Knowledge and Practices Regarding Plantar Fasciitis among the General Population in Arar, Saudi Arabia

Plantar fasciitis can be described as an inflammatory condition precipitated by degenerative changes and irritation of the plantar fascia’s origin, especially where the medial calcaneal tuberosity is located. The plantar fascia is an essential part of foot biomechanics. There are three parts of the plantar fascia that originate from the calcaneus. Its role in the foot biomechanical system is essential in providing arch support and shock absorption upon physical movement. Interestingly, plantar fasciitis is not an inflammatory condition, as confirmed by histological studies that show the absence of inflammatory cells [1].

Plantar fasciitis, a very common and painful condition, has long been linked to standing/walking, middle-aged individuals, excessive physical activity, and contraction of the gastrocnemius muscle.[2] Its development is multifactorial, with excessive mechanical stress being a primary contributor. The patient complains of sharp, localized pains across the foot, particularly the heel, sometimes accompanied by the presence of a spur within the heel, diagnosed by imaging techniques [3]. Plantar fasciitis, identified as one among the major causes of foot pains, affects huge numbers of individuals annually within the United States. A very large study survey carried out in the US in 2018 among 75,000 subjects indicated that 848, or 1.1%, of the surveyed study subjects were diagnosed with PF [4].

Plantar fasciitis is considered difficult to manage, as standard treatments may not give sufficient relief. Even though non-surgical treatments such as stretching exercises and physiotherapy remain the first line of therapy and are effective in most cases, recurrent pain continues to be a common concern [5,6]. The prevalence of plantar fasciitis in Saudi Arabia is most likely affected by peculiar socio-cultural as well as environmental factors, including traditional footwear choices, lifestyle habits, and climate conditions. The problem has a significant impact on one’s quality of life as it reduces the mobility of the patient as well as his activity levels. Understanding the general population's knowledge and practices toward plantar fasciitis is critical for designing effective public health interventions.

A survey conducted in Qassim region of Saudi Arabia, involving 859 participants revealed a concerning lack of awareness and knowledge about plantar fasciitis despite being a prevalent disease. Many participants demonstrated confusion about this disease and its diagnostic procedure. The research revealed a moderate level of awareness deficiency and a statistical significance between awareness and educational levels.[7] Nevertheless, awareness and factors like gender, age, nationality, and residency were found to have no relation to each other. Based on this finding, this research was designed to assess the knowledge and practice relating to plantar fasciitis present among the population at Arar, KSA.

Research Objective

This study aims to assess the knowledge and practice regarding plantar fasciitis among the general population in Arar, Saudi Arabia.

Study Design

This research adopted a cross-sectional design in assessing the awareness and knowledge of the general population in relation to plantar fasciitis and its risk factors for a period of six months in the Northern Border region of Saudi Arabia. This research targeted individuals aged 18 years and above in Arar, Saudi Arabia. A representative sampling of the general community in Arar was adopted using a convenient sampling method.

Data collection

The study used an online questionnaire to collect data. The questionnaire was developed after a thorough analysis of available literature on the topic based on consultations carried out with experts in the field of orthopedic surgery and public health.

The questionnaire was structured into three main sections:

• Demographic data: Age, gender, education level, employment status.
• Knowledge about planter fasciitis and its risk factors
• Practices about plantar fasciitis

Scoring System

The knowledge section consists of 5 questions, with each correct answer scored for points, and 0 points given for any incorrect answers. The result is divided into good knowledge, insufficient knowledge, and excellent knowledge for 12-15 points, below 12 points, and 16-20 points, respectively.

The practice section also had 5 questions, with points awarded for every correct answer, while 0 points were awarded for incorrect answers. The points could be categorized into excellent: 12-15 points, good: 9-11 points, and insufficient: below 9 points.

The total marks, which included both the knowledge as well as practice, carried a maximum of 35 marks, which were divided into excellent performance (scores ranging from 28 to 35), good performance (scores ranging from 20 to 27), and insufficient performance (scores below 20).

Data collection procedure

The questionnaire was translated into the Arabic to accommodate individuals who cannot communicate in English. An informed consent form was also incorporated to be responded before the process continue. The consent form outlined the aim of the study, the voluntary nature of participation, confidentiality, and the right to withdraw from the study at any time. The questionnaire was distributed and responses were collected. The data was entered into a statistical software program SPSS version 22 for analysis.

Data analysis

For data analysis, the software used was SPSS version 22.0. The demographic variables of the subjects were presented using frequencies, proportions, means, and standard deviations. The level of knowledge and practice in plantar fasciitis was presented using similar statistical analysis. The chi-square test was used to determine the relationship between demographic variables (e.g., age, gender, education) and knowledge and practices scores.

Ethical Considerations

The study protocol was reviewed and approved by the Local Committee of Bioethics at Northern Border University with approval number 55/25/H.

This cross-sectional study enrolled 260 participants from Saudi Arabia’s Northern Border Region to assess plantar fasciitis knowledge and practice. Most participants were males (65%) with a young age group of 66.9%, followed by 36-50-year-old subjects (25%), and others above 51 years (8.1%). The majority of the participants were of high educational levels, with 71.9% having a bachelor’s degree, 23.1% having a secondary education degree, and 4.2% having a doctorate degree (Table 1).

Table 1: Sociodemographic Characteristics of Participants (N = 260)

Knowledge Assessment

The average knowledge score was 7.58±5.07 out of 20 points, showing low performance. Few participants, 10.0% (n = 26), showed excellent knowledge performance (16-20 points), 21.5% (n = 56) showed good knowledge performance (12-15 points), and 68.5% (n = 178) showed insufficient (below 12 points) (Table 2).

Table 2: Frequency Distribution of Knowledge Questionnaire Responses (N = 260)

Practice Assessment

The practice assessment part, with a weightage score of 15 points, tested the behavior and attitudes of attendees towards plantar fasciitis prevention and care. Overall practice mean was 9.00±2.93 on a total score of 15, reflecting a mediocre practice attitude. Practice categorization revealed that 21.5% (n = 56) exhibited excellent practice (12-15 points), 38.8% (n = 101) showed good practice (9-11 points), and 39.6% (n = 103) demonstrated insufficient practice (below 9 points). Nearly half of participants reported heel or arch pain, with 70% opting for rest and 22.3% seeking healthcare. While 90% would follow treatment, only 35.4% consistently wear supportive footwear and 29.6% regularly stretch (Table 3).

Table 3: Frequency Distribution of Practice Questionnaire Responses (N = 260)

Overall Performance and Score Distribution

The overall evaluation in terms of both knowledge and practical application, achieved a mean score of 16.59±6.08 on a maximum of 35. This reflects a poor performance. It is pertinent to note here that only 4.6% (n = 12) of the participants performed excellently well with a score ranging between 28-35. On the contrary, 26.2% (n = 68) performed satisfactorily with scores ranging between 20-27. The majority, comprising of 69.2% (n = 180) performed inadequately with scores below 20 points (Table 4).

Table 4: Distribution of Participants by Knowledge, Practice and Total Score Categories (N = 260)

Statistical Associations Between Demographics and Knowledge and Practice Score

The Chi-square tests conducted to identify the correlation between demographic and the categories of the total scores showed significant results. The association between the level of education and the total scores was found to have a highly significant value (χ² = 24.205, p = 0.002), indicating that education has a significant effect on the level of knowledge and practice. The association between the age groups and the total scores was significant (χ² = 9.872, p = 0.043), suggesting the existence of a variation between the age groups and the level of understanding and practice. On the other hand, neither gender (χ² = 2.373, p = 0.305) nor employment status (χ² = 1.139, p = 0.980) showed a significant association with the scores (Table 5).

Table 5: Relation Between Sociodemographic Characteristics and Total Score Categories (N = 260)

p-value was considered significant if <0.05

ANOVA Analysis: Age Groups and Score Performance

ANOVA testing comparing mean scores across age groups found no statistically significant differences in knowledge, practice, or total scores. The 36-50 age group had slightly higher mean knowledge scores (8.43±4.70) than the 18-35 group (7.20±5.35), but these differences were not statistically significant (Table 6).

Table 6: Comparison of Knowledge, Practice and Total Scores Across Age Groups (ANOVA)

p-value was considered significant if <0.05

Figure 1: Distribution of Participants by Knowledge, Practice and Total Score Categories (N = 260)

Plantar fasciitis (PF), a prevalent cause of heel pain globally, imposes a substantial burden on both affected individuals and healthcare systems. Surprisingly, the awareness and knowledge level of the general population about plantar fasciitis (PF) appears to be limited, despite its prevalence. Lack of awareness and knowledge about the disease has become a concern since the disease affects about 10% of the population, with higher rates among active adults [8,9]. A deficit in awareness and knowledge of the disease has also been identified in the current study. Only 10% of participants demonstrated adequate knowledge about PF, while a substantial 68.5% demonstrated inadequate knowledge, which discloses an absence of satisfactory knowledge of the disease amongst the general population. This finding aligns with other studies conducted in Saudi Arabia, including that by Awwad et al. who have reported a marked absence of public awareness or confusion regarding PF and its accurate diagnosis [10].

In line with such reports, there were clear deficiencies among the participants of our survey regarding the perception of particular risk factors and diagnostic criteria of PF. Approximately 30% of participants correctly identified “overuse or prolonged standing” as the fundamental risk factor for PF, and less than a third correctly identified proper clinical diagnostic techniques for it. These findings are consistent with what similar Saudi studies have found, which have found that only fractional percentages of participants correctly identified such risk factors as “prolonged standing” or “excessive exercise” or “inappropriate footwear” among others [8,10]. A study carried out by Khired et al. [11] in the city of Jazan revealed profound gaps in understanding the underlying factors of PF, despite it being highly predominant in occupationally active individuals.

Comparing outcomes from data gathered in Saudi Arabia with global data indicates that a trend of lack of public awareness about PF exists. In UK, a prominent study showed that just 10% of elderly individuals were able to describe disabling symptoms of heel pain, failing to provide functional knowledge necessary for the prevention of PF [12]. Support for this global trend of lack of awareness about PF, risks, and signs of disease among both public and patients is offered by a systematic review carried out by Rhim et al. [13].

Less than a third of participants took part in regular preventive foot exercises and/or supportive shoes, while nearly half suffered with frequent pain in heels and/or arches. Despite this, there was 90% willingness to adhere to health instructions for PF. Even among medically educated cohorts, Almogbil et al. [14] observed that clinical-phase medical students, despite their overall knowledge, demonstrated weaknesses in practice and management knowledge, suggesting a systemic deficit in nationwide health education. Daily practice and the need for preventive measures remain lacking in Saudi population, despite willingness if formally diagnosed, possibly due to patient education and clinical counseling limitations.

A particularly noteworthy finding observed within our research is the association between higher educational levels and increased scores relevant to PF knowledge and practice. The significance of said association, as observed within our findings and supported by other studies such as Alayed et al. [7] and Alyami et al. [15] within osteoarthritis awareness studies, accentuates the belief that education could play a crucial role as the biggest modifiable factor improving health literacy within Saudi Arabia. Meanwhile, results failed to show significant differences within gender and employment status regarding said knowledge and practices, consistent with previous findings in comparable Saudi cross-sectional studies.

There is a lack of understanding concerning plantar fasciitis and methods of prevention in the Northern Border Region population. Educational level is the best predictor of understanding and healthy practices, indicating the importance of appropriate public health interventions.

Strengths of the Study

This study provides valuable regional information on plantar fasciitis awareness in Arar, Saudi Arabia, an area with limited prior data. The use of a structured, bilingual questionnaire improved accessibility for participants with diverse linguistic backgrounds. The scoring system allows for comparison of awareness levels and highlights areas for community health education.

Limitations

The cross-sectional nature of the research limits causal interpretation, and the fact that it was conducted online may mean it is not an entirely representative sample, as people who have access to the internet and possibly higher education may be over-represented. Despite these limitations, the results support the need for public health efforts at improving awareness of PF.

There was no institutional, commercial, or governmental funding source for this study. Every phase of the research, including data gathering, analysis, and manuscript preparation, was completed without outside funding.

Conflict of Interest

The authors certify that this study has no conflicts of interest. Financial, professional, or personal ties had no bearing on how the research was conducted, interpreted, or reported.

The authors extend their appreciation to the Local Committee of Bioethics and Deanship of Scientific Research at Northern Border University, Arar, Saudi Arabia in providing ethical clearance and streamlining the administrative procedure.

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