Journal of Biomechanics 105 (2020) 109773

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Journal of Biomechanics
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Plantar pressure distribution and spatiotemporal gait parameters after

the radial shock wave therapy in patients with chronic plantar fasciitis
Anna Brachman a,⇑, Grzegorz Sobota a, Wojciech Marszałek b, Michał Pawłowski b, Grzegorz Juras b,
Bogdan Bacik a
a
Institute of Sport Sciences, Department of Biomechanics, The Jerzy Kukuczka Academy of Physical Education in Katowice, Poland
b
Institute of Sport Sciences, Department of Human Motor Behavior, The Jerzy Kukuczka Academy of Physical Education in Katowice, Poland

a r t i c l e i n f o a b s t r a c t

Article history: Radial shock wave therapy (RSWT) has been recommended as an appropriate, safe and effective method
Accepted 28 March 2020 in the treatment of chronic plantar fasciitis (PF). The main purpose of this study was to examine how
RSWT affects gait parameters.
This study included 23 patients with unilateral, chronic PF. RSWT were administered in 5 interventions,
Keywords: during a consecutive 3-week period. Objective kinetic (force distribution under the forefoot, midfoot,
Plantar fasciitis (PF) rearfoot) and spatiotemporal parameters (cadence, step length, stance phase duration) during treadmill
Biomechanics
walking at, preferred” speed were evaluated on.
Treadmill walking
Radial shock wave therapy (RSWT)
4 sessions: before therapy, immediately after (primary endpoint), 3 and 6 weeks after therapy.
The mean reduction in the reported pain when taking first steps in the morning from baseline to the
primary endpoint, 3- and 6-weeks post procedure was 42.7%, 50.1% and 66.9% respectively. Similar reduc-
tion was seen in the reported pain during walking. After the therapy during gait at the preferred speed
patients had a significantly higher force beneath the rearfoot and forefoot of both limbs. Force beneath
the midfoot was not significantly affected by treatment. The step length in both limbs increased by
3.3–3.6 cm after RSWT. After the therapy stance phase duration in symptomatic foot was longer by 7%
and it slightly decreased until POST-6wk. Similar changes were seen in an asymptomatic limb.
The spatiotemporal and kinetic results indicate that RSWT therapy induces changes in patient’s gait
structure and alter regional loading in the affected foot.
Ó 2020 Elsevier Ltd. All rights reserved.

1. Introduction weightbearing activities, including walking (Ribeiro et al., 2011;

Plantar fasciitis (PF) is one of the most common pathologies of
the foot, affecting approximately 10% of the population during
their lifetime. Plantar fasciitis is a self-limiting condition. However,
because of its prolonged course (symptoms resolve in 80% of cases
within 10 months (Davis et al., 1994; League, 2008) patients expe-
rience serious deterioration in their quality of life (Riddle et al.,
2004). Plantar fasciitis is thought to result from excessive strain
of the plantar fascia due to the repetitive microtrauma associated
with persistent load-bearing, which eventually incites an inflam-
matory response and degenerative changes (League, 2008;
Wearing et al., 2012). Plantar fasciitis is characterized by pain
localized on the plantar fascia insertion, which is aggravated when
taking the first few steps in the morning or during prolonged
⇑ Corresponding author at: Department of Biomechanics, The Jerzy Kukuczka
Academy of Physical Education, Katowice, Poland.
Riddle et al., 2004). Because walking is an essential function of
daily living, plantar fasciitis may account for the reduced general
health-related quality of life (Phillips and McClinton, 2017). Some
researchers have shown that patients with PF or hindfoot fractures
walk at slower speed than controls (Katoh et al., 1983; Rosenbaum
et al., 1995). There are varied reports regarding foot loading during
walking in people with plantar fasciitis, however most of the pre-
vious studies observed that it alters patients’ plantar load distribu-
tion (Bedi and Love, 1998; Chang et al., 2014; Ribeiro et al., 2011;
Wearing et al., 2002; Wearing et al., 2003). Some researchers have
shown reductions of vertical ground reaction force in first (Katoh
et al., 1983) or second peak (at propulsion) (Chang et al., 2014;
Katoh et al., 1983; Wearing et al., 2003). Wearing et al. (2003)
and Sullivan et al. (2015) observed significantly lower forefoot
impulses, Katoh et al. (1983) obtained similar results but they also
noticed higher midfoot impulses when compared to controls.
Wearing et al. (2002), Wearing et al. (2003) and Sullivan et al.

https://doi.org/10.1016/j.jbiomech.2020.109773
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(2015) have shown lowered rearfoot impulses in patients. Katoh
et al. (1983) and Bedi and Love (1998), in contrast, observed that
regional loading of the heel is unchanged in individuals with PF.
As walking speed has been shown to influence plantar pressure
distribution (Sullivan et al., 2015) and peak ground reaction forces
(Andriacchi et al., 1977); Chang et al. (2014)) suggested that these
discrepancies may result from different walking speeds adopted by
patients.
During the last two decades, radial shock wave therapy (RSWT)
as a new treatment modality has largely gained in popularity. It is
thought that biological effect caused by shock waves is the result of
pain relief caused by overstimulation of the treated site, stimula-
tion of tissue regeneration and destruction of calcifications
(Schmitz et al., 2013; van der Worp et al., 2014). Shock wave ther-
apy has been shown to promote cell growth and collagen synthesis
and initiate a healing response of the tendon with a minor inflam-
matory reaction (Ogden et al., 2001; Rompe et al., 2007; Vetrano
et al., 2011). RSWT has been investigated in numerous well-
designed, randomized, and placebo-controlled trials, providing
strong evidence for its effectiveness (Gerdesmeyer et al., 2008;
Ibrahim et al., 2010; Mardani-Kivi et al., 2015; Rompe et al.,
2005). Hence, it has been recommended as an appropriate, safe
and effective method in the treatment of chronic plantar fasciitis
(Chang et al., 2012; Ioppolo et al., 2014).
Although gait analysis has been cited as an objective tool for
evaluating the progression of plantar fasciitis and the efficacy of
treatment protocols (Bedi and Love, 1998; Katoh et al., 1983;
Wearing et al., 2003), little is known about the influence of RSWT
treatment on gait in patients with plantar fasciitis. Plantar pressure
distribution has been thought to provide valuable information in
the study of specific pathologies of the foot (Mann et al., 2016;
Rosenbaum and Becker, 1997), moreover as indicated by
Rosenbaum et al. (1995) it is useful to evaluate foot function by
comparing the loads between pre- and post-treatment states. A
greater understanding of load distribution under the foot and spa-
tiotemporal parameters during walking could provide clearer
insight into foot function after RSWT treatment. Hence, the main
purpose of this study was to investigate the effect of RSWT on
kinetic and spatiotemporal gait parameters in patients with
chronic PF.
Three patients withdrew, and another three patients declined to
sign the consent form. The study was carried out in accordance
with the guidelines proposed in the Declarations of Helsinki and
it was approved by Institutional Ethics Committee (no. 8/2013)
After inclusion in the study, patients were asked to refrain from
any other treatment modalities, excessive effort and orthotics
could not be modified until the last follow-up (Gerdesmeyer
et al., 2008; Ibrahim et al., 2010; Rompe et al., 2015).
The mean age was 55.7 (range, 45–78; SD, 8.5) years, mean
height was 165.7 (range, 157–186; SD, 7.9) cm, mean weight was
80.5 (range, 56.5–119; SD, 16.7) kg, and mean body mass index
was 29.18 (range, 21.6–38.3; SD, 4.9) kg/m2. The mean comfortable
gait speed on the ground was 4.25 (range, 3.3–5.8; SD, 0.7) km/h
and on the treadmill was 2.93 (range, 2.5–4.5; SD, 0.5) km/h.
2.2. Treatment
Radial extracorporeal shock wave therapy was administered in
5 interventions, each 2–3 days apart. A total of 2000 shock waves
per session were delivered with the BTL-6000 SWT Topline. Each
procedure was conducted in accordance with the manufacturer’s
instructions (BTL Industries, Inc.). During the first part of the pro-
cedure, shock waves were applied at the point of maximum pain
level (at the beginning 400 pulses with 2.5 bar, then dose was
gradually increased to the subject’s maximum tolerable level –
1000 pulses). In the second part, the procedure involved adjacent
tissues (600 pulses).
In previous research frequency and energy densities varied
widely between studies but all authors have demonstrated positive
clinical changes and significant reduction of pain (Gerdesmeyer
et al., 2008; Ibrahim et al., 2010; Lohrer et al., 2010; Mardani-
Kivi et al., 2015). Therapeutic effect appears to be dose dependent,
with greater success seen in higher dose regimens (Chang et al.,
2012; Chow and Cheing, 2007; Speed, 2013). That is why in this
study 2000 pulses with 10 Hz frequency and a maximal air pres-
sure tolerable for the patients (as in Chow and Cheing (2007)
was applied (up to 4 bar, which is equal to a positive energy flux
density of 0.23 mJ/mm2). Before the intervention the point of max-
imum tenderness was clinically located by the treating clinician
and ultrasound gel was used as a coupling agent. No local anesthe-
sia was applied.

2.3. Study procedures

2. Materials and methods
2.1. Participants
A clinical trial of radial shock wave therapy was performed on
23 subjects with unilateral chronic plantar fasciitis. Twenty nine
patients were diagnosed by orthopedic practitioners. Diagnosis
was based on the patient’s history, functional tests, palpations,
range of motion tests of the foot and ankle joints, and additional
X-ray or ultrasound imaging, if needed. In order to be eligible par-
ticipants had to meet inclusion criteria and exclusion criteria given
in Table 1.
According to the other studies (Ibrahim et al., 2010; Lohrer
et al., 2010; Mardani-Kivi et al., 2015); in order to check whether
the applied therapy was effective all patients were subjectively
evaluated using the visual analog scale (VAS) to measure pain
(VAS 1 - pain when taking first steps in the morning; VAS 2 - pain
during walking). Pain was recorded before and after therapy, 3 and
6 weeks post the procedure on a scale of 0 to 10, with 0 indicating,
no pain” and 10, the worst imaginable pain”.
To check whether this type of therapy affects foot function dur-
ing gait in this group of patients, kinetic and spatiotemporal
parameters during treadmill walking at, preferred” speed were

Table 1
Inclusion and Exclusion Criteria.

Inclusion criteria: Adults over the age of 18 years; Diagnosis of plantar fasciitis with the following positive clinical signs:1. Pain when taking the first few steps in the
morning (VAS for pain >5) 2. Local tenderness over the plantar-medial aspect of the calcaneal tuberosity 3. Increasing pain with extended walking or standing;
History of pain >3 months; Signed informed consent
Exclusion criteria: Bilateral plantar fasciitis; Local and systemic neurologic disorders (including tarsal tunnel syndrome, sciatica, posterior tibial and abductor digiti
quinti nerve entrapment); Posterior calcaneal spur; Sever’s disease; Reiter’s syndrome; Achilles tendonitis; Calcaneal stress fracture; Plantar fascia rupture; Knee or
ankle joint dysfunction; Balance disorders or musculoskeletal conditions likely to affect ability to walk on a treadmill; Leg length discrepancy >1 cm; History of
lower-extremity injury or fractures within 6 months prior to participation in the study; Rheumatologic disorders; Infections or tumors of the lower extremity;
Coagulopathies; Operative treatment of the heel spur; Diabetes Mellitus; Pregnancy

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 A. Brachman et al. / Journal of Biomechanics 105 (2020) 109773 3

evaluated. The following variables were assessed by using Zebris
system (Zebris FDM–T, Zebris Medical GmbH,Isny,Germany):
cadence (steps/min); step length (the distance measured from
the heel of the one foot to the heel of the other foot) normalized
to leg length; stance phase duration (s); peak vertical force normal-
ized to body weight (%BW) under the forefoot, midfoot and heel.
All variables were recorded immediately before the initial treat-
ment (baseline) and immediately after the last shock wave treat-
ment (primary endpoint). Follow-up investigations were
performed 3 (POST-3wk) and 6 (POST-6wk) weeks post procedure
repeating the baseline measures.
The illustration of the results of the walking trial measurement
is shown in Fig. 1.
2.4. Walking test protocol
All participants were asked to walk barefoot three times at a
self-selected speed along a 10-m walkway in order to determine
individual comfortable walking speed. Subjects were requested
to walk normally, without rushing, acceleration or deceleration.
In previous studies familiarization time to the treadmill conditions
varied between 1 and 2 min and 10 min. (Bisiaux and Moretto,
2008; Dingwell and Marin, 2006; Faude et al., 2012; Nagano
et al., 2013). In our research the treadmill condition included a
4–5 min familiarization time. During this period preferred tread-
mill walking speed was determined by starting from the over-
ground comfortable walking speed and decreasing by 0.5 km/h
every 10 strides until participants reported that it was uncomfort-
able to maintain normal walking. Speed was then increased sys-
tematically by 0.5 km/h until reported as being uncomfortably
fast. Due to the heel pain accompanying barefoot locomotion in
examined patients this procedure was repeated twice with the
average of the four reported speeds taken as preferred walking
speed on the treadmill. In order to determine, preferred” treadmill
walking speed this protocol has been applied in previous research
(Dingwell and Marin, 2006; Nagano et al., 2013). Spatiotemporal
and kinetic parameters have been reported to be speed dependent
(Rosenbaum et al., 1994); accordingly, to ensure the same experi-
mental conditions between the walking tests, the treadmill speed
was maintained at the baseline preferred walking speed. In each
trial subjects walked barefoot for 30 s on the Zebris FDM–T tread-
mill system. The 94.8
40.6 cm pressure platform mounted in the
treadmill comprises 5376 pressure sensors.
A sampling rate of 100 Hz was used to acquire all data. Before
each use, autocalibration was performed in accordance with man-
ufacturer recommendations. Previous authors have already con-
firmed the validity and reliability of the Zebris treadmill system
(Faude et al., 2012; Reed et al., 2013). They provided evidence for

Fig. 1. Illustration of the results of the walking trial measurement. (A) Force curve graphs (B) foot subregions: forefoot, midfoot, rearfoot.

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4 A. Brachman et al. / Journal of Biomechanics 105 (2020) 109773
the repeatability and sensitivity of spatiotemporal measurements
(ICC  0.86) and vertical ground reaction forces measurements
taken with treadmill system.
In order to ensure safety and to maintain constant speed,
patients were instructed to keep a constant distance from the front
handrail.
2.5. Statistical analysis
The time course of average changes in dependent variables dur-
ing the four sessions were analyzed using a one-factorial repeated
measures analysis of variance (ANOVA) with Bonferroni-adjusted
post hoc comparisons or a Friedman ANOVA according to the nor-
mal distribution, if necessary. Differences between symptomatic
and asymptomatic limb were evaluated using paired t-test.
The assumption of homogeneity of variance was assessed using
Levene’s test. The assumption of sphericity was assessed using
Mauchly’s test. When the assumption of uniformity was violated,
an adjustment to the degrees of freedom of the F-ratio was made
using Greenhouse-Geisser Epsilon, thereby making the F-test more
conservative. Effect sizes were calculated to infer the importance of
mean differences: small (0.01), medium (0.06), and large (0.14)
(Cohen, 1988). To improve the comparability of effect sizes
between studies, less biased, partial omega squared (x2p) effect size
was computed (Lakens, 2013). To describe an effect between symp-
tomatic and asymptomatic limbs in each session the standardized
mean difference effect size for within-subjects designs was calcu-
lated (Cohen’s dz). Effect sizes were as follow: small (d = 0.2), med-
ium (d = 0.5), and large (d = 0.8) (Cohen, 1988). For all statistical
procedures Statistica software package version 13 for Windows
(Statsoft) was used. An a-level of p  0.05 was accepted as statisti-
cally significant.
3. Results
The mean reduction in the VAS 1 score from baseline to the pri-
mary endpoint, 3 and6 weeks post procedure was 42.7%, 50.1% and
66.9% respectively (F(3. 66) = 30.0, p < 0.001, x2p = 0.49). Similar
reduction was seen in VAS 2. The repeated measures analysis of vari-
Fig. 2. The mean visual analog scale (VAS) score changes for 4 sessions: before (BASELINE), immediately after therapy (PRIMARY E.P.), 3 (POST-3wk) and 6 (POST-6wk) weeks
after the last shock wave treatment; error bars indicate 0.95 confidence interval. Black bars represent pain when taking first steps in the morning (VAS1) and grey bars
represent pain during walking (VAS2); *p < 0.05.
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ance test indicated that the VAS scores in both conditions changed
significantly from before to after treatment at all sessions (Fig. 2).
The mean kinetic parameters, expressed as a percentage of body
weight, for treadmill walking during the 4 gait sessions are pre-
sented in Table 2.
After therapy during gait at the preferred speed patients had a
significantly higher force beneath the rearfoot and forefoot of both
limbs. Force beneath the midfoot was not significantly affected by
treatment. The load under the painful area of the symptomatic
limb increased significantly (F(3. 66) = 8.38, p < 0.001) by 12.2%
between baseline and primary endpoint and by 14.1% between
baseline and POST-3wk, and remained stable until POST-6wk. Sim-
ilar increase was seen in asymptomatic limb. The load under the
forefoot of the symptomatic limb was significantly higher after
therapy, it rose (v2ANOVA = 18.81, p < 0.001) by 5.6% between
baseline and POST-3wk and it decreased slightly until POST-6wk,
so that the difference didn’t remain significant. In asymptomatic
limb similar gain (F(3. 66) = 26.06, p < 0.001) was seen immedi-
ately after treatment and it remained stable until POST-6wk. There
were no significant differences between symptomatic and asymp-
tomatic limb with respect to force beneath the forefoot, midfoot
and rearfoot (Table 2)
There was a significant main effect for all evaluated spatiotem-
poral parameters.
The step length in both limbs increased by about 8% after RSWT
therapy (symptomatic: F(3,66) = 25.97, p < 0.001, x2p = 0.45;
asymptomatic: F(3, 66) = 25.31, p < 0.001, x2p = 0.44) and it
remained stable throughout entire experiment (Fig. 3), these are
changes of about 3.1–3.6 cm. While the constant walking speed at
each measurement was maintained, adequately to increase in step
length, a significant decrease in cadence was observed (F(3. 66) =
27.11p < 0.001, x2p = 0.46) (Fig. 4). Fig. 5 shows the stance phase
duration time for both limbs. For symptomatic foot stance phase
duration was longer (F(3, 66) = 22.42, p < 0.001, x2p = 0.41) by
6.9% after therapy when compared to baseline and remained stable
until POST-6wk. Similar changes were seen in asymptomatic limb.
There were no significant differences between symptomatic and
asymptomatic limb with respect to step length and stance phase
duration (Figs. 3 and 5).
 A. Brachman et al. / Journal of Biomechanics 105 (2020) 109773 5

Table 2
Mean of the regional maximum force, expressed as a percentage of body weight, before (BASELINE), immediately after therapy (PRIMARY E.P.), 3 (POST-3wk) and 6 (POST-6wk)
weeks after the last shock wave treatment.

BASELINE PRIMARY E.P. POST-3wk POST-6wk Effect size (x2p)

   
x ± SD x ± SD x ± SD x ± SD
Forefoot (%) S 93.0 ± 10.5 95.7 ± 12.9 98.2 ± 11.4 à** 97.2 ± 12.6 0.17
A 94.6 ± 5.8 99.6 ± 6.4 y 101.9 ± 7 à 100.9 ± 6.1* 0.45
S versus A p = 0.32 p = 0.09 p = 0.052 p = 0.12

dz = 0.21 dz = 0.37 dz = 0.42 dz = 0.34

Midfoot (%) S 24.3 ± 11.5 25.2 ± 10.4 25.9 ± 10.8 26 ± 10.6 0,04
A 26.3 ± 12.2 26.5 ± 10.9 27.4 ± 10.8 27 ± 10.2 0.01
S versus A p = 0,16 p = 0.39 p = 0.33 p = 0.55

dz = 0.31 dz = 0.18 dz = 0.21 dz = 0.12

Rearfoot (%) S 48.2 ± 11.2 54.1 ± 8.9y 55 ± 8.5 à 55.1 ± 9.1* 0.19
A 49.6 ± 10.1 56.7 ± 7.7y 57.5 ± 7.8 à 57.9 ± 8.1* 0.29

S versus A p = 0.41 p = 0.09 p = 0.20 p = 0.053

dz = 0.17 dz = 0.36 dz = 0.27 dz = 0.42


Mean (x) and standard deviation (SD); S, symptomatic limb; A, asymptomatic limb.
y Differences statistically significant between BASELINE vs PRIMARY ENDPOINT (p < 0.05).
à Differences statistically significant between BASELINE vs POST-3wk (p < 0.05).
* Differences statistically significant between BASELINE vs POST-6wk (p < 0.05).
x2p, partial omega squared; dz, standardized Cohen’s d for within-subjects designs
**
Differences statistically significant between PRIMARY E.P. vs POST-3wk (p < 0.05).

Fig. 3. The mean step length changes in symptomatic (black line) and asymptomatic limb (grey dotted line) for 4 sessions: before (BASELINE), immediately after therapy
(PRIMARY E.P.), 3 (POST-3wk) and 6 (POST-6wk) weeks after the last shock wave treatment; error bars indicate 0.95 confidence interval; *p < 0.05.

4. Discussion reported in other articles (Gerdesmeyer et al., 2008; Greve et al.,

Although gait analysis has been cited as an objective tool for
evaluating the progression of plantar fasciitis and the efficacy of
treatment protocols (Bedi and Love, 1998; Katoh et al., 1983;
Wearing et al., 2003); the effect of plantar fasciitis on gait has
not been reported in literature very often (Bedi and Love, 1998;
Katoh et al., 1983; Liddle et al., 2000; Wearing et al., 2007;
Wearing et al., 2003). Furthermore, knowledge about the effect of
radial shock wave therapy on gait parameters in patients with PF
is scarce.
During the current experiment, a significant reduction of pain
was observed, which continued after 6 weeks from the last shock
wave treatment. Changes in the VAS scores are similar to that
2009; Lohrer et al., 2010; Rompe et al., 2003).
Average treadmill velocity observed in the current study was
2.93 (SD 0.62) km/h, which is less than reported by Faude et al.
(2012) for normal gait (5.0 (SD 0.4) km/h) in similarly aged individ-
uals. Based on the work of Bohannon (1997), also overground
velocity normalized to body height in the current investigation
was slower (men – 0.64, women – 0.71) in comparison to gait in
similarly aged healthy individuals (men – 0.79, women – 0.86). It
would seem, therefore, that in present investigation plantar fasci-
itis individuals may have adopted a slower walking speed due to
the protective mechanism of pain. Similar findings have been
reported by earlier authors (Chang et al., 2014; Katoh et al.,
1983; Rosenbaum et al., 1995; Wearing et al., 2002).

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Fig. 4. The mean cadence changes for 4 sessions: before (BASELINE), immediately after therapy (PRIMARY E.P.), 3 (POST-3wk) and 6 (POST-6wk) weeks after the last shock
wave treatment; error bars indicate 0.95 confidence interval; *p < 0.05.

Fig. 5. The mean stance phase duration changes in symptomatic (black line) and asymptomatic limb (grey dotted line) for 4 sessions: before (BASELINE), immediately after
therapy (PRIMARY E.P.), 3 (POST-3wk) and 6 (POST-6wk) weeks after the last shock wave treatment; error bars indicate 0.95 confidence interval; *p < 0.05.

The spatiotemporal and kinetic results indicate that radial
shock wave therapy induces changes in patient’s gait structure
and alter magnitude of regional loading in the affected foot. Earlier
studies revealed inconsistent findings regarding the effect of plan-
tar fasciitis on loading pattern of the symptomatic limb (Chang
et al., 2014; Katoh et al., 1983; Liddle et al., 2000; Wearing et al.,
2007; Wearing et al., 2002; Wearing et al., 2003), however, as sug-
gested by Chang et al. (2014) none of them addressed the possibil-
ity of walking speed being a confounding factor. Walking speed
was controlled across each visit in the current study such that
reductions in pain and healing would manifest in changes to gait
performance independent of changes to gait speed. This is
expressed in a significant lengthening of the step and a significant
lengthening of the stance phase duration. Although the mean
change for step length values was 4.1–3.6 cm which may be con-
sidered small at first glance, statistics suggest a meaningful result.
Moreover Faude et al. (2012) have shown that minimal detectable
change for stride length in similar aged population on the treadmill
walk is 6.4 cm which is equivalent to 3.2 cm for step length. The
plantar fascia absorbs dynamic reaction forces during locomotion
and facilitates their transfer from rearfoot to forefoot (Chang
et al., 2014; Cheng et al., 2008). Cadaver models (Flanigan et al.,
2007) and finite element analyses (Chen et al., 2001) have shown
that tension in the plantar fascia increases with the magnitude of
toe dorsiflexion (Cheng et al., 2008). Wearing et al. (2003) pro-
posed that patients, to avoid pain, place the foot on the ground
in a relatively plantigrade position which, in turn, results in a
reduced step length. Other authors (Daly and Kitaoka, 1992) sug-

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 A. Brachman et al. / Journal of Biomechanics 105 (2020) 109773
gested that patients progressed through the stance phase more
rapidly than controls. Thus, significant lengthening of the step
and stance phase duration after RSWT seen in the current study
contributed to a restoration of a more normal gait pattern. In con-
trast to the current study, Hsu et al. (2013) observed increased
cadence and no differences in the step length after focused shock
wave therapy. The reason for these discrepancies might be that
in the current study patients could not change their walking speed
and Hsu et al. (2013) observed that after treatment patients walked
at a faster velocity.
The changes in spatiotemporal parameters are a consequence of
the increase in generated forces. It has been suggested that
patients with heel pain make gait adjustments that specifically
avoid dynamic loading of the painful area (Katoh et al., 1983;
Wearing et al., 2007; Wearing et al., 2002). Previous authors have
also speculated that the plantar aponeurosis is most stretched dur-
ing the propulsion phase, therefore PF patients decrease force
under forefoot during walking (Bedi and Love, 1998; Wearing
et al., 2003). As shown by Wearing et al. (2003) patients with PF
had reduced force under the painful heel and forefoot of the symp-
tomatic foot by approximately 8% and 6% bodyweight, respectively.
These authors also observed similar changes in the asymptomatic
foot. It is consistent with findings reported by other authors, who
have shown reduced loading of the rear- (Bedi and Love, 1998;
Wearing et al., 2002) or forefoot (Chang et al., 2014; Katoh et al.,
1983) in the symptomatic foot when compared to controls. Results
observed in the current study are in line with these findings. After
therapy patients increased the load beneath the painful heel sug-
gesting significant improvement of the heel impact phase. These
results are also comparable to those of Molund et al. (2018) who
demonstrated an increased fore- and rearfoot pressure during
walking after gastrocnemius recession and stretching exercises in
patients with PF. In contrast to the current study Hsu et al.
(2013) observed that focused shock wave therapy did not influence
the peak contact pressure in the rearfoot. However, the differences
between the pain level at baseline and the final follow-up reported
by Hsu et al. were less than those observed in the current study.
Furthermore, in their study participants received 3 sessions of
FSWT and in the current study patients received 5 sessions of
RSWT. It would seem, therefore, that in the current investigation,
patients after RSWT treatment could increase the load in the pain-
ful heel during walking along with a reduction in pain. After ther-
apy patients exhibited approximately 6% increase of the load
beneath the forefoot in both limbs. Although the force beneath
the forefoot in the symptomatic limb was higher in POST-6wk
when compared to baseline, the difference didn’t remain signifi-
cant. In each of the analyzed parameters a generally symmetrical
gait pattern between the symptomatic and asymptomatic limbs
was observed, suggesting a global gait adaptation.
Despite the relatively short follow-up, the effectiveness of radial
shock wave treatment and changes induced in gait parameters
were evident even at that short time-frame. Nonetheless, further
studies are recommended to assess the long-term results regarding
the influence of RSWT on gait. Another limitation is lack of a con-
trol group, however RSWT has been previously investigated in
numerous well-designed, randomized, and placebo-controlled tri-
als, providing strong evidence for its effectiveness (Gerdesmeyer
et al., 2008; Ibrahim et al., 2010; Mardani-Kivi et al., 2015;
Rompe et al., 2005). Shock wave therapy has been shown to pro-
mote tendon healing and tissue regeneration (Ogden et al., 2001;
Rompe et al., 2007; Vetrano et al., 2011), thus the successive
improvement of gait parameters observed in the present study
may suggest functional improvement of the plantar fascia. How-
ever, as we did not collect any measures verifying healing pro-
cesses, we cannot draw a conclusion on whether gait
improvement is the result of pain relief, healing processes or both.
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7
Further research is required to ascertain the relationship between
gait improvement, plantar fascia healing and symptoms associated
with plantar fasciitis after RSWT. Another limitation is the sample
size, which was relatively small, but it was similar to previous
studies on this subject.
In conclusion, RSWT not only decreases the pain level in
patients with PF but also improves the gait parameters and con-
tributes to a restoration of a more normal gait pattern in patients
with PF.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgments
The authors would like to thank the Outpatient Clinic AMED
GCMiR for helping with execution of the study.
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