A Closer Look at Localized and Distant Pressure Pain Hypersensitivity in People With Lower Extremity Overuse Soft Tissue Painful Conditions: A Systematic Review and Meta-Analysis

Document Type

Journal Article

Publication Date



Physical therapy




Achilles Tendon; Plantar Fascitis; Tendinopathy; meta-analysis; patella; pressure pain


OBJECTIVE: The nociceptive pain processing of soft tissue overuse conditions is under debate as no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft tissue conditions and controls who were pain free. METHODS: Five databases were searched from inception to December 1, 2021. Case-control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared. RESULTS: After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome [GTPS], plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = -262.92 kPa, 95% CI = 323.78 to -202.05 kPa; nonaffected side: MD = -216.47 kPa, 95% CI = -304.99 to -127.95 kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = -176.39 kPa, 95% CI = -306.11 to -46.68 kPa) and distant pain-free (MD = -97.27 kPa, 95% CI = 133.21 to -61.33 kPa) areas compared with controls. CONCLUSION: Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions when compared to pain-free controls, particularly in plantar fasciitis and GTPS. Participants with plantar fasciitis showed a reduction of PPTs on the affected and nonaffected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence).


Health, Human Function, and Rehabilitation Sciences