Gait retraining with real-time visual biofeedback reduces pain, plantar loading and increase function in runners with plantar fasciitis: randomized clinical trial

Gait retraining with real-time visual biofeedback reduces pain, plantar loading and increase function in runners with plantar fasciitis: randomized clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gait retraining with real-time visual biofeedback reduces pain, plantar loading and increase function in runners with plantar fasciitis: randomized clinical trial Giovanna Truyts Biscardi Pinto, Marcos Antônio Leite Pereira Pinto, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5823721/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2026 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted 4 You are reading this latest preprint version 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, randomized clinical trial with blinded evaluators. Participants: 24 runners were evaluated and divided into two groups: 12 runners with plantar fasciitis and 12 control runners. 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). 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 and physical-functional performance, as well as a reduction in plantar overload on the rearfoot after the intervention protocol when compared to the initial assessment and control, with a moderate to high effect size. 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. Conclusion A ten-week treadmill gait retraining program using real-time visual biofeedback was effective in reducing pain and plantar pressure on the rearfoot, favoring an increase in the functionality of the feet and lower limbs of runners with plantar fasciitis. Trial registration number : RBR-5m6msq7 Figures Figure 1 Figure 2 INTRODUCTION Plantar fasciitis (PF) affects approximately 2 million individuals per year [1], 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 [2,3]. PF stands out as the third most common injury in runners [4], generating health costs of around $ 192 to $ 376 million [5], with lost productivity (absenteeism from work) and absence from sports practice [6]. PF is characterized by a musculoskeletal disorder of inflammatory and degenerative origin of the plantar fascia, whose most common clinical symptom is typical pain in the inferomedial region of the calcaneus [7]. Currently, it is speculated that weakness or atrophy of the intrinsic muscles of the feet in runners with PF occurs in both clinical phases of the disease (acute and chronic), contributing greatly to higher plantar overloads in different regions of the feet [8–13] and worse functional impairment in sports practice of runners affected by the injury [14,15]. Some scientific evidence has revealed that a reduction in the strength of the intrinsic muscles of the feet may have a greater contribution to the mechanical inefficiency of the plantar arch and, consequently, to greater tensional forces on the plantar fascia, thus promoting the emergence of acute PF and, over time, progressing to the chronic phase of the condition [9–12,16]. Given the above rationale, reducing overload has been one of the main objectives of the conservative clinical treatment of PF [17]. However, treatment is often complex, due to limited understanding of the pathophysiological mechanisms of PF, which initially occurs through the acute process of inflammation, and, oppositely and subsequently, to the chronic phase of degeneration of the collagen fibers of the plantar fascia [11,16,17]. The different phases of PF, which include periods of remission and relapses, make it difficult for healthcare professionals, especially doctors and physiotherapists, to establish and direct the best therapeutic approach to treating the disease [18,19]. One of the problems with conservative treatments aimed at exercises involving the intrinsic muscles of the feet is that only four studies have included interventions with these muscles of the feet in individuals with PF [20–23] and a fifth study reports only a foot exercise protocol in individuals with PF [24]. Two of these studies, one with runners [21] and the other with adults diagnosed with PF [20], investigated 4 weeks of multimodal interventions, in which exercise of the intrinsic muscles of the feet were combined with manual therapy, electrotherapy, stretching, and/or medication, making it difficult to verify the effect of training on the intrinsic muscles of the feet. The other study investigated the addition of intrinsic muscle exercises to calf stretching for 8 weeks in individuals with heel pain and reported no difference when compared to calf stretching alone [22]. In another study, high-load strength training promoted a reduction in foot pain and improved function [23]. The final study only reported a description of an exercise protocol for the intrinsic muscles of the feet and their mobility for individuals with PF [24]. Recent studies have shown the effectiveness of gait retraining to reduce vertical loading rates in healthy runners by adjusting the balance of the intrinsic muscles of the feet for better plantar support and, thus, dissipating the impact forces received by the rearfoot [25]. Other evidence showed improved running mechanics and greater foot functionality in military runners who underwent 10 weeks of gait retraining [26]. A controlled and randomized clinical trial carried out by Neto, Lopes and Ribeiro (2022) [27], showed that a gait retraining program, for two consecutive weeks, combined with visual biofeedback, resulted in a decrease in the plantar load on the rearfoot, favoring better arch index support for recreational runners. Furthermore, static training was effective in reducing foot pronation. Another study associating gait retraining, combined with the use of minimalist sports footwear, for 12 consecutive weeks, reduced peak impact force and the loading rate on the rearfoot associated with an increase in plantar flexion, making it a potential strategy to reduce the risk of injury caused by impact forces [28]. Other evidence from a clinical trial in runners with injuries, such as patellofemoral syndrome, has shown the benefits of gait retraining for eight consecutive weeks to reduce the rate of vertical load when combined with exercise [29], while another study with a protocol of two consecutive weeks of gait retraining reduced muscular activity during the stance phase and increased the final swing phase, minimizing the impact of the plantar loading on the feet [30]. Despite the great benefits of gait retraining in healthy runners and those with knee injuries, its benefits and effectiveness in runners with PF have not yet been observed, given the presence of muscular atrophy in the different clinical phases of the disease (acute and chronic), as well as the functional limitations and overload on the heel. Only with this understanding will it be possible to increase and establish effective pragmatic actions in the conservative treatment of the injury. Another important issue that must be taken into consideration is that recent studies have shown how the COVID-19 pandemic influenced the exercise behavior of runners, with a reduction in the volume and intensity of training, as well as lower motivation to run and train without supervision from a professional or technical trainer [31,32]. A recent study, carried out by Silva et al. , (2023) [33] with Brazilians from the State of São Paulo, observed that two years of the COVID-19 pandemic (2021–2022), with periods of lockdown, negatively affected behavior of physical exercise by runners, due to the respiratory symptoms of COVID-19 and the reduction in training intensity, which is carried out without any professional or technical supervision. These points can lead to worsening of the clinical framework of PF and progression of the disease, as well as greater risk of other injuries (knees and feet) when returning to running [32]. On the return to outdoor running, after a period of quarantine of COVID-19 pandemic, investigations show that recreational and/or amateur runners reduced their training and started to run without professional supervision in relation to more advanced runners with experience, leading to reduced physical performance after the quarantine period, with a greater risk of injuries and side effects of detraining on the return to outdoor running [34]. The pandemic presents a unique external pressure on the running community, and is likely to affect the worsening of injuries, necessitating training adaptations to the biomechanical aspects associated with the onset of PF. Given the scientific evidence, it is extremely important to understand, the pattern of plantar overload in runners with PF after gait retraining, in order to better adjust rehabilitation strategies that are effective in reducing pain and improving biomechanical gait patterns and foot functionality. Thus, the objective of this randomized clinical trial (RCT) 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 plantar fasciitis. Our hypothesis was that the intervention program of gait retraining with real-time visual feedback, for two months, will produce clinical improvements in pain, plantar loading patterns and physical function of the lower limb and feet, during running of the runners with PF compared to runners’ control. METHODS AND ANALYSIS Study design and sample selection This is a randomized, controlled and single-blinded clinical trial, in which 24 recreational runners with and without plantar fasciitis were evaluated, between the years of January 2022 and December 2023 (two consecutive years of the COVID-19 pandemic), 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 Santo Amaro-UNISA (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: 01/29/2024 on Committee of the University Santo Amaro-UNISA and study start date: 03/29/2024). Figure 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]. The diagnosis of all runners with unilateral plantar fasciitis was confirmed by clinical examination and ultrasound examination, which enabled verification of the inflammatory process and perifascial fluids, and alterations in the plantar fascia tissue, such as: thickening, fragmentation, and degeneration, with hypoechoic changes at the calcaneus [16,17]. These runners presented pain when palpating the plantar fascia, when waking up in the morning, and when remaining in a standing position, standing still, or when taking the first steps to move around, and, as well as after remaining for long periods in a sitting position and when performing physical activities [17]. Clinical and functional assessment protocol for the feet and lower limbs Patients The clinical assessment consisted of the clinical diagnosis carried out by the responsible physician, through clinical and ultrasound examinations to monitor PF. Soon after, the Visual Analogue Scale (VAS) was applied to verify the symptom of pain in the feet. The instrument quantitatively assesses pain using a numerical scale from 0 to 10 centimeters, with 0 being the absence of pain and 10 being unbearable pain [16,17]. The runner was asked about the pain felt in the previous week when walking and running. The Foot Function Index (FFI) is an instrument validated for the Portuguese language. This questionnaire contains 23 items about the impact of disability on the feet, subdivided into three domains: foot pain (9 items), difficulty (9 items), and functional limitation (5 items). Each item is measured using a visual analogue scale from zero to ten. To obtain the score for each domain, the values are added and divided by the number of questions answered. The final score is obtained by adding the three domains and dividing the result by the number of domains. The score varies from 0 to 10; the higher the result, the worse the impact of disability on the feet [35]. The Foot and Ankle Ability Measure (FAAM) is an instrument that assesses the functionality of the ankle and foot after suffering from musculoskeletal disorders. The FAAM is composed of two scales, one for assessing functionality in activities of daily living (ADL Scale) and the other for assessing functionality in sporting activities (Sports Scale), being a self-administered questionnaire containing 32 questions, scored on the Likert scale of 5 points. A higher FAAM score represents a higher functional level of the individual [36]. The Lower Extremity Functional Scale (LEFS) is an instrument that assesses the functionality of the lower limbs in the present musculoskeletal conditions. The LEFS-Brazil contains 20 question items, each scored on a Likert scale of 0–4 (extremely difficult to no difficulty for the activities) and the overall score varies from 0 to 80, which represents maximum functional capacity [37]. Foot Posture Index Assessment (FPI) The foot posture assessment was carried out using the Foot Posture Index (FPI), a clinical diagnostic tool designed to quantify the degree to which the foot can be considered supinated, pronated, or normal. The runner was placed in an orthostatic position, with bipedal support, with a 7.5 cm EVA rectangle between the feet to further standardize the base of support for the plantar surface. In addition, participants were instructed to position their upper limbs along the trunk, with their gaze directed forward. This position was necessary, as moving and tilting the body significantly alters the results. These assessments were performed by a single trained physiotherapist, who attributed the values to a series of observations carried out in three regions of the feet (rearfoot, midfoot, and forefoot), where positive values (+ 2) indicate a pronated foot posture, negative values (-2) a supinated foot posture, and values of zero a neutral foot posture (0). Each of the six criteria was graded between 0 (neutral), + 1 or + 2 (pronated), and − 1 or -2 (supinated). The final score is a number between − 12 and + 12 [17, 27]. Gait biomechanical assessment protocol For biomechanical evaluation of plantar pressure distribution during gait, a pressure platform (Loran® Sensor Medica Inc., Rome, Italy) was used, with dimensions 3240 mm long, 620 mm wide, 20 mm high, and weighing 29 kg. Part of the equipment is made up of resistive pressure sensors, homogeneously distributed (4 sensors/cm2). The platform was connected to a desktop notebook to transmit the data, which were collected at a frequency of 100Hz. The runners walked at a pre-established cadence [17, 27]. To ensure that they remained at the same cadence, plantar pressure acquisitions were monitored using a stopwatch. The runners were familiarized with the collection environment and instruments to reduce the retroactive effect. After the setting-up, the runners walked on a flat synthetic rubber track for a distance of 20 meters. The steps included in the intermediate 10 meters were timed and valid for collections, thus totaling approximately 12 steps, captured in 3 attempts [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 medial and lateral (30% of the foot length), midfoot (30% of the foot length), and forefoot and toes (40% of the foot length) [17, 27]. Randomization and blinding The assessment of the runners, with and without PF, were allocated to the intervention protocol with gait retraining with visual feedback during treadmill running. The runners were randomized into two groups that received the intervention protocol: FP and control. All runners received the same intervention protocol. The researchers were blinded in the evaluation processes both before and after the intervention protocol [27]. Primary and secondary outcomes Primary outcomes were: feet pain by visual analogue scale and plantar pressure during gait on the pressure platform Thus, the feet pain intensity verified by the Visual Analogue Scale (VAS), and the plantar pressure during gait verified through of the pressure platform. As secondary outcomes, 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. Randomization and blinding The assessment of the runners, with and without PF, were allocated to the intervention protocol with gait retraining with visual feedback during treadmill running. The runners were randomized into two groups that received the intervention protocol: FP and control. All runners received the same intervention protocol. The researchers were blinded in the evaluation processes both before and after the intervention protocol [27]. Intervention protocol with gait retraining with visual feedback For The intervention protocol with gait retraining with visual feedback during treadmill running was carried out for a period of five consecutive weeks, over two months (2 sessions/week, lasting 40 min/session, totaling 10 sessions over two months of intervention), 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. Another important point was the visual biofeedback, which was provided to each runner in the form of the vertical ground reaction force signal emitted by the pressure platform when their heel was placed on the platform. This image was recorded during the gait assessment and made available to the runner, individually, in addition to the image of the foot support displayed on the monitor for better adaptation and understanding of the plantar support during running. Visual biofeedback was displayed throughout the treadmill intervention protocol, using data show equipment, on a wall in front of the runner. (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. Participants were asked to “run as softly as possible” to reduce the amplitude of the peak vertical force impact (maximum force, N/body weight), especially on the rearfoot (heel), favoring flattening and support of the midfoot. The total training time on the treadmill was 40 min, over the 5 consecutive weeks of training with visual biofeedback (Fig. 2 ). After gait retraining with visual feedback, static plantar support retraining was performed to correct foot pronation. For static training, the runner remained barefoot, in a static position, on the pressure platform, for a period of 10 minutes. During this period, the participant received visual biofeedback, through a monitor placed in front of the runner, on the oscillation of their plantar support and visual demonstrations of the peak pressure on the rearfoot (medial and lateral) for self-correction and reduction in foot pronation. It is worth noting that participants did not receive any other verbal guidance from the physiotherapist during any stages of the intervention protocol [27]. Participants in the control group received the same intervention protocol (gait retraining with visual feedback during treadmill running), in order to guarantee and avoid possible bias when evaluating the intervention effect on the pathological condition of runners with PF. The entire participant reassessment process was carried out after completion of the intervention protocol with gait retraining with visual feedback [27]. Data management, monitoring and sharing All data collected during the trial were compiled electronically. Data integrity and validity were verified at the time of data entry (edit checks). The project manager and research assistant were regularly monitor the study datasets and make recommendations regarding necessary protocol modifications or termination of all or part of the study. Participant data that underlie the results reported in this paper were shared after blinding (text, tables, figures, appendices), immediately following publication. In addition, the study protocol and clinical trial report (both with the planned statistical analysis) were made available by the researchers who proposed the methodology. Requests for data or any form of analysis should be directed to [email protected] . Requesters were asked to sign a data access agreement. Any changes made to the protocol were reported to the research ethics committee via its national website: http://plataformabrasil.saude.gov.br/ . Changes were also be included in the clinical trial registry ( https://ensaiosclinicos.gov.br ). Statistical Analyses Intention-to-treat statistical analysis were conducted. Missing data were treated by imputation methods depending on the type: missing completely at random, missing at random, or missing not at random. 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. Two-way analysis of variance (ANOVA; 2 × 2 factorial design) was performed to assess differences between groups and intervention, followed by Tukey post-hoc tests. 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/cm 2 ) 78.3 ± 14.5 75.1 ± 13.3 0.170 Height (cm) 1.73 ± 8.8 1.70 ± 9.1 0.380 BMI (Kg/cm 2 ) 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) - * ANOVA test, two-way, significant differences p < 0.05. Legend: BMI: Body Mass Index; (F): female; (M): male. Table 1 Table 2 shows that runners with PF presented an improvement in physical-functional performance after the intervention protocol when compared to the initial assessment, with a moderate to high effect size, demonstrating the effectiveness of the intervention protocol. In relation to the control group, there were no significant differences after the intervention, with a slight effect size for the functional variables. In relation to the control group, there were no significant differences in physical-functional performance after the intervention protocol. In the inter-group comparison (CG and FP), improvement was observed only for the FAAM after the intervention period, demonstrating similarity to the CG, as shown in Table 2 . Regarding the symptom of pain, the group of runners with PF presented a pre-intervention score of 7.9 ± 1.5, with a reduction after the intervention protocol to a score of 3.9 ± 1.8. 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). Physical-functional performance Intervention protocol Time PF (n = 12) CG (n = 12) p Foot Function Index - FFI (score) Pre Post 4.0 ± 1.5 1.8 ± 0.7 0.6 ± 0.2 0.5 ± 0.1 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 97.5 ± 5.0 99.6 ± 0.5 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 82.2 ± 1.6 88.8 ± 2.8 0.001 # 0.001 # p Cohen’s d 0.023* 0.47 0.563 0.30 ANOVA test, two-way, significant differences p < 0.05. Significant differences between moments: *pre and post-intervention # inter-groups (FP and CG) after intervention protocol. Table 2 In Table 3 , no significant differences were observed for the foot posture index before and after the intervention protocol between the groups of runners with and without PF, showing a slight effect size for runners with PF. In addition, regarding the inter-group comparison for both assessment moments (initial and final), no significant differences were observed. 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) CG (n = 12) p # Right Foot (score) Pre Post 2.8 ± 1.4 2.2 ± 1.8 3.0 ± 2.0 2.9 ± 1.9 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 2.4 ± 0.7 2.6 ± 1.0 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 3 In Table 4 , a significant reduction in the rate of plantar overload on the medial and lateral rearfoot region (peak pressure and maximum force) was observed for the groups of runners both with and without PF, showing a positive effect of the intervention protocol for the runners. However, the effect size was moderate for runners with PF compared to control runners, who presented a slight effect size. 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 Plantar Load Foot Regions Pre Post d p Pre Post d p Contact Area (cm 2 ) 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 Midfoot 11.6 ± 9.5 8.7 ± 3.6 0.40 0.339 8.7 ± 4.8 9.1 ± 5.6 0.07 0.587 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 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 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 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 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* 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* 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 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 Medial rearfoot 31.4 ± 9.2 27.0 ± 10.7 0.44 0.051* 31.5 ± 9.8 27.8 ± 9.7 0.37 0.021* Lateral rearfoot 32.3 ± 9.6 29.5 ± 12.7 0.24 0.037* 29.7 ± 12.1 26.7 ± 9.1 0.28 0.034* * Student t test dependent, significant differences p < 0.05. Cohen’s d test to verify the effect of the intervention. Table 4 DISCUSSION The current study is the first aimed at verifying the effectiveness of treadmill gait retraining with visual biofeedback for runners with plantar fasciitis. This intervention strategy was based on a previous study with healthy runners carried out by Neto, Lopes and Ribeiro (2022) [27], with the adaptation of treadmill training, to improve the rehabilitation treatment of runners with symptomatic plantar fasciitis. According to Gaudette et al., (2022) [38], in a review study with runners diagnosed with patellofemoral pain syndrome, 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. 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 as minimizing by 62% the appearance of lesions after the end of the intervention [41]. It is worth mentioning that in the current study we did not evaluate the appearance of injuries, but rather, runners already injured, with a diagnosis of plantar fasciitis, and the results showed that the intervention program of gait retraining on the treadmill with real-time visual feedback minimized the risk factors related to the progression of plantar fasciitis, such as overload of the rearfoot and decreased mobility and function of the feet [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 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 gait retraining on a treadmill 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 were satisfactory for reducing pain and increasing the dynamic function of the feet, even without changing the supinated foot support posture observed in the static condition. Limitations and perspectives: The limitations of this study must be considered, as it focused on the short-term effects on running kinetics of treadmill gait retraining in runners with plantar fasciitis, and a post-intervention follow-up to verify retention of treadmill gait retraining was not performed. Future perspectives, with clinical trials, are necessary for medium and long-term follow-up and monitoring after gait retraining of these runners. CONCLUSION A ten-week treadmill gait retraining program using real-time visual biofeedback was effective in reducing pain and plantar pressure on the rearfoot, favoring an increase in the functionality of the feet and lower limbs of 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. Declarations 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). Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. 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 certify that there are no conflicts of interest with any financial organization regarding the material discussed in the manuscript. Author details 1 University Santo Amaro, School of Medicine, Biomechanics and Musculoskeletal Rehabilitation Laboratory, Health Science Post-Graduate Department, São Paulo, Brazil. 2 Hospital Geral do Grajaú, Orthopedics and Traumatology Department, São Paulo, Brazil. 3 Shanghai Jiao Tong University, School of Mechanical Engineering, Laboratory of Mechanical System and Vibration, Shanghai, China 3 University of Sao Paulo, Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, Sao Paulo, Brazil. References Pfeffer G, Bacchetti P, Deland J, et al. 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Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2026 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted Editorial decision: Revision requested 28 Jan, 2025 Editor assigned by journal 14 Jan, 2025 Submission checks completed at journal 14 Jan, 2025 First submitted to journal 13 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5823721","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401990173,"identity":"f4d015b2-f61e-4753-bfa3-a805f7d9c252","order_by":0,"name":"Giovanna Truyts Biscardi Pinto","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Giovanna","middleName":"Truyts Biscardi","lastName":"Pinto","suffix":""},{"id":401990174,"identity":"6baa989d-ec70-4fb6-aafe-1b62e83a0f35","order_by":1,"name":"Marcos Antônio Leite Pereira Pinto","email":"","orcid":"","institution":"Hospital Geral do Grajaú, Orthopedics and Traumatology Department, São Paulo, Brazil.","correspondingAuthor":false,"prefix":"","firstName":"Marcos","middleName":"Antônio Leite Pereira","lastName":"Pinto","suffix":""},{"id":401990175,"identity":"f4cf45df-a334-4ecc-b2cc-27254c326b65","order_by":2,"name":"Júlia Constante Souza","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Júlia","middleName":"Constante","lastName":"Souza","suffix":""},{"id":401990176,"identity":"ad51059a-7df9-4c5a-b918-cd222a9888b1","order_by":3,"name":"Guilherme Silveira Maia","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Guilherme","middleName":"Silveira","lastName":"Maia","suffix":""},{"id":401990177,"identity":"bb8e97d1-362d-4bf9-84b0-7074129d09bd","order_by":4,"name":"André Luiz Cruz Esteves","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"André","middleName":"Luiz Cruz","lastName":"Esteves","suffix":""},{"id":401990178,"identity":"4f60244e-c58c-4fff-9038-b43ffdc790ad","order_by":5,"name":"Ricardo Cesar Salomão","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Ricardo","middleName":"Cesar","lastName":"Salomão","suffix":""},{"id":401990179,"identity":"41169e61-0688-4410-8cd5-d5c25872c6c7","order_by":6,"name":"Gabrielle Souza Oliveira","email":"","orcid":"","institution":"University Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Gabrielle","middleName":"Souza","lastName":"Oliveira","suffix":""},{"id":401990180,"identity":"d51c70f6-0552-4191-a265-9f6b4c84060a","order_by":7,"name":"Peter B. Shull","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"B.","lastName":"Shull","suffix":""},{"id":401990181,"identity":"62f43754-6d2e-4364-a967-f63fdd162cc7","order_by":8,"name":"Ana Paula Ribeiro","email":"data:image/png;base64,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","orcid":"","institution":"University Santo Amaro","correspondingAuthor":true,"prefix":"","firstName":"Ana","middleName":"Paula","lastName":"Ribeiro","suffix":""}],"badges":[],"createdAt":"2025-01-14 03:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5823721/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5823721/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13102-025-01471-1","type":"published","date":"2026-01-07T15:59:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":74074743,"identity":"e7356c3a-f3cd-4687-a746-a556f1e5ee08","added_by":"auto","created_at":"2025-01-17 13:30:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":242831,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of the evaluation process and intervention protocol with gait retraining of runners with and without plantar fasciitis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5823721/v1/1f41d70daceb01d33783a591.png"},{"id":74074744,"identity":"6b71969d-8824-40e1-b96e-8d5551ddf6a3","added_by":"auto","created_at":"2025-01-17 13:30:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":983525,"visible":true,"origin":"","legend":"\u003cp\u003eDemonstration of gait retraining with visual feedback on the treadmill in runners with and without plantar fasciitis.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5823721/v1/98f6339b197255550e053afd.png"},{"id":100069433,"identity":"d0ae6a4e-3e9d-483b-976f-a6fcad602938","added_by":"auto","created_at":"2026-01-12 16:13:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2979689,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5823721/v1/a2c479a2-21be-4577-aefe-c8c7e24face1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gait retraining with real-time visual biofeedback reduces pain, plantar loading and increase function in runners with plantar fasciitis: randomized clinical trial","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePlantar fasciitis (PF) affects approximately 2\u0026nbsp;million individuals per year [1], affecting approximately 10\u0026ndash;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 [2,3]. PF stands out as the third most common injury in runners [4], generating health costs of around \u003cspan\u003e$\u003c/span\u003e192 to \u003cspan\u003e$\u003c/span\u003e376\u0026nbsp;million [5], with lost productivity (absenteeism from work) and absence from sports practice [6].\u003c/p\u003e \u003cp\u003ePF is characterized by a musculoskeletal disorder of inflammatory and degenerative origin of the plantar fascia, whose most common clinical symptom is typical pain in the inferomedial region of the calcaneus [7]. Currently, it is speculated that weakness or atrophy of the intrinsic muscles of the feet in runners with PF occurs in both clinical phases of the disease (acute and chronic), contributing greatly to higher plantar overloads in different regions of the feet [8\u0026ndash;13] and worse functional impairment in sports practice of runners affected by the injury [14,15].\u003c/p\u003e \u003cp\u003eSome scientific evidence has revealed that a reduction in the strength of the intrinsic muscles of the feet may have a greater contribution to the mechanical inefficiency of the plantar arch and, consequently, to greater tensional forces on the plantar fascia, thus promoting the emergence of acute PF and, over time, progressing to the chronic phase of the condition [9\u0026ndash;12,16]. Given the above rationale, reducing overload has been one of the main objectives of the conservative clinical treatment of PF [17]. However, treatment is often complex, due to limited understanding of the pathophysiological mechanisms of PF, which initially occurs through the acute process of inflammation, and, oppositely and subsequently, to the chronic phase of degeneration of the collagen fibers of the plantar fascia [11,16,17]. The different phases of PF, which include periods of remission and relapses, make it difficult for healthcare professionals, especially doctors and physiotherapists, to establish and direct the best therapeutic approach to treating the disease [18,19].\u003c/p\u003e \u003cp\u003eOne of the problems with conservative treatments aimed at exercises involving the intrinsic muscles of the feet is that only four studies have included interventions with these muscles of the feet in individuals with PF [20\u0026ndash;23] and a fifth study reports only a foot exercise protocol in individuals with PF [24]. Two of these studies, one with runners [21] and the other with adults diagnosed with PF [20], investigated 4 weeks of multimodal interventions, in which exercise of the intrinsic muscles of the feet were combined with manual therapy, electrotherapy, stretching, and/or medication, making it difficult to verify the effect of training on the intrinsic muscles of the feet. The other study investigated the addition of intrinsic muscle exercises to calf stretching for 8 weeks in individuals with heel pain and reported no difference when compared to calf stretching alone [22]. In another study, high-load strength training promoted a reduction in foot pain and improved function [23]. The final study only reported a description of an exercise protocol for the intrinsic muscles of the feet and their mobility for individuals with PF [24].\u003c/p\u003e \u003cp\u003eRecent studies have shown the effectiveness of gait retraining to reduce vertical loading rates in healthy runners by adjusting the balance of the intrinsic muscles of the feet for better plantar support and, thus, dissipating the impact forces received by the rearfoot [25]. Other evidence showed improved running mechanics and greater foot functionality in military runners who underwent 10 weeks of gait retraining [26].\u003c/p\u003e \u003cp\u003eA controlled and randomized clinical trial carried out by Neto, Lopes and Ribeiro (2022) [27], showed that a gait retraining program, for two consecutive weeks, combined with visual biofeedback, resulted in a decrease in the plantar load on the rearfoot, favoring better arch index support for recreational runners. Furthermore, static training was effective in reducing foot pronation. Another study associating gait retraining, combined with the use of minimalist sports footwear, for 12 consecutive weeks, reduced peak impact force and the loading rate on the rearfoot associated with an increase in plantar flexion, making it a potential strategy to reduce the risk of injury caused by impact forces [28].\u003c/p\u003e \u003cp\u003eOther evidence from a clinical trial in runners with injuries, such as patellofemoral syndrome, has shown the benefits of gait retraining for eight consecutive weeks to reduce the rate of vertical load when combined with exercise [29], while another study with a protocol of two consecutive weeks of gait retraining reduced muscular activity during the stance phase and increased the final swing phase, minimizing the impact of the plantar loading on the feet [30].\u003c/p\u003e \u003cp\u003eDespite the great benefits of gait retraining in healthy runners and those with knee injuries, its benefits and effectiveness in runners with PF have not yet been observed, given the presence of muscular atrophy in the different clinical phases of the disease (acute and chronic), as well as the functional limitations and overload on the heel. Only with this understanding will it be possible to increase and establish effective pragmatic actions in the conservative treatment of the injury. Another important issue that must be taken into consideration is that recent studies have shown how the COVID-19 pandemic influenced the exercise behavior of runners, with a reduction in the volume and intensity of training, as well as lower motivation to run and train without supervision from a professional or technical trainer [31,32]. A recent study, carried out by Silva \u003cem\u003eet al.\u003c/em\u003e, (2023) [33] with Brazilians from the State of S\u0026atilde;o Paulo, observed that two years of the COVID-19 pandemic (2021\u0026ndash;2022), with periods of lockdown, negatively affected behavior of physical exercise by runners, due to the respiratory symptoms of COVID-19 and the reduction in training intensity, which is carried out without any professional or technical supervision. These points can lead to worsening of the clinical framework of PF and progression of the disease, as well as greater risk of other injuries (knees and feet) when returning to running [32].\u003c/p\u003e \u003cp\u003eOn the return to outdoor running, after a period of quarantine of COVID-19 pandemic, investigations show that recreational and/or amateur runners reduced their training and started to run without professional supervision in relation to more advanced runners with experience, leading to reduced physical performance after the quarantine period, with a greater risk of injuries and side effects of detraining on the return to outdoor running [34]. The pandemic presents a unique external pressure on the running community, and is likely to affect the worsening of injuries, necessitating training adaptations to the biomechanical aspects associated with the onset of PF. Given the scientific evidence, it is extremely important to understand, the pattern of plantar overload in runners with PF after gait retraining, in order to better adjust rehabilitation strategies that are effective in reducing pain and improving biomechanical gait patterns and foot functionality. Thus, the objective of this randomized clinical trial (RCT) 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 plantar fasciitis. Our hypothesis was that the intervention program of gait retraining with real-time visual feedback, for two months, will produce clinical improvements in pain, plantar loading patterns and physical function of the lower limb and feet, during running of the runners with PF compared to runners\u0026rsquo; control.\u003c/p\u003e"},{"header":"METHODS AND ANALYSIS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample selection\u003c/h2\u003e \u003cp\u003eThis is a randomized, controlled and single-blinded clinical trial, in which 24 recreational runners with and without plantar fasciitis were evaluated, between the years of January 2022 and December 2023 (two consecutive years of the COVID-19 pandemic), participants in running events or sports clubs from different regions of the city of S\u0026atilde;o Paulo/SP. The study protocol was reviewed and approved by the Departmental Research Committee of the University Santo Amaro-UNISA (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.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and 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).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003e\u0026ndash; Consort: Flow diagram\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003eAs 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].\u003c/p\u003e \u003cp\u003eThe diagnosis of all runners with unilateral plantar fasciitis was confirmed by clinical examination and ultrasound examination, which enabled verification of the inflammatory process and perifascial fluids, and alterations in the plantar fascia tissue, such as: thickening, fragmentation, and degeneration, with hypoechoic changes at the calcaneus [16,17]. These runners presented pain when palpating the plantar fascia, when waking up in the morning, and when remaining in a standing position, standing still, or when taking the first steps to move around, and, as well as after remaining for long periods in a sitting position and when performing physical activities [17].\u003c/p\u003e\n\u003ch3\u003eClinical and functional assessment protocol for the feet and lower limbs\u003c/h3\u003e\n\u003cp\u003ePatients The clinical assessment consisted of the clinical diagnosis carried out by the responsible physician, through clinical and ultrasound examinations to monitor PF. Soon after, the Visual Analogue Scale (VAS) was applied to verify the symptom of pain in the feet. The instrument quantitatively assesses pain using a numerical scale from 0 to 10 centimeters, with 0 being the absence of pain and 10 being unbearable pain [16,17]. The runner was asked about the pain felt in the previous week when walking and running.\u003c/p\u003e \u003cp\u003eThe Foot Function Index (FFI) is an instrument validated for the Portuguese language. This questionnaire contains 23 items about the impact of disability on the feet, subdivided into three domains: foot pain (9 items), difficulty (9 items), and functional limitation (5 items). Each item is measured using a visual analogue scale from zero to ten. To obtain the score for each domain, the values are added and divided by the number of questions answered. The final score is obtained by adding the three domains and dividing the result by the number of domains. The score varies from 0 to 10; the higher the result, the worse the impact of disability on the feet [35].\u003c/p\u003e \u003cp\u003eThe Foot and Ankle Ability Measure (FAAM) is an instrument that assesses the functionality of the ankle and foot after suffering from musculoskeletal disorders. The FAAM is composed of two scales, one for assessing functionality in activities of daily living (ADL Scale) and the other for assessing functionality in sporting activities (Sports Scale), being a self-administered questionnaire containing 32 questions, scored on the Likert scale of 5 points. A higher FAAM score represents a higher functional level of the individual [36].\u003c/p\u003e \u003cp\u003eThe Lower Extremity Functional Scale (LEFS) is an instrument that assesses the functionality of the lower limbs in the present musculoskeletal conditions. The LEFS-Brazil contains 20 question items, each scored on a Likert scale of 0\u0026ndash;4 (extremely difficult to no difficulty for the activities) and the overall score varies from 0 to 80, which represents maximum functional capacity [37].\u003c/p\u003e\n\u003ch3\u003eFoot Posture Index Assessment (FPI)\u003c/h3\u003e\n\u003cp\u003eThe foot posture assessment was carried out using the Foot Posture Index (FPI), a clinical diagnostic tool designed to quantify the degree to which the foot can be considered supinated, pronated, or normal. The runner was placed in an orthostatic position, with bipedal support, with a 7.5 cm EVA rectangle between the feet to further standardize the base of support for the plantar surface. In addition, participants were instructed to position their upper limbs along the trunk, with their gaze directed forward. This position was necessary, as moving and tilting the body significantly alters the results.\u003c/p\u003e \u003cp\u003eThese assessments were performed by a single trained physiotherapist, who attributed the values to a series of observations carried out in three regions of the feet (rearfoot, midfoot, and forefoot), where positive values (+\u0026thinsp;2) indicate a pronated foot posture, negative values (-2) a supinated foot posture, and values of zero a neutral foot posture (0). Each of the six criteria was graded between 0 (neutral), +\u0026thinsp;1 or +\u0026thinsp;2 (pronated), and \u0026minus;\u0026thinsp;1 or -2 (supinated). The final score is a number between \u0026minus;\u0026thinsp;12 and +\u0026thinsp;12 [17, 27].\u003c/p\u003e\n\u003ch3\u003eGait biomechanical assessment protocol\u003c/h3\u003e\n\u003cp\u003eFor biomechanical evaluation of plantar pressure distribution during gait, a pressure platform (Loran\u0026reg; Sensor Medica Inc., Rome, Italy) was used, with dimensions 3240 mm long, 620 mm wide, 20 mm high, and weighing 29 kg. Part of the equipment is made up of resistive pressure sensors, homogeneously distributed (4 sensors/cm2). The platform was connected to a desktop notebook to transmit the data, which were collected at a frequency of 100Hz. The runners walked at a pre-established cadence [17, 27].\u003c/p\u003e \u003cp\u003eTo ensure that they remained at the same cadence, plantar pressure acquisitions were monitored using a stopwatch. The runners were familiarized with the collection environment and instruments to reduce the retroactive effect. After the setting-up, the runners walked on a flat synthetic rubber track for a distance of 20 meters. The steps included in the intermediate 10 meters were timed and valid for collections, thus totaling approximately 12 steps, captured in 3 attempts [17, 27].\u003c/p\u003e \u003cp\u003eThe 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 cm\u0026sup2;). 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 medial and lateral (30% of the foot length), midfoot (30% of the foot length), and forefoot and toes (40% of the foot length) [17, 27].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRandomization and blinding\u003c/h2\u003e \u003cp\u003eThe assessment of the runners, with and without PF, were allocated to the intervention protocol with gait retraining with visual feedback during treadmill running. The runners were randomized into two groups that received the intervention protocol: FP and control. All runners received the same intervention protocol. The researchers were blinded in the evaluation processes both before and after the intervention protocol [27].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrimary and secondary outcomes\u003c/h3\u003e\n\u003cp\u003ePrimary outcomes were: feet pain by visual analogue scale and plantar pressure during gait on the pressure platform Thus, the feet pain intensity verified by the Visual Analogue Scale (VAS), and the plantar pressure during gait verified through of the pressure platform. As secondary outcomes, 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.\u003c/p\u003e\n\u003ch3\u003eRandomization and blinding\u003c/h3\u003e\n\u003cp\u003eThe assessment of the runners, with and without PF, were allocated to the intervention protocol with gait retraining with visual feedback during treadmill running. The runners were randomized into two groups that received the intervention protocol: FP and control. All runners received the same intervention protocol. The researchers were blinded in the evaluation processes both before and after the intervention protocol [27].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntervention protocol with gait retraining with visual feedback\u003c/h2\u003e \u003cp\u003eFor The intervention protocol with gait retraining with visual feedback during treadmill running was carried out for a period of five consecutive weeks, over two months (2 sessions/week, lasting 40 min/session, totaling 10 sessions over two months of intervention), 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.\u003c/p\u003e \u003cp\u003eAnother important point was the visual biofeedback, which was provided to each runner in the form of the vertical ground reaction force signal emitted by the pressure platform when their heel was placed on the platform. This image was recorded during the gait assessment and made available to the runner, individually, in addition to the image of the foot support displayed on the monitor for better adaptation and understanding of the plantar support during running. Visual biofeedback was displayed throughout the treadmill intervention protocol, using data show equipment, on a wall in front of the runner. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 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. Participants were asked to \u0026ldquo;run as softly as possible\u0026rdquo; to reduce the amplitude of the peak vertical force impact (maximum force, N/body weight), especially on the rearfoot (heel), favoring flattening and support of the midfoot. The total training time on the treadmill was 40 min, over the 5 consecutive weeks of training with visual biofeedback (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter gait retraining with visual feedback, static plantar support retraining was performed to correct foot pronation. For static training, the runner remained barefoot, in a static position, on the pressure platform, for a period of 10 minutes. During this period, the participant received visual biofeedback, through a monitor placed in front of the runner, on the oscillation of their plantar support and visual demonstrations of the peak pressure on the rearfoot (medial and lateral) for self-correction and reduction in foot pronation. It is worth noting that participants did not receive any other verbal guidance from the physiotherapist during any stages of the intervention protocol [27].\u003c/p\u003e \u003cp\u003eParticipants in the control group received the same intervention protocol (gait retraining with visual feedback during treadmill running), in order to guarantee and avoid possible bias when evaluating the intervention effect on the pathological condition of runners with PF. The entire participant reassessment process was carried out after completion of the intervention protocol with gait retraining with visual feedback [27].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData management, monitoring and sharing\u003c/h2\u003e \u003cp\u003eAll data collected during the trial were compiled electronically. Data integrity and validity were verified at the time of data entry (edit checks). The project manager and research assistant were regularly monitor the study datasets and make recommendations regarding necessary protocol modifications or termination of all or part of the study. Participant data that underlie the results reported in this paper were shared after blinding (text, tables, figures, appendices), immediately following publication. In addition, the study protocol and clinical trial report (both with the planned statistical analysis) were made available by the researchers who proposed the methodology. Requests for data or any form of analysis should be directed to [email protected]. Requesters were asked to sign a data access agreement. Any changes made to the protocol were reported to the research ethics committee via its national website: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://plataformabrasil.saude.gov.br/\u003c/span\u003e\u003cspan address=\"http://plataformabrasil.saude.gov.br/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Changes were also be included in the clinical trial registry (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ensaiosclinicos.gov.br\u003c/span\u003e\u003cspan address=\"https://ensaiosclinicos.gov.br\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eIntention-to-treat statistical analysis were conducted. Missing data were treated by imputation methods depending on the type: missing completely at random, missing at random, or missing not at random. 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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;0, 25), power of 80%, and a significance level of 5%. Data normality was tested using the Shapiro-Wilks test. Two-way analysis of variance (ANOVA; 2 \u0026times; 2 factorial design) was performed to assess differences between groups and intervention, followed by Tukey post-hoc tests. 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).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatient and public involvement\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eInitially, 35 runners volunteered to participate in this study, of whom 11 were excluded due to running experience\u0026thinsp;\u0026lt;\u0026thinsp;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.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it can be observed that runners with and without PF did not differ in anthropometric characteristics, running experience, and weekly training volume.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Comparison of anthropometric aspects and time spent practicing physical exercise between different assessment times.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRunners (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePF\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCG\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (Kg/cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.73\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.70\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Kg/cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRunning experience (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining volume (km/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (F and M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42% (F)\u003c/p\u003e \u003cp\u003e58% (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41% (F)\u003c/p\u003e \u003cp\u003e59% (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003e* ANOVA test, two-way, significant differences p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Legend: BMI: Body Mass Index; (F): female; (M): male.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that runners with PF presented an improvement in physical-functional performance after the intervention protocol when compared to the initial assessment, with a moderate to high effect size, demonstrating the effectiveness of the intervention protocol. In relation to the control group, there were no significant differences after the intervention, with a slight effect size for the functional variables. In relation to the control group, there were no significant differences in physical-functional performance after the intervention protocol. In the inter-group comparison (CG and FP), improvement was observed only for the FAAM after the intervention period, demonstrating similarity to the CG, as shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Regarding the symptom of pain, the group of runners with PF presented a pre-intervention score of 7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5, with a reduction after the intervention protocol to a score of 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; 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).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhysical-functional performance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIntervention protocol\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTime\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePF\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCG\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot Function Index - FFI (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e0.010\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot and Ankle Ability Measure - FAAM (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003cp\u003e97.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003cp\u003e99.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Extremity Functional Scale - LEFS (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003cp\u003e32.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003cp\u003e88.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.023*\u003c/p\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eANOVA test, two-way, significant differences p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Significant differences between moments: *pre and post-intervention\u003c/em\u003e \u003csup\u003e\u003cem\u003e#\u003c/em\u003e\u003c/sup\u003e\u003cem\u003einter-groups (FP and CG) after intervention protocol.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIn Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, no significant differences were observed for the foot posture index before and after the intervention protocol between the groups of runners with and without PF, showing a slight effect size for runners with PF. In addition, regarding the inter-group comparison for both assessment moments (initial and final), no significant differences were observed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; 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).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFPI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIntervention protocol\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTime\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePF\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCG\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight Foot (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep*\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft foot (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep*\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eANOVA test, two-way, significant differences p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Significant differences between moments: *pre and post-intervention #intergroups (FP and CG) after intervention protocol.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIn Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, a significant reduction in the rate of plantar overload on the medial and lateral rearfoot region (peak pressure and maximum force) was observed for the groups of runners both with and without PF, showing a positive effect of the intervention protocol for the runners. However, the effect size was moderate for runners with PF compared to control runners, who presented a slight effect size.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; 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).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003ePF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlantar Load\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFoot Regions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eContact Area\u003c/p\u003e \u003cp\u003e(cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForefoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.712\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedial rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e20.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLateral rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePeak Pressure\u003c/p\u003e \u003cp\u003e(KPa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForefoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e331.8\u0026thinsp;\u0026plusmn;\u0026thinsp;61.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e340.0\u0026thinsp;\u0026plusmn;\u0026thinsp;57.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e372.2\u0026thinsp;\u0026plusmn;\u0026thinsp;53.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e367.2\u0026thinsp;\u0026plusmn;\u0026thinsp;50.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e102.9\u0026thinsp;\u0026plusmn;\u0026thinsp;50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e92.5\u0026thinsp;\u0026plusmn;\u0026thinsp;61.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e104.8\u0026thinsp;\u0026plusmn;\u0026thinsp;79.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e102.4\u0026thinsp;\u0026plusmn;\u0026thinsp;88.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedial rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e333.7\u0026thinsp;\u0026plusmn;\u0026thinsp;97.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e288.4\u0026thinsp;\u0026plusmn;\u0026thinsp;54.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.035*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e331.6\u0026thinsp;\u0026plusmn;\u0026thinsp;69.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e302.6\u0026thinsp;\u0026plusmn;\u0026thinsp;90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.027*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLateral rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e327.8\u0026thinsp;\u0026plusmn;\u0026thinsp;93.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e290.8\u0026thinsp;\u0026plusmn;\u0026thinsp;64.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e319.3\u0026thinsp;\u0026plusmn;\u0026thinsp;81.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e288.2\u0026thinsp;\u0026plusmn;\u0026thinsp;90.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.024*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMaximum force (N/BW)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForefoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedial rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.051*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e31.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.021*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLateral rearfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.037*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.034*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003e* Student t test dependent, significant differences p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Cohen\u0026rsquo;s d test to verify the effect of the intervention.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe current study is the first aimed at verifying the effectiveness of treadmill gait retraining with visual biofeedback for runners with plantar fasciitis. This intervention strategy was based on a previous study with healthy runners carried out by Neto, Lopes and Ribeiro (2022) [27], with the adaptation of treadmill training, to improve the rehabilitation treatment of runners with symptomatic plantar fasciitis.\u003c/p\u003e \u003cp\u003eAccording to Gaudette et al., (2022) [38], in a review study with runners diagnosed with patellofemoral pain syndrome, 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.\u003c/p\u003e \u003cp\u003eSecond 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.\u003c/p\u003e \u003cp\u003eScientific 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\u0026ndash;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.\u003c/p\u003e \u003cp\u003eCombining 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 as minimizing by 62% the appearance of lesions after the end of the intervention [41]. It is worth mentioning that in the current study we did not evaluate the appearance of injuries, but rather, runners already injured, with a diagnosis of plantar fasciitis, and the results showed that the intervention program of gait retraining on the treadmill with real-time visual feedback minimized the risk factors related to the progression of plantar fasciitis, such as overload of the rearfoot and decreased mobility and function of the feet [11,16,17].\u003c/p\u003e \u003cp\u003eReal-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].\u003c/p\u003e \u003cp\u003eAn 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\u0026ndash;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 plantar fasciitis.\u003c/p\u003e \u003cp\u003eMost 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 gait retraining on a treadmill 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 were satisfactory for reducing pain and increasing the dynamic function of the feet, even without changing the supinated foot support posture observed in the static condition.\u003c/p\u003e \u003cp\u003eLimitations and perspectives: The limitations of this study must be considered, as it focused on the short-term effects on running kinetics of treadmill gait retraining in runners with plantar fasciitis, and a post-intervention follow-up to verify retention of treadmill gait retraining was not performed. Future perspectives, with clinical trials, are necessary for medium and long-term follow-up and monitoring after gait retraining of these runners.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eA ten-week treadmill gait retraining program using real-time visual biofeedback was effective in reducing pain and plantar pressure on the rearfoot, favoring an increase in the functionality of the feet and lower limbs of 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.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGTB 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was financially supported by the National Council for Scientific and Technological Development (CNPq - Process number: 160055/2022-9 and 105398/2024-1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that there are no conflicts of interest with any financial organization regarding the material discussed in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eUniversity Santo Amaro, School of Medicine, Biomechanics and Musculoskeletal Rehabilitation Laboratory, Health Science Post-Graduate Department, S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eHospital Geral do Graja\u0026uacute;, Orthopedics and Traumatology Department, S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Shanghai Jiao Tong University, School of Mechanical Engineering, Laboratory of Mechanical System and Vibration, Shanghai, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eUniversity of Sao Paulo, Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, Sao Paulo, Brazil.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePfeffer G, Bacchetti P, Deland J, et al. 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Gait Retraining as an Intervention for Patellofemoral Pain. Curr Rev Musculoskelet Med. 2020;13(1):103-114. doi: 10.1007/s12178-020-09605-3.\u003c/li\u003e\n\u003cli\u003eUğurlar M, S\u0026ouml;nmez MM, Uğurlar \u0026Ouml;Y, Adıyeke L, Yıldırım H, Eren OT. Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial. J Foot Ankle Surg. 2018;57(5):913-918. doi: 10.1053/j.jfas.2018.03.017.\u003c/li\u003e\n\u003cli\u003eRibeiro AP, de Souza BL, Jo\u0026atilde;o SMA. Effectiveness of mechanical treatment with customized insole and minimalist flexible footwear for women with calcaneal spur: randomized controlled trial. BMC Musculoskelet Disord. 2022;13;23(1):773. doi: 10.1186/s12891-022-05729-4.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5823721/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5823721/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlantar fasciitis (PF) affects approximately 2\u0026nbsp;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eControlled, randomized clinical trial with blinded evaluators. Participants: 24 runners were evaluated and divided into two groups: 12 runners with plantar fasciitis and 12 control runners. 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). 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRunners with PF presented improvement in pain and physical-functional performance, as well as a reduction in plantar overload on the rearfoot after the intervention protocol when compared to the initial assessment and control, with a moderate to high effect size. 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA ten-week treadmill gait retraining program using real-time visual biofeedback was effective in reducing pain and plantar pressure on the rearfoot, favoring an increase in the functionality of the feet and lower limbs of runners with plantar fasciitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration number\u003c/strong\u003e: RBR-5m6msq7\u003c/p\u003e","manuscriptTitle":"Gait retraining with real-time visual biofeedback reduces pain, plantar loading and increase function in runners with plantar fasciitis: randomized clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-17 13:30:07","doi":"10.21203/rs.3.rs-5823721/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-28T07:21:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-14T11:41:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-14T11:40:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Sports Science, Medicine and Rehabilitation","date":"2025-01-14T03:27:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"191cb9b3-9fbe-44ec-a2f2-873b065f1576","owner":[],"postedDate":"January 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:06:21+00:00","versionOfRecord":{"articleIdentity":"rs-5823721","link":"https://doi.org/10.1186/s13102-025-01471-1","journal":{"identity":"bmc-sports-science-medicine-and-rehabilitation","isVorOnly":false,"title":"BMC Sports Science, Medicine and Rehabilitation"},"publishedOn":"2026-01-07 15:59:16","publishedOnDateReadable":"January 7th, 2026"},"versionCreatedAt":"2025-01-17 13:30:07","video":"","vorDoi":"10.1186/s13102-025-01471-1","vorDoiUrl":"https://doi.org/10.1186/s13102-025-01471-1","workflowStages":[]},"version":"v1","identity":"rs-5823721","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5823721","identity":"rs-5823721","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}