What are the management options for persistent plantar fasciitis pain?

Management Options for Persistent Plantar Fasciitis Pain

For persistent plantar fasciitis pain, a structured approach including proper footwear, stretching exercises, orthotic interventions, and in recalcitrant cases, consideration of more invasive therapies such as extracorporeal shock wave therapy is recommended. 1, 2

First-Line Interventions

• Stretching and Strengthening Exercises:

  • Implement plantar fascia-specific stretching and calf stretching exercises daily to reduce tension on the plantar fascia 3
  • Consider an 8-12 week foot-ankle exercise program under supervision of a healthcare professional to reduce risk factors for worsening symptoms 1

• Footwear Modifications:

  • Educate patients to wear properly fitting footwear that accommodates the shape of the feet 1
  • Avoid walking barefoot, in socks only, or in thin-soled slippers, both indoors and outdoors 1

• Orthotic Interventions:

  • For patients with foot deformities or pre-ulcerative lesions, consider prescribing extra-depth shoes, custom-made footwear, or custom-made insoles 1
  • Appropriate orthotics can help redistribute pressure and reduce strain on the plantar fascia 3

Second-Line Interventions

• Night Splints:

  • Consider night dorsiflexion splinting to maintain the ankle in a neutral position during sleep, preventing morning pain and stiffness 3

• Ice Massage and NSAIDs:

  • Recommend ice massage to the affected area to reduce pain and inflammation 2
  • Consider nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief 2

• Activity Modification:

  • Advise decreasing cyclical repetitive loading of the plantar fascia during the treatment phase 3
  • For those at low or moderate risk, a gradual increase in weight-bearing activity (approximately 1000 steps/day) may be safe when using appropriate footwear 1

Advanced Interventions for Persistent Pain

• Imaging:

  • For pain persisting beyond three months despite treatment, ultrasonography is a reasonable and inexpensive diagnostic tool (80% sensitivity, 88% specificity) 1, 4, 2
  • MRI may be considered for more detailed evaluation of the plantar fascia and is the most sensitive imaging study for diagnosis 1, 4

• Corticosteroid Injections:

  • May provide short-term pain relief but must be weighed against risks of fat pad atrophy and plantar fascia rupture 3

• Extracorporeal Shock Wave Therapy (ESWT):

  • Consider ultrasonography-guided focal extracorporeal shock wave therapy for chronic plantar fasciitis that hasn't responded to conservative treatments 3

• Surgical Options:

  • Endoscopic fasciotomy may be required for patients with pain that limits activity and function despite exhausting non-operative treatment options 2
  • Consider digital flexor tendon tenotomy for patients with non-rigid hammertoe with nail changes, excess callus, or pre-ulcerative lesions on the toe 1

Special Considerations

• Monitoring Progress:

  • With proper treatment, approximately 80% of patients with plantar fasciitis improve within 12 months 2
  • Treatment is more effective when started soon after symptom onset 5

• Self-Monitoring:

  • For patients at moderate or high risk, consider coaching them to self-monitor foot skin temperatures daily to identify early signs of inflammation 1
  • If temperature difference between corresponding regions of left and right foot exceeds 2.2°C on two consecutive days, advise reducing activity and consulting a healthcare professional 1

• Integrated Care:

  • Provide integrated foot care for patients at moderate or high risk of complications 1
  • A multimodal approach including manual therapy, strengthening and stretching exercises, patient education, and self-management techniques has shown effectiveness 6