Rheumatology International

, Volume 37, Issue 7, pp 1175–1182 | Cite as

Foot pain severity is associated with the ratio of visceral to subcutaneous fat mass, fat-mass index and depression in women

  • Tom P. WalshEmail author
  • John B. Arnold
  • Tiffany K. Gill
  • Angela M. Evans
  • Alison Yaxley
  • Catherine L. Hill
  • E. Michael Shanahan
Observational research


Body composition and poor mental health are risk factors for developing foot pain, but the role of different fat deposits and psychological features related to chronic pain are not well understood. The aim of this study was to investigate the association between body composition, psychological health and foot pain. Eighty-eight women participated in this study: 44 with chronic, disabling foot pain (mean age 55.3 SD 7.0 years, BMI 29.5 SD 6.7 kg/m2), and 44 age and BMI matched controls. Disabling foot pain was determined from the functional limitation domain of the Manchester Foot Pain and Disability Index. Body composition was measured using dual X-ray absorptiometry and psychological health (catastrophisation, central sensitisation and depression) was measured using three validated questionnaires. Between-group analyses found that foot pain was not significantly associated with body composition variables, but was significantly associated with all psychological health measures (P < 0.001–0.047). Within-group analyses found that the severity of foot pain was significantly correlated with body composition measures: fat mass (total, android, gynoid, and visceral), fat-mass ratios [visceral/subcutaneous (VAT/SAT), visceral/android], fat-mass index (FMI), and depression. In multivariable analysis, VAT/SAT (β 1.27, 95% CI 0.28–2.27), FMI (β 0.14, 95% CI 0.02–0.25) and depression (β 0.06, 95% CI 0.00–0.12) were independently associated with foot pain severity. Psychological health, not body composition, was associated with prevalent foot pain. For women with foot pain, VAT/SAT, FMI and depression were associated with severity. Further work is needed to determine if a reduction in fat mass reduces the severity of foot pain.


Foot Pain Obesity Intra-abdominal fat 



The authors would like to thank all the study participants who made this study possible.


TPW is funded by a Nursing and Allied Health Scholarship and Support Scheme funded by the Commonwealth Department of Health and administered by Services for Australian Rural and Remote Allied Health. This study was funded by the Australian Podiatry Education and Research Foundation (APERF).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.


  1. 1.
    Thomas MJ, Roddy E, Zhang W, Menz HB, Hannan MT, Peat GM (2011) The population prevalence of foot and ankle pain in middle and old age: a systematic review. Pain 152:2870–2880CrossRefPubMedGoogle Scholar
  2. 2.
    Gorter KJ, Kuyvenhoven MM, de Melker RA (2000) Nontraumatic foot complaints in older people. A population-based survey of risk factors, mobility, and well-being. J Am Podiatr Med Assoc 90:397–402CrossRefPubMedGoogle Scholar
  3. 3.
    Menz HB, Tiedemann A, Kwan MMS, Plumb K, Lord SR (2006) Foot pain in community-dwelling older people: an evaluation of the Manchester Foot Pain and Disability Index. Rheumatology 45:863–867CrossRefPubMedGoogle Scholar
  4. 4.
    Roddy E, Muller S, Thomas E (2011) Onset and persistence of disabling foot pain in community-dwelling older adults over a 3-year period: a prospective cohort study. J Gerontol A Biol Sci Med Sci 66:474–480CrossRefPubMedGoogle Scholar
  5. 5.
    Butterworth PA, Landorf KB, Smith SE, Menz HB (2012) The association between body mass index and musculoskeletal foot disorders: a systematic review. Obes Rev 13:630–642CrossRefPubMedGoogle Scholar
  6. 6.
    Gay A, Culliford D, Leyland K, Arden NK, Bowen CJ (2014) Associations between body mass index and foot joint pain in middle-aged and older women: a longitudinal population-based cohort study. Arthritis Care Res 66:1873–1879CrossRefGoogle Scholar
  7. 7.
    Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP (2006) Musculoskeletal disorders associated with obesity: a biomechanical perspective. Obes Rev 7:239–250CrossRefPubMedGoogle Scholar
  8. 8.
    Tanamas SK, Wluka AE, Berry P et al (2012) Relationship between obesity and foot pain and its association with fat mass, fat distribution, and muscle mass. Arthritis Care Res 64:262–268CrossRefGoogle Scholar
  9. 9.
    Butterworth PA, Urquhart DM, Cicuttini FM et al (2013) Fat mass is a predictor of incident foot pain. Obesity 21:E495–E499PubMedGoogle Scholar
  10. 10.
    Walsh TP, Gill TK, Evans AM et al (2016) Association of fat mass and adipokines with foot pain in a community cohort. Arthritis Care Res 68:526–533CrossRefGoogle Scholar
  11. 11.
    Cotchett M, Munteanu SE, Landorf KB (2016) Depression, anxiety, and stress in people with and without plantar heel pain. Foot Ankle Int 37:816–821CrossRefPubMedGoogle Scholar
  12. 12.
    Awale A, Dufour AB, Katz P, Menz HB, Hannan MT (2016) Link between foot pain severity and prevalence of depressive symptoms. Arthritis Care Res 68:871–876CrossRefGoogle Scholar
  13. 13.
    Butterworth PA, Urquhart DM, Cicuttini FM et al (2014) Relationship between mental health and foot pain. Arthritis Care Res 66:1241–1245CrossRefGoogle Scholar
  14. 14.
    Cotchett MP, Whittaker G, Erbas B (2015) Psychological variables associated with foot function and foot pain in patients with plantar heel pain. Clin Rheumatol 34:957–964CrossRefPubMedGoogle Scholar
  15. 15.
    Somers TJ, Keefe FJ, Carson JW, Pells JJ, Lacaille L (2008) Pain catastrophizing in borderline morbidly obese and morbidly obese individuals with osteoarthritic knee pain. Pain Res Manag 13:401–406CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Imamura M, Imamura ST, Kaziyama HHS et al (2008) Impact of nervous system hyperalgesia on pain, disability, and quality of life in patients with knee osteoarthritis: a controlled analysis. Arthritis Rheum 59:1424–1431CrossRefPubMedGoogle Scholar
  17. 17.
    Schutz Y, Kyle UUG, Pichard C (2002) Fat-free mass index and fat mass index percentiles in Caucasians aged 18–98 y. Int J Obes Relat Metab Disord 26:953–960CrossRefPubMedGoogle Scholar
  18. 18.
    Blaak E (2001) Gender differences in fat metabolism. Curr Opin Clin Nutr Metab Care 4:499CrossRefPubMedGoogle Scholar
  19. 19.
    Lemieux S, Prud’homme D, Bouchard C, Tremblay A, Després J-P (1993) Sex differences in the relation of visceral adipose tissue accumulation to total body fatness. Am J Clin Nutr 58:463–467PubMedGoogle Scholar
  20. 20.
    Murabito JM, Massaro JM, Clifford B, Hoffmann U, Fox CS (2013) Depressive symptoms are associated with visceral adiposity in a community-based sample of middle-aged women and men. Obesity 21:1713–1719CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Lee ES, Kim YH, Beck S-H, Lee S, Oh SW (2005) Depressive mood and abdominal fat distribution in overweight premenopausal women. Obes Res 13:320–325CrossRefPubMedGoogle Scholar
  22. 22.
    Dantzer R (2012) Depression and inflammation: an intricate relationship. Biol Psychiatry 71:4–5CrossRefPubMedGoogle Scholar
  23. 23.
    Wellen KE, Hotamisligil GS (2003) Obesity-induced inflammatory changes in adipose tissue. J Clin Invest 112:1785–1788CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Capuron L, Lasselin J, Castanon N (2017) Role of adiposity-driven inflammation in depressive morbidity. Neuropsychopharmacology 42:115–128CrossRefPubMedGoogle Scholar
  25. 25.
    Garrow AP, Papageorgiou AC, Silman AJ et al (2000) Development and validation of a questionnaire to assess disabling foot pain. Pain 85:107–113CrossRefPubMedGoogle Scholar
  26. 26.
    Kaul S, Rothney MP, Peters DM, Wacker WK (2012) Dual-energy X-ray absorptiometry for quantification of visceral fat. Obesity 20:1313–1318CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Rothney MP, Martin F-P, Xia Y et al (2012) Precision of GE Lunar iDXA for the measurement of total and regional body composition in nonobese adults. J Clin Densitom 15:399–404CrossRefPubMedGoogle Scholar
  28. 28.
    Radloff LS (1977) The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1:385–401CrossRefGoogle Scholar
  29. 29.
    Weissman MM, Sholomskas D (1977) Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol 106:203–214CrossRefPubMedGoogle Scholar
  30. 30.
    Mayer TG, Neblett R, Cohen H et al (2012) The development and psychometric validation of the central sensitization inventory. Pain Pract 12:276–285CrossRefPubMedGoogle Scholar
  31. 31.
    Neblett R, Cohen H, Choi Y et al (2013) The central sensitization inventory (CSI): establishing Clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain 14:438–445CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Sullivan MJL, Bishop SR, Pivik J (1995) The pain catastrophizing scale: development and validation. Psychol Assess 7:524–532CrossRefGoogle Scholar
  33. 33.
    Walton DM, Wideman TH, Sullivan MJL (2013) A Rasch analysis of the pain catastrophizing scale supports its use as an interval-level measure. The Clin J Pain 29:499–506CrossRefPubMedGoogle Scholar
  34. 34.
    Roddy E, Muller S, Thomas E (2009) Defining disabling foot pain in older adults: further examination of the Manchester Foot Pain and Disability Index. Rheumatology 48:992–996CrossRefPubMedGoogle Scholar
  35. 35.
    Gijon-Nogueron G, Ndosi M, Luque-Suarez A et al (2014) Cross-cultural adaptation and validation of the Manchester Foot Pain and Disability Index into Spanish. Qual Life Res 23:571–579CrossRefPubMedGoogle Scholar
  36. 36.
    Freynhagen R, Tölle TR, Gockel U, Baron R (2016) The painDETECT project—far more than a screening tool on neuropathic pain. Curr Med Res Opin 32:1033–1057CrossRefPubMedGoogle Scholar
  37. 37.
    Freynhagen R, Baron R, Gockel U, Tölle TR (2006) painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 22:1911–1920CrossRefPubMedGoogle Scholar
  38. 38.
    Kaess BM, Pedley A, Massaro JM et al (2012) The ratio of visceral to subcutaneous fat, a metric of body fat distribution, is a unique correlate of cardiometabolic risk. Diabetologia 55:2622–2630CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Bair MJ, Robinson RL, Katon W, Kroenke K (2003) Depression and pain comorbidity: a literature review. Arch Intern Med 163:2433–2445CrossRefPubMedGoogle Scholar
  40. 40.
    Capuron L, Poitou C, Machaux-Tholliez D, Frochot V, Bouillot JL, Basdevant A et al (2011) Relationship between adiposity, emotional status and eating behaviour in obese women: role of inflammation. Psychol Med 41:1517–1528CrossRefPubMedGoogle Scholar
  41. 41.
    Lasselin J, Kemani MK, Kanstrup M et al (2016) Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults. J Behav Med 39:916–924CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Guneli E, Gumustekin M, Ates M (2010) Possible involvement of ghrelin on pain threshold in obesity. Med Hypotheses 74:452–454CrossRefPubMedGoogle Scholar
  43. 43.
    Younger J, Kapphahn K, Brennan K, Sullivan SD, Stefanick ML (2016) Association of leptin with body pain in women. J Womens Health (Larchmt) 25:752–760CrossRefGoogle Scholar
  44. 44.
    Rechardt M, Shiri R, Lindholm H, Karppinen J, Viikari-Juntura E (2013) Associations of metabolic factors and adipokines with pain in incipient upper extremity soft tissue disorders: a cross-sectional study. BMJ Open 3:e003036CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Després J-P, Lemieux I (2006) Abdominal obesity and metabolic syndrome. Nature 444:881–887CrossRefPubMedGoogle Scholar
  46. 46.
    Dugan SA, Powell LH, Kravitz HM et al (2006) Musculoskeletal pain and menopausal status. Clin J Pain 22:325–331CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.School of Medicine, Faculty of Medicine, Nursing and Health SciencesFlinders UniversityBedford ParkAustralia
  2. 2.Department of Orthopaedics and TraumaThe Queen Elizabeth HospitalWoodville SouthAustralia
  3. 3.Alliance for Research in Exercise, Nutrition and Activity, Sansom Institute for Health Research, School of Health SciencesUniversity of South AustraliaAdelaideAustralia
  4. 4.School of Medicine, Faculty of Health SciencesThe University of AdelaideAdelaideAustralia
  5. 5.Discipline of Podiatry, College of Science, Health and EngineeringLa Trobe UniversityBundooraAustralia
  6. 6.Nutrition and Dietetics, School of Health Sciences, Faculty of Medicine, Nursing and Health SciencesFlinders UniversityBedford ParkAustralia
  7. 7.Department of RheumatologyThe Queen Elizabeth HospitalWoodville SouthAustralia
  8. 8.Department of RheumatologySouthern Adelaide Local Health NetworkAdelaideAustralia

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