Treatment for Severe Plantar Fasciitis
For severe plantar fasciitis that has not responded to initial treatments, a TNF inhibitor should be considered, especially in cases with disabling symptoms that significantly impact quality of life and function. 1
Initial Treatment Options
Initial management should follow a stepwise approach:
- Regular calf-muscle stretching and plantar fascia-specific stretching exercises to reduce tension on the fascia 1, 2
- Cryotherapy (ice massage) to reduce pain and inflammation 1
- Over-the-counter heel cushions and arch supports to provide mechanical relief 1
- Weight loss if indicated to reduce mechanical stress on the plantar fascia 1
- Activity limitation and avoidance of flat shoes and barefoot walking 1
- NSAIDs to reduce pain and inflammation, though evidence suggests modest benefits 1, 3
- Padding and strapping of the foot to provide support 1
Intermediate Treatment Options (if no improvement after 6 weeks)
If symptoms persist after 6 weeks of initial treatment, consider:
- Customized orthotic devices to provide better arch support 1
- Night splinting to maintain dorsiflexion and prevent morning pain 1
- Corticosteroid injections (limited number) - particularly effective when combined with controlled training 1, 4
- Casting or use of a fixed-ankle walker-type device during activity 1
Advanced Treatment Options (if no improvement after 2-3 months)
For severe cases that don't respond to the above treatments:
- Cast immobilization if not previously used 1
- Extracorporeal shock wave therapy for chronic cases 1, 5
- Surgical intervention (plantar fasciotomy) may be considered as a last resort 1, 2
- TNF inhibitors should be considered in severe cases with disabling symptoms, especially when other treatments have failed 1
Evidence for TNF Inhibitors in Severe Cases
The GRAPPA Treatment Recommendations Committee specifically recommends TNF inhibitors for severe enthesitis (including plantar fasciitis) that has failed other therapies. In their case example, a patient with disabling plantar fasciitis who failed NSAIDs, oral corticosteroids, physiotherapy, and plantar fascia injection was recommended for TNF inhibitor treatment 1.
Combination Therapy
- The combination of corticosteroid injections with controlled training (strength training and stretching) has shown superior results compared to either treatment alone, with benefits maintained at long-term follow-up 4
- This combined approach demonstrated clinically relevant improvements in both foot function and pain scores 4
Important Considerations and Pitfalls
- Corticosteroid injections should be used judiciously due to risks of fat pad atrophy and plantar fascia rupture 5
- Local injections of corticosteroids are not recommended for insertional Achilles tendonitis, which can sometimes coexist with plantar fasciitis 1
- Treatment is generally more effective when started early after symptom onset 6
- With proper treatment, approximately 80% of patients improve within 12 months 2
- Recalcitrant cases may require referral to a podiatric foot and ankle surgeon 1
- Ultrasonography can be useful for diagnosis in cases that persist beyond three months despite treatment 2