Pain catastrophizing beliefs and neuropathic symptoms are associated with poorer long-term recovery in chronic plantar heel pain: a cohort study

Key points

1. 01Increasing pain catastrophizing scores were associated with less pain improvement over 12 months (interaction beta = -0.39, 95% CI -0.01 to -0.77).
2. 02Increasing neuropathic symptom scores (painDETECT) were also associated with poorer pain recovery (interaction beta = -0.79, 95% CI -0.10 to -1.48).
3. 03People classified as 'catastrophizing' (PCS >20) had approximately 15 points less pain improvement than those who were not (interaction beta = -15, 95% CI -28.5 to -1.4), exceeding the minimal important difference.
4. 04People classified as 'probably neuropathic' (painDETECT >=19) had approximately 15.8 points less pain improvement (interaction beta = -15.8, 95% CI -29.9 to -1.7).
5. 05BMI, waist girth, ankle plantarflexor strength, depression, and multisite pain were not significantly associated with pain, function, or quality-of-life outcomes in full multivariable models.

How it was conducted

Design

Prospective cohort study with longitudinal follow-up at 12 months

Participants

220 adults with a clinical diagnosis of chronic plantar heel pain recruited in southern Tasmania, Australia (2014-2016)

Key exposures

Pain catastrophizing (Pain Catastrophizing Scale), neuropathic symptoms (painDETECT), BMI, waist circumference, ankle plantarflexor strength, ankle dorsiflexion, multisite pain, depression (PHQ-9), physical activity (accelerometry)

Primary outcomes

Foot Health Status Questionnaire (FHSQ) pain and function domains (0-100 scale); 6-dimension Assessment of Quality of Life Scale (AQoL-6D)

Analysis

Linear mixed-effects models with exposure x time interaction terms; inverse probability weighting for missing data

What they found

• Mean FHSQ pain scores improved from 48.8/100 at baseline to 75.9/100 at 12 months (mean improvement approximately 27 points).
• 67% of participants achieved clinically important pain improvement (>=13 points on FHSQ pain scale, the minimal important difference).
• 21% of participants reported no pain at follow-up (FHSQ = 100/100).
• Foot function improved from 65.7 to 86.13/100 (approximately 31% improvement).
• Quality-of-life scores improved from 76.4 to 81.6/100 (approximately 7% improvement).
• In fully adjusted models, worsening painDETECT score was associated with poorer pain recovery: interaction beta = -0.79 (95% CI -0.10 to -1.48).
• In fully adjusted models, worsening pain catastrophizing score was associated with poorer pain recovery: interaction beta = -0.39 (95% CI -0.01 to -0.77).
• Participants classified as catastrophizing (PCS >20) had 15 points less pain improvement than non-catastrophizing participants (interaction beta = -15, 95% CI -28.5 to -1.4).
• Participants classified as probably neuropathic (painDETECT >=19) had 15.8 points less pain improvement than those not neuropathic (interaction beta = -15.8, 95% CI -29.9 to -1.7).
• No significant associations were found between BMI, waist girth, ankle plantarflexor strength, or multisite pain and any outcome in fully adjusted models.
• Steps per day was weakly negatively associated with function (interaction beta = -1.50, 95% CI -2.89 to -0.11) and moderate-to-vigorous physical activity was weakly negatively associated with quality of life (interaction beta = -0.04, 95% CI -0.07 to -0.01), likely reflecting regression to the mean.

Limitations

• Single follow-up at 12 months may miss variability in recovery trajectories; intermediate time points were not feasible.
• Observational design cannot prove causation; findings may be subject to reporting bias given reliance on self-report for key exposures.
• Sample size calculations were based on correlation size and may have underestimated requirements for mixed-effects models, potentially reducing power and estimate precision.
• Treatment data were collected by self-report only, limiting ability to distinguish natural history from treated course and to account for treatment expectations.

Why it matters

For patients

People with long-lasting heel pain who notice they are catastrophizing about their pain or have nerve-like symptoms (burning, shooting) may be at risk of slower recovery and should discuss these factors with their treating clinician.

For clinicians

Screening for pain catastrophizing (PCS >20) and neuropathic features (painDETECT >=19) can help identify patients with chronic plantar heel pain likely to have a poorer prognosis, warranting targeted interventions such as pain science education or neuropathically informed treatment.

For readers

This is the first prospective cohort study to confirm that psychological and neurogenic pain factors independently predict pain outcomes in chronic plantar heel pain, shifting focus beyond local foot pathology toward person-level mechanisms.