Factors associated with plantar fasciitis

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Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners.
Pohl MB, Hamill J, Davis IS.
Clin J Sport Med. 2009 Sep;19(5):372-6.

 

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an increased ankle dorsiflexion range of motion compared with the control group. 

I find this interesting! Has this been associated with PF previously. (yes I am lazy to look it up myself)

Regards,

Con

 

Hi Con,

We reported a similar finding in our case-control study:

BMC Musculoskelet Disord. 2007 May 17;8:41.

Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study

Irving DB, Cook JL, Young MA, Menz HB.

Musculoskeletal Research Centre, La Trobe University, Bundoora, Victoria, Australia.

BACKGROUND: Chronic plantar heel pain (CPHP) is one of the most common musculoskeletal disorders of the foot, yet its aetiology is poorly understood. The purpose of this study was to examine the association between CPHP and a number of commonly hypothesised causative factors. METHODS: Eighty participants with CPHP (33 males, 47 females, mean age 52.3 years, S.D. 11.7) were matched by age (+/- 2 years) and sex to 80 control participants (33 males, 47 females, mean age 51.9 years, S.D. 11.8). The two groups were then compared on body mass index (BMI), foot posture as measured by the Foot Posture Index (FPI), ankle dorsiflexion range of motion (ROM) as measured by the Dorsiflexion Lunge Test, occupational lower limb stress using the Occupational Rating Scale and calf endurance using the Standing Heel Rise Test. RESULTS: Univariate analysis demonstrated that the CPHP group had significantly greater BMI (29.8 +/- 5.4 kg/m2 vs. 27.5 +/- 4.9 kg/m2; P < 0.01), a more pronated foot posture (FPI score 2.4 +/- 3.3 vs. 1.1 +/- 2.3; P < 0.01) and greater ankle dorsiflexion ROM (45.1 +/- 7.1 degrees vs. 40.5 +/- 6.6 degrees; P < 0.01) than the control group. No difference was identified between the groups for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. Multivariate logistic regression revealed that those with CPHP were more likely to be obese (BMI > or = 30 kg/m2) (OR 2.9, 95% CI 1.4 - 6.1, P < 0.01) and to have a pronated foot posture (FPI > or = 4) (OR 3.7, 95% CI 1.6 - 8.7, P < 0.01). CONCLUSION: Obesity and pronated foot posture are associated with CPHP and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress may not play a role in CPHP.

Full-text here.

 

Hylton;

would you be so kind as to explain the marker set you used to evaluate the AJ range of motion in your posted study?

My clinical experience shows loss of AJ DFion in this patient subset the majority of the time, almost to the point of exclusivity.

In my reading of so many of these studies where they incorporate AJ increases in DFion ROM I can only conclude that the marker set did not differentiate between the FF, midfoot/ MTJ and AJ. Therefore any FF / midfoot increase in compensation DFion motion would be incorporated into the AJ measurement. This is a very important point, and I have yet to have seen a paper that explains this as a significant misleading finding.

Was this true of your study adn would you care to elaborate on this please?

Sincerely;
Bruce Williams

 

There were no kinematics in this study - we used a simple static measure of ankle ROM (the WB lunge test).

 

In a retrospective study, if the plantar fasciitis patients had all been stretching their gastroc-soleus muscles before the study in an attempt to rid themselves of the plantar fasciitis, then it makes sense that they would have greater ankle joint dorsiflexion than the controls.

 

Kevin;

They used the lunge test to evaluate the AJ Rom in Hylton's paper. That means, as the picture in the paper shows, that the knee is flexed when the maximum AJ rom is taken.

They did not need to stretch the gastroc for the lunge test, only the Soleus!

Regardless, the use of a test such as that will not correlate with functional walking AJ ROM.

The point is, we all see severe limitations in AJ ROM in this PF patient population. Until this is addressed openly in publications people will continue to believe that AJ DFion is actually increased with Plantar Fascitis patients when that is rarely if ever the case.

Bruce

 

Bruce:

I believe Ron (Atlas), myself and a few others had quite a lengthy discussion on the problems associated with using the knee flexed lunge test for predicting walking injuries here on Podiatry Arena about a year or so ago.

However, I am sure, that if you took a group of subjects that had plantar fasciitis and had been stretching their calf muscles to treat it on their own and then the researchers did not control for whether the calf muscle had been stretched over the previous weeks or months in their groups before the retrospective research study began, then those with plantar fasciitis would have increased ankle joint dorsiflexion, whether that ankle joint dorsiflexion was evaulated with the knee extended or with the knee flexed. That is a good example of why prospective studies are always preferred in injury studies.:drinks

 

Bruce and Kevin,

The lunge test certainly has its limitations (as all clinical measurements do) which have been discussed at length previously, and were acknowledged in the paper, eg:

"...it is possible that tightness in the gastrocnemius muscle may have gone undetected in the case group"​

In our paper, the lunge test measurement was not retained in the multivariate analysis, indicating that the other two key variables - obesity and pronated foot type (using the FPI) - were more important in identifying the PF group. Hence, our key conclusion from this study was that obesity and pronated foot type may be associated with PF.

There's lots of potential explanations for the slightly higher lunge test scores in the PF group, although I think the suggestion that all the cases had been busily stretching their gastroc-soleal muscles before the study commenced is unlikely.

Our systematic review (link) found 5 studies that had examined ankle ROM (4 case-control and 1 case series). Four studies found no difference (or neglible differences) between the groups, and only one (Riddle et al) reported a significant decrease in the PF group. This review was conducted before our case-control study and that of Pohl et al.

The very limited evidence available is therefore somewhat inconclusive regarding the role of ankle ROM in PF. Ideally, to adequately answer this question you would need to undertake a large, prospective risk factor study in the general population with a long period of follow-up, but this would be logistically very difficult (not to mention expensive).

Your clinical observations may indeed be found to be correct, but it's worth keeping in mind that clinical observations of such associations are not infallible as they are inherently retrospective (patients presenting to the clinic already have the condition), and have no matched control group as a comparison.

I suspect that there may actually be a U-shaped relationship between AJDF ROM and risk of PF, ie: both extremes of inadequate and excessive ROM may contribute, but have no evidence for this.

 

Hylton;

thank you for your response, I was hoping for more from you than you initially served up... and you delivered! ;-)

I agree that my clinical findings may be proven correct or incorrect over time and study. I would definitely be skeptical of a study that proved me wrong... but old habits die hard!

My ultimate point still is that those who study foot and lower extremity related disorders continue to treat the foot with motion only at the Aknle joint, Heel/STJ, and at times the 1st mpj.

Chris Nester's work is showing more and more the importance of the dorsiflexion of the 1st and 5th metatarsals as compensation as opposed to the MTJ. I think it is time for those in academia to start to address this more valiantly in their future studies, or to at least address the potential failures of their conclusions if they do not.

There is too much going on in between the ankle and forefoot that is being regularly ignored. Future studies need to find an effective way to address this issue, or to at least mention the fact that there studies may be at a significant loss in reliability for not doing so.

thanks again sincerely;
Bruce