ORIGINAL ARTICLE www.ijcmr.

com Section: Orthopedics

Relationship between Hamstring Tightness and Planter Fasciitis

Shrestha R1, Poudel KP, Adhikari BR3, Karanjit A4, Pande R5, Sapkota B6

seen in the adult population.

ABSTRACT The most common symptom associated with plantar fasciitis
Introduction: Plantar fasciitis is a pathological condition is heel pain and PF is the most common cause of chronic
whose etiology is multifactorial. It constitutes a major bulk pain beneath the heel in adults. The patient complains of
of patients attending our outpatient department. Some of the pain in the medial side of the heel, most noticeable with
risk factors involved are sport or physical exercise, being initial steps after a period of inactivity and usually lessens
overweight, age, gender, prolonged standing, increased with increasing level of activity during the day, but will
subtalar pronation accompanying pes cavus or flat feet, and
tend to worsen towards the end of the day. Symptoms may
limited ankle dorsiflexion. There have been few studies about
become worse following prolonged weight bearing and often
the relationship between tightness of the posterior lower limb
muscles such as hamstring tightness and plantar fasciitis, and
precipitated by increase in weight bearing activity.2
most of them can be interpreted in terms of some contracture Although several factors have been proposed as causes of
of the hamstring muscles of thigh being present in cases of plantar fasciitis, biomechanical abnormalities are considered
plantar fasciitis. So, we hypothesized there is relation between to play a major role in this condition. However, the exact
hamstring tightness and plantar fasciitis. changes to the biomechanics that cause this ailment are
Material and Methods: A total of 68 subjects, 34 with plantar controversial and inconclusive. The effect of tight posterior
fasciitis and 34 matching controls were recruited. Hamstring leg muscles causing decreased ankle dorsiflexion has been
was evaluated through the straight leg elevation test, popliteal studied and has been determined to be detrimental to the
angle test, and ankle dorsiflexion (with knee extended and stress applied to the plantar fascia. Harty at el suggested
knee flexed). At least three measurements were taken and tight hamstrings increase knee flexion, which in turn induces
a mean value was calculated. All variables were compared
prolonged forefoot loading and engages the windlass
between the 2 groups. Along with hamstring tightness other
mechanism. Other biomechanics include tightness of the
characteristics such as age, gender, and BMI were also
compared. Univariate analysis was done with chi-square test Achilles tendon and plantar fascia, reductions in strength
and t-test. in foot and ankle muscles, and abnormal foot alignment.
Results: Difference between the 2 groups for the tests used With repetitive use of the foot and ankle, the plantar fascia is
to assess hamstring tightness were highly significant i.e., loaded and can develop chronic degenerative changes with
p<0.001 in comparing the values of Popliteal angle (PA) marked thickening and fibrosis within the fascia.3
and p=0 of Ankle dorsiflexion with knee flexed (ADFKF), In Plantar fasciitis, there is inflammation and healing with
moderately significant i.e. p = 0.032 in comparing the fibrosis because of the repeated microtears. This results in
values of Ankle dorsiflexion with knee extended (ADFKE). contracture of the plantar fascia which decreases its elasticity
However, there was no significant difference p=0.588 in and makes it more vulnerable to further microtear as loss
comparing the values of Straight leg elevation test (SLET).
of elasticity decreases the threshold of breakage point in the
Since there were significant relation in three parameters PA,
stretch strain curve of the fascia. There is vicious cycle of
ADFKF and ADFKE we can conclude there is hamstring
tightness in patients with plantar fasciitis. In comparing the
microtears caused by stress of normal walking during day
values regarding Body Mass Index between the 2 groups, and healing by fibrosis during rest at night. So, this vicious
there was highly significant statistical difference (p<0.001). cycle of microtear and fibrosis should be interrupted in order
Conclusion: There is significant association between to restore the normal threshold of breakage point of plantar
hamstring tightness in patients with plantar fasciitis. These fascia, which can be done by stretching the plantar fascia
results of the study suggest that therapists who are going to
employ a stretching protocol for treatment of plantar fasciitis
should look for hamstring tightness.
1
Rajiv Shrestha, MDGP, Civil Service Hospital, Kathmandu, 2Prof.
Dr. Krishna Prasad Poudel, Department of Orthopedics and Trauma
Key words: Plantar Fasciitis, Hamstring Tightness, Straight Surgery, Chitwan Hospital, Chitwan, Nepal, 3Bishwa Raj Adhikari,
Leg Elevation Test, Popliteal Angle MS, Department of Orthopaedics and Trauma Surgery, Bharatpur
Hospital, Nepal, 4Anugya Karanjit, MDS, NAMS, Bir Hospital,
5
Rohendra Pande, MDGP, HAMS Hospital, Kathmandu, 6Bishrut
Sapkota, MDGP, Civil Service Hospital, Kathmandu
INTRODUCTION
Plantar fasciitis is an inflammation of plantar fascia. It Corresponding author: Rajiv Shrestha, Department of Family
Medicine and Emergency Medicine, Civil Service Hospital
is composed of dense collagen fibers arranged mainly
longitudinally, arises posteriorly from the medial process of How to cite this article: Shrestha R, Poudel KP, Adhikari BR,
the calcaneus and fans out over the sole and divides into five Karanjit A, Pande R, Sapkota B. Relationship between hamstring
bands, one for each toe.1 It is a painful heel condition that can tightness and planter fasciitis. International Journal of Contemporary
affect both sedentary and active individuals and is most often Medical Research 2023;10(1):A1-A6.

International Journal of Contemporary Medical Research Section: Orthopedics A1

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 10 | Issue 1 | January 2023 |
Shrestha, et al. Hamstring Tightness and Planter Fasciitis

within its elastic limits. gender, height, weight, duration of symptom, history of
Risk factors identified for plantar fasciitis are obesity, recent trauma or surgery on the lower limb and co-morbid
sedentary lifestyle, wearing inappropriate shoes, frequent conditions. Radiographs were evaluated for the presence of
running and long standing.4 an infracalcaneal spur.
Differential diagnosis includes plantar fascia rupture, The straight leg elevation test (SLET), Popliteal angle (PA),
enthesopathies, fat pad atrophy, heel bruise, bursitis, stress Ankle dorsiflexion with the knee extended (ADFKE) and
fracture of calaneum, pagets disease, primary and secondary Ankle dorsiflexion with the knee flexed (ADFKF) were
tumor, infection, tarsal tunnel syndrome, trapped abductor measured.
digiti quinti nerve and sciatica.5 The final value of each variable to be measured with
Most patients have spontaneous resolution of symptoms but the goniometer was obtained by the mean of 3 repeated
about 10% tent to chronic symptoms. Though both surgical measurements.
and non-surgical approaches are available for management, In cases where plantar fasciitis was unilateral, the affected
non-surgical approaches are generally considered as limb was the one to be measured. In cases where plantar
first line. Use of night splint to keep foot in dorsiflexion, fasciitis is bilateral, only the more affected limb was
ultrasound massage, custom designed shoes, prefabricated included, or if both were affected equally, a coin toss was
soft insoles, Achilles tendon stretching exercise and plantar done to select the limb to measure at random. Measurements
fascia stretching exercise are some of the available options.6 were always made by the same researcher.
Local steroid is often painful with risks of plantar fascial RESULTS
rupture, fat pad atrophy, lateral plantar nerve injury and
calcaneal osteomyelitis.4 Orthotics gives poor patient Frequency distributions of different variables in study and
compliance of bulky night splints and is expensive. Surgery control group were observed.
caries the risk of residual pain (approximately 25% of As the inclusion criteria included age above 18 years there
patients will still experience heel pain), flat foot deformity were 47.06% of patients in the age group 18-40 years,
due to over-release of the plantar fascia, medial calcaneal 44.12% in 41-65 years and 8.82% in 65 years and above age
nerve injury, plantar tendon scar and infection.7 group both in the study and control group.

MATERIAL AND METHODS

Female
A comparative cross-sectional study was designed. A total 90 Male
of 68 subjects, 34 with plantar fasciitis and 34 matching
80 76.5 76.5
controls were recruited from March, 2018 to May, 2019
at Bharatpur Hospital. Hamstring was evaluated through 70
the straight leg elevation test, popliteal angle test, and
60
ankle dorsiflexion (with knee extended and knee flexed).
Percentage

At least three measurements were taken and a mean value 50

was calculated. All variables were compared between the 2 40
groups. Individuals with plantar fasciitis were included in
30 26.5
the study group and individuals without plantar fasciitis in 23.5
control group i.e., apparently healthy individuals. Along 20
with hamstring tightness other characteristics such as age, 10
gender, and BMI were also compared. Univariate analysis
was done with chi-square test and t-test. 0
Study Control
History taking and thorough physical examination was done.
Figure-1: Sex Distribution
After confirmation of clinical diagnosis of plantar fasciitis,
patients who met the inclusion criteria were allocated to the
study group.
Patients who served as the control group were matched in
age, sex and lower limb side.
Study Group: Individuals with plantar fasciitis.
Control Group: Individuals without plantar fasciitis after
pair matching.
Verbal and written instructions regarding the examination
and a university-approved consent form, signed prior to
participation were given to the individuals. The patients
were asked questions in order to complete a questionnaire
that provided information and a history profile of the
heel pain. The background information included age, Figure-2: History of plantar fasciitis in the study group

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Section: Orthopedics International Journal of Contemporary Medical Research
Volume 10 | Issue 1 | January 2023 | ISSN (Online): 2393-915X; (Print): 2454-7379
 Shrestha, et al. Hamstring Tightness and Planter Fasciitis

Majority of the patients were female, accounting for 76.5% Only 2 patients i.e., 5.9% in the study group with plantar
of the total patients in each group. fasciitis had radiographic presence of calcaneal spur in the
About 55.9% of the patients had a history of bilateral heel study group.
pain and 44.1% had a history of unilateral heel pain. About 14.7% had Hypertension, 5.9% had Hypothyroidism,
The mean duration of pain in patients in the study group was 2.9% had Hyperthyroidism and 8.8% had Hyperuricemia in
about 8.94 months with standard deviation of 11.73. the study group. About 5.9% had COPD, 8.8% had DM-type
II and 2.9% had Hypertension in the control group.
The mean weight in the study group was 65.79 kg and in the
Study Control
90 control group was 56.43 kg. The mean height was 1.57 m in
82.4
study group and 1.59 m in control group. The mean BMI was
80
70.6 26.74 in the study group and 22.44 in control group.
70
The comparison of the values of weight and BMI between
60 the two groups showed statistically significant differences in
Percentage

50 all cases as shown in the table 8 with p value <0.001.

40 Nearly 27% smoke among study group as compared to
30 29.4% in control group. The difference in percent of smokers
is not significantly different for case and control.
20
8.8 8.8 About 17.6 % among case take alcohol among the study
10 5.9 5.9 5.9
0 0 2.9 0 2.9 0 0 group in comparison to 8.8 % in control group. The difference
0 in percent of individuals who take alcohol is no significant
for both the study and the control group.
SM

ISM
N

IA
PD

NE
-II

HT
DM

EM

NO
CO

DI

ID

Mean SLET was 76.26 in study group as compared to 77.5

RIC
OI

RO
YR

RU
HY
TH

in control group, the mean difference was not significant

PE
RT
PO

HY
PE
HY

(p=0.588). The mean PA was 29.35 in study group as

HY

Figure-3: Co-Morbidities in patients in study and control group

Age (years) Study Group (n=34) Control Group (n=34)

Frequency Percent Frequency Percent
18-40 16 47.06 16 47.06
41-65 15 44.12 15 44.12
66 and above 3 8.82 3 8.82
Total 34 100 34 100
Table-1: Age distribution

Mean Standard Deviation

Duration of pain 8.94 11.73
Table-2: Duration of pain in the study group

Calcaneal SPUR Frequency Percent

Absent 32 94.1
Present 2 5.9
Total 34 100.0
Table-3: Radiographic presence of calcaneal spurs in study group.

Measurement Study Group (n=34) Control Group (n=34)

Age 45.59 (29-75) 45.59 (29-75)
Gender M/F 8/26 8/26
Weight (Kg) 65.79 (45-90) 56.43 (42-76)
Height (m) 1.57 (1.42-1.65) 1.59 (1.5-1.7)
Body mass index (BMI) 26.74 (19.5-36.6) 22.44 (17.8-28.9)
Duration of Pain (months) 8.94 (1-48) -
Calcaneal spur Absent= 32 -
Present= 2
Smoking (No/Yes) 25/9 24/10
Alcohol (No/Yes) 28/6 31/3
Table-4: Summary of baseline measures of the study and control group

International Journal of Contemporary Medical Research Section: Orthopedics

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 10 | Issue 1 | January 2023 |
Shrestha, et al. Hamstring Tightness and Planter Fasciitis

Group Mean SD t p
Age Study 45.59 13.46 0 1
Control 45.59 13.46
Weight Study 65.79 10.77 4.043 <0.001
Control 56.43 8.15
Height Study 1.57 0.06 -1.026 0.309
Control 1.59 0.06
BMI Study 26.74 4.32 4.907 <0.001
Control 22.44 2.75
Table-5: Comparison of variables Age, Weight, Height and BMI between the 2 groups.

Smoking Study group % Control group % Chi Square p

No 25 73.5 24 70.6 0.073 0.787
Yes 9 26.5 10 29.4
Total 34 100.0 34 100.0
Table-6: Comparison of Smoking between two groups

Alcohol Study group % Control group % Chi square p

No 28 82.4 31 91.2 0.512 0.474
Yes 6 17.6 3 8.8
Total 34 100.0 34 100.0
Table-7: comparison of Alcohol intake between two groups

Group Mean SD t p
SLET Study 76.26 9.10 -0.544 0.588
Control 77.50 9.61
PA Study 29.35 10.41 4.785 <0.001
Control 18.76 7.63
ADFKE Study 17.71 4.03 -2.196 0.032
Control 19.91 4.25
ADFKF Study 17.44 6.80 -4.64 0
Control 24.47 5.64
Table-8: Comparison of Variables SLET, PA, ADFKE and ADFKF between the 2 groups.

compared to 18.76 in control group, the mean difference The relationship between plantar fasciitis and contracture of
was significant (p<0.001). The mean ADFKE was 17.71 in the posterior muscles of lower extremity such as hamstring
study group as compared to 19.91 in control group, the mean group of muscles has previously been studied. Rome et al
difference was significant (p=0.032). The mean ADFKF
18
found no statistically significant differences (p=0.39)
was 17.44 in study group as compared to 24.47, the mean between a control group and a group with PF with respect
difference was significant (p=0). The comparison of the to limited ankle dorsiflexion. Taunton et al 19 retrospectively
values of PA, ADFKE and ADFKF between the two groups reviewed 267 cases of PF, of which 43 (16%) had excessive
showed statistically significant in all cases. However, the contracture of the gastrocnemius-soleus complex. Irving
value of SLET was not significant. Even though the value of et al 20 reported a case-control study that included ankle
SLET did not come out to be significant, the three values of dorsiflexion as a variable. The results showed the PF group
PA, ADFKE and ADFKF that measure the elasticity of the to present greater values of this angle than the control group.
hamstring muscles and triceps surae muscular bellies in the On the other hand, most current evidence suggests that
soleus region showed significant differences. tight hamstring and gastrocnemius is an etiologic factor for
PF. Harty et al20 observed a significant contracture of the
DISCUSSION
hamstrings muscles in a group of subjects PF compared
Plantar fasciitis comprises a significant bulk of patients with a control group. Domiguez et al 21 observed a limited
attending in General OPD and Orthopedics OPD. These ankle dorsiflexion and knee extension in most of the PF
patients undergo various treatment modalities ranging from subjects, which would confirm contracture of triceps
NSAIDS, physiotherapy, Orthotics and even surgery. Over surae and hamstrings. Labovitz et al17 found that patients
the past years various studies has been carried out and it is with hamstring tightness were about 8.7 times as likely to
now established that the outcome of the disease is typically experience PF in the corresponding foot compared with
favorable. patients without hamstring tightness. The results of the

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Section: Orthopedics International Journal of Contemporary Medical Research
Volume 10 | Issue 1 | January 2023 | ISSN (Online): 2393-915X; (Print): 2454-7379
Shrestha, et al. Hamstring Tightness and Planter Fasciitis

above mentioned studies support the functional deficit of and the efficacy of treatments that are directed toward the
the plantar fascia caused by hamstring shortening. That is, tight hamstrings in plantar fasciitis patients.
tight hamstrings could increase knee flexion, which in turn This study supports the tight hamstrings can lead to plantar
would induce prolonged forefoot loading and would engage fasciitis so stretching, aggressive physical therapy and other
the windlass mechanism. Also, when tight posterior leg treatments will likely address tight hamstrings since these
muscle group exists, ankle range of motion is limited, and it modalities have successfully targeted gastrocnemius-soleus
may be compensated by excessive pronation of the subtalar complex. Treatment and rehabilitation of plantar fasciitis can
joint, causing tension on the plantar fascia. Additionally, also be focused on the epidemiologic at-risk groups to target
the significance of this deficit is demonstrated since clinical a more effective outcome for the individual patient.
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Source of Support: Nil; Conflict of Interest: None

Submitted: 22-11-2022; Accepted: 26-12-2022; Published: 30-01-2023

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Section: Orthopedics International Journal of Contemporary Medical Research
Volume 10 | Issue 1 | January 2023 | ISSN (Online): 2393-915X; (Print): 2454-7379