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Background: Plantar fasciitis (PF) and Achilles tendinopathy (AT) are common injuries that primarily affect people engaged in sport or occupational weightbearing activities. Identifying modifiable risk factors is important for the treatment and prevention of these injuries. The purpose of this study was to evaluate whether foot posture or ankle dorsiflexion are risk factors for developing AT or PF, and if there were any differences between PF and AT patients., Methods: This was a case-control study of 108 patients with PF and 114 patients with AT, compared to the same number of referred patients in 2 control groups never having had these injuries, matched for sex, age, body mass index (BMI), sport, and occupational weightbearing activities. Included patients were 20-65 years with ultrasonographic-verified PF or midsubstance AT. Foot posture was assessed using Foot Posture Index (FPI) classifying the feet into 3 categories: FPI 0-5 normal foot, 6-12 hyperpronated, <0 hypopronated. Ankle dorsiflexion was measured with a goniometer in weightbearing with straight and bent knee., Results: Abnormal foot posture was associated with an increased risk for sustaining both AT (odds ratio [OR] 3.4-4.1) and PF (OR 3.2-3.8). Hyperpronation being the major reason for this association with ORs 5.4-5.5 compared with hypopronation with ORs 2.6-2.9. However, decreased dorsiflexion was not a risk factor: instead, there was an increased ankle dorsiflexion in patients with AT or PF compared with their control groups. Comparison between PF and AT patients demonstrated that PF affected mostly women, and AT mostly men, PF patients were 2.4 years (CI 0.2-4.5) younger, and had 25% more occupational weightbearing than AT patients. However, no differences in BMI or weightbearing physical activity was demonstrated., Conclusion: Hypopronation and hyperpronation but not limited ankle dorsiflexion was associated with increased risk for AT or PF., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Given the prevalence of plantar fasciitis (PF) among middle-aged women, we investigated the immediate impact of custom foot orthoses (CFO) on pain and static and dynamic postural balance, addressing a critical gap in understanding the potential benefits of CFO in managing PF-related pain and postural instability. Nine middle-aged women with PF and obesity were evaluated for pain levels and center of pressure (CoP) values in bipedal, unipedal with a non-affected foot, and unipedal with an affected foot on the Timed Up and Go (TUG) test, while they were barefoot, wearing standard insoles (SI), and wearing CFO. We found that CFO significantly and immediately reduced pain ( p < .01) improved CoP values ( p < .01) in the unipedal stance with the affected foot, and enhanced TUG test scores ( p < .001). The results demonstrated a significant ( p < .01) improvement in CoP area values and TUG test scores with CFO, compared to SI. These findings underscore the immediate benefits of CFO in alleviating pain and improving postural balance in obese middle-aged women with PF, highlighting their potential as a valuable intervention., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Plantar fasciitis is a major cause of heel pain, resulting from repetitive trauma to the plantar fascia and leading to structural changes within the fascia. It has been observed that plantar fascia thickness in plantar fasciitis patients exceeds that of normal individuals. However, the biomechanical properties of the plantar fascia in patients with plantar fasciitis remain unclear. Therefore, this study aimed to compare plantar fascia stiffness between healthy individuals and patients with plantar fasciitis across different areas., Methods: Fifty-eight participants were divided into 2 groups: 29 healthy individuals and 29 individuals with plantar fasciitis. B-mode ultrasonography was used to assess plantar fascia thickness, whereas shear wave elastography was employed to measure plantar fascia stiffness. The study focused on 3 distinct areas: calcaneal insertion, 1-cm distal area, and 2-cm distal area. Additionally, the most painful area reported by patients was marked in the plantar fasciitis group., Results: The findings showed that the plantar fasciitis group exhibited significantly greater plantar fascia stiffness in almost all areas compared to the healthy group ( P  < .05). Moreover, the stiffness of the plantar fascia in the most painful area demonstrated the highest value compared with other areas within the plantar fasciitis group ( P  < .05)., Conclusion: This study suggests structural and mechanical changes in the plantar fascia in patients with plantar fasciitis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Tanwarat Thanwisate, MS, reports support for the present manuscript from Siriraj Graduate Scholarship of the Faculty of Medicine, Siriraj Hospital, Mahidol University. Bavornrit Chuckpaiwong, MD, reports support for the present manuscript from Siriraj Research Fund of the Faculty of Medicine, Siriraj Hospital, Mahidol University (R016333046). Disclosure forms for all authors are available online.

Introduction: Plantar fasciopathy is a common foot-related musculoskeletal disorder. It has been hypothesized that this disorder could be linked to a dysfunctional windlass mechanism. However, no study to date has quantified this link to validate or refute this hypothesis. The first metatarsophalangeal joint (1st MPJ) dorsiflexion resistance test is a reliable test to evaluate the force required to initiate the windlass mechanism. Comparing the results of this test in individuals with and without plantar fasciopathy will allow for a better understanding of the relationship between plantar fasciopathy and the windlass mechanism. Thus, this study aimed to compare 1st MPJ dorsiflexion resistance in individuals with plantar fasciopathy and healthy controls. Additionally, this study aimed to explore the correlations between 1st MPJ dorsiflexion resistance and other commonly used foot orthopedic tests, specifically the supination resistance test and the Foot Posture Index., Material and Methods: Twenty participants with plantar fasciopathy and 20 healthy controls were recruited in this case-control study. First MPJ dorsiflexion resistance was quantified and compared between groups and between feet using a repeated measures ANOVA with one within-subject factor with two levels and one between-subject factor with two levels. It was also correlated with supination resistance and the Foot Posture Index., Results: There were no significant differences in 1st MPJ dorsiflexion resistance between injured and healthy feet as well as control and plantar fasciopathy groups. There was a moderate to strong correlation (r = 0.674 to 0.891) between 1st MPJ dorsiflexion resistance and supination resistance in both groups. There was no significant correlation between 1st MPJ dorsiflexion resistance and the Foot Posture Index., Conclusions: The lack of alterations in 1st MPJ dorsiflexion resistance among individuals with plantar fasciopathy implies a potential need to reconsider the biomechanical model, proposing that a dysfunctional windlass mechanism is associated with the development of plantar fasciopathy, may need reconsideration., Competing Interests: Declaration of Competing Interest We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property. associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We further confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. We understand that the Corresponding Author is the sole contact for the Editorial process. (including Editorial Manager and direct communications with the office). He is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author and which has been configured to accept email from gabriel.moisan@uqtr.ca., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

[Purpose] The purpose of this study was to compare the effectiveness of the Structural Diagnosis and Management (SDM) approach with Myofascial Release (MFR) in improving plantar heel pain, ankle range of motion, and disability. [Subjects] Sixty-four subjects, aged 30-60 years, with a diagnosis of plantar heel pain, plantar fasciitis, or calcaneal spur by a physician according to ICD-10, were equally allocated to the MFR ( n  = 32) and SDM ( n  = 32) groups by hospital randomization and concealed allocation. [Methods] In this assessor-blinded randomized clinical trial, the control group performed MFR to the plantar surface of the foot, triceps surae, and deep posterior compartment calf muscles, while the experimental group performed a multimodal approach utilizing the SDM concept for 12 sessions over 4 weeks. Both groups also received strengthening exercises, ice compression, and ultrasound therapy. Pain, activity limitations and disability were assessed as primary outcomes using the Foot Function Index (FFI) and Range of motion (ROM) assessment of the ankle dorsiflexors and plantar flexors using a universal goniometer. Secondary outcomes were measured using the Foot Ankle Disability Index (FADI) and a 10-point manual muscle testing process for the ankle dorsiflexors and plantar flexors. [Results] Both MFR and SDM groups exhibited significant improvements from baseline in all outcome variables, including pain, activity level, disability, range of motion, and function after the 12-week intervention period ( p  < .05). The SDM group showed more improvements than MFR for FFI pain ( p  < .01), FFI activity ( p  < .01), FFI ( p  < .01) and FADI ( p  = <.01). [Conclusion] Both MFR and SDM approaches are effective in reducing pain, improving function, ankle range of motion, and reducing disability in plantar heel pain, however, the SDM approach may be a preferred treatment option.

Background and Objectives: Treatment of chronic plantar fasciitis is challenging given that there are various of available treatment options with no clear gold standard. The aim of the study was to examine the dose-escalation effect of rESWT on the biomechanical parameters of the plantar fascia and pain ailments. Materials and Methods: In the experimental group ( n = 30), the intensity of the shock wave was increased every two subsequent treatment sessions. In the control group ( n = 32), the treatment parameters were not changed. In both groups, six treatments were performed, with two treatment sessions a week. In order to assess the biomechanical parameters of the plantar fascia, myotonometric measurements were performed. The pain intensity was assessed using the Visual Analog Scale (VAS). Results: The tension of the plantar fascia attachment in the experimental group decreased from 27.69 ± 2.06 [Hz] before treatment to 26.29 ± 1.69 [Hz] after treatment ( p = 0.009) and to 26.03 ± 2.15 [Hz] 1 month after the beginning of treatment ( p = 0.003). In the control group, the frequency results did not change significantly ( p > 0.05). Flexibility increased in both groups. The test results before treatment and 1 month after the beginning of the treatment showed statistical significance in the experimental group ( p = 0.001) vs. ( p = 0.002) in the control group. The differences were not statistically significant between groups ( p > 0.05). The assessment of pain intensity carried out 1 month after the end of treatment in the experimental group amounted to 3.14 ± 2.28 points, which was statistically significantly lower compared to that in the control group, where it amounted to 5.14 ± 1.92 points. ( p < 0.001). Conclusions: The use of rESWT performed with an increasing intensity of impact during subsequent treatment procedures demonstrated greater effectiveness in improving the biomechanical parameters of the plantar fascia and was also more effective in reducing the pain ailments. Our results are encouraging. The dose escalation in the treatment cycle is worth considering. To prove that this method of treatment is more effective, a randomized controlled trial should be carried out on a representative sample.

Purpose: A fundamental understanding of plantar pressure distribution is important for prescribing an appropriate orthosis and applying nonoperative methods, such as stretching exercises, for the treatment of plantar fasciitis. Despite existing research on plantar pressure distribution, discrepancies between affected and unaffected sides in unilateral plantar fasciitis patients warrant further investigation. This study aimed to evaluate the plantar pressure distribution in patients with unilateral plantar fasciitis by comparing it with that on the contralateral unaffected side., Methods: We retrospectively reviewed records from 20 consecutive patients diagnosed with unilateral plantar fasciitis, using the unaffected side as the control. The emed ® pedobarographic system was used to measure the plantar pressure distribution during gait. The analysis was performed using a 4-mask configuration (toes, forefoot, midfoot, and hindfoot)., Results: Both sides showed no significant differences in radiographic parameters. The affected side showed a significantly higher contact area, maximum force, and force-time integrals in the midfoot. However, the unaffected side demonstrated significantly higher maximum force and force-time integrals in the hindfoot. There was no difference in the distribution of the peak pressure and pressure-time integrals between the two sides in all mask regions. The increased contact area and maximum force in the midfoot on the side with plantar fasciitis may result from heel pain-induced weight transfer from the hindfoot., Conclusion: The findings of this study provide a basic understanding of plantar pressure distribution in the treatment of plantar fasciitis and highlight the importance of considering inter-side differences when designing treatment interventions or orthotic devices., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Chronic plantar heel pain (CPHP) is associated with calcaneal bone spurs, but its associations with other calcaneal bone features are unknown. This study therefore aimed to determine associations between having CPHP and bone density and microarchitecture of the calcaneus. We assessed 220 participants with CPHP and 100 age- and sex-matched population-based controls. Trabecular bone density, thickness, separation and number, BV/TV, and cortical density, thickness and area were measured using a Scanco Xtreme1 HR-pQCT scanner at a plantar and mid-calcaneal site. Clinical, physical activity and disease history data were also collected. Associations with bone outcomes were assessed using multivariable linear regression adjusting for age, sex, physical activity, BMI and ankle plantarflexor strength. We assessed for potential effect modification of CPHP on these covariates using interaction terms. There were univariable associations at the plantar calcaneus where higher trabecular bone density, BV/TV and thickness and lower trabecular separation were associated with CPHP. In multivariable models, having CPHP was not independently associated with any bone outcome, but modified associations of BMI and ankle plantarflexor strength with mid-calcaneal and plantar bone outcomes respectively. Beneficial associations of BMI with mid-calcaneal trabecular density (BMI-case interaction standardised X/unstandardised Y beta -10.8(mgHA/cm3) (se 4.6), thickness -0.002(mm) (se 0.001) and BV/TV -0.009(%) (se 0.004) were reduced in people with CPHP. Beneficial associations of ankle plantarflexor strength with plantar trabecular density (ankle plantarflexor strength -case interaction -11.9(mgHA/cm3) (se 4.4)), thickness -0.003(mm) (se 0.001), separation -0.003(mm) (se 0.001) and BV/TV -0.010(%) (se 0.004) were also reduced. CPHP may have consequences for calcaneal bone density and microarchitecture by modifying associations of BMI and ankle plantarflexor strength with calcaneal bone outcomes. The reasons for these case-control differences are uncertain but could include a bone response to entheseal stress, altered loading habits and/or pain mechanisms. Confirmation with longitudinal study is required., Competing Interests: Competing interests: Jason Rogers is a Director and employee of Allcare Physiotherapy Tasmania, which provided funding support to conduct this study. No other author reports an affiliation or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Funding bodies had no involvement in the design, implementation, analysis nor reporting of this study.

Pes cavus is a complicated, multiplanar deformity that requires a thorough understanding in order to provide the appropriate level of care. The foot and ankle surgeon should perform a comprehensive examination, including a neurologic evaluation, in the workup of this patient population. Understanding the cause of the patient's deformity is a critical step in predicting the disease course as well as the most acceptable form of treatment. The surgical correlation with the patient's pathologic anatomy requires an in-depth clinical evaluation, in addition to the radiographic findings, as the radiographic findings do not necessarily correlate with the patient's discomfort., Competing Interests: Disclosure Dr A.M. Jacobs has nothing to disclose regarding this topic., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To evaluate the factors that influence gait by comparing lower extremity kinematics during the stance phase of the gait cycle between individuals with and without plantar fasciitis., Design: A cross-sectional study., Setting: Motion analysis research laboratory., Participants: Thirty subjects with plantar fasciitis and 30 aged-matched controls., Main Outcome Measure(s): Range of motion of the lower extremity and multi-segment foot during gait using a three-dimensional motion analysis system., Results: The plantar fasciitis group showed significant differences in motion in the multi-segment foot, ankle, knee, and hip from the control group during various subphases of the stance phase. Specifically, relative to the control group, the plantar fasciitis group had more rearfoot adduction, forefoot eversion, ankle abduction, and hip abduction. They also had less midfoot dorsiflexion, forefoot dorsiflexion, knee extension, knee external rotation, and hip extension (all Ps < 0.05)., Conclusions: Individuals with plantar fasciitis exhibited more flexibility in the ankle-foot complex and poorer quality of lower-extremity movement than the group that did not have plantar fasciitis. Thus, differences in structures in both the ankle-foot complex as well as those in the hip and knee joints appear to be associated with the presence of plantar fasciitis., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Gastrocnemius-soleus recession has been used to treat midfoot-forefoot overload syndrome and plantar fasciitis induced by equinus of the ankle joint. A controlled and selective amount of recession is imperative to maintain muscle strength and stability. The objective of this study was to conduct a parametric study to quantify the relationship between the level of recession and plantar fascia stress. A finite element model of the foot-ankle-shank complex was reconstructed from magnetic resonance and computed tomography images of a 63-year-old normal female. The model was validated by comparing modeled stresses to the measured plantar pressure distribution of the model participant during balanced standing. The midstance and push-off instants of walking stance were simulated with different levels and combinations of gastrocnemius-soleus recession resembled by different amounts of muscle forces. Halving the muscle forces at midstance reduced the average plantar fascia stress by a quarter while reducing two-third of the muscle forces at push-off reduced the average fascia stress by 18.2%. While the first ray of the plantar fascia experienced the largest stress among the five fasciae, the stress was reduced by 77.8% and 16.9% when the load was halved and reduced by two-third at midstance and push-off instants, respectively. Reduction in fascia stress implicates a lower risk of plantar fasciitis and other midfoot-forefoot overload syndromes. The outcome of this study can aid physicians to determine the amount of gastrocnemius-soleus recession towards patients with vdifferent levels of plantar fascia overstress. A detailed three-dimensional modelling on the plantar fascia is warranted in future study.

Context: Plantar fasciitis (PF) is a common condition in active individuals. The lack of agreement on PF etiology makes treatment challenging and highlights the importance of understanding risk factors for preventive efforts., Objective: The purpose of this systematic review and meta-analysis was to determine what factors may put physically active individuals at risk of developing PF., Data Sources: CENTRAL, CINAHL, EMBASE, Gray Lit, LILACS, MEDLINE (PubMed), ProQuest, Scopus, SPORTDiscus, and Web of Science were searched through April 2018 and updated in April 2020., Study Selection: Studies were included if they were original research investigating PF risk factors, compared physically active individuals with and without PF, were written in English, and were accessible as full-length, peer-reviewed articles., Study Design: Systematic review and meta-analysis., Level of Evidence: Level 3, because of inconsistent definitions and blinding used in the included observational studies., Data Extraction: Data on sample characteristics, study design and duration, groups, PF diagnosis, and risk factors were extracted. The methodological quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. When means and standard deviations of a particular risk factor were presented 2 or more times, that risk factor was included in the meta-analysis., Results: Sixteen studies were included in the systematic review and 11 risk factors in the meta-analysis. Increased plantarflexion range of motion (weighted mean difference [MD] = 7.04°; 95% CI, 5.88-8.19; P < 0.001), body mass index (MD = 2.13 kg/m 2 ; 95% CI, 1.40-2.86; P < 0.001; I 2 = 0.00%), and body mass (MD = 4.52 kg; 95% CI, 0.55-8.49; P = 0.026) were risk factors for PF., Conclusion: Interventions focused on addressing a greater degree of plantarflexion range of motion, body mass index, and body mass and their load on the force-absorbing plantar surface structures may be a good starting point in the prevention and treatment of active individuals with PF.

Human steady-state locomotion modes are symmetrical, leading to symmetric mechanical function of human feet in general; however, track distance running in a counterclockwise direction exposes the runner's feet to asymmetrical stress. This may induce asymmetrical adaptation in the runners' foot arch functions, but this has not been experimentally tested. Here, we show that the plantar fascia (PF), a primary structure of the foot arch elasticity, is stiffer for the left than the right foot as a characteristic of runners, via a cross-sectional study on 10 track distance runners and 10 untrained individuals. Shear wave velocity (index of tissue stiffness: SWV) and thickness of PF and foot dimensions were compared between sides and groups. Runners showed higher PF SWV in their left (9.4 ± 1.0 m/s) than right (8.9 ± 0.9 m/s) feet, whereas untrained individuals showed no bilateral differences (8.5 ± 1.5 m/s and 8.6 ± 1.7 m/s, respectively). Additionally, runners showed higher left to right (L/R) ratio of PF SWV than untrained men (105.1% and 97.7%, respectively). PF thickness and foot dimensions were not significantly different between sides or groups. These results demonstrate stiffer PF in the left feet of runners, which may reflect adaptation to their running-specific training that involves asymmetrical mechanical loading.

Background: Plantar heel pain (PHP) accounts for 11-15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study., Methods: Thirty-six people (19 females & 17 males; 20-63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures., Results: There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = - 0.31-0.25). Questionnaire reliability was good or excellent (ICC 2,1&#95;absolute )(ICC 0.86-0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces., Conclusion: Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible., Level of Evidence: IV.

Foot posture and ankle joint dorsiflexion have long been proposed to be risk factors for plantar heel pain, however body mass may be a confounder when investigating these factors. The aim of this study was to determine if clinical measures of foot posture and ankle joint dorsiflexion differ in adults with and without plantar heel pain after accounting for body mass. This was a cross-sectional observational study that compared 50 participants with plantar heel pain to 25 control participants without plantar heel pain who were matched for age, sex and body mass index. Foot posture was assessed using the Foot Posture Index and the Arch Index. Ankle joint dorsiflexion was assessed with a weightbearing lunge test with the knee extended and with the knee flexed. No significant differences (P < 0.05) were found between the groups for foot posture, whether measured with the Foot Posture Index or the Arch Index. Similarly, no significant differences were found in the weightbearing lunge test whether measured with the knee extended or with the knee flexed. Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain when body mass is accounted for. Therefore, clinicians should not focus exclusively on foot posture and ankle dorsiflexion and ignore the contribution of overweight or obesity.

Current treatments of plantar fasciitis are based on the premise that the Achilles tendon (AT) and plantar fascia (PF) are mechanically directly linked, which is an area of debate. The aim of this study was to assess the morphological relationship between the AT and PF. Nineteen cadaveric feet were x-ray imaged, serially sectioned and plastinated for digital image analyses. Measurements of the AT and PF thicknesses and cross-sectional areas (CSA) were performed at their calcaneal insertion. The fiber continuity was histologically assessed in representative subsamples. Strong correlations exist between the CSA of the AT and PF at calcaneal insertion and the CSA of PF's insertional length (r = 0.80), and between the CSAs of AT's and PF's insertional lengths. Further correlations were observed between AT and PF thicknesses (r = 0.62). This close morphological relationship could, however, not be confirmed through x-ray nor complete fiber continuity in histology. This study provides evidence for a morphometric relationship between the AT and PF, which suggests the presence of a functional relationship between these two structures following the biological key idea that the structure determines the function. The observed morphological correlations substantiate the existing mechanical link between the AT and PF via the posterior calcaneus and might explain why calf stretches are a successful treatment option for plantar heel pain.

Objectives: This study compared the effectiveness of soft vs hard orthotics in treating heel pain and plantar fasciitis in adults. It also compared the level of function after orthotic use, cost, and number of visits for orthotics and explored whether age was a factor in orthotic effectiveness., Design: Randomized controlled trial. Before randomization, patients were stratified by age (younger vs older adults) in blocks of 4 to ensure that there were an equal number of participants in each group (soft vs hard orthotics)., Setting: An orthotic clinic in a community-based hospital and a private orthotic clinic., Participants: The participants were adults aged 18 years or older (N=44) with heel pain and plantar fasciitis., Intervention: Participants received hard or soft customized orthotics., Main Outcome Measures: Participants rated their pain intensity and pain interference before and after orthotic use using subscales from the Brief Pain Inventory. Function was similarly measured using the Late Life Function and Disability Instrument: Function component. Analyses of age, cost, and number of visits were also compared., Results: There was a reduction in pain intensity (P=.010) and pain interference (P<.001) but no change in function over time (P=.333), and no difference between the groups who received hard vs soft orthotics. Age had no effect on orthotic effectiveness. Soft orthotics were less expensive (P<.0001) and required fewer visits for fabrication (P<.0001)., Conclusion: Both soft and hard orthotics provided effective pain relief, but soft orthotics are less expensive., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: It is known that there is an association between gastrocnemius tightness and plantar fasciitis, but this has never been quantified. The purpose of the study was to determine the correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis., Methods: Thirty-three patients were prescribed physiotherapist-directed gastrocnemius stretching exercises, a Strassburg Sock or night splint, and silicone heel insoles as required. Outcome measures included (1) gastrocnemius tightness, (2) 100-mm visual analog scale (VAS) for pain on the first steps in the morning, and (3) 100-mm VAS for the worst pain felt during the previous week. Gastrocnemius tightness was measured by the difference in maximal ankle dorsiflexion between knee bent and straight with a goniometer., Results: The mean gastrocnemius tightness was 22 degrees at baseline compared with 9 degrees at the final follow-up ( P < .01). A reduction in VAS for pain on the first steps in the morning and VAS for the worst pain felt during the previous week from baseline to final follow-up was observed ( P < .01). Correlation analysis of 105 data points between gastrocnemius tightness and VAS for pain on the first steps in the morning was R = 0.757 ( P < .001), and between gastrocnemius tightness and VAS for the worst pain felt during the previous week was R = 0.781 ( P < .001)., Conclusion: The study observed a strong, statistically significant correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis., Level of Evidence: Level IV, case series.

Background: Extracorporeal shock wave therapy is among the conservative treatments for symptomatic heel spur., Objective: The purpose of this trial is to evaluate and compare the therapeutic effects of radial shock wave (RSWT) and focused shock wave (FSWT) applied in the treatment of symptomatic heel spur., Methods: Fifty-five participants were randomly divided into two comparative groups that were administered FSWT and RSWT, respectively. The severity of dysfunction (Foot Function Index, FFI), ground reaction forces (GRF) and walking temporal parameters were measured in all patients at baseline and at weeks 1, 3, 6, 12 and 24 after treatment., Results: In both groups, a gradual decrease in the FFI values occurred after treatment. The percentage reduction in the FFI was comparable for both groups. Statistically significant changes were only noted between some measurements of GRF and walking temporal parameters. The percentage changes in the values of the force and temporal parameters were similar between the groups., Conclusions: Both FSWT and RSWT are efficacious in the treatment of symptomatic heel spur and their therapeutic effects are comparable. Objective data registered by force platforms during walking are not useful for tracing the progress of treatment applied to patients with symptomatic heel spur between consecutive procedures.

Purpose: Plantar fasciitis is a frequent and painful condition with a lifetime incidence of 10%. Good results have been reported for operative treatment of plantar fasciitis refractory to non-surgical interventions in uncontrolled studies. The aim of this study was to compare the results of operative treatment (endoscopic debridement, removal of the heel spur and partial resection of the plantar fascia) with those of a controlled and supervised non-operative rehabilitation program., Methods: Thirty consecutive patients with plantar fasciitis during more than 3 months were randomized to either (1) non-operative treatment with corticosteroid injections and a controlled strength training program or (2) an endoscopic 2-incision operation with partial fasciotomy and heel spur removal followed by the same strength training program. Patients were evaluated at entry and 3, 6, 12 and 24 months post-operatively with the foot function index (FFI) and pain score during activity on a 100 mm VAS scale (VAS activity). FFI at 6 and 12 months was defined a priori as primary endpoint., Results: Both groups improved significantly over time. The FFI score was significantly better in the operated group compared to the non-surgically treated group 12 months post-operatively (p = 0.033), at 24 months this was, however, not significant (p = 0.06). VAS activity at 24 months was significantly (p = 0.001) in favor of the operative group. More patients returned to running and jumping in the operative group (p = 0.04)., Conclusion: This randomized controlled trial found significant and clinically relevant superior results for the operative treatment of plantar fasciitis as measured by Foot Function Index at 1 year and by VAS activity at 2-year follow-up when compared to the results of a supervised rehabilitation program., Level of Evidence: I.

Background: Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions., Methods: Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12)., Results: For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R 2  = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R 2  = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R 2  = 0.33, p < 0.001), improvement in foot function (adjusted R 2  = 0.37, p < 0.001) and reduction in first-step pain (adjusted R 2 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R 2  = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R 2  = 0.38, p < 0.001)., Conclusions: People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

Background: Plantar fasciitis is commonly found among the physically active population, including conscripts. Some studies have reported that being overweight and having psychological symptoms contribute to pain from plantar fasciitis. However, there is a lack of information regarding the physical predictors, and more research is needed to determine the relationship between such predictors and pain intensity from plantar fasciitis in conscripts., Objective: To determine which physical and psychological variables act as predictors of pain intensity among Thai novice conscripts with plantar fasciitis., Methods: Two hundred and seventy Thai novice conscripts without musculoskeletal pain completed the Depression, Anxiety and Stress Scale short version and then received baseline assessment of ankle dorsiflexion angle, ankle plantarflexor strength, and quality of lower extremity movement from a physical therapist. After 10 weeks of military training, 71 of these Thai conscripts developed pain from plantar fasciitis. Multiple linear regression analysis with the forward stepwise method was used to explore the predictors of pain intensity due to plantar fasciitis., Results: Using a forward regression analysis, anxiety (B=0.13; 95% CI, 0.06-0.20; p<0.01) and quality of movement score (B=0.87; 95% CI, 0.28-1.47; p=0.01) were significant predictors of pain intensity. The regression model with these predictors explained 25% of the variability in pain intensity from plantar fasciitis., Conclusion: Higher scores of anxiety and movement quality on the lateral step-down task were associated with pain intensity from plantar fasciitis after the completion of a 10-week military program. However, lower ankle dorsiflexion angle and ankle plantarflexor strength did not predict pain intensity., (Copyright © 2019. Publicado por Elsevier Editora Ltda.)

Background and aims Persistent tendinopathies were previously considered solely as peripheral conditions affecting the local tendinous tissue until quantitative sensory testing identified involvement of altered pain processing. In similar fashion, pain in patients with persistent plantar fasciopathy may also involve more than local tissue. The aim of this pilot study was to investigate potential differences in conditioned pain modulation and pressure and thermal pain thresholds, between individuals with PF and healthy pain-free controls, as a precursor to a larger-scale study. Methods We assessed 16 individuals with plantar fasciopathy and 11 pain-free controls. Plantar fasciopathy diagnosis was: palpation pain of the medial calcaneal tubercle or the proximal plantar fascia, duration ≥3 months, pain intensity ≥2/10, and ultrasound-measured plantar fascia thickness ≥4 mm. Quantitative sensory tests were performed locally at the plantar heel and remotely on the ipsilateral elbow. Assessments included pain thresholds for pressure, heat and cold, and conditioned pain modulation measured as change in local resting pressure pain threshold with cold water hand immersion. Participants rated pain intensity at pain threshold. Additionally, the area and distribution of plantar fasciopathy pain was drawn on a digital body chart of the lower limbs. Descriptive analyses were performed and between-group differences/effects expressed as standardised mean differences (d). Results There was no conditioned pain modulation difference between participants with plantar fasciopathy and controls (d = 0.1). Largest effects were on local pressure pain threshold and reported pain intensity on pressure pain threshold (d > 1.8) followed by pain intensity for heat and cold pain thresholds (d = 0.3-1.5). According to the digital body chart, pain area extended beyond the plantar heel. Conclusions The unlikelihood of a difference in conditioned pain modulation yet a pain area extending beyond the plantar heel provide a basis for exploring altered pain processing in a larger-scale study. Implications This was the first study to investigate the presence of altered pain processing in individuals with plantar fasciopathy using a conditioned pain modulation paradigm and thermal pain thresholds. We found no indication of an altered pain processing based on these measures, however, patients rated pain higher on thresholds compared to controls which may be important to clinical practice and warrants further exploration in the future.

Plantar heel pain is a common musculoskeletal foot disorder that can have a negative impact on activities of daily living and it is of multifactorial etiology. A variety of mechanical factors, which result in excessive load at the plantar fascia insertion, are thought to contribute to the onset of the condition. This review presents the evidence for associations between commonly assessed mechanical factors and plantar heel pain, which could guide management. Plantar heel pain is associated with a higher BMI in non-athletic groups, reduced dorsiflexion range of motion, as well as reduced strength in specific foot and ankle muscle groups. There is conflicting, or insufficient evidence regarding the importance of foot alignment and first metatarsophalangeal joint range of motion. Plantar heel pain appears to be common in runners, with limited evidence for greater risk being associated with higher mileage or previous injuries. Conflicting evidence exists regarding the relationship between work-related standing and plantar heel pain, however, longer standing duration may be associated with plantar heel pain in specific worker groups. The evidence presented has been generated through studies with cross-sectional designs, therefore it is not known whether any of these associated factors have a causative relationship with plantar heel pain. Longitudinal studies are needed to ascertain whether the strength and flexibility impairments associated with plantar heel pain are a cause or consequence of the condition, as well as to establish activity thresholds that increase risk. Intervention approaches should consider strategies that improve strength and flexibility, as well as those that influence plantar fascia loading such as body weight reduction, orthoses and management of athletic and occupational workload., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The objectives of this study were (1) to investigate the passive stiffness of the medial gastrocnemius (MG) and lateral gastrocnemius (LG) in patients with and without plantar fasciitis (PF), (2) to explore the correlation between gastrocnemius stiffness and plantar fascia thickness (PFT) as well as the intensity of pain in patients with PF, (3) to detect optimal cut-off points for stiffness of the MG and LG for identifying patients with PF. Forty patients (mean age = 51.1 years ± 12.9) participated in this study. The elastic properties of the MG and LG were quantified using shear wave elastography ultrasound. The thickness of the plantar fascia was measured by B-mode imaging. The intensity of pain was assessed using a visual analogue scale. The results showed that when the ankle was in the relaxed position, patients with PF had increased passive stiffness in the MG (P < 0.05) but not in the LG. Significant correlations were found between pain and the stiffness of the MG (middle, distal; all P-values < 0.05) and no correlation was observed between pain and PFT (P = 0.416). The initial cut-off point for the stiffness of the MG was 29.08 kPa when the ankle was in the relaxed position. The findings from the present study show that an increase in muscle stiffness is not the same in the individual muscles of the gastrocnemius muscle. Traditional treatment of the whole gastrocnemius muscle might not be targeted at the tight muscle.

Extracorporeal shockwave therapy (ESWT) is proposed to be effective in reducing pain and improving functional outcome in chronic plantar fasciitis. However, no long-term reports exist on the changes in plantar fascia (PF) elasticity after ESWT. We aimed to evaluate the changes in PF stiffness in patients with plantar fasciitis undergoing ESWT. The visual analogue scale (VAS, 0-100) was used for evaluating heel pain severity. B-mode sonography and strain sonoelastography were used for evaluating the PF thickness and stiffness. The sonoelastogram was analyzed using hue histogram analysis (value: 0-255, from stiffer to softer). All evaluations were recorded before ESWT, and 1 week, 1 month, 3 months, 6 months, and 12 months after ESWT. Repeated measures ANOVA was used to compare pain VAS, PF thickness, and PF hue value at different follow-up time-points. Twenty-two participants (8 men, 14 women) completed all measurements for 12 months. The VAS of heel pain, PF thickness, and PF hue values at pre-ESWT, and 1-week, 1-month, 3-month, 6-month, and 12-month evaluations after ESWT were 62.4 ± 4.2, 49.3 ± 5.8, 38.3 ± 5.7, 27.9 ± 5.3, 18.9 ± 4.7, and 13.2 ± 3.0 (p < 0.01 in all measurements post ESWT versus pre-ESWT); 5.57 ± 0.22 mm, 5.64 ± 0.18 mm, 5.45 ± 0.24 mm, 5.37 ± 0.20 mm, 5.08 ± 0.20 mm, and 4.62 ± 0.15 mm (p < 0.01 at 6-month; otherwise p > 0.05); and 24.5 ± 2.4, 35.2 ± 3.1, 31.0 ± 4.1, 30.5 ± 3.9, 21.4 ± 2.1, and 15.9 ± 1.6 (p < 0.01 at 1-week and 6-month; otherwise p > 0.05), respectively. In conclusion, the heel pain intensity and PF thickness reduced gradually over 12 months after ESWT. The PF stiffness decreased during the first week and increased thereafter; at the 12-month follow-up, stiffness was more than at pre-ESWT.

Background: Plantar fasciopathy has a lifetime prevalence of 10%. Patients experience sharp pain under the heel, often for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. A corticosteroid injection offers short-term pain relief but is no better than placebo in the longer term (> 8 weeks). Heavy-slow resistance training has shown potentially positive effects on long-term outcomes (> 3 months), and combining exercises with an injection may prove to be superior to exercises alone. However, the effect of heavy-slow resistance training compared with a simpler approach of patient advice (e.g., load management) and insoles is currently unknown. This trial compares the efficacy of patient advice with patient advice plus heavy-slow resistance training and with patient advice plus heavy-slow resistance training plus a corticosteroid injection in improving the Foot Health Status Questionnaire pain score after 12 weeks in patients with plantar fasciopathy., Methods: In this randomised superiority trial, we will recruit 180 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of three groups: (1) patient advice and an insole (n = 60); (2) patient advice, an insole, and self-dosed heavy-slow resistance training consisting of heel raises (n = 60); or (3) patient advice, an insole, heavy-slow resistance training, and an ultrasound-guided corticosteroid injection (n = 60). All participants will be followed for 1 year, with the 12-week follow-up considered the primary endpoint. The primary outcome is the Foot Health Status questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a 7-point Global Rating of Change, the Pain Self-Efficacy Questionnaire, physical activity level, health-related quality of life measured by the EQ-5D-5L, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Additionally, a health economic evaluation of the treatments will be carried out., Discussion: This trial will test if adding heavy-slow resistance training to fundamental patient advice and an insole improves outcomes and if a corticosteroid injection adds even further to that effect in patients with plantar fasciopathy., Trial Registration: ClinicalTrials.gov, NCT03804008. Prospectively registered on January 15, 2019.

Background: The objective of this study was to determine whether the injection of botulinum toxin A (BTA) in the medial head of the gastrocnemius muscle could yield improvements in function and disability in patients with chronic plantar fasciitis with follow-up 12 months after treatment., Methods: Thirty-two patients with chronic plantar fasciitis were included in the study and randomly allocated to the BTA and placebo groups. The visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores were used to evaluate pain levels pre- and postinjection as well as function of the foot, respectively. Patients were also asked to rate their treatment satisfaction 1 year after injection. The range of dorsiflexion was measured before and 12 months after the injection., Results: At the 12-month follow-up, the mean VAS decreased from 7.8 to 4 in the placebo group and from 8 to 0.33 in the BTA group. Furthermore, the mean AOFAS scores increased from 48.4 to 65.3 in the placebo group and from 45.5 to 90.6 in the BTA group. The postinjection scores in the BTA group were significantly higher than those in the placebo group ( P < .001). Patient satisfaction in the BTA group was higher than that in the placebo group at the 12-month follow-up., Conclusion: In patients with chronic plantar fasciitis, the use of BTA had a positive effect on improvement in pain and foot function 1 year after treatment., Level of Evidence: Level I, prospective randomized controlled trial.

Background: Heating the skin and muscles is a commonly accepted method of pain relief and a modality to increase relaxation in muscles and increase tissue blood flow., Objective: The purpose of the present study was to examine the effect of local heat applied to trigger points and to determine if there was pain relief in the neck and plantar fascia., Methods: Forty adults were divided into 2 different groups according to their pain; twenty subjects had plantar foot pain and the other 20 had nonspecific neck pain. The 20 subjects in each group were randomly subdivided into a heat and a sham group. Sensitivity to pressure was measured with an algometer. A stopwatch was given to the subject and started when either the heat patch or placebo was applied. Heat cells were applied at trigger points on the pain area., Results: Subjective pain significantly decreased in both sham and heat group patients with neck pain (p< 0.05), however, the change was greater in the heat group and there was a significant difference between the heat and sham groups (p= 0.002, d= 0.81). For the plantar pain group, a significant decrease in subjective pain was found in the heat group but not in the sham group. Pressure pain threshold significantly decreased in the heat group patients both with neck and plantar pain but for the sham group there was an increase in the pressure after sham treatment. Pain relief during the intervention was also significantly different between the heat and sham group in both patients with neck and plantar pain., Conclusion: The effect of local heat on trigger points of the body on pain relief was significantly better in the heat groups than in the sham groups. This finding is significant because using heat on trigger points could be an alternative to dry needling performed by healthcare professionals. This modality can be alternative for home use and avoids opioids.

Background: To conduct a meta-analysis comparing the efficacy of general ESWT with that of other therapies and to assess its effectiveness in chronic plantar fasciitis., Methods: A literature search was performed in PubMed, Embase, Web of Science and the Cochrane Library for information from the earliest date of data collection to March 2018. Studies comparing the benefits and risks of extracorporeal shock wave therapy with those of other therapies for chronic plantar fasciitis were included. Statistical heterogeneity was quantitatively evaluated by a X 2 test with the significance set as P<0.10 or I 2 >50%., Results: Thirteen trials consisting of 1,185 patients were included (637 patients were treated with ESWT; 548 patients, with OT). The results showed that patients treated with ESWT had increased success or improvement rates, an increased modified Roles & Maudsley (RM) score, a reduction of pain scales, reduced return to work time, and fewer complications than patients treated with other therapy methods (P<0.1)., Conclusions: Compared with patients who received other therapies for chronic plantar fasciitis, patients treated with ESWT responded better, had less complications and showed a clear difference in efficacy between ESWT and other therapy in chronic plantar fasciitis., Level of Evidence: Level IV, therapeutic study., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Shock-wave therapy (SWT) has been widely applied and proven to be an effective treatment in ameliorating symptoms of plantar fasciitis (PF). Ultrasound therapy (UT) is another common treatment of PF, and several researches have documented its advantages when compared to corticosteroid injection. Despite this, few studies have focused on comparing the use of SWT and UT in the treatment of PF. The purpose of our meta-analysis is to evaluate whether SWT is better than UT in managing PF, both in terms of ameliorating pain and improving functionality., Methods: A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov and OVID from the databases' inception to October 2018. All studies comparing the efficacy of SWT and UT in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3., Results: Five studies were included in the current meta-analysis. A significant difference in VAS score (MD = - 13.14, Cl - 14.07 to - 12.75 P < 0.00001, I 2  = 100%) was noted between the SWT group and the UT group. No significant difference was seen in the AOFAS (MD = 3.19, Cl - 1.72 to 8.10 P = 0.20, I 2  = 100%); FFI or PFPS score was not found significant difference either (SMD = - 1.17, Cl - 4.45 to 2.10 P = 0.48, I 2  = 96%)., Conclusions: The results from this meta-analysis highlight the effectiveness of both SWT and UT in the treatment of PF. Although inter-group differences were not significant, the VAS score was better improved in the SWT group, suggesting that SWT may be a superior alternative for the treatment of PF.

Introduction: Plantar fasciopathy (PF) is a degenerative condition of the plantar fascia, secondary to repetitive overloading. For the majority, PF is self-limiting with greater than 80% of those affected gaining complete resolution within 1 year. However, persistent symptoms develop in approximately 10% of cases. Clinical practice guidelines for first-line treatment of PF recommend conservative management. For people with persistent symptoms that have not resolved following a trial of 6-12 months of conservative management, surgery may be offered. However, to date there are no systematic reviews of the effectiveness of the various surgical procedures for PF. We aim to systematically review quantitative studies assessing the effectiveness of surgical interventions in the management of PF., Methods and Analysis: We will search for all published and unpublished randomised clinical trials evaluating surgical interventions in the management of PF. Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (OVID), EMBASE (OVID), Web of Science (ISI) and Google Scholar will be searched without restrictions on date or language of publication. Inclusion criteria will include people over 18 years, diagnosed by clinical examination with PF, or with an alternative diagnostic label (eg, plantar fasciitis, plantar heel pain, plantar fasciosis). The primary outcomes are changes in pain severity/intensity for first-step pain, and incidence and nature of adverse events. Secondary outcomes include foot and ankle-related disability/function, health-related quality of life, cost-effectiveness, changes in other reported measures of pain (eg, overall pain) and medication use. Outcomes will be assessed (1) short term (≤3 months after intervention), (2) medium term (>3 months to ≤6 months after intervention) or (3) long term (>6 months to ≤2 years after treatment). All data extraction will be performed by at least two independent reviewers on the basis of a priori developed extraction form. Where adequate data are found meta-analysis will be used to combine the results of studies for all core comparisons and outcomes using random effects models. Overall certainty of the evidence for each outcome will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach., Ethics and Dissemination: This systematic review does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at appropriate conferences., Prospero Registration Number: CRD42019133563., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Plantar fasciitis is a frequently occurring overuse injury of the foot. Shoes with a stiff rocker profile are a commonly prescribed treatment modality used to alleviate complaints associated with plantar fasciitis. In rocker shoes the apex position was moved proximally as compared to normal shoes, limiting the progression of the ground reaction forces (GRF) and peak plantarflexion moments during gait. A stiff sole minimizes dorsiflexion of the toes. The aim of this study was to investigate whether the biomechanical effects of rocker shoes lead to minimization of plantar aponeurosis (PA) strain during gait in patients with plantar fasciitis and in healthy young adults. 8 patients with plantar fasciitis (1 male, 7 females; mean age 55.0 ± 8.4 years) and 8 healthy young adults (8 females; mean age 24.1 ± 1.6 years) participated in the study. Each participant walked for 1 minute on an instrumented treadmill while wearing consecutively in random order shoes with a normal apex position (61.2 ± 2.8% apex) with flexible insole (FN), normal apex position with stiff insole (SN), proximal apex position (56.1 ± 2.6% apex) with flexible insole (FR) and proximal apex position with stiff insole (SR). Marker position data of the foot and lower leg and GRF were recorded. An OpenSim foot model was used to compute the change in PA length based on changes in foot segment positions during gait. The changes in PA length due to increases in Achilles tendon forces were computed based on previous data of a cadaver study. PA strain computed from both methods was not statistically different between shoe conditions. Peak Achilles tendon force, peak first metatarsophalangeal (MTP1) joint angle and peak plantarflexion moment were significantly lower when walking with the rocker shoe with a proximal apex position and a stiff insole for all subjects (p<.05). Changes in Achilles tendon forces during gait accounted for 65 ± 2% of the total PA strain. Rocker shoes with a stiff insole reduce peak dorsiflexion angles of the toes and plantar flexion moments, but not PA strain because the effects of a proximal apex position and stiff insole do not occur at the same time, but independently affect PA strain at 80-90% and 90-100% of the stance phase. Rocker shoes with an apex position of ~56% are insufficient to significantly reduce peak PA strain values in patients with plantar fasciitis and healthy young adults., Competing Interests: The authors have declared that no competing interests exist.

Background: Plantar heel pain is one of the most common foot pain conditions treated by health care providers., Objectives: To investigate differences in topographical pressure pain sensitivity maps of the feet between patients with unilateral plantar heel pain and healthy individuals, and to determine the relationship between topographical pressure maps, pain intensity, disability, and fascia thickness., Methods: Thirty-five patients with unilateral plantar heel pain and 35 matched healthy controls participated in this cross-sectional, case-control study. Pressure pain thresholds (PPTs) were assessed over 7 plantar locations on each foot. Topographical pressure pain sensitivity maps of the plantar region were generated using the averaged PPT of each assessed point. Pain and related disability were assessed with a numeric pain-rating scale (0-10) and the Foot and Ankle Ability Measure, respectively. Plantar fascia thickness was measured via ultrasound. All outcomes were obtained by an assessor blinded to the participants' condition., Results: Topographical pressure sensitivity maps revealed lower bilateral PPTs in patients with plantar heel pain compared to healthy controls, and a higher PPT on the calcaneus bone ( P <.01). Women had lower PPTs than men in all areas ( P <.001). Individuals with plantar heel pain also had thicker fascia, but only on the affected side, compared to healthy controls. Higher pressure pain sensitivity in the foot was associated with higher pain intensity at first step in the morning and thicker fascia at the calcaneus bone., Conclusion: People with unilateral plantar heel pain had generalized bilateral pressure pain sensitivity in the plantar region of the foot. Greater pain intensity and fascia thickness were associated with higher pressure pain sensitivity in people with plantar heel pain., Level of Evidence: Case-control study, level 4. J Orthop Sports Phys Ther 2019;49(9):640-646. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8813 .

Background: Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment. Therefore, this study reviewed randomised trials to estimate the effectiveness of corticosteroid injection for plantar heel pain., Methods: A systematic review and meta-analysis of randomised trials that compared corticosteroid injection to any comparator. Primary outcomes were pain and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks)., Results: A total of 47 trials (2989 participants) were included. For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection (SMD -0.56; 95% CI, - 0.86 to - 0.26) and foot orthoses (SMD -0.91; 95% CI, - 1.69 to - 0.13). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than dry needling (SMD 1.45; 95% CI, 0.70 to 2.19) and platelet-rich plasma injection (SMD 0.61; 95% CI, 0.16 to 1.06). Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short (SMD -0.98; 95% CI, - 2.06, 0.11) and medium terms (SMD -0.86; 95% CI, - 1.90 to 0.19). For improving function, corticosteroid injection was more effective than physical therapy in the short term (SMD -0.69; 95% CI, - 1.31 to - 0.07). When trials considered to have high risk of bias were excluded, there were no significant findings., Conclusions: Based on the findings of this review, corticosteroid injection is more effective than some comparators for the reduction of pain and the improvement of function in people with plantar heel pain. However, corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. Further trials that are of low risk of bias will strengthen this evidence., Registration: PROSPERO registration number CRD42016053216 .

BACKGROUND There are many methods of dynamic analysis of foot loading, however, we still need a simple, easily applicable system for foot plantar pressure analysis. In this study we asked the question: "Can a new system for foot evaluation, the ITE System, provide a good quantitative dynamic foot pressure analysis? Can it be used in clinical practice?". MATERIAL AND METHODS Twenty healthy volunteers, 8 females and 12 males, aged 20 to 25 years old took part in this study. Normal static foot loading was tested using a typical pedobarographic platform, followed by a dynamic analysis using the foot-pressure ITE System. A new algorithm for data analysis (from 8 sensors) was proposed. RESULTS The sum of all maximal values from sensors was 11.71 N mean, with relatively low standard deviation (SD) of 1.81. Loading of sensor 1 (heel) was the highest - on average 29.84%. Sensor 2 (medial midfoot) received the lowest loading - normal range for this segment would be 0-4%. The manner of loading heel/toes, dynamics of changes in loading during gait was quite diverse; when analyzing courses of changes on sensors, 4 gait patterns were observed. CONCLUSIONS Use of the ITE System creates a new possibility for dynamic foot evaluation, drawing from pedobarography and methods of gait analysis. The proposed data analysis algorithm is simple and can be applied in all cases. Normally, 30% of the sum of all pressures during stance phase falls on the rearfoot; 39% falls on forefoot.

Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appropriate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.

Background:: Ultrasound is a widely used diagnostic tool for patients with plantar fasciitis. However, the lack of standardization during the measurement for plantar fascia thickness has made it challenging to understand the etiology of plantar fasciitis, as well as identify risk factors, such as gender. The purpose of this study was to investigate gender differences regarding plantar fascia thickness while controlling for metatarsophalangeal (MTP) joint position in the healthy and those with unilateral plantar fasciitis., Methods:: Forty participants (20 with unilateral plantar fasciitis and 20 controls) with plantar fascia thickness (mean age, 44.8 ± 12.2 years) participated in this study. The majority were females (n = 26, 65%). Plantar fascia thickness was measured via ultrasound 3 times at 3 different MTP joint positions: (1) at rest, (2) at 30 degrees of extension, and (3) at maximal extension., Results:: When comparing gender differences, the males in the plantar fasciitis group had a significantly thicker plantar fascia than the females ( P = .048, η 2 = 2.35). However, no significant differences were observed between healthy males and females. The males with unilateral plantar fasciitis also had significantly thicker asymptomatic plantar fasciae collectively compared with controls ( P < .05), whereas females with unilateral plantar fasciitis had a similar but not significant change., Conclusion:: It appears that healthy males and females have similar plantar fascia thickness. However, as plantar fasciitis develops, males tend to develop thicker plantar fasciae than their female counterparts, which could have future treatment implications., Level of Evidence:: Level III, case-control comparative study.

The goal of our study was to investigate the cumulative effect of combining medium-energy extracorporeal shock wave therapy (ESWT) and photobiomodulation therapy (PBMT), as well as to compare between their relative effectiveness in the management of plantar fasciitis (PF). One hundred twenty participants with chronic PF, more than 6 months with failure to respond to conservative treatment, were randomly assigned into four equal groups. Participants received either ESWT with PBMT, ESWT (once a week), PBMT (three times a week), or sham-PBMT (three times a week) for three consecutive weeks. A home exercise program was also included for all four groups. Outcome measures included pressure pain threshold (PPT), visual analogue scale (VAS), and functional foot index disability subscale (FFI-d) that were collected prior to the first treatment session and at the end of the 3-week treatment period, as well as at a follow-up session, 12 weeks after the final treatment session. There were statistically significant improvements in post-intervention and follow-up PPT, VAS, and FFI-d values in all treatment groups (P < 0.0001). As for the sham-PBMT, no significant difference was found between the pre-, post-intervention and follow-up values (P > 0.05). Bonferroni correction test revealed that there was a significant difference between all the four groups in PPT, VAS, and FFI-d values (P < 0.0001). All active treatment groups maintained the treatment effect at the 12-week follow-up. Both ESWT and PBMT were effective in increasing PPT values, decreasing pain and increasing functional ability. Additionally, application of PBMT after ESWT was shown to be superior over ESWT and PBMT alone, and ESWT was superior over PBMT in terms of reducing pain sensitivity and increasing function.Level of Evidence II.

The purpose of our study is to identify the predictive factors for a minimum clinically successful therapy after extracorporeal shock wave therapy for chronic plantar fasciitis. The demographic and clinical characteristics were evaluated. The artificial neural networks model was used to choose the significant variables and model the effect of achieving the minimum clinically successful therapy at 6-months' follow-up. The multilayer perceptron model was selected. Higher VAS (Visual Analogue Score) when taking first steps in the morning, presence of plantar fascia spur, shorter duration of symptom had statistical significance in increasing the odd. The artificial neural networks model shows that the sensitivity of predictive factors was 84.3%, 87.9% and 61.4% for VAS, spurs and duration of symptom, respectively. The specificity 35.7%, 37.4% and 22.3% for VAS, spurs and duration of symptom, respectively. The positive predictive value was 69%, 72% and 57% for VAS, spurs and duration of symptom, respectively. The negative predictive value was 82%, 84% and 59%, for VAS, spurs and duration of symptom respectively. The area under the curve was 0.738, 0.882 and 0.520 for VAS, spurs and duration of symptom, respectively. The predictive model showed a good fitting of with an overall accuracy of 92.5%. Higher VAS symptomatized by short-duration, severer pain or plantar fascia spur are important prognostic factors for the efficacy of extracorporeal shock wave therapy. The artificial neural networks predictive model is reasonable and accurate model can help the decision-making for the application of extracorporeal shock wave therapy.

Purpose: The objective of this study was to compare the ground reaction forces (GRFs) and the multi-segment foot motion between individuals with plantar fasciitis (PF) and healthy controls., Methods: Twenty-one individuals with PF and 21 matched-case healthy controls who passed the criteria participated in the study. Gait data were assessed during their self-selected comfortable speeds by the 3D motion analysis system. The multi-segment foot motions were determined by the Oxford Foot Model. Outcome measures included the vertical and antero-posterior ground reaction forces (GRFs) and the multi-segment foot motions [the dorsiflexion (DF), plantarflexion (PF), inversion (Inv), eversion (Eve), adduction (Add), and abduction (Abd) peak angles for the forefoot with respect to hindfoot (FFHF) and the DF, PF, Inv, Eve, internal rotation (IR), and external rotation (ER) peak angles for the hindfoot with respect to tibia (HFTB) as well as their ranges (R)]., Results: Comparisons between individuals with PF and healthy controls showed no significant differences in any of the GRFs. Significant reductions were found in the FFHF-DF, FFHF-DF-R, FFHF-Inv, and HFTB-Inv/Eve-R in individuals with PF. In addition, there were tendencies of the increased angles of the FFHF-PF, HFTB-DF, HFTB-Inv, and HFTB-ER, but not significantly for individuals with PF, compared to healthy controls., Conclusions: Adaptations of the intra-foot motion showed the reduction of some angles but no change for the GRFs in individuals with PF compared to the healthy controls when both groups walked at a similar gait speed.

Plantar fasciitis is a cause of chronic pain under the heel and bottom of the foot. One of the treatments to reduce pain consists of using plantar orthoses to address specific imbalances during foot placement or gait. The aim of the present study was to determine if reduction of pain with a treatment based on plantar orthoses is related to changes in reflexes and muscle activity of the muscles of the lower limbs. Ten patients (51.0±3.5 years, 76.0±2.38 kg, 171.9±1.8 cm, 3 women and 7 men) with plantar fasciitis for less than 1 year were followed up during nine weeks. Soleus M, H, and V waves recorded at rest and during voluntary contraction and Root Mean Square-Electromyogram from four leg muscles recorded during walking and static position were analyzed in patients before and 3, 6, and 9 weeks after wearing orthoses. Pain level and gait and posture parameters were also analyzed. Results were compared to five healthy participants exhibiting no pain (30.6±2.1 years, 60.0±3.5 kg, 167.0±3.4 cm, 3 women and 2 men). Results indicated that pain was significantly reduced after 3 weeks. H max /M max and H sup /M sup ratios were significantly higher and M Hmax /M max and M Hsup /M sup were significantly lower in healthy participants compared to patients with plantar fasciitis . No difference in the V/M sup ratio was found between groups. Furthermore, all other measured locomotor, stabilometric, and electromyographic parameters remained unchanged throughout the entire protocol. The reduction of pain is not related to change in neural activity suggesting that, after 9 weeks of wearing plantar orthoses, patients are not yet cured and return to physical activity should be delayed.

Background: The argument on whether extracorporeal shock-wave therapy (ESWT) and corticosteroid injections (CSIs) exert an equivalent pain control or which is the better treatment for plantar fasciitis (PF) in adults remains to be resolved. It is important and necessary to conduct a meta-analysis to make a relatively more credible and overall assessment about which treatment method performs better pain control in treatment of PF in adults., Methods: From the inception to July 2018, the Embase, PubMed, Web of Science, and Cochrane Library electronic databases were searched for all relevant studies. Only randomized controlled trials (RCTs) focusing on comparing ESWT and CSI therapies in PF cases in adults were included. The primary outcome measure was visual analog scale (VAS) reduction, whereas the secondary outcomes included treatment success rate, recurrence rate, function scores, and adverse events., Results: Nine RCTs involving 658 cases were included in this meta-analysis. In the present study, meta-analysis showed that high-intensity ESWT had superior pain relief and success rates relative to the CSI group within 3 months, but the ESWT with low intensity was slightly inferior to CSI for efficacy within 3 months. In addition, patients with CSI may tend to increase the need for the analgesic and more adverse events may be associated with the ESWT. However, the ESWT and CSI present similar recurrent rate and functional outcomes., Conclusion: Our analysis showed that the pain relief and success rates were related to energy intensity levels, with the high-intensity ESWT had the highest probability of being the best treatment within 3 months, followed by CSI, and low-intensity ESWT. More high-quality RCTs with long-term follow-up time are needed to further compare the differences of CSI and ESWT for adults with PF.

Objective: The aim of this study was to define a quantitative parameter to indicate which cases of plantar fasciitis will benefit from local corticosteroid injection or ESWT and to compare the efficacy of two different treatment modalities., Methods: Seventy patients (mean age: 49.10; range: 41-58) with chronic plantar fasciitis unresponsive to conservative treatment for 3 months were treated with either betamethasone injection or extracorporeal shock wave therapy (ESWT). Correlation between AOFAS scores, fascia thickness, duration of symptoms, age and calcaneal spur length were assessed., Results: Degree of fascial thickening (mean 4.6 mm for all patients) did not influence baseline AOFAS scores (r = -0.054). Plantar fascia thickness significantly decreased in both groups after treatment (1.2 mm for steroid, 1.2 mm for ESWT) (p < 0.01 for both groups). Percentage of change in AOFAS scores (68% for steroid and 79% for ESWT, p = 0.069) and fascial thickness (24% for steroid and 26% for ESWT, p = 0.344) were similar between two groups. Functional recovery was not correlated with baseline fascial thickness (r = 0.047) or degree of fascial thinning after treatment (r = -0.099). Percentage of change in AOFAS scores was correlated only with baseline AOFAS scores (r = -0.943)., Conclusions: Plantar fascia thickness increases significantly in plantar fasciitis and responds to treatment. Both ESWT and betamethasone injection are effective in alleviating symptoms and reducing plantar fascia thickness in chronic plantar fasciitis. However, the only predictive factor for functional recovery in terms of AOFAS scores is patients' functional status prior to treatment. Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis., Level of Evidence: Level III, Therapeutic study., (Copyright © 2018 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Objective: The bundled, crescent-shaped trabeculae within the calcaneal tuberosity-which we term and refer to here as the "calcaneal crescent"-may represent a structural adaption to the prevailing forces. Given Wolff law, we hypothesized that the calcaneal crescent would be more robust in patients with plantar fasciitis, a syndrome in part characterized by overload of the Achilles tendon-calcaneal crescent-plantar fascia system, than in patients without plantar fasciitis., Materials and Methods: MR images of 37 patients (27 women and 10 men; mean age ± SD, 51 ± 13 years; mean body mass index [BMI, weight in kilograms divided by the square of height in meters], 26.8 ± 6.3) referred for workup of foot or ankle pain were retrospectively evaluated by two blinded readers in this study. Patients were assigned to two groups: group A, which was composed of 15 subjects without clinical signs or MRI findings of Achilles tendon-calcaneal crescent-plantar fascia system abnormalities, or group B, which was composed of 22 patients with findings of plantar fasciitis. The thickness and cross-sectional area (CSA) of the Achilles tendon, calcaneal crescent, and plantar fascia were measured on proton density (PD)-weighted MR images. The entire crescent volume was manually measured using OsiriX software on consecutive sagittal PD-weighted images. Additionally, contrast-to-noise ratio (CNR) as a surrogate marker for trabecular density and the mean thickness of the calcaneal crescent were determined on PD-weighted MR images. The groupwise difference in the morphologic measurements were evaluated using ANOVA with BMI as a covariate. Partial correlation was used to assess the relationships of measurements for the group with plantar fasciitis (group B). Intraclass correlation coefficient (ICC) statistics were performed., Results: Patients with plantar fasciitis had a greater CSA and volume of the calcaneal crescent and had lower CNR (i.e., denser trabeculae) than those without Achilles tendon-calcaneal crescent-plantar fascia system abnormalities (CSA, 100.2 vs 73.7 mm 2 , p = 0.019; volume, 3.06 vs 1.99 cm 3 , p = 0.006; CNR, -28.40 vs -38.10, p = 0.009). Interreader agreement was excellent (ICC = 0.85-0.99)., Conclusion: In patients with plantar fasciitis, the calcaneal crescent is enlarged compared with those without abnormalities of the Achilles tendon-calcaneal crescent-plantar fascia system. An enlarged and trabeculae-rich calcaneal crescent may potentially indicate that abnormally increased forces are being exerted onto the Achilles tendon-calcaneal crescent-plantar fascia system.

Background:: Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF., Methods:: A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type., Results:: Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01)., Conclusions:: We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

The aim of this study was to determine the diagnostic capability of a dynamic gait analysis insole and compare its ability to detect clinical correlations to a common stationary analysis tool. Twenty-five patients with chronic plantar fasciitis were included in this prospective, blinded, diagnostic study. Conventional, stationary gait analysis on a force plate on an even surface and continuous dynamic pedobarography on a standardized course consisting of different gait tasks were performed and correlated to the disease severity. Mean patient age was 53.6 (range 41 to 68) years, with a mean pain level of 6.1 (range 4 to 10) on the Visual Analogue Scale and a calcaneodynia score of 48.7 (range 33 to 66). Significant correlations were seen between several dynamic gait values and clinical scoring: cadence (r s  = 0.56, p = .004), stance time (r s  = -0.6, p = .002), center-of-pressure velocity (r s  = 0.44, p = .046), and double support time (r s  = 0.42, p = .042). No significant correlations were seen between any force plate gait analysis values and clinical scoring. In this study setting, dynamic gait analysis was able to identify clinically relevant correlations to plantar fasciitis disease severity that standard force plate measurements could not., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

BACKGROUND The aim of this study was to assess the passive stiffness of the medial and lateral gastrocnemius (MG and LG), Achilles tendon (AT), and plantar fascia (PF) at different ankle and knee positions. MATERIAL AND METHODS Stiffness was assessed using a portable hand-held device (MyotonPRO). In 30 healthy participants (15 males, 15 females) with the knee fully extended or flexed 90°, stiffness of the MG, LG, AT, and PF was measured at 50° plantar flexion, 0° (neutral position), and 25° dorsiflexion (not for AT) of the ankle joint by passive joint rotation. RESULTS With the knee fully extended, passive dorsiflexion caused significant increase in muscle stiffness (P<0.001), whereas AT and PF stiffness increased with passive ankle dorsiflexion regardless of knee position (P<0.001). Increased stiffness was observed in MG compared to LG (P<0.001) and at the 3-cm site of AT compared to the 6-cm site (P<0.05). Stiffness was greater in LG compared to MG at -50° plantar flexion (P<0.001) and was greater in MG compared to LG at 25° dorsiflexion (P<0.05). Stiffness of AT increased in a distal-to-proximal pattern: 0 cm >3 cm >6 cm (P<0.001). CONCLUSIONS Stiffness assessed by use of the MyotonPRO was similar assessments using other techniques, suggesting that the MyotonPRO is capable of detecting the variations in stiffness of MG, LG, AT, and PF at different ankle and knee positions.

We aimed to compare the efficacy of low-level laser therapy (LLLT) and high-intensity laser therapy (HILT) in the treatment of plantar fasciitis (PF). Seventy patients were randomized into either the LLLT (8 men, 27 women; mean age 48.65 ± 10.81 years) or HILT (7 men, 28 women; mean age 48.73 ± 11.41 years) groups. LLLT (904 nm) and HILT (1064 nm) were performed three times per week, over a period of 3 weeks. Each treatment combined with silicone insole and stretching exercises. Patients' pain and functional status were evaluated with Visual Analog Scale, Heel Tenderness Index, and Foot and Ankle Outcome Score before and after treatment. A chi-square test was performed to compare demographic and clinical characteristics. Within-group and between-group differences were also investigated. Paired samples t test was used to analyze the differences between baseline and after treatment values, while independent samples t test was used to compare the two groups. Both groups contained similar demographic characteristics including age, sex, and body mass index (all p > 0.05). Three and two patients in the HILT and LLLT group, respectively, were lost to follow-up. At the study onset, there were no statistically significant differences between the two groups in the Visual Analog Scale, Heel Tenderness Index, and Foot And Ankle Outcome Scores. Three weeks later, both groups showed significant improvement in all parameters (p < 0.05). The HILT group demonstrated better improvement in all parameters than the LLLT group. Although both treatments improved the pain levels, function, and quality of life in patients with PF, HILT had a more significant effect than LLLT.

Background: The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition., Methods: Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients., Results: In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36., Conclusion: The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning., Level of Evidence: Level IV, case series.