From the Guidelines
For plantar fasciitis that hasn’t responded to acupuncture, orthotics, or steroid injections, referral to a podiatric foot and ankle surgeon for consideration of extracorporeal shock wave therapy or surgery (plantar fasciotomy) is appropriate. According to the American College of Foot and Ankle Surgeons 1, if no improvement occurs after six weeks of initial treatment, referral to a specialist is recommended. Initial treatment measures, such as customized orthotic devices, night splinting, and limited corticosteroid injections, should be continued, and additional treatments may be considered. Some key considerations for treatment include:
- Continuing initial treatment measures until symptoms resolve
- Adding cast immobilization if not previously used
- Exploring other diagnoses if no improvement occurs after two to three months
- Considering surgery (plantar fasciotomy) or extracorporeal shock wave therapy as further options 1. While waiting for specialist evaluation and treatment, patients can continue with a comprehensive home program, including:
- Daily calf and plantar fascia stretching
- Ice massage using a frozen water bottle
- Night splints to maintain foot dorsiflexion during sleep
- Consideration of a walking boot for 2-4 weeks to completely rest the area if pain is severe.
From the Research
Treatment Options for Plantar Fasciitis
- Plantar fasciitis is a common problem that can be treated with various methods, including stretching, ice massage, and nonsteroidal anti-inflammatory drugs 2.
- For recalcitrant plantar fasciitis, treatments such as injections, extracorporeal shock wave therapy, or surgical procedures may be considered, although evidence is lacking 2.
- Acupuncture has been shown to be an effective treatment for plantar fasciitis, with a network meta-analysis indicating that it had the highest mean difference in visual analog scale (VAS) scores compared to placebo at one month 3.
Comparison of Treatment Options
- A systematic review of randomized controlled trials compared the use of platelet-rich plasma (PRP) and corticosteroids (CSs) for the treatment of plantar fasciitis, finding that PRP resulted in decreased pain levels and improved patient outcomes at 6 and 12 months 4.
- Another study found that PRP had a superior effect to steroid injections in terms of American Orthopaedic Foot and Ankle Society (AOFAS) scores at 12 months, but not at 1,3, or 6 months 5.
- Minimally invasive non-surgical techniques, including injectable pharmaceutical agents such as corticosteroids and PRP, have been shown to be effective in treating plantar fasciitis, with some studies indicating that they may have similar or better results than traditional treatments 6.
Treatment of Recalcitrant Plantar Fasciitis
- For cases of plantar fasciitis that do not respond to acupuncture, orthotics, or steroid injections, other treatment options such as PRP injections, extracorporeal shock wave therapy, or surgical procedures may be considered 2, 3, 4.
- A systematic review of minimally invasive non-surgical techniques found that treatments such as shock wave therapy, botulinum toxin type-A injections, and intratissue percutaneous electrolysis dry needling may be effective in treating plantar fasciitis, although more research is needed to confirm these findings 6.