Abstract
Background
Plantar fasciitis (PF) affects approximately 2 million individuals per year, affecting approximately 10–25% of runners around the world. It is considered to have a great impact on health, especially due to the pain and functional limitations of the feet and lower limbs. Thus, the objective of this randomized clinical trial was to verify the effect of gait retraining with real-time visual feedback on pain, function, and biomechanical parameters of plantar loading in runners with and without PF.
Methods
Controlled, clinical trial with blinded evaluators. Participants: 24 runners were evaluated and divided into two groups: 12 runners with plantar fasciitis (39.3 years, 78.3 kg, 1.73 cm, 58% male and 42% female) and 12 control runners (40.4 years, 75,1 kg, 1.70 cm, 59% male and 41% female). The assessments were performed pre-intervention and post-intervention. The intervention protocol consisted of gait retraining during treadmill running, for 5 consecutive weeks, over two months (2 sessions/week, 40 min/session, total of 10 sessions). During treadmill running at self-selected and progressively increased speeds (3–12 km/h), participants received real-time visual feedback on vertical ground reaction force and foot support via a front-facing monitor. They were instructed to “run as softly as possible,” encouraging midfoot strike and reducing rearfoot impact. Primary outcomes were: feet pain by visual analogue scale and plantar pressure during gait on the pressure platform. Secondary outcomes were: functionality of the feet and lower limbs, evaluated through the questionnaires: Foot Function Index, Foot and Ankle Ability Measure and Lower Extremity Functional Scale, and the Foot Posture Index. Data were analyzed according to intention-to-treat.
Results
Runners with PF presented improvement in pain (p = 0.001, d = 0.92).and physical-functional performance (FFI p = 0.001 d = 0.80; FAAM p = 0.003 d = 0.59; LEFS p = 0.023 d = 0.47), as well as a reduction in plantar overload on the rearfoot (medial p = 0.035 d = 0.57; lateral p = 0.020 d = 0.50) after the intervention protocol when compared to the initial assessment and control, but without difference to FPI (p > 0.005). In relation to the control group, there were no significant differences after intervention in physical-functional performance, but there was a reduction in the loading rate on the rearfoot (medial p = 0.027 d = 0.35; lateral p = 0.024 d = 0.36).
Conclusion
Gait retraining program using real-time visual biofeedback, 10 sessions over five weeks across two consecutive months, effectively reduced rearfoot plantar pressure and pain, while improving foot and lower limb function in runners with plantar fasciitis.
Trial registration
RBR-5m6msq7; registration date: 21/03/2024.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13102-025-01471-1.
Keywords: Retraining, Gait, Pain, Function, Runners, Exercise
Introduction
Plantar fasciitis (PF) affects approximately 2 million individuals annually, with 10–25% of runners worldwide impacted by the condition [1]. It is recognized for its significant health impact, primarily due to the pain and functional limitations it causes in the feet [2, 3]. PF is the third most common injury among runners [4], resulting in health-related costs ranging from $192 million to $376 million [5]. These costs are further exacerbated by lost productivity, including work absenteeism and decreased participation in sports activities [6]. PF is a musculoskeletal disorder of inflammatory and degenerative origin, typically causing pain in the inferomedial region of the calcaneus [7]. It is believed that weakness or atrophy of the intrinsic foot muscles occurs in both acute and chronic phases of PF in runners, leading to increased plantar overload and greater functional impairment in sports performance [8–15].
Evidence suggests that reduced strength of the intrinsic foot muscles contributes to mechanical inefficiency of the plantar arch, increasing tension on the plantar fascia and promoting the onset of acute PF, which can progress to the chronic phase over time [9–12, 16]. As a result, reducing overload is a key goal in conservative PF treatment [17]. However, treatment is complex due to limited understanding of the pathophysiology, as PF transitions from acute inflammation to chronic degeneration of the plantar fascia collagen fibers [11, 16, 17]. The condition’s cyclical nature, with periods of remission and relapse, complicates the development of effective treatment strategies by healthcare professionals [18, 19].
Conservative treatments focusing on the intrinsic foot muscles for PF are extremely important for gait [19]. A study with healthy individuals showed that the functions of the plantar intrinsic foot muscles include shock absorption and facilitation of efficient foot-ground force transmission during the stance phase of gait [19]. Thus, the relationship between hypofunction of the plantar intrinsic foot muscles and PF has been suggested [19–21]. With this in mind, some clinical studies have been conducted in individuals with PF to improve the distribution of impact forces during gait and foot functionality [20–24]. Two studies combined intrinsic muscle exercises with other therapies such as manual therapy and electrotherapy, making it difficult to isolate the effect of the muscle exercises [20, 21]. Another study found no difference between intrinsic muscle exercises and calf stretching for 8 weeks [22], while one reported pain reduction and improved function with high-load strength training [23]. A final study simply described an intrinsic muscle exercise protocol for PF [24].
Recent studies also highlight the effectiveness of gait retraining to reduce vertical loading rates in runners by improving foot muscle balance and impact absorption [25, 26]. Gait retraining with real-time visual feedback is a method that provides runners with immediate visual cues—usually via a screen—during treadmill running to encourage biomechanical adjustments, such as reducing impact forces and adopting a midfoot strike pattern [26, 27]. This technique aims to promote motor learning and optimize foot-ground interaction by modifying gait in real time. Compared to other interventions like manual therapy, stretching, or strengthening exercises, gait retraining directly targets the running mechanics that contribute to plantar overload, offering a more dynamic and task-specific therapeutic approach [27].
A controlled trial by Neto, Lopes, and Ribeiro (2022) [27] found that a two-week gait retraining program with visual biofeedback reduced rearfoot plantar load and improved arch index support in recreational runners, while also decreasing foot pronation. Another study combining gait retraining with minimalist footwear for 12 weeks reduced peak impact force and rearfoot loading, promoting plantar flexion and potentially lowering injury risk from impact forces [28]. Additionally, a clinical trial with runners suffering from injuries, including patellofemoral syndrome, showed that eight weeks of gait retraining reduced vertical load rates when combined with exercise [29], while a two-week protocol reduced muscular activity during stance and improved the swing phase, minimizing plantar loading impact [30].
Although gait retraining has demonstrated positive effects in healthy runners [27] and those with knee injuries [28–30], its specific effectiveness in individuals with plantar fasciitis (PF) remains unclear. This uncertainty may be attributed to characteristic factors of the condition, such as muscle atrophy in both acute and chronic stages, functional impairments, and excessive rearfoot loading [8–16]. These factors are important, especially after the negative impact of the COVID-19 pandemic on recreational runners, leading to decreased performance, worsening PF symptoms and increasing the risk of other injuries upon returning to running [31–34]. From a biomechanical perspective, a predominant rearfoot strike pattern has been associated with higher vertical loading rates and increased tensile stress on the plantar fascia, contributing to symptom persistence and tissue degeneration [35–37]. In contrast, a midfoot or forefoot strike tends to distribute plantar loads more evenly and reduce impact transients, potentially alleviating fascia strain [38–40]. These alterations in strike mechanics, combined with intrinsic muscle weakness, may compromise running performance and perpetuate pain and dysfunction in individuals with PF [11, 16]. Understanding these factors is essential for optimizing conservative treatment strategies aimed at reducing pain and improving function in runners with PF.
Given the altered gait patterns and abnormal plantar pressure distribution observed in individuals with PF, it is critical to explore interventions that directly target these biomechanical dysfunctions. Real-time visual biofeedback during gait retraining has emerged as a promising strategy to promote motor learning and optimize loading patterns by encouraging a softer landing and midfoot strike. While previous studies have investigated intrinsic foot muscle strengthening and its effects on plantar loading and function, the findings remain inconclusive due to methodological heterogeneity and difficulty in isolating intervention effects. Although gait retraining with visual biofeedback has demonstrated positive outcomes in healthy runners [27] and those with knee injuries [28–30], its isolated application in runners with PF—a group characterized by muscular deficits and rearfoot overload—remains underexplored.
Therefore, this study aims of this clinical trial (RCT) was to investigate the effects of a gait retraining program with real-time visual biofeedback on pain, function, and biomechanical parameters of plantar loading in runners with and without plantar fasciitis. We hypothesized that runners with PF undergoing a 10-session treadmill gait retraining program with real-time visual feedback would show (1) significant improvements in pain, plantar loading patterns, and foot and lower limb function from pre- to post-intervention (within-group), and (2) greater improvements in these outcomes compared to control runners (between-group).
Methods and analysis
Study design and sample selection
This is a controlled and single-blinded clinical trial, in which 24 recreational runners were evaluated and allocated into two groups based on clinical diagnosis: with plantar fasciitis (PF group) and healthy controls (control group), between the years of March and December 2024, participants in running events or sports clubs from different regions of the city of São Paulo/SP. The study protocol was reviewed and approved by the Departmental Research Committee of the University Local (number: 5.503.901), in accordance with the Helsinki Declaration and relevant guidelines and regulations. Prior to participation, all participants electronically signed the free and informed consent form, in accordance with resolution 466/12 of the National Health Council. The study protocol is in accordance with the recommendations set out in the Standard Protocol Items: Recommendations for Interventional Trials and Consolidated Standards of Reporting Trial Guidelines (Fig. 1) and was registered on the clinical trial platform (trial registration number: RBR-5m6msq7; registration date: 21/03/2024 on Committee of the University Santo Amaro-UNISA and study start date). In addition, study adheres to CONSORT guidelines.
Fig. 1.
Consort: Flow diagram
Participants
The runners were divided into two groups: 12 runners with plantar fasciitis and 12 control runners without injury in the previous 6 months. Runners from both groups were evaluated at two different times: (1) pre-intervention and (2) post-intervention with gait retraining with visual feedback.
As inclusion criteria, runners were required to present: age between 20 and 50 years, of both sexes, running experience of at least two years, running at least 20 km per week, having experience in long-distance races or competitions, and regular pattern of rearfoot support. Exclusion criteria were: history of previous foot surgery, trauma or fractures in the previous six months, and musculoskeletal disorders, such as: neuropathies, obesity, rheumatoid arthritis, tendonitis, bursitis, ankylosing spondylitis, and difference in length of lower limbs greater than 1.5 cm [16, 17].
Diagnosis of unilateral plantar fasciitis in all runners was confirmed through clinical and ultrasound examinations, which revealed inflammation, perifascial fluid, and changes in the plantar fascia tissue, such as thickening, fragmentation, degeneration, and hypoechoic alterations at the calcaneus [16, 17]. These runners experienced pain when palpating the plantar fascia, upon waking, standing, taking the first steps, after prolonged sitting, and during physical activities [17].
Clinical and functional assessment protocol for the feet and lower limbs
The clinical assessment included a diagnosis by the responsible physician using clinical and ultrasound examinations to monitor PF. The Visual Analogue Scale (VAS) was then used to assess foot pain, with a scale from 0 (no pain) to 10 (unbearable pain) [16, 17]. Runners were asked about pain experienced during the previous week while walking and running.
The Foot Function Index (FFI), validated in portuguese, consists of 23 items assessing the impact of foot disability across three domains: foot pain (9 items), difficulty (9 items), and functional limitation (5 items). Each item is rated on a visual analogue scale from 0 to 10. Domain scores are calculated by summing responses and dividing by the number of answers. The final score, obtained by averaging the domain scores, ranges from 0 to 10, with higher scores indicating greater disability impact on the feet [35].
The Foot and Ankle Ability Measure (FAAM) evaluates foot and ankle function after musculoskeletal disorders. It includes two scales: one for daily living activities (ADL Scale) and one for sports (Sports Scale). This self-administered questionnaire contains 32 questions, scored on a 5-point Likert scale, with higher scores indicating better functional ability [36].
The Lower Extremity Functional Scale (LEFS) assesses lower limb functionality in musculoskeletal conditions. The LEFS-Brazil includes 20 items, scored on a 0–4 Likert scale (from extremely difficult to no difficulty), with a total score ranging from 0 to 80, representing maximum functional capacity [37].
Foot posture index assessment (FPI)
The Foot Posture Index (FPI) was used to assess foot posture, classifying it as supinated, pronated, or neutral. Runners were placed in an orthostatic position with feet 7.5 cm apart on an EVA rectangle for standardization. A trained physiotherapist observed three feet regions (rearfoot, midfoot, forefoot), assigning scores based on a 6-criteria scale: +2 for pronation, −2 for supination, and 0 for neutral. The final score ranges from − 12 to + 12 [17, 27]. It is worth noting that in runners with plantar fasciitis, the symptomatic foot (right or left) was used for all clinical and biomechanical assessments, including the Foot Posture Index (FPI). For participants in the control group, the dominant foot (right or left) was used for consistency.
Gait Biomechanical assessment protocol
Plantar pressure distribution during gait was assessed using a Loran® pressure platform (3240 mm x 620 mm x 20 mm, 29 kg) with resistive sensors (4 sensors/cm²). The platform was connected to a notebook to collect data at 100 Hz. Runners walked at a pre-established cadence, monitored with a stopwatch, and familiarized with the equipment. They walked 20 m on a synthetic rubber track, with data collected from the middle 10 m over three attempts, totaling about 12 steps [17, 27]. The following plantar pressure variables that were analyzed and measured: (1) Maximum peak pressure value per selected area: representing the maximum pressure value (expressed in kPa); (2) Maximum mean pressure: representing the mean value of the maximum pressure (expressed in kPa), and (3) Contact area: representing the area in which the sensors were activated (pressed) in each step (expressed in cm²). All plantar pressure variables were analyzed in 4 plantar areas of the feet. For this, the foot was divided into four areas: medial and lateral rearfoot (30% of the foot length), midfoot (30% of the foot length), and forefoot and toes (40% of the foot length) [17, 27].
Allocation and blinding
Participants were allocated into two groups according to clinical diagnosis: runners with plantar fasciitis (PF group) and healthy controls (control group). Both groups received the same gait retraining protocol with real-time visual feedback during treadmill running. The physiotherapist responsible for delivering the intervention and the researcher conducting the outcome assessments were blinded to group allocation and pre- or post-intervention time points [27]. This double blinding between evaluator and therapist helped reduce measurement and performance bias after intervention.
Primary and secondary outcomes
Primary outcomes were foot pain (VAS) and plantar pressure during gait (pressure platform). Secondary outcomes included foot and lower limb functionality, assessed by the Foot Function Index, Foot and Ankle Ability Measure, Lower Extremity Functional Scale, and Foot Posture Index.
Intervention protocol with treadmill gait retraining and visual feedback
The intervention protocol with treadmill gait retraining and visual feedback was carried out for a period of five consecutive weeks, (2 sessions/week, lasting 40 min/session, totaling 10 sessions) over two months to the overall study duration, established by Neto, Lopes and Ribeiro (2022) [27]. During training, participants were asked to run on the treadmill at a self-selected speed, with gradual progression during training. All gait retraining sessions were supervised and performed within each participant’s pain tolerance, emphasizing soft landings and progressive load adjustment to ensure comfort and safety.
Participants ran at a self-selected speed, gradually increasing from 3, 6, 9 to 12 km/h, while visual biofeedback showing vertical ground reaction force and foot support, was displayed on a monitor in front of them. The aim was to reduce rearfoot impact by encouraging runners to “run as softly as possible,” focusing on midfoot support. Training lasted 40 minutes per session over the 5 consecutive weeks (Fig. 2). The running speed on the treadmill was gradually and progressively increased by 3, 6, 9, and 12 km/h, in order to respect the runner’s pain threshold or their discomfort, as established by Neto, Lopes, and Ribeiro (2022) [27]. Participants were not explicitly instructed to adopt a midfoot strike. Rather, they received the cue to ‘run as softly as possible’ while monitoring real-time visual feedback of ground reaction forces, which encouraged a more balanced foot contact and reduced rearfoot loading.
Fig. 2.
Demonstration of gait retraining with visual feedback on the treadmill in runners with and without plantar fasciitis
After treadmill gait retraining with visual feedback, static plantar support retraining was performed to correct foot pronation. Runners stood barefoot on the pressure platform for 10 min, receiving visual biofeedback on foot oscillation and peak pressure on the rearfoot for self-correction. No verbal guidance was provided by the physiotherapist during the intervention protocol [27]. Participants in the control group received the same gait retraining with visual feedback to avoid bias in evaluating the intervention’s effect on PF. Reassessments were conducted after completing the intervention [27].
Data management, monitoring and sharing
All trial data were compiled electronically, with integrity and validity verified during entry. The project manager and research assistant monitored datasets and recommended protocol modifications or study termination. Compliance was monitored by recording attendance at each session; participants who completed fewer than 80% of sessions were excluded from the final analysis (although no dropouts occurred in this study). Participant data underlying the results were shared after blinding, following publication. The study protocol and clinical trial report, including statistical analysis, were available from the researchers. Data access requests should be directed to anapribeiro@prof.unisa.br, with a signed agreement. Any protocol changes were reported to the research ethics committee and included in the clinical trial registry.
Statistical analyses
Intention-to-treat statistical analysis were conducted. Both intention-to-treat and per-protocol analyses were performed; missing data were imputed as appropriate, although no dropouts occurred. Per protocol analysis were include only patients who attend at least 80% of the sessions and complete the follow-up in the allocated intervention group. The required sample size (n = 24) was calculated for the primary outcome variable (peak pressure and maximum force driven by the vertical ground reaction force) using the G*Power program, considering a moderate effect size (F = 0, 25), power of 80%, and a significance level of 5%. Data normality was tested using the Shapiro-Wilks test. A two-way mixed-model repeated-measures ANOVA was performed to assess differences between groups and intervention, followed by Tukey post-hoc tests. This study involved two independent groups (runners with PF and healthy controls) assessed at two different time points (pre- and post-intervention). This structure is best analyzed using a two-way mixed-design ANOVA, which allows simultaneous testing of: Main effect of group (differences between PF and control groups, regardless of time); Main effect of time (changes over time, regardless of group), and Group × time interaction (whether the change over time differs between groups). Using multiple t-tests would not only increase the risk of Type I error inflation due to multiple comparisons, but also prevent us from detecting interaction effects, which are central to evaluating the differential effect of the intervention between groups. Therefore, the two-way mixed ANOVA was the most statistically appropriate and efficient method for our research question. Furthermore, to calculate the effect size, the Cohen d test was used, with values of 0.2, 0.5, and 0.8 being considered small, medium, and large effect sizes, respectively. For all analyses, a significance level of 5% was adopted. All statistical analyses were performed using SPSS version 24 (IBM, Chicago, IL, USA).
Patient and public involvement
The authors state that neither patients nor the public were involved in the intervention protocol of this study, i.e., maintaining the blinding for the different intervention groups. However, patients were actively involved in the intervention protocol, as a marker of good research practice because it leads to research that is relevant, better designed, with clearer outcomes, and a faster uptake of new evidence.
Results
Initially, 35 runners volunteered to participate in this study, of whom 11 were excluded due to running experience < 1 year, age over 55 years, and forefoot running. Thus, a total of 24 runners participated and completed the entire evaluation process and intervention protocol (Fig. 2).
In Table 1, it can be observed that runners with and without PF did not differ in anthropometric characteristics, running experience, and weekly training volume.
Table 1.
Comparison of anthropometric aspects and time spent practicing physical exercise between different assessment times
| Variables | Runners (n = 24) | ||
|---|---|---|---|
| PF (n = 12) |
CG (n = 12) |
p | |
| Age (years) | 39.3 ± 8.3 | 40.4 ± 9.6 | 0.809 |
| Weight (Kg) | 78.3 ± 14.5 | 75.1 ± 13.3 | 0.170 |
| Height (m) | 1.73 ± 8.8 | 1.70 ± 9.1 | 0.380 |
| BMI (kg/m²) | 24.0 ± 2.3 | 22.0 ± 2.6 | 0.654 |
| Running experience (years) | 6.2 ± 3.5 | 5.9 ± 3.6 | 0.121 |
| Training volume (km/week) | 57.9 ± 10.1 | 61.5 ± 9.5 | 0.724 |
| Sex (F and M) |
42% (F) 58% (M) |
41% (F) 59% (M) |
- |
Legend: BMI: Body Mass Index; (F): female; (M): male
* ANOVA test, two-way, significant differences p < 0.05
Table 2 shows the results for physical-functional performance and pain perception. Runners with PF demonstrated significant improvements after the intervention: Foot Function Index (FFI) reduced from 4.0 ± 1.5 to 1.8 ± 0.7 (p = 0.001; Cohen’s d = 0.80), indicating a large effect size. FAAM improved from 62.4 ± 16.4 to 97.5 ± 9.3 (p = 0.003; d = 0.59), a moderate effect. LEFS increased from 16.8 ± 1.4 to 32.8 ± 4.5 (p = 0.023; d = 0.47), showing a small-to-moderate effect. Pain score dropped significantly from 7.9 ± 1.5 to 3.9 ± 1.8 (p = 0.001; d = 0.92), a large and clinically meaningful reduction. In contrast, the control group showed no significant changes across these measures, with small or negligible effect sizes (e.g., FFI pre = 0.6 ± 0.2; post = 0.5 ± 0.1; d = 0.10). Between-group comparison after the intervention showed statistically significant differences for FFI (p = 0.010) and FAAM (p = 0.057), favoring the PF group.
Table 2.
Analysis of physical-functional performance between groups of runners: PF and control, and pre and post - intervention protocol (gait retraining with visual feedback during treadmill running)
| Pain and Physical-functional performance | Intervention protocol | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Time | PF (n = 12) |
IC
95% |
CG (n = 12) |
IC
95% |
p # | ||||
| Foot Function Index - FFI (score) |
Pre Post |
4.0 ± 1.5 1.8 ± 0.7 |
2.7–5.1 1.4–2.2 |
0.6 ± 0.2 0.5 ± 0.1 |
0.4–0.9 0.3–0.6 |
0.001# 0.010# |
|||
|
p Cohen’s d |
0.001* 0.80 |
0.987 0.10 |
|||||||
| Foot and Ankle Ability Measure - FAAM (score) |
Pre Post |
62.4 ± 16.4 97.5 ± 9.3 |
47.4 ± 80.9 94.9 ± 100 |
97.5 ± 5.0 99.6 ± 0.5 |
94.3–100 98.4–100 |
0.011# 0.057 |
|||
|
p Cohen’s d |
0.003* 0.59 |
0.122 0.40 |
|||||||
| Lower Extremity Functional Scale - LEFS (score) |
Pre Post |
16.8 ± 1.4 32.8 ± 4.5 |
15.9–17.8 21.0–44.5.0.5 |
78.2 ± 1.6 80.0 ± 2.8 |
76.1–79.8 78.1–80.0 |
0.001# 0.001# |
|||
|
p Cohen’s d |
0.023* 0.47 |
0.563 0.30 |
|||||||
ANOVA test, two-way, significant differencesp< 0.05
Significant differences between moments: *pre and post-intervention #inter-groups (FP and CG) after intervention protocol
Table 3 shows no significant changes in the Foot Posture Index (FPI) in either group: for the PF group, right foot FPI changed from 2.8 ± 1.4 to 2.2 ± 1.8 (p = 0.450; d = 0.37), and left foot from 1.7 ± 0.9 to 2.0 ± 1.1 (p = 0.835; d = 0.29), both indicating small effect sizes. The control group had negligible changes with minimal effect sizes (right foot d = 0.05; left foot d = 0.23). No significant between-group differences were found at any time point.
Table 3.
Analysis of the foot posture Index - FPI between groups of runners: FP and control, and pre and post - intervention protocol (gait retraining with visual feedback during treadmill running)
| FPI | Intervention protocol | |||||||
|---|---|---|---|---|---|---|---|---|
| Time | PF (n = 12) |
IC
95% |
CG (n = 12) |
IC
95% |
p # | |||
| Right Foot (score) |
Pre Post |
2.8 ± 1.4 2.2 ± 1.8 |
0.8–3.3 1.4–2.8 |
3.0 ± 2.0 2.9 ± 1.9 |
1.8–4.7 2.1–4.0.1.0 |
0.271 0.764 |
||
|
p* Cohen’s d |
0.450 0.37 |
0.932 0.05 |
||||||
| Left foot (score) |
Pre Post |
1.7 ± 0.9 2.0 ± 1.1 |
0.7–2.9 1.0–2.4.0.4 |
2.4 ± 0.7 2.6 ± 1.0 |
1.9–2.8 2.0–2.7.0.7 |
0.573 0.605 |
||
|
p* Cohen’s d |
0.835 0.29 |
0.905 0.23 |
||||||
ANOVA test, two-way, significant differences p < 0.05
Significant differences between moments: *pre and post-intervention #intergroups (FP and CG) after intervention protocol
Table 4 presents biomechanical gait outcomes. For runners with PF, significant improvements were observed in plantar load distribution, especially in the rearfoot: Peak pressure in the medial rearfoot decreased from 333.7 ± 97.4 to 288.4 ± 54.4 KPa (p = 0.035; d = 0.57). Lateral rearfoot peak pressure also reduced from 327.8 ± 93.0 to 290.8 ± 64.5 KPa (p = 0.020; d = 0.50). Maximum force in the medial rearfoot dropped from 31.4 ± 9.2 to 24.0 ± 10.7 N/BW (p = 0.051; d = 0.44), and in the lateral rearfoot from 32.3 ± 9.6 to 26.5 ± 12.7 N/BW (p = 0.037; d = 0.24). In the control group, changes were also statistically significant in some regions (e.g., medial rearfoot force p = 0.021), but effect sizes remained small (d ≈ 0.3–0.4). Between-group comparisons post-intervention confirmed greater improvements in the PF group for rearfoot pressure and force (e.g., medial rearfoot peak pressure p = 0.001; lateral rearfoot pressure p = 0.032).
Table 4.
Comparison of Biomechanical gait parameters between groups of runners: with plantar fasciitis (FP) and control (CG), and pre and post - intervention protocol (gait retraining with visual feedback during treadmill running)
| PF | CG | Post FP-GC | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Plantar Load | Foot Regions | Pre | Post | d | p * | Pre | Post | d | p * | p # |
|
Contact Area (cm2) |
Forefoot | 10.7 ± 1.3 | 10.4 ± 1.5 | 0.21 | 0.410 | 10.4 ± 1.5 | 10.6 ± 1.8 | 0.12 | 0.712 | 0.423 |
| IC 95% | 10.1–11.3 | 9.8–11.0 | - | - | 9.8–11.3 | 9.4–11.2 | - | - | - | |
| Midfoot | 1.6 ± 9.5 | 8.7 ± 3.6 | 0.40 | 0.339 | 8.7 ± 4.8 | 9.1 ± 5.6 | 0.07 | 0.587 | 0.287 | |
| IC 95% | 6.6–16.4 | 4.7–11.8 | - | - | 5.4–12.7 | 5.9–15.4 | - | - | - | |
| Medial rearfoot | 29.0 ± 14.3 | 20.9 ± 3.4 | 0.77 | 0.314 | 20.0 ± 3.4 | 19.3 ± 3.1 | 0.21 | 0.603 | 0.764 | |
| IC 95% | 25.6–38.3 | 18.7–21.5 | - | - | 17.9–21.5 | 18.6–20.8 | - | - | - | |
| Lateral rearfoot | 20.1 ± 4.2 | 20.4 ± 3.2 | 0.08 | 0.815 | 20.5 ± 3.6 | 19.9 ± 3.0 | 0.18 | 0.941 | 0.786 | |
| IC 95% | 18.1–22.0 | 18.9–21.8 | - | - | 18.6–21.4 | 18.4–21.5 | - | - | - | |
|
Peak Pressure (KPa) |
Forefoot | 331.8 ± 61.4 | 340.0 ± 57.7 | 0.13 | 0.572 | 372.2 ± 53.3 | 367.2 ± 50.7 | 0.64 | 0.789 | 0.234 |
| IC 95% | 369.5–426.7.5.7 | 365.6–414.3.6.3 | - | - | 349.6–380.5.6.5 | 337.4.397.0 | - | - | - | |
| Midfoot | 102.9 ± 50.0 | 92.5 ± 61.1 | 0.18 | 0.103 | 104.8 ± 79.5 | 102.4 ± 88.0 | 0.02 | 0.452 | 0.876 | |
| IC 95% | 79.4–126.3.4.3 | 63.7–98.6 | - | - | 58.7–110.0 | 56.1–108.5.1.5 | - | - | - | |
| Medial rearfoot | 333.7 ± 97.4 | 288.4 ± 54.4 | 0.57 | 0.035* | 331.6 ± 69.7 | 302.6 ± 90.5 | 0.35 | 0.027* | 0.001* | |
| IC 95% | 288.1–379.2.1.2 | 271.0–305.8.0.8 | - | - | 264.4–340.0 | 293.7–369.5.7.5 | - | - | - | |
| Lateral rearfoot | 327.8 ± 93.0 | 290.8 ± 64.5 | 0.50 | 0.020* | 319.3 ± 81.9 | 288.2 ± 90.3 | 0.36 | 0.024* | 0.032* | |
| IC 95% | 284.3–371.3.3.3 | 260.0–304.6.0.6 | - | - | 250.1–326.3.1.3 | 280.5–358.1.5.1 | - | - | - | |
| Maximum force (N/BW) | Forefoot | 16.6 ± 4.0 | 20.0 ± 3.7 | 0.88 | 0.067 | 18.1 ± 3.8 | 17.8 ± 4.1 | 0.07 | 0.778 | 0.652 |
| IC 95% | 18.6–21.2 | 18.4–21.5 | - | - | 16.4–19.6 | 16.0–19.5.0.5 | - | - | - | |
| Midfoot | 6.2 ± 3.5 | 5.3 ± 3.2 | 0.26 | 0.481 | 5.5 ± 3.6 | 7.3 ± 4.2 | 0.46 | 0.464 | 0.588 | |
| IC 95% | 3.2–9.2 | 2.4–7.4 | - | - | 2.7–8.3 | 3.2–11.2 | - | - | - | |
| Medial rearfoot | 31.4 ± 9.2 | 24.0 ± 10.7 | 0.44 | 0.051* | 31.5 ± 9.8 | 27.8 ± 9.7 | 0.37 | 0.021* | 0.038* | |
| IC 95% | 25.7–37.0 | 26.1–29.3 | - | - | 23.2–32.3 | 27.3–35.7 | - | - | - | |
| Lateral rearfoot | 32.3 ± 9.6 | 26.5 ± 12.7 | 0.24 | 0.037* | 29.7 ± 12.1 | 29.7 ± 9.1 | 0.28 | 0.034* | 0.035* | |
| IC 95% | 27.3–37.2 | 25.1–30.8 | - | - | 22.4–30.9 | 24.6–34.7 | - | - | - | |
* ANOVA test, two-way, significant differences p < 0.05
Significant differences between moments: *pre and post-intervention #intergroups (FP and CG) after intervention protocol
Discussion
This study aimed to investigate the effects of a 10-session gait retraining program with real-time visual biofeedback on pain, plantar pressure, and physical-functional performance in recreational runners with plantar fasciitis. Our findings demonstrated that runners with PF showed a significant reduction in pain and plantar pressure on the rearfoot, along with improvements in foot and lower limb function after the intervention, reflecting short-term adaptations. These changes were not observed in the control group, except for a reduction in rearfoot loading rate, suggesting that the intervention had a clinically meaningful effect on biomechanical outcomes. The reduction in pain and rearfoot plantar pressure observed in our study is consistent with previous research indicating that gait retraining can positively influence biomechanical loading patterns and symptom relief in runners [27]. These outcomes are interpreted as short-term adaptations consistent with motor learning and load redistribution, rather than direct proof of causality. The improvement observed could be partially influenced by natural recovery, learning effects, or participant expectations, as commonly reported in pain-related interventions. However, given that all participants with PF had chronic symptoms (> 3 months), spontaneous recovery alone is unlikely to account for the magnitude of improvement observed.
Studies focusing on gait retraining for other lower limb conditions, such as patellofemoral pain and medial tibial stress syndrome, have also reported reductions in impact forces and pain [25–27, 29, 30]. However, lack of studies that have explored these effects specifically in runners with PF. Our findings extend current knowledge by demonstrating that a structured 10-session protocol with real-time visual biofeedback can produce clinically relevant improvements in functional performance and pain in PF, which have traditionally been addressed through passive therapies or isolated strengthening programs. Unlike previous interventions that often lacked objective gait monitoring, the real-time visual biofeedback employed in this study likely enhanced motor learning by stimuli immediate sensory cues that enabled participants to self-correct their foot strike patterns in real time. This continuous feedback may have facilitated a more efficient redistribution of plantar loads, thereby minimizing rearfoot overload and promoting a more balanced gait pattern.
According to Gaudette et al., (2022) [38], in a review study with runners diagnosed with patellofemoral pain syndrome, the gait retraining was shown to be effective in reducing pain and increasing functionality, aimed at increasing cadence, decreasing hip adduction, and facilitating a lower load impact pattern on the rearfoot and increased trunk inclination during running. According to the authors, gait retraining could be applied to the treatment of other injuries in runners, although there is limited evidence to support this, specifically for other running-related injuries. In the present study, we aimed to study runners with plantar fasciitis, and gait retraining promoted a reduction in foot pain after the intervention protocol), as well as increased functional performance of the feet and lower limbs. Although plantar fasciitis can resolve spontaneously in the acute phase, particularly within the first few months of symptom onset, it is important to highlight that all participants in the PF group included in this study had experienced symptoms for more than three months, meeting the criteria for chronic plantar fasciitis. Chronic cases are less likely to resolve without targeted intervention. Therefore, the improvements observed in pain, plantar loading, and foot function after the gait retraining program are unlikely to be attributed solely to natural recovery. Furthermore, the magnitude and specificity of these improvements — particularly in biomechanical parameters directly targeted by the intervention — reinforce the role of the gait retraining with visual biofeedback in promoting functional recovery.
Second Davis and Futrell (2016) [39], understanding the ideal way to retrain gait patterns in runners is extremely important, given that the human body has a considerable capacity for motor adaptation. Providing runners with the ability to alter inadequate movement patterns in order to reduce or minimize risk factors for injury is a powerful tool, which was observed in the present study, given the effectiveness of gait retraining to alleviate pain, increase the functionality of the feet, and reduce the impact of force on the rearfoot of runners with plantar fasciitis.
Scientific evidence has already observed and highlighted the effectiveness of intervention strategies with gait retraining to reduce plantar overload on the rearfoot (heel) [25, 27, 39–44]. The difference in the present study was to verify that not only was there a reduction in impact forces on the rearfoot, but also an increase in the functionality of the feet and lower limbs (hip, knee, and ankle-foot), with maintenance of the static posture of the feet, after two months of a gait retraining intervention on the treadmill. According to Doyle et al., (2022) [25], gait retraining interventions positively altered stride speed and the kinematics of knee movements in order to reduce vertical loading rates on the feet, while not affecting running performance, according to the reduction in plantar loading rate observed in the current study, however, in runners with plantar fasciitis.
Combining the intervention strategy with gait retraining and real-time visual feedback, a clinical trial study carried out for 2 consecutive weeks was effective in reducing plantar impact forces on the feet of recreational runners, as well a 62% reduction in injury incidence after two weeks of intervention [41]. While we did not assess injury incidence, this study focused on runners already diagnosed with PF, and the intervention was effective in reducing known risk factors for PF progression, such as rearfoot overload and functional limitation [11, 16, 17].
Real-time visual biofeedback, chosen for the study, was important in retraining gait on the treadmill in order to improve the proprioception of the feet of runners with plantar fasciitis, which favored the reduction in plantar overload on the support of the rearfoot, as also explored in a study with healthy runners [27]. According to Fyock et al., (2022) [45], there is level 2 evidence that supports the implementation of gait retraining with visual feedback over a period of 2 consecutive weeks (8 sessions) to conservatively treat patients diagnosed with Patellofemoral Syndrome. Still in this rationale, some studies also inferred that a gait retraining program with visual feedback in a total of 8 sessions reduces the peak tibial shock and vertical loading rates during distracted running, with a positive influence on the kinetic control of movement [46, 47].
An et al., (2019) [48], when studying brain activity, through electroencephalography, incorporating visual or auditory feedback to acquire a new gait pattern (peak acceleration and load on the heel), found that visual or auditory feedback effectively improved motor planning to acquire a new foot support pattern during treadmill gait training, compared to participants who did not receive feedback. Although the current study did not evaluate changes in runners’ brain activation in relation to gait behavior, we were able to verify that the strategy of retraining gait on the treadmill with visual feedback both reduced the plantar loading rate on the rearfoot and increased motor function. of the lower limbs. In addition, a reduction in pain during the two-month treatment period was observed in recreational runners with plantar fasciitis in relation to controls, as reported in previous studies in runners with patellofemoral syndrome and tibial stress fracture [49–51]. Therefore, the gait retraining protocol with real-time visual feedback was shown to be extremely effective and applicable for the non-invasive treatment of runners with chronic plantar fasciitis.
Most conservative treatments for runners with plantar fasciitis are aimed at reducing pain and improving function, and few clinical trials are concerned with making biomechanical alterations in the plantar support pattern [52]. In this rationale, only two recent studies were carried out with patients with plantar fasciitis and heel spurs, in which both studies observed a reduction in pain and an improvement in the functional and biomechanical patterns of plantar load with the use of minimalist shoes and insoles [17, 53]. However, the purpose of this study was to observe the effectiveness of the intervention strategy with a 10-session treadmill gait retraining program with real-time visual feedback, and not with the use of a mechanical action of the footwear or shoe insert. To this end, we were careful to have runners perform walking training on a treadmill barefoot, with slow progression in training speed, in order to mimic the influence of footwear on the motor adjustment of the lower limbs and support of the feet with less impact from strength. The results this study differs by using an active intervention (barefoot treadmill gait retraining), allowing assessment of motor adaptation in a controlled, low-impact setting. Even without altering static foot posture, we observed improvements in dynamic function and pain reduction.
Limitations and perspectives: This study presents some limitations that should be acknowledged. First, it evaluated only the short-term effects of treadmill gait retraining on running kinetics in runners with plantar fasciitis, and no post-intervention follow-up was conducted to assess the retention or durability of the observed effects. Therefore, future clinical trials are warranted to investigate the medium- and long-term outcomes of gait retraining, including monitoring of biomechanical and functional changes over time. Second, the analysis of plantar loading was restricted to the stance phase of gait, and time-series analyses, such as those using Statistical Parametric Mapping (SPM), were not performed. These methods could provide a more comprehensive understanding of the temporal distribution of plantar forces throughout the entire gait cycle. Future studies should consider incorporating continuous biomechanical analyses to capture subtle variations and adaptations over time. Finally, this study did not include a sex-stratified analysis, which may limit the interpretation of potential gender-related differences in biomechanical response to the intervention. Given known differences in running mechanics and injury patterns between males and females, future research should consider gender as a potential moderator variable, either through stratified analyses or by including interaction effects in statistical models.
Conclusion
Gait retraining program using real-time visual biofeedback, 10 sessions over five weeks across two consecutive months, effectively reduced rearfoot plantar pressure and pain, while improving foot and lower limb function in runners with plantar fasciitis. Most importantly, these observations will help healthcare professionals understand the importance of a gait retraining program that uses real-time visual biofeedback to improve pain and promote motor adjustment, by reducing the plantar pressure distribution pattern and increasing the physical-functional performance during the rehabilitation process of runners with plantar fasciitis.
Supplementary Information
Acknowledgements
The authors would like to thank the runners, sports clubs related to physical exercise practice in the state of Sao Paulo-SP, Brazil, collaborators and medical students from the different institutions involved for their contribution and valuable support during the study.
Authors’ contributions
GTB and APR contributed substantially to the conception or design of the manuscript; GTB, MALP, JCS, GSM, ALCE, GSO, RCS, PBS and APR, contributed substantially to the acquisition, analysis, and interpretation of the data. All authors participated in drafting the manuscript GTB, PBS and APR revised the manuscript critically. All authors contributed equally to the manuscript and read and approved the final version of the manuscript.
Funding
The study was financially supported by the National Council for Scientific and Technological Development (CNPq - Process number: 160055/2022-9 and 105398/2024-1).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The Institutional Review Board at Santo Amaro University, School of Medicine, approved the study, according to the Declaration of Helsinki (approval number: 5.503.901). Written informed consent was obtained from all participants above 18 years and also from parents/legal guardians of participants below 18 years. This study also was registered on the clinical trial platform (trial registration number: RBR-5m6msq7; registration date: 01/29/2024 on Committee of the University Santo Amaro-UNISA and study start date: 03/29/2024).
Consent for publication
Not applicable.
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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Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.