When to refer a patient with plantar fasciitis to an orthopedic specialist?

From the Guidelines

Patients with plantar fasciitis should not be referred to an orthopedic specialist immediately, but rather after six weeks of failed conservative treatment, as recommended by the American College of Foot and Ankle Surgeons 1. When considering referral to an orthopedic specialist, it's essential to first attempt conservative management, which typically includes rest, ice application, stretching exercises, night splints, and appropriate footwear with arch support.

• Key considerations for referral include:
  • Failure to improve after six weeks of conservative treatment 1
  • Severe symptoms that significantly impact daily activities
  • Diagnostic uncertainty or atypical presentations
  • Presence of systemic conditions that might complicate treatment, such as rheumatoid arthritis or diabetes
• Advanced interventions that an orthopedic specialist can offer include:
  • Corticosteroid injections
  • Extracorporeal shock wave therapy
  • Platelet-rich plasma injections
  • Surgical release of the plantar fascia in rare cases It's crucial to prioritize conservative management and only consider referral when these measures fail to provide relief, as this approach can help prevent unnecessary interventions and promote optimal outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Referral to Orthopedic Specialist for Plantar Fasciitis

• Referral to an orthopedic specialist may be considered for patients with plantar fasciitis who do not respond to conservative treatment options 2, 3, 4, 5.
• The American Family Physician recommends that treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs 2.
• If the patient's symptoms persist beyond three months despite treatment, ultrasonography may be used as a diagnostic tool to confirm the diagnosis 2.
• Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking 2.
• A study published in Cureus found that autologous platelet-rich plasma (PRP) injections are superior to corticosteroid injections in terms of long-term pain alleviation and functional improvement for patients suffering from chronic plantar fasciitis 6.

Indications for Referral

• Patients who have not responded to conservative treatment options after 6-12 months 2, 5.
• Patients with chronic recalcitrant plantar fasciitis lasting six months or longer 5.
• Patients who require further diagnostic evaluation or specialized treatment, such as ultrasonography, extracorporeal shock wave therapy, or surgical procedures 2, 3, 4.

Treatment Options

• Conservative treatment options, such as stretching, ice massage, and nonsteroidal anti-inflammatory drugs, should be tried first 2, 5.
• If symptoms persist, physician-prescribed treatments, such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections, may be considered 5.
• Autologous PRP injections may be considered as a therapeutic choice for patients with chronic plantar fasciitis who have not shown improvement with conservative treatment 6.