Abstract
Summary
By analyzing data from NHANES, we aimed to evaluate the prevalence, characteristics, and associated factors of plantar heel pain in Americans aged 20 or above.
Introduction
Plantar heel pain is a prevalent problem that affects a substantial number of adults and significantly impairing their quality of life.
Objective
To investigate the prevalence and characteristics of plantar heel pain, exploring the associated risk factors.
Methods
This is a cross-sectional study. We analyzed data from 4957 individuals aged 20 or above who participated in the 2009–2010 NHANES.
Results
Among the total 4957 US participants ≥ 20 years of age, 549 (11.1%) participants reported plantar heel pain. There was a significant difference in distribution between female and male (p = 0.002). Furthermore, participants aged between 50 and 65 years had the highest plantar heel pain prevalence of 14.5% among the entire population, however, among the female participants, those aged ≥ 65 years demonstrated the highest prevalence (19.8%) of plantar heel pain. In addition, compared to those with BMI < 25 kg/m2, BMI with 25–30 kg/m2 had 1.5-fold risk of plantar heel pain(OR:1.50, 95%CI:1.10–2.05), while BMI with 30–35 kg/m2 had a 2.1-fold higher risk and those with BMI ≧ 35 kg/m2 had a 2.7-fold risk to experience plantar heel pain. Age, BMI, female (OR:1.35, 95%CI:1.07–1.70), kidney stones history (OR:1.52, 95%CI:1.09–2.11), hypertension (OR:1.54, 95%CI:1.20–1.96) and osteoporosis (OR:1.75, 95%CI:1.10–2.78) were independent risk factors for plantar heel pain. Further subgroup analysis indicated that osteoporosis is the independent risk factor for women (OR:2.00, 95%CI:1.19–3.37) but not men (OR:0.65, 95%CI:0.15–2.86) for plantar heel pain.
Conclusion
Our findings might offer evidences for the prevention and treatment of plantar heel pain. Further prospective studies are needed to confirm our findings.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13018-024-05300-y.
Keywords: Plantar heel pain, Risk factors, Cross-sectional study, NHANES, Osteoporosis
Introduction
Plantar heel pain is a prevalent problem that affects a substantial number of adults and significantly impairing their quality of life [1].The occurrence of plantar heel pain is frequently observed in runners, and its presence of plantar heel pain in elite athletes can significantly impact their level of function, potentially necessitating an extended period of rest and exerting a notable influence on performance throughout the season [2].Moreover, Plantar heel pain has long been acknowledged as highly prevalent among the elderly population, affecting approximately one in three individuals aged over 65 years [3]. According to the study conducted by Chatterton et al., a total of 5109 questionnaires were collected, out of which 675 respondents reported experiencing posterior heel pain (12.5%) [4].In the United States, Nahin et al. [5] reported that 0.85% of adults experienced complaints related to plantar heel pain. It is reported that about 1 million patient consult the physician per year for plantar heel pain [6]. The etiology of plantar heel pain remains elusive, despite its significant impact on individuals’ daily functioning and overall quality of life as well as imposing a substantial economic burden [7]. The existing literature has consistently demonstrated that plantar heel pain is influenced by various person-level factors, such as gender, age, body mass index (BMI), and depression [8]. However, no previous study has comprehensively investigated all of these aspects within a representative general population sample frame. Therefore, the objectives of this study were to (i) investigate the prevalence and characteristics of plantar heel pain in a representative, population-based sample, (ii) examine associated risk factors of plantar heel pain.
Methods
Study population
The National Health and Nutrition Examination Survey (NHANES) is a biennial cross-sectional study conducted by the Center for Disease Control and Prevention (CDC), which aims to collect comprehensive data on the American population. The CDC has obtained written informed consent from each participant, ensuring compliance with ethical guidelines. For this study, we analyzed data from 5106 individuals aged 20 or above who participated in the 2009–2010 NHANES to determine the prevalence of plantar heel pain among U.S. civilians. All participants underwent physical examinations and medical evaluations at designated centers. Three subjects were excluded due to incomplete reporting, additionally, 146 were excluded for reporting the pain at achilles tendon, leaving a cohort of 4957 individuals reported the question of having plantar heel pain or not, including 549 cases of plantar heel pain and 4408 non-plantar heel pain cases.
Study variables and covariates
Self-reported conditions of individuals in the NHANES data were collected through methods of standardized questionnaires and medical evaluation at medical centers with professional assistance. To define diagnosis of plantar heel pain, participants were asked to recall “Besides injuries or fractures, (have you/has SP) ever had pain that is just in one of these two areas every day for at least two weeks? And was the pain at Location A on the diagram (the plantar aspect of the heel)?”. These questions were asked by trained interviews at home using the Computer-Assisted Personal Interviewing (CAPI) system. Answers included “yes, no, refused, don’t know, and missing”. Participants who refused to answer the questions, or whose answer is “I don’t know” or “missing” were excluded from the analysis. Details of questionnaires could be accessed online: https://wwwn.cdc.gov/Nchs/Nhanes/2009-2010/ARQ_F.htm#ARQ110. In combination with the epidemiological characteristics of previous plantar heel pain and NHANES data variables, we collected the following variables of Americans aged 20 and above: age, gender, race (Mexican Americans, other Hispanics, non-Hispanic whites, non-Hispanic blacks, and other race, including multi-racial), education [Less Than 9th Grade,11th Grade (Includes 12th grade with no diploma), High School Grad/GED or Equivalent, Some College or AA degree, College Graduate or above], marital status, smoking history, drinking history, body mass index (BMI), hypertension, diabetes, osteoporosis, Kidney Conditions - Urology, , , Family monthly poverty level category, Vigorous activity. Osteoporosis was defined as “Has a doctor ever told {you/SP} that {you/s/he} had osteoporosis, sometimes called thin or brittle bones?”. Answers included “yes, no, refused, don’t know, and missing”. Kidney conditions were defined as “Ever told you had weak/failing kidneys and Ever had kidney stones? Marital status included living alone (unmarried, separated, divorced, and widowed) and not living alone (living with a partner and married)”. Age was categorized as < 30years, 30-50years, 50–65 years, and ≧ 65years. BMI was calculated from self-reported height and weight, and categorized as < 25.0, 25.0–30, 30.0–35, or ≧ 35.0 kg/m2. Education Level included High school and below [Less Than 9th Grade,11th Grade (Includes 12th grade with no diploma), High School Grad/GED or Equivalent) and College graduate or above (Some College or AA degree, College Graduate or above)].All details of study variables and covariates in the present study could be accessed through the web page www.cdc.gov/nchs/nhanes.
Statistical analysis
Statistical analysis was conducted using SPSS 27.0, while the graph in this study was generated using EXCEL. Variables were assessed for normality through the Shapiro-Wilk test. Continuous data were presented as mean ± standard deviation (SD) or median with interquartile range, whereas dichotomous data were expressed as n(%). Descriptive statistics were compared using appropriate statistical tests, including Student’s T test, Mann-Whitney U test, Chi-squared test, or Fisher’s exact test based on suitability for analysis. Logistic regression analysis was performed to identify the risk factors associated with plantar heel pain. Covariates with a p-value < 0.10 in univariate analysis were included in the multivariate logistic regression analysis to explore plantar heel pain related risk factors. A significance level of p < 0.05 (two-sided) was considered statistically significant.
Results
Study population
Among the total 4957 US participants ≥ 20 years of age, 549 (11.1%) participants reported plantar heel pain. There was a significant difference in distribution between female [318(57.9%)] and male [231(42.1%)] (p = 0.002) (Table 1). Besides, 46(8.4%), 243(44.3%), 210(38.3%) and 50(9.1%) participants reported plantar heel pain among the age groups < 30 years, 30–50 years, 50–65 years and ≧ 65 years, respectively(p = 0.000). Among these, 18(7.8%), 106(45.9%), 94(40.7%) and 13(5.6%) of male participants reported plantar heel pain while 28(8.8%), 137(43.1%), 116(36.5%) and 37(11.6%) of female participants reported plantar heel pain among the age groups < 30 years, 30–50 years, 50–65 years and ≧ 65 years, respectively(p = 0.000). Further demographic characteristics were presented in Table 1. Furthermore, 78(14.2%),151(27.5%), 128(23.3%),107(19.5%) participants reported plantar heel pain among the BMI group of < 25 kg/m2, 25–30 kg/m2, 30–35 kg/m2, ≧35 kg/m2, respectively.
Table 1.
General characteristics of the study participants based on plantar heel pain
| Parameters | Total | Heel pain | Non-heel pain | p-value |
|---|---|---|---|---|
| N(%) | 4957(100.0) | 549(11.1) | 4408(88.9) | - |
| Age group(years)(n,%) | < 0.001 | |||
| <30 | 1025(20.7) | 46(8.4) | 979(22.2) | |
| 30–50 | 2092(42.2) | 243(44.3) | 1849(41.9) | |
| 50–65 | 1445(29.2) | 210(38.3) | 1235(28.0) | |
| ≧65 | 395(7.9) | 50(9.1) | 345(7.8) | |
| Age, Males | < 0.001 | |||
| <30 | 483(20.2) | 18(7.8) | 465(21.5) | |
| 30–50 | 979(40.9) | 106(45.9) | 873(40.4) | |
| 50–65 | 721(30.2) | 94(40.7) | 627(29.0) | |
| ≧65 | 208(8.7) | 13(5.6) | 195(9.0) | |
| Age, Females | < 0.001 | |||
| <30 | 542(21.1) | 28(8.8) | 514(22.9) | |
| 30–50 | 1113(43.4) | 137(43.1) | 976(43.4) | |
| 50–65 | 724(28.2) | 116(36.5) | 608(27.0) | |
| ≧65 | 187(7.3) | 37(11.6) | 150(6.7) | |
| BMI(kg/m2)(n,%) | < 0.001 | |||
| <25 | 1318(26.6) | 78(14.2) | 1240(28.1) | |
| 25–30 | 1425(28.7) | 151(27.5) | 1274(28.9) | |
| 30–35 | 872(17.6) | 128(23.3) | 744(16.9) | |
| ≧35 | 569(11.5) | 107(19.5) | 462(10.5) | |
| Data missing | 773(15.6) | 85(15.5) | 688(15.6) | |
| Gender (n,%) | 0.002 | |||
| Male | 2391(48.2) | 231(42.1) | 2160(49.0) | |
| Female | 2566(51.8) | 318(57.9) | 2248(51.0) | |
| Race(n,%) | 0.044 | |||
| Mexican American | 996(20.1) | 135(24.6) | 861(19.5) | |
| Other Hispanic | 556(11.2) | 59(10.7) | 497(11.3) | |
| Non-Hispanic White | 2180(44.0) | 239(43.5) | 1941(44.0) | |
| Non-Hispanic Black | 938(18.9) | 91(16.6) | 847(19.2) | |
| Other Race | 287(5.8) | 25(4.6) | 262(5.9) | |
| Education(n,%) | 0.167 | |||
| ≤High school | 2484(50.1) | 291(53.0) | 2193(49.8) | |
| ˃High school | 2462(49.7) | 258(47.0) | 2204(50.0) | |
| Data missing | 11(0.2) | 0(0) | 11(0.2) | |
| Marital status(n,%) | 0.005 | |||
| Not living alone | 2990(60.3) | 361(65.7) | 2629(59.6) | |
| Living alone | 1963(39.6) | 187(34.1) | 1776(40.3) | |
| Data missing | 4(0.1) | 1(0.2) | 3(0.1) | |
| Family monthly poverty level category(n,%) | 0.577 | |||
| ≦1.30 | 1796(36.2) | 205(37.3) | 1591(36.1) | |
| 1.3–1.85 | 672(13.6) | 68(12.4) | 603(13.7) | |
| > 1.85 | 2144(43.3) | 227(41.3) | 1917(43.5) | |
| Data missing | 345(6.9) | 49(8.9) | 297(6.7) | |
| Smoke in the past 12 months (n,%) | 0.139 | |||
| ≦ 100 cigarettes | 2443(55.4) | 286(52.1) | 2443(55.4) | |
| ˃100 cigarettes | 1965(44.6) | 263(47.9) | 1965(44.6) | |
| Drink in the past 12 months (n,%) | 0.019 | |||
| 0( ≦ 12 drinks) | 1029(20.8) | 136(24.8) | 2900(65.8) | |
| 1(˃12 drinks) | 3243(65.4) | 343(62.4) | 893(20.3) | |
| Data missing | 685(13.8) | 70(12.8) | 615(13.9) | |
| Hypertension (n,%) | < 0.001 | |||
| No | 3577(72.1) | 320(58.3) | 3257(73.9) | |
| Yes | 1372(27.7) | 228(41.5) | 1144(25.9) | |
| Data missing | 8(0.2) | 1(0.2) | 7(0.2) | |
| Chronic kidney disease(n,%) | 0.005 | |||
| No | 4855(97.9) | 529(96.4) | 4326(98.1) | |
| Yes | 95(1.9) | 19(3.4) | 76(1.7) | |
| Data missing | 7(0.2) | 1(0.2) | 6(0.1) | |
| Ever had kidney stones(n,%) | < 0.001 | |||
| No | 4571(92.2) | 478(87.1) | 4093(92.9) | |
| Yes | 378(7.6) | 70(12.7) | 308(7.0) | |
| Data missing | 8(0.2) | 1(0.3) | 7(0.1) | |
| Diabetes | < 0.001 | |||
| No | 4486(90.5) | 462(84.2) | 4024(91.2) | |
| Yes | 467(9.4) | 87(15.8) | 380(8.6) | |
| Data missing | 4(0.1) | 0(0) | 4(0.1) | |
| Osteoporosis | < 0.001 | |||
| No | 4785(96.5) | 513(93.7) | 4272(96.9) | |
| Yes | 164(3.3) | 35(6.0) | 129(2.9) | |
| Data missing | 8(0.2) | 1(0.3) | 7(0.2) | |
| Vigorous activity | < 0.001 | |||
| Yes | 1066(21.5) | 89(16.2) | 977(22.2) | |
| No | 3891(78.5) | 460(83.8) | 3431(77.8) |
Population prevalence of plantar heel pain
Compared to age < 30 years, there is a significant difference in the prevalence among participants with age of 30–50 years, 50–65 years and those with age ≥ 65years (p < 0.01). Furthermore, participants aged between 50 and 65 years had the highest plantar heel pain prevalence of 14.5% among the entire population,among the female participants, those aged ≥ 65 years demonstrated the highest prevalence (19.8%) of plantar heel pain(Fig. 1). The highest plantar heel pain occurs in the BMI ≥ 35 kg/m2(Fig. 1). Compared to BMI < 25 kg/m2, there is a significant difference in the prevalence among participants with a BMI of 25–30 kg/m2, 30–35 kg/m2 and those with a BMI ≥ 35 kg/m2(p = 0.000). In addition, the prevalence is highest in the Mexican Americans(13.6%) and the other prevalence is as follows: Other Hispanics(10.6%), Non-Hispanic White(11.0%), Non-Hispanic Black(9.7%) and Other Race(8.7%). Participants not living alone had the highest plantar heel pain prevalence of 12.1% among the entire population, however, the participants living alone had 9.5% (see supplementary Fig. 1 ). Additionally, the prevalence of plantar heel pain is 21.3% in individuals with osteoporosis, whereas it is only 10.7% in those without osteoporosis(Fig. 2).
Fig. 1.
The prevalence of plantar heel pain among the participants based on osteoporosis
A: The prevalence of plantar heel pain among male participants; B: The prevalence of plantar heel pain among female participants; C: The prevalence of plantar heel pain among the whole participants based on age group; D: The prevalence of plantar heel pain among the whole participants based on BMI(body mass index) group.
Fig. 2.
The prevalence of plantar heel pain among the participants based on osteoporosis
The associations between variables and plantar heel pain
Univariate analysis of the plantar heel pain and demographic characteristics were shown in Table 2. Correlated factors are age, BMI, gender, race, marital status, drink in the past 12 months, chronic kidney disease, kidney stones, hypertension, diabetes, osteoporosis and vigorous activity. However, no statistical difference was found in race, marital status, drink in the past 12 months, chronic kidney disease, diabetes and vigorous activity after multivariate analysis(we included variables with p < 0.1 in the univariate analysis). In the multivariate analysis(Table 2), participants aged 30–50 years had a 2.4- fold higher risk of experiencing plantar heel pain compared to those aged under 30 years. Similarly, participants aged 50–65 years had a 2.3-fold higher risk, while those aged 65 or above had a 2.1-fold higher risk of experiencing plantar heel pain. In addition, compared to those with BMI < 25 kg/m2, BMI with 25–30 kg/m2 had 1.5-fold risk of plantar heel pain (OR:1.50, 95%CI:1.10–2.05), while BMI with 30–35 kg/m2 had a 2.1-fold higher risk and those with BMI ≧ 35 kg/m2 had a 2.7-fold risk to experience plantar heel pain. Age, BMI, female (OR:1.35, 95%CI:1.07–1.70), ever had kidney stones (OR:1.52, 95%CI:1.09–2.11), hypertension (OR:1.54, 95%CI:1.20–1.96), osteoporosis (OR:1.75, 95%CI:1.10–2.78) were independent risk factors for plantar heel pain.
Table 2.
Associations between characteristics and plantar heel pain
| Parameters | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| 95%CI | p-value | 95%CI | p-value | |
| Age group(n,%) | ||||
| <30 | 1 [ref] | |||
| 30–50 | 2.64(1.98–3.52) | < 0.001 | 2.39(1.61–3.54) | < 0.001 |
| 50–65 | 3.57(2.66–4.78) | < 0.001 | 2.34(1.54–3.55) | < 0.001 |
| ≧65 | 3.12(2.16–4.52) | < 0.001 | 2.10(1.25–3.55) | 0.005 |
| BMI(kg/m2)(n,%) | ||||
| <25 | 1 [ref] | |||
| 25–30 | 1.70(1.33–2.19) | < 0.001 | 1.50(1.10–2.05) | 0.012 |
| 30–35 | 2.36(1.82–3.07) | < 0.001 | 2.05(1.47–2.85) | < 0.001 |
| ≧35 | 3.26(2.47–4.29) | < 0.001 | 2.71(1.91–3.85) | < 0.001 |
| Gender (n,%) (n,%) | ||||
| Male | 1 [ref] | |||
| Female | 1.32(1.11–1.58) | 0.002 | 1.35(1.07–1.70) | 0.010 |
| Race(n,%) | ||||
| Mexican American | 1 [ref] | |||
| Other Hispanic | 1.64(1.05–2.57) | 0.030 | 1.39(0.80–2.41) | 0.247 |
| Non-Hispanic White | 1.24(0.76–2.03) | 0.383 | 0.94(0.52–1.70) | 0.830 |
| Non-Hispanic Black | 1.29(0.84–1.99) | 0.247 | 1.11(0.65–1.89) | 0.698 |
| Other Race | 1.13(0.71–1.79) | 0.616 | 0.80(0.45–1.42) | 0.453 |
| Education | ||||
| ≤High school | 1 [ref] | |||
| ˃High school | 1.13(0.95–1.13) | 0.167 | - | - |
| Marital status(n,%) | ||||
| Not living alone | 1 [ref] | |||
| Living alone | 1.30(1.08–1.57) | 0.005 | 1.22(0.97–1.54) | 0.084 |
| Family monthly poverty level category | ||||
| ≦1.30 | 1 [ref] | |||
| 1.3–1.85 | 1.09(0.89–1.33) | 0.408 | - | - |
| > 1.85 | 0.95(0.72–1.27) | 0.738 | - | - |
| Smoke in the past 12 months (n,%) | ||||
| ≦ 100 cigarettes | 1 [ref] | |||
| ˃100 cigarettes | 1.14(0.96–1.37) | 0.140 | - | - |
| Drink in the past 12 months (n,%) | ||||
| 0( ≦ 12 drinks) | 1 [ref] | |||
| 1(˃12 drinks) | 0.82(0.68–0.99) | 0.047 | 0.91(0.70–1.17) | 0.443 |
| Chronic kidney disease(n,%) | ||||
| No | 1 [ref] | |||
| Yes | 2.04(1.23–3.41) | 0.006 | 0.93(0.47–1.85) | 0.844 |
| Ever had kidney stones(n,%) | ||||
| No | 1 [ref] | |||
| Yes | 1.95(1.48–2.57) | < 0.001 | 1.52(1.09–2.11) | 0.014 |
| Diabetes | ||||
| No | 1 [ref] | |||
| Yes | 1.99(1.56–2.57) | < 0.001 | 1.07(0.77–1.49) | 0.693 |
| Hypertension | ||||
| No | 1 [ref] | |||
| Yes | 1.95(1.55–2.45) | < 0.001 | 1.54(1.20–1.96) | < 0.001 |
| Osteoporosis | ||||
| No | 1 [ref] | |||
| Yes | 2.26(1.53–3.32) | < 0.001 | 1.75(1.10–2.78) | 0.018 |
| Vigorous activity | ||||
| No | 1 [ref] | |||
| Yes | 0.68(0.54–0.86) | 0.001 | 1.07(0.80–1.44) | 0.635 |
The associations between osteoporosis and plantar heel pain
As showed in Table 3, participants with osteoporosis had a higher risk of plantar heel pain in the unadjusted model(OR:2.26, 95%CI:1.54–3.32), after adjusting for age, BMI and gender( OR:1.86, 95%CI:1.21–2.86) and after additionally adjusting for race, marital status, drink in the past 12 months, smoke in the past 12 months, chronic kidney disease, diagnosed kidney stones, hypertension, diabetes, and vigorous activity, it remains statistically significant(OR:1.72, 95%CI:1.08–2.74). However, in the subgroup analysis based on gender, plantar heel pain in the male participants had no significant associations with osteoporosis in the unadjusted analysis, it remained no significant difference after adjusting for age, BMI, (OR:0.65, 95%CI:0.15–2.80) and additionally adjusted for race, marital status, drink in the past 12 months, smoke in the past 12 months, chronic kidney disease, diagnosed kidney stones, hypertension, diabetes, and vigorous activity(OR:0.65, 95%CI: 0.15–2.86). However, female participants with osteoporosis had a higher risk of plantar heel pain both in the unadjusted model (OR:2.31, 95%CI:1.53–3.50) and adjusted model ( OR:2.04, 95%CI:1.27–3.27), ( OR:2.00, 95%CI:1.19–3.37)(Table 4).
Table 3.
The associations between plantar heel pain and osteoporosis
| Parameters | Crude model | Model I | Model II | |||
|---|---|---|---|---|---|---|
| OR | p-value | OR | p-value | OR | p-value | |
| Non-Osteoporosis | Ref | Ref | Ref | |||
| Osteoporosis | 2.26(1.54–3.32) | 0.000 | 1.86(1.21–2.86) | 0.005 | 1.72(1.08–2.74) | 0.022 |
Model I:adjusted for age, BMI and gender; Model II:adjusted for age, BMI, gender, race, marital status, drink, smoke, chronic kidney disease, kidney stones, hypertension, diabetes and vigorous activity.
Table 4.
Subgroup analysis of the population based on gender for the associations between plantar heel pain and osteoporosis
| Parameters | Non-Osteoporosis | Osteoporosis(OR,95%CI) | P-value |
|---|---|---|---|
| Male | |||
| Crude model | 1[Ref] | 1.12(0.34–3.75) | 0.851 |
| Model I | 1[Ref] | 0.65(0.15–2.80) | 0.561 |
| Model II | 1[Ref] | 0.65(0.15–2.86) | 0.571 |
| Female | |||
| Crude model | 1[Ref] | 2.31(1.53–3.50) | 0.000 |
| Model I | 1[Ref] | 2.04(1.27–3.27) | 0.003 |
| Model II | 1[Ref] | 2.00(1.19–3.37) | 0.009 |
Model I:adjusted for age and BMI; Model II:adjusted for age, BMI, race, marital status, drink, smoke, chronic kidney disease, kidney stones, hypertension, diabetes and vigorous activity
Discussion
Plantar heel pain is a prevalent foot disorder with global impact, significantly impairing individuals’ daily activities and work productivity. This article presents the first comprehensive analysis of the prevalence and associated risk factors of plantar heel pain in the general population of the United States. Consistent with previous research findings, this study confirms that age, gender, and BMI are closely linked to plantar heel pain. Whittaker et al. [9] reported a higher proportion of female patients aged 45–64 years old experiencing plantar heel pain. Rasenberg et al. [10] identified that the highest incidence rates occurred at 50 years of age for women and 55 years for men, with a higher prevalence among individuals aged between 45 and 64 years.Thomas et al. [7] estimated an age-specific prevalence rate for chronic plantar heel pain and found it to be highest among individuals aged between 40 and 60. Our findings indicated that the highest incidence rate occurs between ages 50–65 (14.5% in this population), which aligns with Chatterton BD’s study where one in eight individuals over the age of 50 experienced plantar heel pain (12.5%) [4]. Additionally, this study revealed that among female patients, the age group exhibiting the highest prevalence of plantar heel pain was individuals aged over 65 years, with a significant incidence rate of 19.8%. Hong [11] and Ko [12] have postulated that the elevated prevalence in women may be attributed to their frequent use of high-heeled footwear. Their investigations have demonstrated that wearing high heels can induce alterations in foot biomechanics, resulting in a redistribution of pressure from the heel towards the medial aspect of the forefoot. Van et al. [13] identified an augmented incidence of post-heel pain following summer months, which is associated with changes in shoe-wearing habits.
In addition, Dufourl [14] discovered a significant correlation between BMI and foot pain in both males and females, while Rano [15] also observed a positive association between heel pain and BMI. Consistent with previous findings, in this study, the population with a BMI ≥ 35 kg/m² exhibited the most frequent cases of plantar heel pain. Compared to BMI < 25 kg/m2, there is a significant difference in the incidence rate among participants with BMI of 25–30 kg/m2, 30–35 kg/m2, and BMI ≥ 35 kg/m2. Furthermore, Chatterton et al. [4] reported in their case-control study on patients with plantar heel pain, highlighted that the control group reported higher activity levels than the patients experiencing heel pain.However, no significance was observed after adjusting for confounding factors in vigorous activity in this study, which might need to be explored further in the future. Additionally, this study revealed an intriguing connection between osteoporosis and plantar heel pain which has been scarcely explored previously. Previous research [16] primarily linked osteoporosis-related discomfort to fractures occurring in regions such as the lumbar spine and femur.
Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength, which predisposes individuals to an elevated risk of fractures [17].The World Health Organization (WHO) recommends the assessment of bone mineral density (BMD) or bone mineral content (BMC) using dual energy X-ray absorptiometry (DXA) at the lumbar spine, proximal femur, and distal 1/3 of radius as the diagnostic criteria for osteoporosis. Additionally, a T-score below − 2.5 is commonly used [18, 19]. Consistent with previous studies, Liu et al. [20] observed a significant association between osteoporosis and heel pain. Li et al. [21] found that the symptoms of plantar heel pain in the experimental group were significantly relieved through the anti-osteoporosis treatment of patients with intractable plantar heel pain. Our study support the associations between osteoporosis and plantar heel pain. In our findings, the results indicated a significantly higher likelihood of experiencing plantar heel pain among women with osteoporosis.The correlation between osteoporosis and plantar heel pain may be due to the fact that the horizontal loss of bone trabeculae is greater than the vertical loss with age [21]. The bone volume of the residual bone trabeculae decreases more significantly than the bone area under stress stimulation, which leads to the decrease of calcaneal elasticity. On the one hand, the calcaneal microfracture occurs. On the other hand, it aggravates the load of the fascia and muscle groups attached to the calcaneus, which is complicated by strain inflammation and ultimately leads to heel pain [21]. Larger prospective studies are needed to confirm this association and establish temporal relationships.
The advantage of this study lies in its novelty, as there is a paucity of previous research examining the prevalence of plantar heel pain in the general population of the United States. Furthermore, this study specifically focuses on all possible causes of plantar heel pain and screen out the more important risk factors. However, several limitations should be acknowledged in this study: (1) Potential recall bias may affect the results due to reliance on retrospective questionnaire surveys to define exposure; (2) Due to its cross-sectional design, this study precludes the establishment of temporal correlation or causality; (3)The diagnosis of osteoporosis in this article was determined by physicians through a questionnaire survey. In the United States, the diagnostic criteria for osteoporosis are based on the World Health Organization (WHO) guidelines, specifically requiring a T-score below − 2.5. However, there was no clear explanation provided for femoral neck BMD or spine BMD. Additionally, measurement of calcaneus BMD was lacking. This limitation should be acknowledged in our study. Nevertheless, based on a previous study by Jhamaria [22], the calcaneal trabeculae exhibit a scientifically and regularly arranged pattern akin to the trabecular bone found in the proximal femur, thereby facilitating weight-bearing capabilities. Additionally, Jhamaria’s five grading system [22] for calcaneus trabeculae has been found to have a strong correlation (r = 0.99, p < 0.001) with the grading system used for the upper femur bone density assessment [23]. Therefore, the utilization of femoral neck BMD in the diagnosis of osteoporosis can effectively indicate both the occurrence and extent of calcaneal osteoporosis. Definitely, the direct measurement of calcaneal BMD would yield more robust evidence to establish the correlation between calcaneal osteoporosis and heel pain.Thus further prospective studies are warranted for further validation. The main significance for this investigation is the identification of a strong association between plantar heel pain and osteoporosis, particularly among female patients. This finding sheds light on the potential link between these two conditions, providing valuable insights for healthcare professionals and researchers.
Conclusion
Our findings might offer evidences for the prevention and treatment of plantar heel pain. Further prospective studies are needed to confirm our findings.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We thank the NHANES data for being publicly available on the Internet for use by researchers worldwide.
Author contributions
Peng Liu: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Qiang Chen: Writing – review & editing, Methodology. Kun Yang: Writing – review & editing, Methodology.Fei Cai: Writing – review & editing, Supervision, Conceptualization.
Funding
NO funding.
Data availability
Publicly available datasets were analyzed in this study. This data can be found here: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), National Health and Nutrition Examination Survey (NHANES), https://wwwn.cdc.gov/nchs/nhanes/Default.aspx, NHANES 2009-2010.
Declarations
Ethics approval and consent to participate
The studies involving humans were approved by The National Center for Health Statistics. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Consent for publication
Written informed consent was obtained from each patient to authorize the publication of their data.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Publicly available datasets were analyzed in this study. This data can be found here: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), National Health and Nutrition Examination Survey (NHANES), https://wwwn.cdc.gov/nchs/nhanes/Default.aspx, NHANES 2009-2010.