Review
Higher body mass index is associated with plantar
▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2015-094695).
1 Participants Patients with PF.
Department of General
Practice, Erasmus MC
University Medical Center
Rotterdam, The Netherlands
2
Menzies Institute for Medical
Research, University of
Tasmania, Hobart, Tasmania,
Australia
3
Faculty of Health, Menzies
Institute for Medical Research,
University of Tasmania, Hobart,
Tasmania, Australia
Correspondence to
Dr M van Middelkoop,
Department of General
Practice, Erasmus MC Medical
University Rotterdam, P.O. Box
2040, Rotterdam 3000 CA,
The Netherlands;
m.vanmiddelkoop@
erasmusmc.nl
Accepted 2 November 2015
To cite: van Leeuwen KDB,
Rogers J, Winzenberg T,
et al. Br J Sports Med
Published Online First:
[please include Day Month
Year] doi:10.1136/bjsports-
2015-094695
fasciopathy/‘plantar fasciitis’: systematic review and
meta-analysis of various clinical and imaging risk
factors
K D B van Leeuwen,1 J Rogers,2 T Winzenberg,3 M van Middelkoop1
ABSTRACT
Question What (risk) factors are associated with
plantar fasciopathy (PF)?
Design Systematic review with meta-analyses.
Factors All factors described in prospective, case–
control or cross-sectional observational studies.
Results 51 included studies (1 prospective, 46 case–
control and 4 cross-sectional studies) evaluated a total
of 104 variables. Pooling was possible for 12 variables.
Higher body mass index (BMI) (BMI>27, OR 3.7 (95%
CI 2.93 to 5.62)) in patients with PF was the only
significant clinical association, and its effect was the
strongest in the non-athletic subgroup. In people with PF
compared to controls, pooled imaging data
demonstrated a significantly thicker, hypoechogenic
plantar fascia with increased vascular signal and
perifascial fluid collection. In addition, people with PF
were more likely to have a thicker loaded and unloaded
heel fat pat, and bone findings, including a subcalcaneal
spur and increased Tc-99 uptake. No significant
difference was found in the extension of the first
metatarsophalangeal joint.
Conclusions We found a consistent clinical association
between higher BMI and plantar fasciopathy. This
association may differ between athletic and non-athletic
subgroups. While consistent evidence supports a range
of bone and soft tissue abnormalities, there is lack of
evidence for the dogma of clinical and mechanical
measures of foot and ankle function. Clinicians can use
this information in shared decision-making.
INTRODUCTION
Plantar fasciopathy (PF) is the most common cause
of inferior heel pain.1 2 Pain on the underside of
the heel affects 10% of adults in their lifetime,
accounting for one million patient visits per year to
doctors in the USA.3–5 The condition is common
across community, athletic, occupational and mili-
tary settings,6–8 and is one of the most frequently
cited running injuries, with an incidence rate of
31% over 5 years.9
PF is a clinical diagnosis described by pain or
localised tenderness at the insertion of the plantar
fascia on the calcaneus, which becomes worse on
bearing weight in the morning or after periods of
inactivity or with prolonged walking.10 11 The ter-
minology used to describe PF is inconsistent.
Synonyms include plantar heel pain, heel spur syn-
drome and plantar fasciitis. We refer to the diagno-
sis as PF.12
van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695
Multiple treatment options are available for PF,
although effectiveness is generally reported as low
to moderate.2 3 13–18 Lack of consensus on man-
agement strategies may arise from the limited
understanding of the aetiology of PF. Narrative
reviews that summarise the available evidence on
the aetiology of PF are largely based on clinical
experience and few were designed systematic-
ally.2 13 15–17 19 Two high-quality reviews of case–
control and case-series reported that plantar fascia
thickness (PFT), the presence of a heel spur and a
higher body mass index (BMI) were associated
with PF.20 21 Whether these are causes or conse-
quences of PF is a key question and we address it
in the discussion of this paper. There has been no
comprehensive systematic review of all factors,
including prospective and retrospective evidence,
associated with PF. Therefore, we systematically
reviewed all factors associated with PF, as described
in prospective, case–control and cross-sectional
studies.
METHODS
Criteria for considering studies in this review
Type of studies
Prospective studies, case–control studies and cross-
sectional studies—written in English, German or
Dutch—examining factors associated with PF were
eligible (box 1). Given that case–control and cross-
sectional studies provide no information regarding
causality, these were analysed separately from the
prospective study which can identify a candidate
who may be causally associated with PF.
Type of participants
Adolescents and adults suffering from acute or
chronic symptoms of PF were included. There were
no limitations regarding age, gender and setting.
Because of inconsistency in terminology for PF,
studies were included based on the description of
included patients. Studies were only included if
they described patients with one or more of the fol-
lowing criteria:
▸ Tenderness or pain at rest, during exercise or
palpation in
– Inferior heel
– Insertion of the plantar fascia on the
calcaneus
▸ Heel pain >1 month consistent with a history
of PF, or moderate or severe foot pain >1 week
or >3 times/year
1
 Review
Box 1 Inclusion criteria
Design
▸ Prospective study, case–control study, cross-sectional study
Language
▸ English, German, Dutch
Terminology
▸ All synonyms for plantar fasciopathy
Participants—cases
▸ Adolescents, adults
▸ Tenderness or pain at rest, during exercise or palpation in
– The inferior heel
– The insertion of the plantar fascia on the calcaneus
▸ Heel pain for more than 1 month consistent with a history of
plantar fasciopathy, or moderate or severe foot pain lasting
more than 1 week or at least three times/year
▸ Clinical evidence of plantar fasciopathy: pain provoked
when taking the first few steps in the morning or after a
period of rest; increased pain at the commencement of
weight bearing
Participants—controls
▸ Healthy control group
Outcome measures
▸ At least one possible risk factor or variable
Comparison
▸ Plantar fasciopathy versus control
▸ Clinical evidence of PF
– Pain provoked taking the first steps in the morning or after
a period of rest
– Increased pain at the start of weight bearing (WB).
Studies including participants with heel pain in areas
other than the plantar aspect of the heel, studies focusing on
other foot pathologies or describing participants with
systemic diseases were excluded. Studies had to report find-
ings in a healthy control group in order to be included.
Type of measurements
Only studies including and describing at least one possible
factor or variable associated with PF were included in this
review. Data had to be reported on both patients and healthy
control participants.
Search for relevant studies
The primary search was conducted in PubMed (MEDLINE),
EMBASE, Web of Science (WoS), MEDLINE (OVID) and the
Cochrane Central Register up to 4 of June 2014 (see online sup-
plementary file 1).
Data collection and analysis
From titles and abstracts, two reviewers (KDBvL, MvM)
assessed the results of the literature search according to prede-
termined selection criteria to identify potentially relevant
studies for full-text review. Full text was obtained if the abstract
seemed to fulfil the inclusion criteria or if eligibility was unclear.
All full-text articles were further screened on inclusion criteria
by the two independent authors.
2 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695
Methodological quality
A quality assessment list was created based on criteria from the
Dutch Cochrane Centre,22 van Rijn et al23 and Lankhorst
et al24 (table 1). Two reviewers (KDBvL, JR) independently
rated the quality of the studies by scoring each of the nine cri-
teria as ‘positive’, ‘negative’ or ‘unclear’. Differences in assess-
ment were discussed to reach consensus. The quality score of
each study was calculated as the percentage of the positive
scored items divided by the maximum score possible.
Data extraction
Two review authors (KDBvL, JR) extracted relevant data from
the studies. The following data were noted in a standardised
form: (1) study characteristics: design, number of participants,
gender, age, BMI, setting, duration of symptoms and defin-
ition for PF; (2) characteristics of the factors studied: vari-
ables, instruments and scores (eg, mean, median, OR, SD, and
95%CI).
Data analysis and statistical analysis
Comparison variables were combined into main clusters of
factors potentially associated with PF. For all studies that sup-
plied adequate data, mean differences (MD) for continuous data
and OR for dichotomous data with matching 95% CI were cal-
culated. Numbers were estimated when studies reported data
only as graphs.
Where data were not reported, corresponding authors were
contacted and asked to provide original data. If this could not
Table 1 Quality assessment list; criteria for quality score (positive,
negative or unclear)
Item Description and criteria
Study population
1 Study groups (patients and controls) are clearly defined: Positive if at
least four of the following items in both groups were reported at
baseline: age, gender, BMI, physical activity, previous treatments and
duration of symptoms
2 Comparable groups: Positive if the study controls are comparable to the
patients for age and gender
3 Number of cases ≥50: Positive if the total number of cases (patients)
was ≥50
Study design
4 Inclusion and exclusion criteria: Positive if inclusion and exclusion criteria
were described
Inclusion: A clear definition for plantar fasciopathy
Exclusion: A clear definition of the exclusion criteria
Assessment of determinant and outcome
5 Definition of determinant: Positive if a clear definition of potential
determinant (variable that might be associated with plantar fasciopathy)
was described
6 Assessment of determinant: Positive if the type and methods of
measurement and the setting were described and suitable
Analysis and data presentation
7 Data presentation: Positive if risk estimates were presented or when raw
data were given that allow for the calculation of risk estimates, such as
ORs, prevalence ratios or relative risks
8 Consideration of confounders: Positive if at least three of the following
confounders were considered and described: activity levels and/or
standing time, systemic disease, foot alignment, BMI, age and gender
9 Control for confounding: Positive if, for a minimum of three confounders
mentioned in item 8, the method used to control for confounding was
described
BMI, body mass index.
 Review

be obtained, data were not included in the meta-analysis but

were included in the narrative synthesis. If studies did not
provide sufficient information to calculate the 95% CI, informa-
tion on differences between cases and controls (with p value)
were extracted.
We do not report on associations between PF and age and sex
as around 50% of studies definitely matched on these variables,
and the description of sampling on these variables was often
unclear in the other studies.
Meta-analyses were performed using Review Manager 5.2,
using random-effects models. The event was defined as the
number of participants affected with PF. All MDs and ORs were
calculated from cases to controls. Heterogeneity was assessed
using the Q-test and I.2 We assessed publication bias by visual
inspection of funnel plots.

Review protocol
The review protocol was written a priori, but not published or
registered in PROSPERO or a similar database.

RESULTS
Characteristics of the included studies
A total of 51 studies met the inclusion criteria and are included
in this review, including 1 prospective cohort study, 46 case–
control studies and 4 cross-sectional studies (figure 1 and online
supplementary file 2).25 The number of patients included in the
studies ranged from 6 to 190, with a total of 2105 patients
with PF.
Methodological quality
The two raters initially agreed on 85% of the items among the
51 included studies (table 2). The quality score ranged from
11% to 100% and the mean quality score was 58%. Two articles
scored 100%4 26 and three articles scored 11%.27–29 Only 18
studies scored positive on item 1 ‘study groups are clearly
defined’,4 8 26 30–44 and only 15 studies scored positive on item
3 ‘50 cases or more’.4 9 26 31 36 39 45–53
Risk factors for PF
There was just one prospective cohort study— undertaken
over 5 years—which identified an incidence rate of 31.3% in
166 running athletes.9 Six variables were significantly asso-
ciated with a higher risk of PF: varus knee alignment (OR
5.63 (95% CI 2.01 to 15.72)), use of spiked athletic shoes
(OR 5.49 (95% CI 1.71 to 17.64)), cavus arch posture (OR
5.52 (95% CI 2.12 to 14.33)), greater number of days of
practice per week (OR 2.59 (95% CI 1.68 to 3.99)), greater
number of years of activity (MD 3.30 (1.01 to 5.59)), and
running more kilometres per week (MD 20.00 (12.12 to
27.88)).9 This prospective study used no imaging measures;
so all the imaging data reported below comes from case–
control and cross-sectional studies.
Figure 1 Flow chart of study inclusion (PF, plantar fasciopathy).
>27) was found (OR 3.7 (95% CI 2.9 to 5.6), figure 3);48 52
two remaining studies found a positive association between PF
and obesity (BMI >30)4 26 while in the same study no signifi-
cant association was found for overweight status (BMI 25–30).4
No significant association was found in self-reported weight
gain between patients with PF and control participants.36
Muscle strength
Three studies examined differences in muscle strength between
PF and controls.26 30 54 Plantar flexion peak torque measured
with isokinetic dynamometry was significantly less at speeds of
both 60° and 180°/s in PF cases compared to control partici-
pants.54 Calf muscle endurance was significantly greater in the
PF group compared to controls.26 A significantly lower toe
flexor muscle strength was also found in the symptomatic feet
of people with PF compared to control participants.30
Flexibility
Hamstring muscle flexibility
Three studies examined muscle flexibility of the ham-
strings.28 45 55 Two studies reported a significant contracture of
the hamstrings muscles in patients with PF compared to con-
trols,45 55 and people with PF had a smaller straight leg eleva-
tion than control participants;45 both measures indicate less
flexibility in the hamstring muscles of patients with PF.

Factors associated with PF Flexibility of the ankle

Clinical factors
Body mass index
BMI was reported in 28 studies, with 7 excluded from analysis
for applying matching for BMI (see online supplementary
file 3). Of the remaining 21 studies, BMI was measured as a
continuous variable in 19 studies and as dichotomous variable
in 2 studies.4 52 A significantly higher BMI was found in the PF
group compared to the control group ( pooled MD 2.3 kg/m2
(95% CI 1.3 to 3.2)) (figure 2). For the pooled dichotomous
data, a positive association between PF and overweight (BMI
van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695
Differences in flexibility of the ankle joint between patients with
PF and controls were examined in six studies.4 26 28 38 45 54
Two studies reported significantly lower non-weight bearing
(NWB) passive ankle dorsal flexion (DF) range of motion
(ROM).4 45 Two studies assessing athletes found no significant
difference in DF ROM when compared to controls, although
Messier and Pittala28 reported a significant increase in total
sagittal ROM in cases (MD 7.09° (95% CI 5.88 to 8.30)).38 In
a community sample, Irving et al26 reported greater ankle
mobility (MD 4.6° (95% CI 2.48 to 6.72)), which was not
3
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Table 2 Quality assessment of included studies (n=51)

Methodological quality

Number Author, year of publication 1 2 3 4 5 6 7 8 9 Total score Per cent

1 Abdel-Wahab, 2008 0 0 0 0 0 1 0 0 0 1 11
2 Akfirat, 2003 0 0 0 0 0 1 1 0 0 2 22
3 Allen, 2003 1 1 0 1 1 1 1 1 1 8 89
4 Alvarez, 2000 1 1 1 1 1 1 1 1 0 8 89
5 Berkowitz, 1991 0 1 0 0 1 1 1 0 0 4 44
6 Bolivar, 2013 0 1 1 1 1 1 1 1 1 8 89
7 Bygrave, 1998 1 0 0 1 0 0 1 0 0 3 33
8 Cardinal, 1996 0 ? 0 1 1 1 1 0 0 4 44
9 Cetin, 2001 1 0 0 1 1 0 1 1 0 5 56
10 Chen, 2013 1 0 0 1 1 1 1 1 1 7 78
11 Chundru, 2008 0 0 1 0 1 1 1 0 1 5 56
12 Creighton, 1987 0 ? 0 0 1 1 1 0 0 3 33
13 Di Caprio, 2010 0 ? 1 1 0 0 1 0 1 4 44
14 Fabrikant, 2011 0 1 0 1 1 1 1 1 0 6 67
15 Genc, 2005 1 1 0 1 1 1 1 1 1 8 89
16 Gibbon, 1999 0 0 1 1 1 0 0 0 0 3 33
17 Harty, 2005 0 1 0 0 1 1 0 0 0 3 33
18 Irving, 2007 1 1 1 1 1 1 1 1 1 9 100
19 Janchai, 2008 0 ? 0 0 1 1 1 0 0 3 33
20 Johal, 2012 0 1 0 0 1 1 1 0 0 4 44
21 Kamel, 2000 0 1 0 0 1 1 0 0 0 3 33
22 Karabay, 2007 0 ? 0 0 0 0 1 0 0 1 11
23 Kibler, 1991 0 1 0 1 1 0 0 0 0 3 33
24 McMillan, 2013 1 1 0 1 1 1 1 1 1 8 89
25 Messier, 1988 0 ? 0 0 0 0 1 0 0 1 11
26 Osborne, 2006 0 0 0 1 1 1 1 0 0 4 44
27 Ozdemir, 2005 0 0 0 0 1 1 1 0 0 3 33
28 Oztuna, 2002 1 1 0 1 1 1 1 1 1 8 89
29 Prichasuk, 1994 0 0 1 1 1 1 1 1 0 6 67
30 Rano, 2001 1 0 1 1 1 1 1 0 0 6 67
31 Ribeiro, 2011 1 0 0 1 1 1 1 1 0 6 67
32 Riddle, 2003 1 1 1 1 1 1 1 1 1 9 100
33 Rome, 2001—A 1 ? 0 1 1 1 1 0 0 5 56
34 Rome, 2001—B 0 0 0 1 1 1 1 1 0 5 56
35 Rome, 2002 0 0 0 1 1 1 1 1 1 6 67
36 Sabir, 2005 0 1 1 0 1 1 1 1 1 7 78
37 Sadat, 1998 0 0 1 0 1 1 1 0 0 4 44
38 Sahin, 2010 0 1 0 1 1 1 1 1 0 6 67
39 Sconfienza, 2013 0 1 1 1 1 1 1 1 1 8 89
40 Tsai, 2000 1 0 1 1 1 1 1 1 0 7 78
41 Turgut, 1999 0 1 1 1 1 1 0 1 1 7 78
42 Vohra, 2002 0 0 1 1 1 1 0 0 0 4 44
43 Wainwright, 1995 0 1 0 0 1 1 1 0 0 4 44
44 Wall, 1993 0 1 0 1 1 1 1 1 1 7 78
45 Walther, 2004 0 ? 0 1 1 0 1 0 0 3 33
46 Wearing, 2004 1 1 0 1 1 1 1 1 1 8 89
47 Wearing, 2007 1 1 0 1 1 1 1 1 1 8 89
48 Wearing, 2010 1 1 0 1 1 1 1 1 1 8 89
49 Werner, 2010 1 0 0 0 1 0 1 1 1 5 56
50 Williams, 1987 0 0 0 1 1 0 0 0 0 2 22
51 Wu, 2011 0 1 0 1 1 1 1 1 0 6 67
1, positive; 0, negative; ?, unclear.

significant after multivariate analysis. A sixth study presented Flexibility of the first metatarsophalangeal joint
case-–ontrol data from a young (mean age 31) athletic popula- Three studies reported on the ROM of the first metatarsopha-
tion demonstrating significantly lower ankle dorsiflexion (see langeal (MTP) joint.30 42 56 Pooling was possible for two studies
online supplementary file 2).54 reporting on NWB passive extension of the first MTP and no

4 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695

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Figure 2 Forest plot on association plantar fasciopathy and body mass index (continuously measured).

significant difference was found between the groups (MD
−10.73 (95% CI −30.96 to 9.49), figure 4).30 56 However, a
significantly smaller ROM in the PF group was reported in a
single study for active extension, passive flexion and active
flexion (see online supplementary file 3).56 Furthermore, MTP
mobility assessed dynamically during gait with video fluoros-
copy was found to be lower in extension in PF cases.42
reduced sagittal arch angle change between NWB and WB (indi-
cating greater arch stiffness) on X-ray.26 48 58 No significant
associations were found for other types of measurements regard-
ing foot posture.8 28 30 31 37 38 40 57 Static measures of leg align-
ment beyond the significant findings of Di Caprio yielded
non-significant associations with a measure of ‘Q angle’ and
lower limb length discrepancy.28

Posture and alignment Dynamics

Measurements of static foot posture and lower limb alignment
were reported in 11 studies.8 26 28 30 31 37 38 40 48 57 58
Significant findings for foot posture in non-athletic groups
include a more pronated foot posture (Foot Posture Index, MD
1.3 (95% CI 0.42 to 2.18)), a lower sagittal plane calcaneal
pitch on X-ray (MD −4.55° (95% CI −5.62 to −3.48)) and
Three studies examining eight variables reported on kinematic
factors.8 28 42 Messier and Pittala28 reported significant findings
in an athletic population for maximum pronation ROM (°),
maximum pronation velocity (°/s), time to maximum pronation
(ms) and total rear foot movement (°) while running at their
‘average training pace’. Under video fluoroscopy for overground

Figure 3 Forest plot on association plantar fasciopathy and body mass index >27 kg/m2.
van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695 5
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Figure 4 Forest plot on association plantar fasciopathy and passive extension of the first metatarsophalangeal joint (degrees).

walking, no significant difference in stance phase duration,
maximum arch angle or change in arch angle from heel strike to
mid-stance was recorded between participants with and without
PF.42 ‘Abnormal forefoot pronation’ assessed visually in gait was
found to be significantly associated with PF in an occupational
setting.8
Kinetic factors
Four studies examined kinetic factors describing seven vari-
ables.6 8 40 41 The energy dissipation properties of the plantar
fat pad and maximum heel pad stiffness (N/mm) were lower in
PF, whereas peak stress, peak strain and the stress-strain ratio at
the point of peak stress were not associated with the presence of
PF.6 41 Werner et al8 reported a significantly higher metatarsal
pressure (lbs/inch2) in pressure mat gait assessments. Other pres-
sure mat assessments showed no significant differences.40
IMAGING FACTORS
Plantar fascia
Twenty-four studies described characteristics of the plantar
fascia with pooling possible for five variables. Twenty-one
studies described the association between PFT and
PF,27 29 32 34 39 40 43 44 47 49 53 59–68 nine of which applied
matching for possible confounding factors such as age,
gender and body weight (see online supplementary
file 2).34 40 44 47 49 60 62 63 66
PFT was measured using MRI, ultrasound (US) and X-ray.
Pooled data for all imaging techniques from 19 studies showed
that people with PF had an average 2.32 mm (95% CI 1.86 to
2.79) thicker plantar fascia compared to control participants
(MD of (figure 5).27 29 32 34 39 40 43 44 49 59–68 Subgroup ana-
lyses for the separate imaging techniques showed a MD of 2.20
(95% CI 1.68 to 2.72) for US, 3.36 (95% CI 1.81 to 4.90) for
MRI and 2.40 (95% CI 1.88 to 2.92) for X-ray. Similar trends
were seen in the two studies in which pooling was not pos-
sible.47 53 Five studies applied a dichotomous cut-off value (4
and 4.5 mm) for the PFT.39 44 61 66 51 Pooling of these results
produced an OR of 95 (95% CI 11 to 797) in favour of the PF
group (figure 6).39 44 51 61 66
Six studies described the association between hypoechogeni-
city—qualitative changes in the echogenicity of the plantar
fascia on US examination—and PF.34 39 47 51 61 67
Hypoechogenicity was significantly more frequent in people
with PF than healthy controls (OR 150 (95% CI 38 to 593),
figure 7). In addition, pooled data of two studies showed a sig-
nificantly larger number of patients with perifascial fluid collec-
tion compared to control participants (OR 12.2 (95% CI 1.5 to
103), figure 8).59 67

Figure 5 Forest plot on association plantar fasciopathy and plantar fascia thickness (in mm, all imaging techniques).
6 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695

Figure 6 Forest plot on association plantar fasciopathy and plantar fascia thicker than 4 mm (dichotomous).
Three studies described vascular signal within the plantar
fascia.43 44 67 Pooling was possible for the presence of hyper-
aemia, the radiologists subjective opinion of greater than normal
blood flow through the plantar fascia, in people with PF and
controls. An OR of 8.2 (95% CI 2.2 to 30.6) was found in
favour of the PF group (figure 9).44 67 The third study measured
a vascularity index, a quantitative measurement of plantar
fascial blood flow, and similarly found a small but statistically
significant increase in vascular signal in people with PF com-
pared to controls.43
Six studies described eight other characteristics of the plantar
fascia.41 51 58 59 67 68 One study found a positive association
between a shorter plantar fascia and a reduced length and PF.58
One study reported a greater maximum PFT within 3 cm from
the calcaneus in people with PF compared to controls.32 One
study reported significantly more people with PF with blurring
of the superficial and deep borders of the plantar fascia than
controls.51 One study found an association between increased
biconvexity and PF.59
Two studies undertook sonoelastographic assessment of the
plantar fascia and identified a softer PF and less elastic plantar
fascia in PF participants compared to controls ( p<0.001).51 68
No significant associations were found among the other studied
variables.41 59
Heel pad
Nine studies described characteristics of the heel fat pad
0.6 27 31 32 39 49 60 64 69 Pooling was possible for loaded and
unloaded heel pad thickness measured by either MRI or US. In
pooled data, both unloaded and loaded heel pad thickness
was significantly greater in patients with PF compared to con-
trols (5 studies, MD 0.81 mm (95% CI 0.11 to 1.51) (figure 10)
and two studies, MD 1.05 mm (95% CI 0.26 to 1.84) (figure
11) for unloaded and loaded heel pad thickness,
respectively).27 31 32 39 49 69
Figure 7 Forest plot on association plantar fasciopathy and hypoechogenicity of plantar fascia.
van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695
Review
Two studies described the compressibility of the heel pad
using radiography and US. One study examined the difference
in heel fat pad thickness between an unloaded and body weight
loaded state, and demonstrated greater compressibility in people
with PF than controls (MD 0.70 mm (95% CI 0.16 to 1.24))
while the other study found no significant difference between
the groups.31 32 In addition, unclear demarcation of the triangu-
lar fat pad deep to the plantar fascia origin was more frequently
seen in people with PF.64 No association was found between the
presence of subcutaneous fibrous septa and PF.60
Calcaneus
The presence of a calcaneal spur (CS) was examined in 11
studies.31 33 47 48 52 59 60 64 70–72 Six studies matched for age
and gender.47 52 60 70–72 Pooling showed that CS were signifi-
cantly more common in patients with PF than controls (OR
8.21 (95% CI 4.32 to 15.62), figure 12).
Two studies examined Tc-99 uptake in the subcalcaneal
region, indicating metabolic bone activity;33 72 higher uptake of
Tc-99 was significantly more common in patients with PF com-
pared to controls (OR 130.52 (95% CI 16.87 to 1009.72),
figure 13). In one study, a positive association between cortical
irregularity at the plantar fascia origin and PF (OR 7.22 (95%
CI 2.59 to 20.14)) was found. One study found an increased
spur length and spur grade in people with PF compared to
control participants (MD 1.51 and 0.63, respectively).70 No sig-
nificant associations were found among the other studied
variables.47 64
Plantar nerve
One age-matched and BMI-matched study reported a strong
association between PF and abnormal values in nerve conduc-
tion velocity of the medial and lateral plantar nerves (OR
263.57 (95% CI 12.82 to 5417)).35 Abductor digiti minimi
atrophy on MRI, a late-stage marker of lateral plantar nerve
7
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Figure 8 Forest plot on association plantar fasciopathy and perifascial fluid collection.

injury (‘Baxter’s neuropathy’), was also associated with a diag- Footwear

nosis of PF (OR 3.35 (95% CI 1.31 to 8.56)).46
OTHER FACTORS
Activity level
Four studies reported on standing time.4 8 31 33 People with
increased occupational standing time on hard surfaces (OR 1.3
(95% CI 1.1 to 1.6)) and those who spent the majority of their
workday on their feet were more likely to have PF (OR 3.6
(95% CI 1.3 to 10.1)).4 8 No association was found with daily
standing time or having a standing job.31 33
Five other occupational-related variables were examined in
two studies.8 26 The percentage time spent walking at work, the
number of truck entrance/exits and a moderate tenure (11–
20 years) were significantly associated with PF.8 26
An analysis of physical activity in two studies including recre-
ational and competitive athletic activity yielded mixed find-
ings.4 36 Undertaking no regular exercise was associated with an
increased prevalence (OR 3.64 (95% CI 1.62 to 8.19) while
physical activity three times a week for more than 20 min was
associated with decreased prevalence of PF (OR 0.33 (95% CI
0.14 to 0.74)).4 36 Self-reporting as a recreational jogger was
not associated with PF.
In an occupational setting, more frequent shoe rotation was
negatively associated with PF (OR 0.3 (95% CI 0.1 to 0.7)).8
No association was found with flat shoe use and PF.31
Sensitivity and subgroup analyses and publication bias
There was substantial heterogeneity in pooled analyses for PFT,
plantar fascia hypoechogenicity, unloaded heel pad thickness,
presence of CS, BMI and passive extension of the first MTP
joint (figures 2, 4, 7, 9, 11 and 13, respectively).
A significant interaction was noted for the presence of a CS
and age, with a larger effect size for older (>50 years, OR
23.47 (95% CI 9.45 to 58.30)) compared to younger partici-
pants (<50 years, OR 5.78 (95% CI 2.51 to 13.31)), ( p=0.03).
PFT by US yielded significantly different effect sizes for sub-
groups based on the unit of analysis; by heels (MD 1.80 (95%
CI 1.08 to 2.52)) and participant (2.63 (95% CI 2.40 to 2.85)),
(p=0.03). The overall effect size for PFT meta-analysis was
unchanged when a sensitivity analysis was performed assessing
the potential impact of clustering, that is, testing the assumption
that use of two feet from the same participant was more (intra-
class correlation coefficient, ICC=0.8) or less (ICC=0.5)
related. The funnel plots for BMI and PFT but not CS are

Figure 9 Forest plot on association plantar fasciopathy and hyperaemia of the plantar fascia.
8 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695

Figure 10 Forest plot on association plantar fasciopathy and unloaded heel pad thickness (mm).
suggestive of publication bias (see online supplementary file 4).
However, effect sizes using random-effect and fixed effects
models for BMI, PFT and CS are similar.
DISCUSSION
Summary of findings
This review presents a comprehensive appraisal of the evidence
for clinical and imaging factors in PF. From 51 papers, 12 vari-
ables were considered sufficiently comparable to group for
meta-analysis. Consistent poolable imaging findings included a
thickened, hypoechoic plantar fascia and the presence of a sub-
calcaneal spur.
The strongest clinical association was for BMI and there was
some consistency for reduced hamstring flexibility, but overall,
the evidence supporting associations for ankle and first MTP
ROM, muscle strength, kinematic and kinetic factors, foot
posture and physical activity levels was either inconsistent or
inconclusive.
Weight status and patient subgroups
The presence of subgroups within the spectrum of PF might
partly explain the findings of this review. One subgroup could
relate to symptom duration. Increased vascular signal, some-
times referred to as hyperaemia, is an established finding in ten-
dinopathy.73 It would appear that PF has similar presentation to
other tendinopathies; however, we were unable to explore this
further with subgrouping based on disease duration.
Figure 11 Forest plot on association plantar fasciopathy and loaded heel pad thickness (mm).
van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695
Review
The association with BMI appears consistent for participants
in a non-athletic setting. The association between BMI and mus-
culoskeletal symptoms is widely recognised.74 Increased mech-
anical load due to higher BMI is a plausible source of increased
plantar fascial stress. However, both incident and prevalent foot
pain is more strongly associated with fat mass rather than fat
free mass, and therefore adiposity related inflammatory mechan-
isms might play a role.74 75 The lack of association of BMI in
the only prospective study testing an athletic cohort challenges
the notion a high BMI applies to all PF populations and indi-
cates that athletic populations may represent a distinct subgroup
of people with PF.9 While raw BMI data were not provided for
PF cases in the study of Di Caprio et al,9 which precluded ana-
lysis of the role of BMI, the relatively low mean BMI of
<20.6 kg/m2 in 55% of all included participants might indicate
that BMI may be a less important variable in athletic popula-
tions. The lack of other clinical associations does not mean that
they do not play a role in the disease pathway, that is, this might
be caused by a lack of power. Thus, while we report on many
associations, where these sit in the aetiological and disease
pathway is often unclear.
There appears to be two distinct populations affected by PF—
athletes and more sedentary individuals with a relatively high
BMI. The association with BMI, although based on a single
study, seems less evident in athletic populations compared to
populations with a higher BMI. Loading of the plantar fascia
has proved a difficult factor to capture in the studies under
9
 Review

Figure 12 Forest plot on association plantar fasciopathy and presence of a calcaneal spur.

investigation and therefore, not reported on. However, loading however, sensitivity analyses comparing random-effect and fixed
might play a role in both proposed distinct patient populations: effects models suggest that the results were not unduly influ-
both athletes and sedentary populations with a high BMI might enced by small study effects.
exceed a threshold of loading, though caused by different The quality of included studies varied widely (11–100%), and
mechanisms. However, both the inflammatory mechanisms as no less weight was given to studies with a high risk of bias.
well as mechanical mechanisms are likely to play a role in the Whether measures were assessed in a blinded fashion was not
disease pathway in both proposed distinct populations exercise- assessed in our quality score so we cannot assess whether selec-
loading strategies.12 76 tion or observer bias influenced the results. Sensitivity analyses
where meta-analyses were repeated in the above and below
median quality scores showed that study quality did not materi-
Imaging
ally affect effect sizes or our conclusions.
The association between a thickened, hypoechoic plantar fascia
Statistical heterogeneity was seen in some pooled results
and PF is well established. Histopathological changes in the
which might partly be explained by differences in design and
plantar fascia taken from surgical biopsy confirm a range of
participants, including setting, age, gender, BMI and activity
degenerative processes resulting in collagen breakdown, fibro-
levels. However, the number of studies allowed only limited
cyte cell population changes (including death), matrix degrad-
exploration of heterogeneity. Of the variables examined, only
ation and vascular ingrowth, and these appear to represent a
the unit of analysis explained any meaningful degree of hetero-
similar process observed in the tendinopathy continuum.5 77 78
geneity. Inclusion criteria were all based on a clinical definition
It is likely that these processes, along with more acute fluid shift
of PF. It is possible that some cases had heel pain from causes
events, explain these imaging findings. The average thickness of
other than the plantar fascia, which might reduce the apparent
the asymptomatic plantar fascia has been documented at
effect sizes for some factors.
3.5 mm and in this context, the identified effect size of
Finally, with just a single prospective study included in this
2.31 mm in this review is likely to be clinically relevant (ie,
report, most factors identified are based on cross-sectional and
66% increase).79 However, as PFT can also vary with BMI and
case–control observations and preclude a statement regarding
is a target in metabolic diseases, such as diabetes mellitus,
cause or effect.
such diagnostic cut-off points should be viewed with caution,
and comparison should at least be made between affected and
non-affected sides.80 81 However, as US is a sensitive test to
assess PF morphology, the absence of thickening should cer-
tainly raise the possibility of there being alternative sources of
pain.
What are the findings?
Despite the debate about the role of heel spurs in PF, the
presence of a CS is strongly associated with PF both in our own
and in a previous review.21 The role of CS in relation to the ▸ Body mass index was consistently associated with plantar
pathological process of PF is questioned, since these have rela- fasciopathy, though the mechanism for this remains
tively high prevalence in the general population, and increasing uncertain, and may differ in athletic versus non-athletic
age, osteoarthritis and obesity are associated with enthesophyte study populations.
formation.82 83 The causal role of the CS in generating a pain ▸ In addition to the known associations with increased plantar
state is not clear although sensitive neurovascular structures pass fascia thickness, hypoechogenicity and subcalcaneal spurs,
between this and the potentially similarly enlarged plantar we found evidence for an association between the presence
fascia, creating a space occupying (Baxter’s) lesion.46 of PF and increased vascular signal within the plantar fascia
and to a lesser extent, markers of nerve injury.
▸ We examined a wide range of potential clinical measures,
Strengths and limitations
though there is insufficient data to yet judge which of these
Visual inspection of funnel plots for the outcomes of PFT, CS
are likely to be aetiological or of clinical importance.
and BMI suggests there is potential for publication bias;

Figure 13 Forest plot on association plantar fasciopathy and increased uptake of Tc-99 in the subcalcaneal region.
10 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695

How might it impact on clinical practice in the future?
Weight loss might play a role in future plantar fasciopathy
treatment, though feasibility and effectiveness should be
investigated in future studies.
Contributors All four authors collaborated to provide the concept and focus for
this review, have approved the manuscript, and agreed to be accountable for all
aspects of the work. KDBvL, JR, TW and MvM designed the protocol and the search
strategy which was executed by KDBvL. KDBvL and JR screened the initial results
and extracted data from the primary studies. KDBvL drafted the original manuscript
which was then critically revised by MvM, JR and TW.
Funding Dutch Arthritis Foundation
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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12 van Leeuwen KDB, et al. Br J Sports Med 2015;0:1–12. doi:10.1136/bjsports-2015-094695