Plantar Fascia Thickness and Stiffness in Healthy Individuals vs Patients With Plantar Fasciitis

Abstract

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.

Keywords

plantar fascia plantar fasciitis plantar fascia thickness plantar fascia stiffness shear wave elastography

Level of Evidence: Level III, a comparative study.

Introduction

The plantar fascia, a fibrous band connecting the calcaneal tubercle to the toes, plays a crucial role in foot function. It supports the foot arch, functions as a tie-rod tension provider during weightbearing, and aids in shock absorption while walking. Excessive loads, common in athletes and individuals with prolonged standing, can lead to plantar fasciitis.^3,4,31,34 This condition not only causes foot-related issues but also impacts overall health, limiting physical activities and social interactions.^12,35 Plantar fasciitis affects approximately 10% of the US population, with an expected 1 in 10 individuals developing the condition during their lifetime.^6,26 Similarly, data from the Faculty of Medicine, Siriraj Hospital, in Thailand indicates that more than 4000 patients are diagnosed with plantar fasciitis annually. The clinical diagnosis of plantar fasciitis relies on a patient’s medical history and physical examination. Typically, pain manifests near the anteromedial part of the heel and worsens during the initial steps in the morning.³⁸ Physical examination often reveals sensitivity and pain, particularly at the proximal plantar fascial attachment on the anteromedial part of the calcaneus during forced dorsiflexion of the toes at the metatarsophalangeal joints with a stabilized ankle (Windlass test).^7,24

The pathophysiology of plantar fasciitis involves degenerative changes in the fascia, sometimes accompanied by an inflammatory response. Histologic examination reveals fibroblastic hypertrophy, absence of inflammatory cells, disorganized collagen fibers, and deranged vascular hyperplasia with an avascular zone.¹⁶ Persistent microtrauma is believed to cause structural changes and damage at the calcaneal fascial interface.

The study benefits significantly from musculoskeletal ultrasonography because of its increasing prevalence facilitated by recent technological advancements. Ultrasonography offers widespread accessibility and relatively low cost compared with other imaging modalities like magnetic resonance imaging, making it indispensable in musculoskeletal diagnostics.^18,23,30 However, ultrasonography traditionally lacks the ability to assess tissue biomechanical properties, limiting its utility in understanding the relationship between structural changes and clinical pain.⁹ Shear wave elastography (SWE) now allows for quantitative assessment of tissue elasticity, providing valuable insights into tissue degeneration, injury, and healing processes.⁹ This technology represents a ultrasonography-based alternative to manual palpation for diagnosing and characterizing tissue conditions.^10,27

Several studies have used basic mode (B-mode) ultrasonography to investigate plantar fascia thickness, consistently finding greater thickness in plantar fasciitis patients compared to normal individuals.^13,19,25 B-mode ultrasonography reveals thickening, hypoechoic changes, perifascial fluid collections, and bony spurs in the plantar fascia but does not assess its biomechanical properties.^13,37

Currently, SWE, a noninvasive diagnostic ultrasonography modality, is used to analyze tissue biomechanical properties in both healthy and diseased conditions.¹⁴ It can detect morphologic changes and evaluate biomechanical properties such as the stiffness of the tissue. SWE records ultrasound signal changes before and after inducing mechanical stimulation to assess the biomechanical properties of tissues.²⁹ SWE was used to study the stiffness of several muscles and tendons in various studies.^1,11,15,17 Previous studies have applied SWE to study muscle and tendon stiffness, demonstrating its reliability in clinical practice.²¹

However, the biomechanical property of the plantar fascia in terms of stiffness remains unclear. Therefore, the primary objective of this study is to investigate plantar fascia stiffness using SWE in healthy participants and patients with plantar fasciitis across different areas and positions. We hypothesized that the plantar fascia stiffness in the plantar fasciitis group would be greater than in the healthy group. The secondary objective of this study is to compare the plantar fascia stiffness across different fascial locations within a group. We expected that the calcaneal insertion area would have the highest stiffness value in healthy people, whereas the most painful area would have the highest value in plantar fasciitis patients.

Material and Methods

Ethics Statement

This study was approved by Siriraj Institutional Review Board of the Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand (Si 625/2020). Participants were provided comprehensive information about the study procedures, risks, and objectives. Written consent was obtained from all participants prior to their involvement in the study.

Participants

The total sample of 58 participants was divided into 2 groups: 29 healthy individuals and 29 patients with plantar fasciitis. Healthy participants were recruited from the staff at Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand, whereas plantar fasciitis patients were enrolled from the orthopaedics outpatient clinic of Siriraj Hospital between August 2020 and February 2022. These patients had received an initial diagnosis of plantar fasciitis and were referred by an orthopaedic surgeon specializing in foot and ankle conditions.

Inclusion criteria for participants aged 20-70 years in the healthy group included no history of neurologic, psychiatric, or musculoskeletal issues. Patients with plantar fasciitis diagnosed for more than 2 months,³¹ exhibiting soreness in the medial calcaneal tubercle aggravated by big toe dorsiflexion (Windlass Test), and having a visual analog scale (VAS) score of more than 3 of 10 were included.⁵ None of the participants in the plantar fasciitis group had undergone any prior therapeutic intervention. In cases where both feet exhibited symptoms of fasciitis, the foot with the most prominent symptoms was selected.

The exclusion criteria comprised the following: individuals who had a body mass index (BMI) greater than 30,¹⁵ patients who had prior treatments, prior injections of plantar fascia within 6 months, symptoms of calcaneal stress fractures (calcaneal stress test was used by an orthopaedic physician),³⁶ foot deformities, trauma to the lower limbs, or neuromuscular disorders that specifically affected the lower limbs.

The collected and documented data included many demographic variables, such as age, height, weight, duration of disease, level of education, and occupation. The Thai version of the Foot Functional Index (FFI-TH) questionnaire was used to assess the impact of foot disease on function, including pain, disability, and activity restriction.³²

Equipment

Shear wave elastography

Plantar fascia thickness and stiffness were assessed using the LOGIQ E10 series ultrasound (GE Healthcare, Chicago, IL) at the Department of Radiology, Faculty of Medicine, Siriraj Hospital. A 2- to 9-MHz linear-array transducer was used, utilizing b-mode for thickness evaluation and SWE for stiffness assessment. SWE produced both a color map overlay for qualitative elastogram representation and quantitative measurements. During data acquisition, the transducer was positioned with very light pressure on top of a small amount of coupling gel and held stationary for 8 to 12 seconds. The transducer was oriented parallel to the plantar fascia fibers and converted shear waves to create elastograms, which are quantitative maps of tissue elasticity or stiffness values (kPa).^17,27

Measurement locations

This study focused on a single foot, identified as the dominant foot in the healthy group and the symptomatic foot in the plantar fasciitis group. Before investigation, the measuring area was defined and marked with a permanent marker, using an imaginary line from the second metatarsal bone to the calcaneal tubercle as a landmark. This was confirmed with a b-mode ultrasonography to ascertain the calcaneal insertion of the plantar fascia. Subsequently, the plantar fascia was marked at 3 points along its central part: at the calcaneal insertion (C0), 1 cm distal (C1), and 2 cm distal (C2). Additionally, the patient was asked to identify the most painful area (P1).

Research procedure

Participants were instructed to lie in a supine position with fully extended knees and ankles at rest. The protocol included 2 positions: knee fully extended with ankle dorsiflexion (ED) and knee fully extended with ankle at rest (ER). Measurements were taken at each measuring point as previously mentioned, starting from the ankle in fully dorsiflexed and resting positions, respectively.

B-mode ultrasonography was used to measure the thickness of the plantar fascia at each measuring point, as illustrated in Figure 1. Subsequently, shear wave elastography was employed to assess the stiffness of the plantar fascia at each measuring point in the previously mentioned positions. The elastography image was captured at each measuring point, as demonstrated in Figure 2. A 5-minute interval was provided for participants to recover between each examination before continuing the subsequent one. The thickness and stiffness of the plantar fascia were measured by the same radiologist from the Department of Radiology. Each measurement was taken twice, with the average result being used for analysis.

Statistical analysis

Statistical analysis was performed using SPSS (version 18.0; SPSS Inc, Chicago, IL). Descriptive data were presented as mean ± SD. Normal distribution of the data was tested by Kolmogorov-Smirnov goodness of fit test. For normally distributed data, an independent sample t test was used to analyze differences between healthy and plantar fasciitis groups. In the cases where the data did not follow a normal distribution, the Mann-Whitney U test was used. The independent sample t test was used to analyze differences between healthy and plantar fasciitis groups, whereas a paired sample t test was used to analyze differences within each group. A statistical significance was set at P value less than .05.

Results

The demographic data are displayed in Table 1. The data analysis revealed that there were 24 females among the 29 individuals in the healthy group (82.76%), whereas there were 25 females among the 29 patients in the plantar fasciitis group (86.21%). Nevertheless, no statistically significant difference was found between the 2 groups (P = .446). The average age of the healthy group was 44 ± 10.52 years, whereas the average age of the plantar fasciitis group was 49.89 ± 11.84 years (P = .105). The average BMI of the healthy group was 23.18 ± 2.86, whereas the plantar fasciitis group was 25.58 ± 2.98 (P = .003). For the FFI-TH assessment, the pain and disability scale of the plantar fasciitis group was significantly higher compared to that of the healthy group (P < .001 and P < .001, respectively). However, there was no significant difference in activity limitation between the 2 groups (P = .782). The plantar fasciitis group had an average disease duration of 10.97 ± 11.79 months.

Table 1.

Demographic Data and Characteristics of Participants.

Variable	Healthy Subjects	Plantar Fasciitis Subjects	P Value
Participants, n	29	29
Gender: female, n (%)	24 (82.76)	25 (86.21)	.446
Age, y, mean (SD)	44 (10.52)	49.89 (11.84)	.105
BMI, mean (SD)	23.18 (2.86)	25.58 (2.98)	.003*
FFI-TH
FFI pain (SD)	0	6.14 (1.9)	<.001*
FFI disability scale (SD)	0	3.83 (3.05)	<.001*
FFI activity limitation (SD)	0	0.97 (2.46)	.782
Disease duration, mo	0	10.97 (11.79)	<.001*

Abbreviations: BMI, body mass index; FFI-TH, Foot Functional Index–Thai Version.

P < .05.

Plantar Fascia Thickness Using B-mode Ultrasonography

Plantar fascia thickness was assessed in various positions (ED and ER) and areas (C0, C1, C2) (Table 2). In the ED position, plantar fascia thickness in the plantar fasciitis group was significantly greater than in the healthy group (P < .001, P < .031, and P < .014, respectively).

Table 2.

Comparison of Plantar Fascia Thickness (cm) and Stiffness (kPa) Presented as Mean (SD).

Variables	Position	Areas	Healthy Subjects	Plantar Fasciitis Subjects	P Value
Thickness, cm
	ED	C0C1C2P1	0.35 (0.09)0.32 (0.08)0.29 (0.06)–	0.49 (0.14)0.41 (0.11)0.35 (0.09)0.48 (0.14)	<.001* .031* .014*
	ER	C0C1C2P1	0.35 (0.08)0.30 (0.06)0.27 (0.05)–	0.49 (0.13)0.39 (0.10)0.34 (0.10)0.48 (0.14)	<.001* <.001* .064
Stiffness, kPa
	ED	C0C1C2P1	96.01 (36.60)80.68 (39.70)78.01 (52.65)–	155.34 (63.32)128.12 (62.83)101.08 (63.12)190.04 (71.03)	<.001* .002* .174
	ER	C0C1C2P1	98.38 (43.75)98.01 (48.06)67.11 (35.57)–	168.65 (67.39)147.95 (72.12)99.32 (50.52)180.41 (69.09)	<.001* .003* .007*

Abbreviations: ED, knee extension with ankle dorsiflexion; ER, knee extension with ankle resting position; C0, calcaneal insertion area; C1, 1-cm distal area; C2, 2-cm distal area; P1, the most painful area.

P < .05.

In the ER position, significant differences were found at C0 and C1 (P < .001 and P < .001, respectively), with the plantar fasciitis group showing thicker fascia compared to the healthy group. However, no significant difference was observed at C2 (P = .064). In both ED and ER positions, the most painful area (P1) in the plantar fasciitis group measured 0.48 ± 0.14 cm.

Plantar Fascia Stiffness Using SWE

The results of plantar fascia stiffness measurements are presented in Table 2. In the ED position, the plantar fasciitis group exhibited higher stiffness values than the healthy group. Significant differences between groups were noted in C0 and C1 (P < .001 and P = .002, respectively), but not in C2 (P = .174).

In the ER position, the plantar fasciitis group also demonstrated higher stiffness than the healthy group. Significant differences were observed between groups in all three areas (P < .001, .003, and .007, respectively).

Comparison of the Stiffness of Plantar Fascia Within Each Group

The stiffness of the plantar fascia between each area within each group is detailed in Table 3. Within the healthy group, there was no statistically significant difference found in all areas of the ED position (P > .05). During the ER position, a significant difference was observed between C0 compared to C2 area (P = .002) and C1 compared to C2 area (P = .004).

Table 3.

Comparison of the Stiffness of Plantar Fascia (kPa) Within the Group Between Each Area of Plantar Fascia Presented as Mean (SD).

Positions	Area	Stiffness (kPa)	P Value
Positions	Area	Stiffness (kPa)	C1	C2	P1
Within healthy group
ED	C0	96.01 ± 36.60	.083	.091	–
	C1	80.68 ± 39.70		.808	–
	C2	78.01 ± 52.65			–
ER	C0	98.38 ± 43.75	.962	.002*	–
	C1	98.01 ± 48.06		.004*	–
	C2	67.11 ± 35.57
Within plantar fasciitis group
ED	C0	155.34 ± 63.32	.043*	<.001*	.029*
	C1	128.12 ± 62.83		.056	<.001*
	C2	101.08 ± 63.12			<.001*
	P1	190.04 ± 71.03
ER	C0	168.65 ± 67.39	.162	<.001*	.248
	C1	147.95 ± 72.12		<.001*	.037*
	C2	99.32 ± 50.52			<.001*
	P1	180.41 ± 69.09

P < .05.

In the plantar fasciitis group, the ED position exhibited significantly higher stiffness in the P1 area compared to the C0, C1, and C2 areas (P = .029, P < .001, and P < .001, respectively). The C0 area had significantly higher stiffness than the C1 and C2 areas (P = .043 and P < .001, respectively). For the ER position, it was observed that the P1 area was stiffer than the C1 and C2 areas (P = .037 and P < .001, respectively). However, there was no significant difference between the C0 and C1 areas or the C0 and P1 areas (P = .162 and P = .248, respectively).

Discussion

The main findings of the current study demonstrate that the plantar fascia in the plantar fasciitis group displayed more stiffness compared with the healthy group, particularly at the calcaneal insertion (C0) and 1-cm distal (C1) areas across all positions. On the contrary, at the 2-cm distal area, the stiffness of the plantar fascia did not differ significantly between the healthy and plantar fasciitis groups. Furthermore, the plantar fascia stiffness in the P1 area had the strongest impact compared to other areas within the plantar fasciitis group. In addition, the plantar fasciitis group exhibited a significantly increased value of stiffness in the C0 area, indicative of the pathologic conditions present in that group.

There are some studies that evaluated the stiffness of the plantar fascia compared between normal and plantar fasciitis groups.^2,11,28 The results consistently showed that patients exhibited lower stiffness than normal subjects. This contrasts with our findings, which found higher stiffness in the plantar fasciitis. Gatz et al¹¹ were the first to investigate the stiffness of the plantar fascia among asymptomatic, unilateral asymptomatic, and symptomatic plantar fascia using SWE. They reported that the plantar fasciitis group had significantly lower stiffness than the normal group. However, the authors mentioned that the plantar fasciitis group had received different treatments before testing.¹¹ Consequently, the fact that the findings of this research diverge from those of our study could potentially be a significant factor. The participants in our research were individuals who had not received any prior treatment. Therefore, it might be believed that physical therapy and other therapeutic modalities, including therapeutic exercise, may affect the stiffness or elasticity of the fascia.

Dirrichs et al studied the stiffness of the Achilles tendon between athletes and nonathletes. They discovered that athletes’ tendon stiffness was significantly higher than that of the nonathlete group. These findings suggest that repetitive training may cause an excessive load on the Achilles tendon of athletes, leading to higher stiffness in the tendons.⁸ Correspondingly, the plantar fascia of the plantar fasciitis group in our study had a higher stiffness than the healthy group. This could be explained by mechanical overload and excessive strain causing perifascial edema and micro-damage in the plantar fascia, resulting in significant thickening and fibrosis at the insertion point.²⁰ Consequently, it is possible that the patients in our study showed greater fascial stiffness than the general population.

The study by Liu et al²² reported that in the normal population, plantar fascia stiffness increased with increasing ankle dorsiflexion. They mentioned the stretching effect associated with the muscle-tendon-fascia unit, which leads to increased stiffness with an increasing ankle angle. Moreover, they reported that only the stiffness of the proximal part of the plantar fascia increased with increasing ankle dorsiflexion. Consistent with our study, it was found that the ankle posture is associated with plantar fascia stiffness.

Our findings also confirm that B-mode ultrasonography is a useful method for measuring plantar fascia thickness. Our findings are consistent with the previous study,^2,13 which found that plantar fascia thicker than 4 mm is related to plantar fasciitis.

The strength of our study is that the participants in the plantar fasciitis group had not previously received treatment, which eliminated any possible confounding factors. Additionally, we assessed the stiffness in 3 different areas of the plantar fascia, as well as the most painful area of the patient, which can be beneficial in clinical practice. However, the limitation of our study was the lack of measurement of the cutoff value for plantar fascia stiffness. Moreover, the study was conducted by a single experienced radiologist, and intrarater reliability was not evaluated, which could potentially introduce bias into the results. Nevertheless, shear wave elastography (SWE), being a non-manual compression technique, is known for its minimal operator dependence and high reproducibility.³³

Although this study predominantly consisted of female participants, which aligns with the typical higher prevalence of plantar fasciitis in females compared to males, researchers matched participants closely in terms of sex and age to minimize potential confounding factors. In the section on average disease duration, the wide SD is attributable to the extended disease duration among most participants. None of the patients had a disease duration of less than 2 months. We tried to address both recall bias and attrition bias in this study. To mitigate recall bias, we instructed patients before data collection to report current information, minimizing reliance on memory. Additionally, we conducted all tests and assessments within a single visit to avoid attrition bias by ensuring consistent participant engagement throughout the study period.

Conclusion

The stiffness of the plantar fascia in patients with plantar fasciitis was substantially higher than in healthy individuals. We recommend using the calcaneal insertion point and the most painful area as reference points for diagnosing plantar fascia issues. Additionally, SWE can effectively assess the plantar fascia and its changes in plantar fasciitis. In future studies, SWE could be used to evaluate plantar fascia stiffness by comparing pre- and posttreatment measurements in patients.

Supplemental Material

sj-pdf-1-fai-10.1177_10711007241274765 – Supplemental material for Plantar Fascia Thickness and Stiffness in Healthy Individuals vs Patients With Plantar Fasciitis

Supplemental material, sj-pdf-1-fai-10.1177_10711007241274765 for Plantar Fascia Thickness and Stiffness in Healthy Individuals vs Patients With Plantar Fasciitis by Tanwarat Thanwisate, Palanan Siriwanarangsun, Sitha Piyaselakul, Theerawoot Tharmviboonsri and Bavornrit Chuckpaiwong in Foot & Ankle International

Footnotes

Acknowledgements

The authors gratefully acknowledge Miss Theeraya Upachit of Department of Anatomy, Faculty of Medicine, Siriraj Hospital, for her valuable assistance with data collection.

Ethical Approval

This study was approved by Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand (Si 625/2020).

Declaration of Conflicting Interests

The 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.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Siriraj Graduate Scholarship and the Siriraj Research Fund of the Faculty of Medicine, Siriraj Hospital, Mahidol University (R016333046).

ORCID iDs

Tanwarat Thanwisate, MS,

Palanan Siriwanarangsun, MD,

Bavornrit Chuckpaiwong, MD,

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