
plantar aponeurosis (fascia). Skeletal
Radiol. 1999;28:21–26.
1008 f Physical Therapy Volume 87 Number 8
22 Tsai WC, Chiu MF, Wang CL, et al. Ultra-
sound evaluation of plantar fasciitis. Scand
J Rheumatol. 2000;29:255–259.
23 Dougados M, van der Linden S, Juhlin R,
et al. The European Spondylarthropathy
Study Group preliminary criteria for the
classification of spondylarthropathy.
Arthritis Rheum. 1991;34:1218 –1227.
24 Perlman PR, Dubois P, Siskind V. Validat-
ing the process of taking lateral foot x-rays.
J Am Podiatr Med Assoc. 1996;86:
317–321.
25 Saltzman CL, Nawoczenski DA, Talbot KD.
Measurement of the medial longitudinal
arch. Arch Phys Med Rehabil. 1995;76:
45– 49.
26 Wearing SC, Smeathers JE, Yates B, et al.
Errors in measuring sagittal arch kinemat-
ics of the human foot with digital fluoros-
copy. Gait Posture. 2005;21:326 –332.
27 Wearing SC, Urry SR, Smeathers JE.
Ground reaction forces at discrete sites of
the foot derived from pressure plate mea-
surements. Foot Ankle Int. 2001;22:
653– 661.
28 Heitjan DF, Derr JA, Satyaswaroop PG. The
multi-site tumour transplantation model
for human endometrial carcinoma: a sta-
tistical evaluation. Cell Prolif. 1992;
25:193–203.
29 Sabir N, Demirlenk S, Yagci B, et al. Clin-
ical utility of sonography in diagnosing
plantar fasciitis. J Ultrasound Med.
2005;24:1041–1048.
30 Fiolkowski P, Brunt D, Bishop M, et al.
Intrinsic pedal musculature support of the
medial longitudinal arch: an electromyo-
graphy study. J Foot Ankle Surg.
2003;42:327–333.
31 Kibler WB, Goldberg C, Chandler TJ. Func-
tional biomechanical deficits in running
athletes with plantar fasciitis. Am J Sports
Med. 1991;19:66 –71.
32 Allen RH, Gross MT. Toe flexors strength
and passive extension range of motion of
the first metatarsophalangeal joint in indi-
viduals with plantar fasciitis. J Orthop
Sports Phys Ther. 2003;33:468 – 478.
33 Mokone GG, Schwellnus MP, Noakes TD,
Collins M. The COL5A1 gene and Achilles
tendon pathology. Scand J Med Sci Sports.
2006;16:19 –26.
34 Soslowsky LJ, Thomopoulos S, Tun S, et al.
Overuse activity injures the supraspinatus
tendon in an animal model: a histologic
and biomechanical study. J Shoulder
Elbow Surg. 2000;9:79 – 84.
35 Józsa L, Réffy A, Kannus P, et al. Patholog-
ical alterations in human tendons. Arch
Orthop Trauma Surg. 1990;110:15–21.
36 Fredberg U, Bolvig L. Significance of ultra-
sonographically detected asymptomatic
tendinosis in the patellar and achilles ten-
dons of elite soccer players: a longitudinal
study. Am J Sports Med. 2002;30:
488 – 491.
37 Paavola M, Kannus P, Paakkala T, et al.
Long-term prognosis of patients with
Achilles tendinopathy: an observational
8-year follow-up study. Am J Sports Med.
2000;28:634 – 642.
38 Wolgin M, Cook C, Graham C, Mauldin D.
Conservative treatment of plantar heel
pain: long-term follow-up. Foot Ankle Int.
1994;15:97–102.
39 Spears IR, Miller-Young JE, Waters M,
Rome K. The effect of loading conditions
on stress in the barefooted heel pad. Med
Sci Sports Exerc. 2005;37:1030 –1036.
40 Wearing SC, Smeathers JE, Urry SR. A com-
parison of two analytical techniques for
detecting differences in regional vertical
impulses due to plantar fasciitis. Foot
Ankle Int. 2002;23:148 –154.
41 Åström M, Gentz CF, Nilsson P, et al. Im-
aging in chronic achilles tendinopathy: a
comparison of ultrasonography, magnetic
resonance imaging and surgical findings in
27 histologically verified cases. Skeletal
Radiol. 1996;25:615– 620.
42 Peers KH, Brys PP, Lysens RJ. Correlation
between power Doppler ultrasonography
and clinical severity in Achilles tendinopa-
thy. Int Orthop. 2003;27:180 –183.
43 Khan KM, Cook JL, Maffulli N, Kannus P.
Where is the pain coming from in tendi-
nopathy? It may be biochemical, not only
structural, in origin. Br J Sports Med.
2000;34:81– 83.
44 Walther M, Radke S, Kirschner S, et al.
Power Doppler findings in plantar fasciitis.
Ultrasound Med Biol. 2004;30:435– 440.
45 Gisslen K, Alfredson H. Neovascularisation
and pain in jumper’s knee: a prospective
clinical and sonographic study in elite jun-
ior volleyball players. Br J Sports Med.
2005;39:423– 428.
46 Zanetti M, Metzdorf A, Kundert HP, et al.
Achilles tendons: clinical relevance of neo-
vascularization diagnosed with power
Doppler US. Radiology. 2003;227:
556 –560.
47 Gotoh M, Hamada K, Yamakawa H, et al.
Increased substance P in subacromial
bursa and shoulder pain in rotator cuff
diseases. J Orthop Res. 1998;16:618 – 621.
48 Alfredson H, Lorentzon R. Chronic tendon
pain: no signs of chemical inflammation
but high concentrations of the neurotrans-
mitter glutamate. Implications for treat-
ment? Curr Drug Targets. 2002;3:43–54.
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