Public knowledge of plantar fasciitis and its determinants in Saudi Arabia: A national cross-sectional study

Abstract

Introduction:

Plantar fasciitis (PF) is a leading cause of heel pain globally, imposing a significant burden on quality of life. Despite its high prevalence in Saudi Arabia, data regarding public awareness of its etiology, risk factors, and preventive measures remain limited. Understanding these gaps is essential for designing effective health education strategies. Therefore, this study aimed to evaluate public knowledge of plantar fasciitis, its risk factors, and preventive measures among adults in Saudi Arabia.

Material and Methods:

An analytical cross-sectional study was conducted, including 1,032 Saudi adults aged 18 years and older. Data were collected using an online questionnaire. The instrument comprised five sections: (1) demographic characteristics; (2) general knowledge, risk factors, and clinical features of PF; (3) sources of knowledge; (4) knowledge about treatment options; and (5) knowledge of preventive measures. Each knowledge item used a three-point response format (Yes/No/I do not know), and correct answers were scored as “1,” while incorrect and “I do not know” responses were scored as “0.” The questionnaire was administered in Arabic, and participation was voluntary and anonymous. Mann–Whitney U and Kruskal–Wallis tests were employed to assess differences in knowledge scores by demographic variables and information sources.

Results:

The analysis included 1,032 participants (59.5% male, 40.5% female). The most frequently reported information sources were the Internet (60.9%) and social media (57.2%), while professional sources were less common. Participants demonstrated moderate overall knowledge, scoring highest in treatment awareness (55.7%) and lowest in clinical features (44.7%). Of note, demographic disparities were observed: females exhibited higher mean knowledge scores than males (55.4% vs. 47.3%, P < 0.001). Furthermore, participants who obtained information from healthcare professionals achieved significantly higher knowledge scores (e.g., Family Physicians: 65.2%) compared to those relying on social media (58.3%) or the Internet (58.8%) (P < 0.001).

Conclusion:

Public knowledge of PI in Saudi Arabia is satisfactory overall, with notable deficits in understanding specific clinical symptoms and preventive strategies. While the public relies heavily on digital media for health information, this reliance is associated with lower knowledge levels compared to professional consultation. Based on these findings, we recommend integrating professional medical expertise into digital channels and employing multi-platform awareness campaign strategies to enhance public understanding and ensure high-quality information reaches the wider population.

Introduction

Plantar fasciitis (PF) is among the most common causes of heel pain in adults and is characterized by degenerative changes of the plantar fascia at its calcaneal attachment. Globally, PF affects up to 10% of individuals during their lifetime and represents a leading cause of heel pain and functional impairment, contributing substantially to disability, reduced productivity, and increased healthcare utilization, particularly among physically active individuals and workers exposed to prolonged standing.[1] In Saudi Arabia, prevalence estimates vary widely across regions and clinical settings, ranging from 1.7% in a multicenter primary care study at King Abdulaziz Medical City[2] to much higher rates of 12% to 57.8% among patients presenting with heel pain in Makkah and Al Jouf.[3,4] PF is primarily considered a mechanical degenerative condition resulting from repetitive microtrauma and collagen disorganization rather than acute inflammation. Biomechanical factors—such as excessive foot pronation, limited ankle dorsiflexion, and Achilles tendon tightness—increase tension on the plantar fascia, leading to characteristic sharp heel pain with the first steps after rest.[5] Multiple risk factors have been implicated, including obesity, prolonged standing, and inappropriate footwear. Saudi studies have reported higher prevalence among teachers, nurses, and service workers who spend extended periods weight-bearing.[2,6] Sedentary lifestyle and high-impact sports may also increase risk, whereas moderate activity with proper foot support appears protective.

The impact of PF extends beyond localized heel pain. Patients often report substantial reductions in pain-related quality of life, functional capacity, and overall foot health as measured by validated tools such as the Foot Health Status Questionnaire.[7] Although approximately 90% of individuals respond favorably to conservative management—including stretching, orthotics, night splints, and anti-inflammatory medications—chronic or recurrent symptoms are common.[8,9] Persistent pain may contribute to mobility limitations and psychological distress, emphasizing the importance of prevention and early recognition.

Despite its high burden, public knowledge, and awareness of PF remain limited, with recent evidence demonstrating significant gaps in understanding of preventive practices and symptom recognition within general populations.[10] Misconceptions about foot pain, improper footwear choices, and lack of ergonomic awareness contribute to preventable cases and delays in seeking care. Evidence from health education interventions suggests that awareness programs targeting modifiable risk factors can improve preventive behaviors and adherence to treatment recommendations.[4,11] However, data on public knowledge and information-seeking behaviors regarding PF in Saudi Arabia are scarce. Experiences from related musculoskeletal conditions, such as diabetic-foot disorders, demonstrate that knowledge deficits are common and that targeted educational strategies can reduce complications.[6] Improving public knowledge is therefore critical not only for patients—by facilitating early symptom recognition and appropriate self-care—but also for healthcare professionals, as it may reduce delayed presentations, optimize resource utilization, and improve overall treatment outcomes in musculoskeletal conditions.[12]

Given these gaps, this analytical cross-sectional study aimed to assess public knowledge of plantar fasciitis, including its clinical features, risk factors, treatment options, and preventive measures, among adults in Saudi Arabia. Additionally, the study examined how demographic characteristics and information sources influence knowledge levels. Understanding these patterns can help healthcare professionals and policymakers design targeted awareness campaigns to address knowledge gaps, promote early recognition, and support evidence-based self-management strategies.

Materials and Methods

This analytical cross-sectional study was conducted over a 6-month period and targeted adults residing in all regions of Saudi Arabia to assess public knowledge of plantar fasciitis (PF), including its risk factors, clinical features, treatment options, and preventive measures. Data were collected using a snowball sampling technique combined with a convenience-based recruitment approach, allowing voluntary participation from across the Kingdom. We utilized a structured, self-administered electronic questionnaire distributed via social media platforms. Eligible participants were Saudi adults aged ≥18 years, while non-Saudi residents and individuals younger than 18 years were excluded.

The minimum required sample size was calculated using a 95% confidence level, a 5% margin of error, and an assumed population proportion of 50%, yielding a target of 385 respondents. A total of 1,032 valid responses were ultimately included.

A new questionnaire was developed by the research team following a review of relevant literature and consultation with domain experts for content validity. The final instrument consisted of five sections: (1) demographic characteristics (sex, age group, region of residence, occupation, and physical activity level); (2) general knowledge, risk factors, and clinical features of PF; (3) sources of information (healthcare professionals and non-professional sources); (4) knowledge of treatment options; and (5) knowledge of preventive measures. All knowledge items used a three-point response scale (Yes/No/I do not know). Correct answers were coded as “1,” while incorrect and “I do not know” responses were coded as “0.”

The questionnaire was administered in Arabic to ensure linguistic and cultural appropriateness.

Participants were provided with an introductory statement describing the purpose of the study, estimated completion time, and confidentiality assurances. Electronic informed consent was obtained before commencement, and participation was voluntary and anonymous. All responses were automatically recorded and stored in a secure, password-protected database accessible only to the research team.

Data cleaning and descriptive analyses were conducted using Microsoft Excel (Microsoft Corporation, 2018), and inferential analyses were performed using Minitab® Statistical Software. Continuous outcomes (knowledge scores) were summarized as means with 95% confidence intervals (CI). Between-group comparisons were conducted using the Mann–Whitney U test for dichotomous variables and the Kruskal–Walli’s test for variables with more than two categories. Associations between categorical variables were assessed using the Chi-square test. For comparisons involving the number of information sources used (0, 1, 2, or ≥3), a global Kruskal–Walli’s test was applied followed by Holm-adjusted pairwise Mann–Whitney U tests. All statistical tests were two-tailed, and a P value < 0.05 was considered statistically significant.

The study protocol was reviewed and approved by the Institutional Review Board at King Saud University, College of Medicine, Riyadh, Saudi Arabia (approval number KSU-HE-25-695).

Results

A total of 1,032 participants were included in the final analysis, comprising 418 (40.5%) females and 614 (59.5%) males. The most represented age group was individuals younger than 25 years (24.9%). Geographically, the Central region accounted for the highest proportion of participants (83.5%), whereas the Northern region contributed the lowest (2.1%) [Table 1].

Table 1.

Demographic characteristics of study participants

Variable		Category		n		%
Gender		Male		614		59.5
		Female		418		40.5
Age		<25		257		24.9
		25–34		136		13.2
		35–44		207		20.1
		45–54		245		23.7
		55+		187		18.1
Nationality		Saudi		1032		100
Region		Central region		862		83.5
		Southern region		67		6.5
		Western region		47		4.6
		Eastern region		34		3.3
		Northern region		22		2.1
Occupation		Government worker		375		36.3
		Student		211		20.4
		Retired		174		16.9
		Private worker		129		12.5
		Not working		93		9.0
		Other		30		2.9
		Self-employed		20		1.9

The most frequently reported sources of knowledge about plantar fasciitis were Internet websites (60.9%), social media platforms (57.2%), and family and friends (54.2%). In contrast, professional medical sources were less commonly reported, including physiotherapists (37.3%), orthopedic surgeons (34.6%), and family physicians (29.2%) [Table 2].

Table 2.

Reported sources of knowledge about plantar fasciitis

Source		Users (n)		Users (%)
Internet		629		60.9
Social media		590		57.2
Family and friends		559		54.2
Physiotherapist		385		37.3
Orthopedic surgeon		357		34.6
Primary health care provider – Family physician		301		29.2

Across the five knowledge domains, participants demonstrated moderate awareness of plantar fasciitis, with the percentage of correct responses in most domains around 50%. Knowledge of treatment was the highest (55.7% correct), whereas understanding of clinical features was the lowest (44.7% correct) [Table 3].

Table 3.

Average percentage of correct and incorrect responses across knowledge domains

Section		Section avg % Correct		Section avg % Incorrect
Section 2 – General knowledge		55.5		44.5
Section 3 – Risk factors & causes		52.4		47.6
Section 4 – Clinical features		44.7		55.3
Section 6 – Knowledge about treatment		55.7		44.3
Section 7 – Prevention		50.8		49.2

Overall knowledge scores varied significantly across gender, age, and geographic region [Table 4]. Females achieved a higher mean knowledge score (55.4%, 95% CI: 52.8–58.1) compared to males (47.3%, 95% CI: 45.0–49.7), with a mean difference of 8.1 percentage points (P < 0.001).

Table 4.

Differences in overall plantar fasciitis knowledge by demographic variables

Variable		n		Mean % (95% CI)		Δ (max–min) pp		P
Gender						8.1		<0.001
Female		418		55.4 (52.8–58.1)
Male		614		47.3 (45.0–49.7)
Age						9.5		0.0018
<25		257		47.5 (44.0–51.0)
25–34		136		52.2 (46.9–57.4)
35–44		207		51.8 (47.8–55.8)
45–54		245		55.5 (51.9–59.1)
55+		187		46.0 (42.1–50.0)

Mean=mean percent correct; 95% CI=95% confidence interval; pp=percentage points, Δ=absolute difference between highest and lowest mean within variable; P value from Mann–Whitney U (2 groups) or Kruskal–Wallis (≥3 groups), two-sided

Knowledge also differed by age group (P = 0.0018), peaking among participants aged 45–54 years (55.5%), while the lowest mean was observed among those aged 55 years and older (46.0%).

Knowledge scores differed significantly according to the primary source of information about plantar fasciitis (P < 0.001) [Table 5]. Participants who reported obtaining information from family physicians (65.2%, 95% CI: 62.1–68.2), orthopedic surgeons (64.3%, 61.5–67.0), or physiotherapists (63.1%, 60.4–65.7) achieved the highest mean knowledge levels. In contrast, those relying on Internet sources (58.8%, 56.8–60.8), social media (58.3%, 56.2–60.4), or family and friends (57.8%, 55.6–60.1) demonstrated comparatively lower scores.

Table 5.

Mean overall plantar fasciitis knowledge scores among users of each information source

Variable		n		Mean % (95% CI)		Δ (max–min) pp		P
Orthopedic surgeon		357		64.3 (61.5–67.0)		7.3		<0.001
Family physician		301		65.2 (62.1–68.2)
Physiotherapist		385		63.1 (60.4–65.7)
Social media		590		58.3 (56.2–60.4)
Internet		629		58.8 (56.8–60.8)
Family and friends		559		57.8 (55.6–60.1)

Mean=mean percent correct; 95% CI=95% confidence interval; pp=percentage points, Δ=absolute difference between highest and lowest mean within variable; P value from Mann–Whitney U (2 groups) or Kruskal–Wallis (≥3 groups), two-sided

Figure 1 presents a section-by-section comparison, showing that professional sources consistently outperformed non-professional ones across all knowledge domains, particularly in treatment and clinical-feature awareness. Participants who reported obtaining information from General/Family physicians (65.2%), Orthopedic surgeons (64.3%), or Physiotherapists (63.1%) achieved the highest overall mean percentages of correct responses. In contrast, those relying on Internet sources (58.8%), social media (58.3%), or Family and friends (57.8%) demonstrated comparatively lower scores.

Figure 1.

Average percentage of correct responses among users of each information source across knowledge domains

Overall knowledge increased progressively with the number of information sources used [Tables 6 and 7]. Participants who did not report any information source had the lowest mean knowledge score (22.7%, 95% CI: 18.6–26.8), while those using one or two sources showed intermediate scores (44.3% and 48.8%, respectively). The highest knowledge level was observed among participants who used three or more sources (61.4%, 95% CI: 59.2–63.6).

Table 6.

Mean overall knowledge scores by number of information sources used

Sources used		n		Overall mean % (95% CI)
0		157		22.7 (18.6–26.8)
1		163		44.3 (40.0–48.5)
2		180		48.8 (45.3–52.3)
3+		532		61.4 (59.2–63.6)

Table 7.

Pairwise comparisons of overall knowledge scores by number of information sources used (Holm-adjusted Mann–Whitney U tests)

Comparison		n1		n2		Mean1		Mean2		Δ mean (pp)		U		P		Global P
0 vs 1		157		163		22.7		44.3		21.6		7123		>0.001		>0.001
0 vs 2		157		180		22.7		48.8		26.1		6256		>0.001
0 vs 3+		157		532		22.7		61.4		38.7		13279		>0.001
1 vs 2		163		180		44.3		48.8		4.5		13357		0.1522
1 vs 3+		163		532		44.3		61.4		17.1		28243		>0.001
2 vs 3+		180		532		48.8		61.4		12.6		33455		>0.001

Mann–Whitney U tests, two-sided. P values adjusted for multiple comparisons using Holm’s method; global Kruskal–Wallis P value. Means reported in percentage points (pp)

The global Kruskal–Walli’s test confirmed a statistically significant difference across groups (P < 0.001). Pairwise Holm-adjusted Mann–Whitney U tests indicated that all comparisons were significant except between the one-source and two-source groups (P = 0.1522).

Descriptive usage patterns by demographic group are presented in Figures 2 and 3.

Figure 2.

Source usage by gender

Figure 3.

Source usage by age band

Patterns of information source use across demographic subgroups are shown in Figures 2 and 3. Across all categories, Internet and social media were consistently the most frequently reported sources of knowledge about plantar fasciitis.

Gender-related differences were modest [Figure 2], with slightly higher use of social media and Internet among females and marginally greater reliance on family and friends among males. Age-based trends [Figure 3] indicated that younger adults (<35 years) favored online and social media sources, whereas middle-aged participants (45–54 years) more often reported obtaining information from healthcare professionals.

Regional variation [Figure 4] showed particularly high use of online platforms in the Eastern and Southern regions, while the Western region demonstrated lower engagement across all sources. Occupational differences [Figure 5] revealed greater use of Internet and social media among students and self-employed individuals, and a somewhat higher tendency to consult health professionals among retired participants.

Figure 4.

Source usage by region

Figure 5.

Source usage by occupation

Discussion

This study provides a comprehensive national assessment of plantar fasciitis knowledge among adults in Saudi Arabia and highlights several demographic and behavioral factors associated with variation in awareness levels. Overall, participants demonstrated satisfactory overall knowledge across most domains, with the lowest performance observed in recognition of clinical features. Knowledge differed significantly by gender, age, and information-seeking behaviors, underscoring key targets for future public health interventions.

Consistent with previous Saudi research, our finding of moderate overall knowledge aligns with earlier work demonstrating substantial knowledge gaps related to plantar fasciitis.[13] A prior study in Riyadh reported that one-third of participants had never heard of plantar fasciitis, despite the high prevalence of foot pain, which affects nearly 1 in 5 adults globally,[14] and accounts for approximately 10% of all heel pain cases.[11] Although our participants showed greater overall awareness compared with earlier findings, this remains relatively low in the context of a highly prevalent musculoskeletal condition. These patterns mirror broader trends in musculoskeletal health in Saudi Arabia, where public understanding of common conditions remains limited despite a musculoskeletal pain prevalence of 25.4%.[15,16] Together, these findings highlight persistent public knowledge gaps and support the need for targeted health education initiatives. These findings are consistent with more recent studies from the region and internationally, which continue to demonstrate persistent gaps in musculoskeletal health knowledge despite increased access to digital health information.[17]

A notable finding in our study was the weak knowledge of clinical features, where participants demonstrated the lowest accuracy across domains. This mirrors prior research showing that even patients with diagnosed plantar heel pain frequently report confusion about symptom origin and pathophysiology.[18] Qualitative evidence indicates that individuals often misinterpret plantar fasciitis symptoms as bruising, bone injury, or nerve irritation and experience uncertainty regarding early signs.[18] Such diagnostic ambiguity is also documented in other foot conditions, where misinterpretation of early symptoms is linked to delays in seeking care.[19,20]

Our finding that females demonstrated significantly higher plantar fasciitis knowledge than males align with extensive evidence showing gender disparities in health literacy. Studies in Saudi Arabia consistently report higher reading and comprehension scores among women,[21] while men are more likely to exhibit inadequate health literacy overall.[17] Specific to plantar fasciitis, earlier research from Riyadh similarly observed higher awareness among women.[13] Although plantar fasciitis is more prevalent among women,[11] greater health literacy may contribute to earlier symptom recognition and more appropriate health-seeking behavior.[13,22] Even among medical students, females reported better understanding of appropriate footwear recommendations.[23] This recurring gender advantage suggests that future educational interventions should particularly target men, who may be at greater risk of inadequate musculoskeletal health literacy.

Age-related patterns in our study revealed that individuals aged 45–54 years demonstrated the highest knowledge, whereas adults aged ≥55 years had the lowest awareness. These results reflect established trends in Saudi Arabia, where older adults consistently exhibit lower health literacy, including significantly reduced reading scores compared with younger adults.[21] Prior plantar fasciitis–focused research suggests that younger adults often show greater awareness, likely due to higher education levels and increased access to digital information sources.[13] These patterns underscore the need for age-tailored educational strategies to improve musculoskeletal health literacy among older adults.

Information-seeking behavior emerged as a strong determinant of knowledge. Participants who relied on healthcare professionals had significantly higher knowledge scores than those who accessed information from the Internet, social media, or informal networks. This finding is consistent with recent evidence demonstrating that the quality of online musculoskeletal health information remains highly variable, with many sources lacking accuracy, readability, and evidence-based content.[24,25] Healthcare professionals–authored content remains more reliable, and physiotherapists in particular report high adherence to evidence-based patient education practices.[26] Social media, though widely used, presents substantial limitations due to lack of citation, potential conflicts of interest, and inconsistent accuracy.[27] These patterns underscore that the credibility of the information source is critical in shaping public understanding.

Our observation of a dose–response relationship, whereby knowledge increases significantly with the number of information sources used, further reinforces the impact of information exposure on health literacy. Prior studies have shown that increased engagement with health information through social media and digital platforms enhances information-seeking behavior and knowledge acquisition.[28] Among Saudi residents, more than 70% report receiving health information via social media,[29] and high-frequency users often demonstrate greater health awareness. However, the benefits of multipoint exposure depend on the quality of accessed sources; individuals with limited health literacy tend to rely on lower-quality sources such as blogs and informal social media content, whereas those with higher literacy preferentially consult medical websites and healthcare professionals.[30] These findings highlight the importance of promoting diversified and credible information channels.

Finally, the predominance of the Internet and social media as primary sources of plantar fasciitis information in our cohort aligns with national health information–seeking trends. Large-scale surveys in Saudi Arabia show widespread reliance on platforms such as WhatsApp, YouTube, Snapchat, and Twitter for health information.[31,32] While participants frequently perceive these sources as helpful and reliable, the inconsistent quality of digital health information underscores the need for professionally curated, accessible online educational materials—particularly for common musculoskeletal conditions such as PF.

Importantly, this study adds to the existing literature by providing one of the first comprehensive, nationwide assessments of PF knowledge in Saudi Arabia, while simultaneously examining the influence of demographic characteristics and information-seeking behaviors on awareness levels. Unlike prior studies that were limited to specific regions or occupational groups, the present study offers broader population-level insights, thereby enhancing the generalizability of findings and providing a stronger foundation for designing targeted national educational strategies.

Strengths and Limitations

This study draws strength from its large, geographically diverse sample and structured assessment of multiple knowledge domains. The scoring method allowed precise quantification of knowledge patterns across demographic groups. However, limitations include reliance on self-reported data, potential sampling bias toward digitally active individuals, and the use of a non-validated questionnaire, although it was developed based on existing literature and expert review. The cross-sectional design also precludes causal inference.

Conclusion

This national cross-sectional study reveals that public knowledge of plantar fasciitis in Saudi Arabia is moderate, with notable gaps in recognizing clinical features and risk factors. Knowledge varied significantly across demographic groups, with females and middle-aged adults demonstrating higher awareness. Participants who used multiple information sources showed substantially higher knowledge scores, emphasizing the importance of diversified and credible health information exposure. Although the Internet and social media were the most used sources, professional sources—such as physicians and physiotherapists—were associated with higher accuracy. These findings highlight the need for targeted public health education, improved digital health communication, and region-specific outreach strategies to enhance awareness, support early symptom recognition, and promote evidence-based management of plantar fasciitis.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board at the College of Medicine, King Saud University, Ref. No. (KSU-HE-25-695). All participants provided written informed consent prior to the commencement of the study.

Availability of data and materials

The data sets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.