Tag Archives: BMI

A study to associate the Flamingo Test and the Stork Test in measuring static balance on healthy adults

by Kranti Panta, BPT1, Watson Arulsingh D.R.², Joseph Oliver Raj³, Mukesh Sinha, Mansoor Rahman4pdflrg

The Foot and Ankle Online Journal 8 (3): 4

The Flamingo and Stork tests are frequently used clinical tests to measure static balance. However, the association between these tests has not been explored to date. This study is focused on finding association between these two clinical tools in measuring static balance on healthy adults. Twenty-four healthy collegiate students were chosen on convenient sampling method. The Flamingo Static Balance Test and the Standing Stork Balance Test were carried out on all participants. Each subject was instructed on the test procedure and performed three trails on each leg, and the average was taken. Statistical Package for the Social Sciences (IBM SPSS) version 16 was used for data analysis. Test of normality was done.  Based on this, Pearson’s R Correlation Test was used.  When corelated, the Stork test values of right leg stance against the Flamingo test values of the right leg stance exhibited positive correlation r=0.646 with p= 0.001. Similarly, the Stork test values of the left leg stance against the Flamingo test values of the left leg stance exhibited positive correlation r= 0.5666, p=0.004. Hence, this study concludes that the Flamingo test and the Stork test have revealed high association to each other as a clinical tool to measure static balance with statistical significance.

Keywords single stance balance test, BMI, base of support, center of gravity

ISSN 1941-6806
doi: 10.3827/faoj.2015.0803.0004

Address correspondence to: Watson Arulsingh DR
[1] Alva’s college of physiotherapy and research centre, Moodbidri
[2] Associate professor, Alva’s college of physiotherapy and research centre, Moodbidri
[3] Professor, Alva’s college of physiotherapy and research centre, Moodbidri
[4] Lecturer, Alva’s college of physiotherapy and research centre, Moodbidri

Balance is an important aspect that helps to maintain a stable posture for performing daily activities while counteracting external or internal conflicts [1]. In terms of biomechanics, balance is the process that maintains the center of gravity (COG) or center of mass (COM) within the body’s base of support [2]. When the body is at rest it is called static balance, and when the body is at steady state motion then it is called dynamic balance [1]. The factors affecting balance are breathing, vision, vestibular function, and musculoskeletal alignment and proprioception [3]. Tests to measure static balance are FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) which includes parallel, semi-tandem, tandem, and one-legged stance test [4].

Frequently used for research purposes are functional reach test, multidirectional reach test, standing stork test and the Flamingo test. Among these, the flamingo balance test is a total body balance test in order to test static balance [2]. It achieves the requirements of simplicity, low cost, and is capable for mass investigations [2]. This test assesses the strength of the leg, pelvic, and trunk muscle, as well as dynamic balance [5]. Limitations are that equipment is required to conduct the test.  The stork test is used to monitor the development of the individual’s ability to maintain a state of equilibrium (balance) in a static position [6]. Advantages of the test is that no equipment required, it is simple to set up and conduct and it can be conducted almost anywhere. The disadvantage is that an assistant is required to conduct this test [7]. Despite the fact that both these tests are widely practiced and used for research purposes, these two tools have not been correlated to each other previously. Hence, the purpose of this study was to correlate both of these tools to look for any significance.


Figure 1 Materials; stadiometer, weighing machine, calculator, stopwatch, wooden beam.


Twenty-four collegiate students from Dakshina Kannada were taken on convenient sampling method within the age group of 18-25 of either gender for this study. Candidates were excluded if he or she had any disease or functional impairments of the auditory, visual, vestibular and proprioceptive systems, history of injury to or surgery on the lower limbs and trunk, congenital deformities, current use of any medications that might alter postural balance, presence of knee or ankle clinical instability, and presence of neurological, cardiovascular, metabolic, rheumatic diseases and underweight and obese subjects. Materials used included weighing machine, calculator, stadiometer, and a wooden beam (Figure 1).


The tests were demonstrated to all participants and the students were allowed to practice three times to avoid all possible errors. Tests were practiced with eyes open without shoes for both the right and left leg. To administer the flamingo test (Figure 2), the subject was asked to stand on the wooden beam (50 cm long, 5 cm high, 3 cm wide) with shoes removed on the tested leg and bend the free leg at the knee, and the foot of this leg was held close to the buttocks with both hands on the iliac crests, standing like a Flamingo. Participants were instructed to maintain this position as long as they can. Stopwatch was used to note each time the person loses balance either by falling off the beam or letting go of the foot being held or hands removed off the body [5]. To administer the Stork test (Figure 2), the subject was made to stand comfortably on both feet with hands on the hip and instructed to lift one leg and place the toes of that foot against the knee of the other leg. The subject was then asked to raise the heel and stand on their toes on command. The stopwatch was started as the heel was raised from the floor. The stopwatch was stopped if the hand(s) came off the hips or the supporting foot swiveled or moved in any direction, or the non-supporting foot lost contact with the knee, or the heel of the supporting foot touched the floor [6]. Every student was made to perform three attempts for each of the test and the average was recorded for statistical analysis of this study.


Figure 2 Flamingo test (left) and Stork test (right).


SPSS 16 version was used for data analysis. Test of normality was also done.  Based on this, the Pearson’s R Correlation Test was used to correlate the measurements. Table 1 describes the demographic data of particpants of this study. Table 2 illustrates the correlation analysis between the stork test and the flamingo test in the right and left leg stance. Table 3 provides mean values of the stork test values of the right leg stance. Table 4 provides mean values of the stork test values of the left leg stance.


This study resulted in showing a good association between the flamingo test and the stork test measured on 24 healthy collegiate students. This result has shown high significance in all correlation values as r values were 0.64 and 0.56 for the right leg and left leg respectively. Hence, one can understand these two tests are highly valid in measuring static balance on the young adult, provided considering all advantages and disadvantages [7] for these tests discussed previously. Stork tests normative values and its reliability is already provided for 16-19 age groups. Out of this study’s result, one can practice both the tests interchangeably to assess static balance in healthy adults.

Table 1
Participant’s demographic data. 

Table 2
Correlation analysis between stork test and flamingo in right and left leg stance. 


Table 3  Mean values of stork test values right leg stance.


Table 4 Mean values of stork test values left leg stance.


It is concluded that the flamingo test and the stork test which were administered on 24 collegiate students revealed high association to each other as a clinical tool to measure static balance with statistical significance.   Hence, both tests are found to be highly valid in measuring static balance for young adults.

Clinical Implication

Both the stork and flamingo tests are moderately associated to one another in evaluating static balance of healthy young adults. Therefore, it is recommended to evaluate static balance and can be of value in research purposes.


  1. P. Ratan Khuman, T. Kamlesh, L. Surbala. Comparison of static and dynamic balance among collegiate cricket, soccer and volleyball male players .International Journal of Health and allied Sciences; 2014, 3(1): 9-13.
  2. R. A. Bakhtiari. Evaluation of Static and Dynamic Balance and Knee Proprioception in Young Professional Soccer Players. Annals of Biological Research 2012, 3 (6):2867-2873.
  3. Young, J. Factors of Body Equilibrium & Balance Livestrong, Aug 19, 2013. [Link]
  4. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-57. [Link]
  5. Johnson BL, Nelson JK. Practical measurements for evaluation in physical education. 4th Edit. Minneapolis: Burgess, 1979.
  6. Arnot R, Gaines C. Mobility and balance. Sports Talent. Harmondsworth: Penguin, 1984.
  7. Mackenzie, B. Standing stork test – blind. 2000. [Link]

Foot Health and Elevated Body Mass Index

by H.F. Jelinek 1 , D. Fox 2 

The Foot and Ankle Online Journal 2 (8): 4

Objective: Investigate the relationship between the subcategories included in the Foot Health Status Questionnaire (FSHQ) and body mass index (BMI).
Design: Cross-sectional study of people attending a general health screening clinic.
Subjects: Fifty participants aged between 40 and 60 years filled out the FHSQ and were included in this study. These were divided into the three groups according to the BMI classification of underweight to Class 3 obesity.
Measurements: Demographic variables, blood pressure, BMI as well as medical history were recorded. Relationships between the subcategories of the FSHQ and BMI were investigated. All statistics were deemed significant if p < 0.05.
Results: We found that there is a significant correlation between BMI and foot pain (p = 0.047), foot function (p = 0.004), footwear (p = 0.007) and general foot health (p = 0.013).
Conclusion: The foot health questionnaire is an internally consistent, all in one foot health and function assessment tool, which indicated significant impact of BMI on pain, foot function and foot health, as well as choice of foot wear. These issues can ideally be addressed by primary care physicians to improve health and quality of life for people that are overweight through effective weight loss programs.

Keywords: Obesity, foot health, Body Mass Index, Foot Health Status Questionnaire.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: August, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0208.0004

Obesity is a significant health problem and the incidence of the condition is increasing. Studies by the World Health Organization have found more than one billion adults are overweight (body mass index [BMI] >25) and at least 300 million of them are clinically obese (BMI > 30). [1] In Australia, the levels of obesity have been increasing by about one percent per year since 1980.

Effect of obesity on the foot

Obesity leads to an increase in the occurrence of diverse diseases either independently or in association with other diseases and exacerbates disease progression as well as adversely affecting foot function. [2,3] Increased weight on the feet significantly increases contact areas, with increased pressure on these areas leading to increased foot problems such as pain, vascular and neuropathic disease, deformity and joint mobility. [4,5,6] The Foot Health Status Questionnaire (FHSQ) measures foot specific health related quality of life incorporating the domains of functional ability, social functioning psychological wellbeing, somatic sensation (e.g. pain), and life satisfaction. [7]

The advantage of this questionnaire is that it is internally consistent and includes both physical and psychological variables. The focus of this project was to identify if an association exists between an increased body mass index and the four domains of the Foot Health Status Questionnaire.

Foot Health Status Questionnaire

The FHSQ is comprised of three sections. Questions in section one span the four domains of foot health: foot pain, foot function, footwear, and general foot health. Psychometric evaluation of the FHSQ found that the tool demonstrated a high degree of content, criterion, and construct validity and test retest reliability. [7]


The research project was approved by the Charles Sturt University Ethics in Human Research Committee. Participants were selected via stratified random sampling from the Allied Health and Diabetes Screening Program database. Individuals had the questionnaire explained and any other questions answered prior to completing the FHSQ.

Participants completed the FHSQ version 1.03. [7] Missing items in the questionnaires (when fewer than 50% of the items for any one scale were missing) were assigned with the average value of the completed items for that scale as suggested in the instructions. [8] Statistical analysis was undertaken using Spearman’s correlation coefficient for non-normally distributed data. Significance level was set at p < 0.05 for a one tailed test.


Data from 50 participants who had completed the FHSQ was analysed. Overweight was taken as a BMI greater than 25. Participant’s characteristics are presented in Table 1.

Table 1 Participant characteristics.

Body Mass Index and FHSQ scores

The relationship between BMI divisions and FHSQ domain scores were analysed using Spearman’s rho correlation coefficient as the data was not normally distributed. There was a significant negative Spearman’s rho correlation coefficient between increased BMI and foot pain, r(47) = 27, p < 0.05, foot function, r(47) = 37, p<0.01, footwear, r(47) = 34, P < 0.01, and general foot health, r(47) = 31, P < 0.05 (Table 2). These results indicate that as BMI increases the foot health domain scores decrease.

Table 2  Correlation between FHSQ domains and BMI.


Several studies and different questionnaires have addressed foot function and foot health. However previous work has not utilised the FHSQ as a tool, which combines both function and psychological aspects of foot health.

Landorf and Keenan compared the Foot Function Index to the FHSQ, as measures of health related quality of life. These authors suggested that the FHSQ be viewed as the preferred questionnaire when evaluating health related quality of life where there is no marked impairment or disability. [9]

The findings of the study reported here suggest that obesity has a significant effect on the level of foot pain independent of condition (p<0.05). An increased BMI was also found to be associated with a reduction in perceived foot function by the participants using the FHSQ (p<0.01). This is in line with previous work but does not require separate test batteries to be performed for foot pain and foot function. [4,10] Han, et al., quantified the impairment of quality of life attributable to body fatness using the SF 36 Health Survey and concluded that quality of life measures were related to body mass index, and that participants with a high body mass index were more likely to have poor physical functions that limited many common basic activities of daily living. [11] The current study showed that comfortable and appropriate footwear was perceived as more difficult to find as BMI increased as extra wide shoe fittings are not always commercially available (p< 0.01). [12] Finally, BMI has an impact on general health as reported by previous authors. [13,14]

The relationship between obesity and foot specific health is unclear. The FHSQ is capable of measuring physical and social functioning as subjectively reported by individual, therefore the four domains of the FHSQ may be considered suitable to determine if a relationship exists between obesity, as measured by BMI, and foot specific health. Similarly covariates, such as age, gender, BMI and diabetes mellitus, account for much more of the variance explained by the foot function domain of the FHSQ than do foot disorders themselves. [10]


The findings of the present study and similar findings from other authors clearly support the concept that obesity influences foot function. The main aim of this study was to identify if a relationship existed between increased BMI and foot health as measured by the four domains of the FHSQ, foot pain, foot function, footwear, and general foot health.

This study showed that obesity has a significant effect on the level of foot pain, normal foot function, the adequate fit of footwear, and general foot health as determined by the FHSQ.


1. WHO. World Health Organisation, Global strategy on diet, physical activity and health. Available at: http://www.who.int. Accessed 14 October, 2008.
2. Hills AP, Henning EM, Byrne NM, Steele JR: The biomechanics of adiposity – structural and functional limitations of obesity and implications for movement. Obesity Reviews 3: 35 – 43, 2002.
3. Rejeski WJ, Focht BC, Messier SP, Morgan T, Pahor M, Penninx B: Obese, older adults with knee osteoarthritis: weight loss, exercise and quality of life. Health Psychology 21: 419 – 426, 2002.
4. Gravante G, Russo G, Pomara F, Ridola C: Comparison of ground reaction forces between obese and control young adults during quit standing on a baropodometric platform. Clinical Biomechanics 18: 780 – 782, 2003.
5. Lievense AM, Bierma-Zeinstra SMA, Verhagen AP, van Baar ME, Verhaar JAN, Koes BW: Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology 41: 1155 – 1162, 2004.
6. van Schie CHM, Boulton AJM: The effect of arch height and body mass on plantar pressure. Wounds 12 (4): 88 – 95, 2000.
7. Bennett PJ, Patterson CP, Wearing S, Baglioni T: Development and validation of a questionnaire designed to measure foot-health status. Journal of the American Podiatric Medical Association 88: 419 – 428, 1998.
8. Bennett PJ, Patterson CP, Dunn JE: Health related quality of life following podiatric surgery. Australasian Journal of Podiatric Medicine 32 (3): 164 – 173, 2001.
9. Landorf KB, Keenan A-M: An evaluation of two foot-specific, health-related quality-of-life measuring instruments. Foot and Ankle International. 23: 538 – 546, 2002.
10. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT: Foot musculoskeletal disorders, pain and foot-related functional limitation in older persons. Journal of the American Geriatrics Society 53: 1029 – 1033, 2005.
11. Han TS, Tijhuis MAR, Lean MEJ, Seidell JC: Quality of life in relation to overweight and body fat distribution American Journal of Public Health 88: 1814 – 1820, 1998.
12. Burns SL, Leese GP, McMurdo ME: Older people and ill fitting shoes. Postgraduate Medical Journal 78: 344 – 346, 2002.
13. Fontaine KR, Bartlett SJ, Barofsky I. Health-related quality of life among obese persons seeking and not currently seeking treatment. International Journal of Eating Disorders 27: 101 – 105, 2000.
14. Hakim Z, Wolf A, Garrison LP: Estimating the effect of changes in body mass index on health state preferences. Pharmacoeconomics 20: 393 – 404, 2002.

Address correspondence to: Herbert F. Jelinek, email: hjelinek@csu.edu.au

1,2  School of Community Health.  Diabetes Complications Screening Research Initiative (DiScRi)
Charles Sturt University, Albury, NSW 2640,Australia.

© The Foot and Ankle Online Journal, 2009

Prevalence of Equinus in Patients Diagnosed with Plantar Fasciitis

by EM Wenzel, MT(ASCP), DPM1, Z Kajgana , DPM1, KD Kelley, DPM2 , KM Mason DPM, C Ped3,
JS Wrobel, DPM4, MS, DG Armstrong DPM, PhD5,6

The Foot and Ankle Online Journal 2 (3): 1

Background: Plantar fasciitis is one of the most common complaints seen in podiatric practice. Typically, the diagnosis is made based on clinical presentation and patient history. Biomechanics is believed to also contribute to the onset of this condition through a decreased ankle joint range of motion.
Methods: The design was a retrospective case-control study of patients with plantar fasciitis (n = 23) and a control group (n = 54). Medical records from the Scholl Foot Clinic at Rosalind Franklin University were abstracted for measurements for ankle joint dorsiflexion with the knee extended and flexed along with other patient variables.
Results: Patients diagnosed with plantar fasciitis did not have a significant decrease in ankle joint dorsiflexion (p = 0.8979). A significantly higher body mass index (BMI) was noted in patients diagnosed with plantar fasciitis as compared to the control group (34 +/- 7.99 v. 29 +/-5.81; p = 0.0046). Increased plantar fasciitis was also noted in cavus foot structure (p = 0.0323) and in women (p = 0.0147 for left and p = 0.0250 for right).
Conclusions: An increased BMI, cavus foot structure, and female gender were found to be associated with a diagnosis of plantar fasciitis.

Key words: Plantar fasciitis, cavus foot, BMI.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: February, 2009
Published: March, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0203.0001

Previous research has estimated that approximately two million Americans are annually affected by plantar fasciitis [1] and it is further estimated that up to 25% of all foot injuries are due to plantar fasciitis. [2]

Plantar fasciitis, the inflammation of the plantar aponeurosis (most often of the central portion), is commonly responsible for the symptoms of the heel, midfoot and forefoot pain. [1,3,4] Its diagnosis is usually made solely on history and physical examination despite the etiology of being poorly understood. [5,6]

It has been hypothesized that anatomical, biomechanical and environmental factors may influence the inflammation of the plantar aponeurosis. [7] Anatomical factors include weight, tarsal coalition, and fat atrophy, where as biomechanical and environmental factors include tight Achilles tendon and poor footwear or walking barefoot respectively. [8]

Furthermore, a plantarflexed ankle joint allows for the contraction of the fascial tissue which is stretched during the midstance possibly causing microtears which induce a reparative inflammatory response. [6] This latter consideration has led us to believe that the chief etiology might indeed be of a biomechanical nature (i.e. tight Achilles tendon), since a majority of runners have a tight Achilles tendon which leads to the plantarflexed ankle. [6]

Values for dorsiflexion of the ankle joint vary in the literature significantly and range from 0 degrees to 25 degrees.9 However, for the purpose of this study it was necessary to classify the minimum amount of motion that must occur at the ankle joint for a patient to be classified as having normal ankle joint range of motion and those with less being classified as having an equinus. While it has been found that static measures and dynamic measures are not well correlated, the most widely accepted values in the literature for static measurements, and for the purpose of this study, state that the minimum amount of dorsiflexion necessary at the ankle for the normal gait is 10 degrees of motion. [10,11,12,13,14,15]

We hypothesized that patients complaining of plantar fasciitis would have an increased incidence of equinus deformity as compared to a control group of patients who do not complain of symptoms relating to plantar fasciitis and who had no previous history of a plantar fasciitis diagnosis.


A retrospective study of patient records was performed at the Rosalind Franklin Student Clinics. The study protocol and procedures were approved by the University’s Institutional Review Board. Consecutive records from the archives were pulled from podiatric patients with a diagnosis code of plantar fasciitis, beginning before and up to March 3rd, 2005 resulting in 48 patient records. These were selected for review based upon complete record of the following criteria: age, height, weight, occupation, typical shoe gear, what elicited pain for the patient, whether radiographs were obtained and the findings, bilateral ankle joint range of motion (knee extended and flexed) and foot structure. Any chart with incomplete or missing data according to the criteria previously set forth was excluded resulting in a patient population of 23 (17 women and 6 men) with a mean ± standard deviation (SD) age of 49 ± 11 years (range 25 to 69 years).

A control group was formed from consecutive patient charts without a diagnosis code of plantar fasciitis or history of ankle joint trauma. These charts were reviewed and included upon complete notation of the following criteria: age, height, weight, occupation, typical shoe gear, bilateral ankle joint range of motion (knee extended and flexed) and foot structure.

Following chart review and exclusion criteria a group of 54 patients was formed to serve as the control group with a mean age of 49 ± 11 years (range 18 to 68 years).

Data analysis was performed using STATA (version 9.1, College Station, TX) to determine whether a significant difference existed in the prevalence of equinus between the plantar fasciitis group and the control group. Other variables were also analyzed to determine the interrelationship with plantar fasciitis including BMI, gender, shoe gear, foot structure, and occupation. For continuous predictor variables one-way analysis of variance (ANOVA) with Bartlett’s test for equal variance was used. For categorical predictor variables ANOVA with Scheffe’s Post Hoc test was utilized. For dichotomous predictor variables Fisher’s exact test was used.


While a trend towards plantar fasciitis patients having decreased ankle dorsiflexion was expected, these findings were not significant (p = 0.8979) (Figs. 1 and 2).

Figure 1  Box Plot for Degrees of Dorsiflexion Knee Extended.

Figure 2  Box Plot for Dorsiflexion Knee Flexed.

Mean dorsiflexion ± SD of the left ankle was found to be -1.91 ± 7.44 with the knee extended and 5.96 ± 7.85 with the knee flexed. For the right ankle these values were -1.74 ± 6.12 knee extended and 6.57 ± 7.19 knee flexed (Table 1).

A significant difference was found to exist between the control group and the plantar fasciitis group in BMI (p = 0.0046); those being diagnosed with plantar fasciitis having an increase in BMI. (Fig. 3)

Figure 3  Box Plot for BMI.

A similar trend in respect to weight (p = 0.0394) was also noted. An increased incidence of plantar fasciitis was found in those patients with a cavus foot structure (p = 0.0323). An increase in plantar fasciitis was found in women (p = 0.0147 for left and p = 0.0250 for right) (Table 2). No correlation between the patients with plantar fasciitis and their occupation, shoe gear or age was found.


In this retrospective study patients with equinus were in fact not found to have a significant difference in the formation of plantar fasciitis (p=0.8979) (Figures 1,2). A trend was noted in increased gastroc-soleal (32% greater) and gastrocnemius equinus (20% increase) as compared to the control group. Despite these trends a statistical significance was not found to exist disproving our initial hypothesis.

The etiology of equinus deformity has spawned much research into determining its associated causes and complications. Some that have been more anecdotal include increased weight, age, foot structure, sex, occupation, or poor shoe gear. Another theory has been that if an ankle joint that is already compromised by an abnormally limited range of motion, as in equinus formation, is then subjected to unusual stress or exertion, such as repetitive daily trauma to the surrounding structures, conditions such as plantar fasciitis are a probable result. [6]

Although its link to plantar fasciitis may seem obvious, there are few articles that directly state or have adequate statistical value to prove the link. Riddle, et al., state that equinus, BMI, and work related weightbearing are the most relevant risk factors in predicting plantar fasciitis. [1] However, in their more recent article on the same topic they state BMI as being the only contributory variable for a reduced Lower Extremity Functional Score. [16]

Other authors such as Warren found a higher incidence of equinus in those patients who had not had symptoms of plantar fasciitis. [17]

As obesity is an often cited cause of plantar fasciitis the weight and BMI calculations of the plantar fasciitis group were compared to the control group. [1] This was performed using the Centers for Disease Control and Prevention (CDC) guidelines for calculation and categorization: normal (BMI <25), overweight (25-<32), obese (32-<36), grossly obese (36-<40), and morbidly obese (greater than 40) based on the patient’s height and weight. [18] Data analysis revealed a significant difference existed between the two groups (p=0.0046) for BMI and also for weight (p=0.0394) supporting the theory that BMI and weight are predictive for the development of plantar fasciitis. (Fig. 3)

Gender has long been thought to play a role in the development of plantar fasciitis and women are considered to be the group most often affected with plantar fasciitis. [6]

Although this can be attributed to shoe gear difference when compared to the control group, a trend that did not reach significance could be seen in a larger number of women being afflicted with plantar fasciitis than the more evenly distributed gender of the control group (74% compared to 59%). This study revealed that women had a significant decrease in ankle joint dorsiflexion with the knee extended (p = 0.0147 for left and p = 0.0250 for right). The shoe gear of men versus women was analyzed and no significant finding could be noted. This supports the theory that decreased ankle joint dorsiflexion might be another contributory factor in plantar fasciitis development in women.

Foot structure is commonly noted a predictive factor in the formation of plantar fasciitis, pes planus being more susceptible to its formation. [7,8] In this study it was found that pes cavus feet actually had an increased incidence of plantar fasciitis than pes planus feet (p = 0.0323). Other factors such as age, occupation, and shoe gear were analyzed and no significant finding could be noted in the formation of plantar fasciitis.

There are several primary limitations for this study. First, since research was collected from previous medical chart data that was documented by students, there is a potential for evaluator variability. It is safe to assume that the ankle joint ranges of motion measurements for each patient were not done by the same person and there is a potential for differing amounts of force applied during dorsiflexion exam. [8] Since the students taking the measurements were supervised by experienced clinicians, any gross errors or miscalculations are less likely. Furthermore, Martin and McPoil state that in ankle dorsiflexion measurements, interrater reliability can be expected. [19]

Because patients self report their height and weight there is a potential under or overestimation of the BMI. Recent research however has shown that underestimation is more likely than overestimation in self reported groups. [20] This study was also limited by lack of consistent detail provided by the medical charts this study required, therefore resulting in a reduction in sample size from the initial group of patients diagnosed with plantar fasciitis. However, a larger sample size may have provided the power to detect differences in ankle joint dorsiflexion. A limitation related to the data analysis is that this study used the foot as a unit and rather than using a clustered analysis of feet.


The authors hypothesized that a greater incidence of equinus deformity could be found among patients with plantar fasciitis than in those without history of plantar fasciitis. Upon examination of the data it was found that this initial hypothesis could not be supported by the analysis. Females diagnosed with plantar fasciitis were found to have to have a significant decrease in ankle joint dorsiflexion with the knee extended. An increased BMI and weight as well as a cavus foot structure were the only variables that showed a significant increase among all patients diagnosed with plantar fasciitis as compared to the control group. Other variables such as occupation, age, and shoe gear were not found to be of statistical significance when compared to a control group.

The results of this study suggest that weight loss should be utilized as a primary conservative treatment for patients diagnosed with plantar fasciitis who have a higher than normal BMI and weight before surgical alternatives are employed. Further prospective study with a larger patient population is warranted ensuring consistent charting and including clinically measured height and weight data.


1. Riddle DL, Pulisic M, Pidcoe P, Johnson RE: Risk factors for plantar fasciitis: A matched case-control study. J Bone Joint Surg 85A: 872 – 877, 2003.
2. Landorf KB, Keenan AM, Herbert RD: Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis. JAPMA 94 (6): 542 – 549, 2004.
3. Ward ED, Smith KM, Cocheba JR, Patterson PE, Phillips RD: In vivo forces in the plantar fascia during the stance phase of gait. JAPMA 93 (6): 429 – 442, 2003.
4. DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST Jr, Cziernecki J, Sangeorzan BJ: Isolated gastrocnemius tightness. J Bone Joint Surg 84A: 962 – 970, 2002.
5. Gheluwe BV, Kirby KA, Roosen P, Phillips RD: Reliability and accuracy of biomechanical measurements of the lower extremities. JAPMA 92 (6): 317 – 326, 2002.
6. Singh D, Angel J, Bentley G, Trevino SG: Fortnightly review: Plantar fasciitis. BMJ 315 (July): 172 – 175, 1997.
7. Richie DH: The best treatments for plantar heel pain. Podiatry Management 135, August 2002. Access date and url is required.
8. Martin JE, Hosch JC, Goforth WP, Murff RT, Lynch DM, Odom RD: Mechanical treatment of plantar fasciitis: A prospective study. JAPMA 91 (2): 55 – 62, 2001.
9. Saxena A, Kim W: Ankle dorsiflexion in adolescent athletes. JAPMA 93 (4): 312 – 314 , 2003.
10. Knutzen KM, Price A. Lower extremity static and dynamic relationships with rearfoot motion in gait. JAPMA 84 (4): 171 – 180, 1994.
11. Nuber GW. Biomechanics of the foot and ankle during gait. Clin Sports Med 7 (1): 1 – 13, 1988.
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Address correspondence to: KD Kelly, DPM PGY-2 resident in Podiatric Medicine and Surgery at the Central Alabama Veterans Health Care System in Montgomery, Alabama.
E-mail: Kristin.Kelley@va.gov

PGY-II Podiatry Resident, Forum Health/Western Reserve Care System Podiatric Residency Program
PGY-II Chief Podiatry Resident, Central Alabama Veterans’ Health Care System
Chair, Department of Biomechanics and Orthopedics
Director, Outcomes Research, Center for Lower Extremity and Ambulatory, CLEAR
Chair, Research; Assistant Dean; Professor of Surgery
Director, Center for Lower Extremity and Ambulatory Research, CLEAR

© The Foot and Ankle Online Journal, 2009