What are alternative pain management options for foot pain due to plantar fasciitis and osteoarthritis (OA) that has not responded to Arthotec (diclofenac)?

Alternative Pain Management Options for Foot Pain Due to Plantar Fasciitis and Osteoarthritis

Physical activity and exercise interventions should be the first-line treatment for foot pain due to plantar fasciitis and osteoarthritis, as they have shown the most uniformly positive effects on pain reduction across multiple studies. 1

Non-Pharmacological Options

Exercise and Physical Activity

• General exercise programs have shown uniform positive effects on pain for foot/ankle osteoarthritis and plantar fasciitis 1
• Stretching of the plantar fascia and Achilles tendon should be included in the exercise regimen 2
• Strength and resistance training specifically targeting the foot muscles can improve function and reduce pain 1

Orthotics and Assistive Devices

• Orthopedic shoes have shown small but consistent positive effects on pain for osteoarthritis of the knee and may help with foot OA 1
• Custom foot orthoses have demonstrated effectiveness in managing plantar fasciitis when standard treatments fail 3
• Splints and night splints can help maintain proper foot positioning during rest 2

Manual Therapy

• Manual therapy has shown greater improvements in pain and function compared to orthotic interventions in plantar fasciitis 3
• Ice massage can provide temporary relief for acute pain episodes 2

Psychological Interventions

• Cognitive behavioral therapy (CBT) has shown uniform positive effects on pain for osteoarthritis 1
• Relaxation interventions have demonstrated benefits for general osteoarthritis pain 1
• Biofeedback techniques may be helpful, particularly for inflammatory arthritis 1

Pharmacological Alternatives

Topical Treatments

• Topical NSAIDs should be considered as the first pharmacological choice due to their favorable safety profile compared to oral medications 1
• Topical treatments are preferred over systemic treatments for hand OA and may be beneficial for foot OA as well 1

Oral Analgesics

• Acetaminophen can be used as first-line treatment for mild to moderate pain due to its favorable safety profile 4, 5
• If diclofenac (Arthrotec) has not helped, consider alternative NSAIDs such as naproxen or celecoxib, which may have different efficacy profiles in individual patients 5, 6
• NSAIDs should be used for limited duration due to risks of GI, renal, and cardiovascular side effects 1, 4

Advanced Interventions

• Corticosteroid injections may be considered for recalcitrant plantar fasciitis, though evidence is mixed 2, 7
• Platelet-rich plasma (PRP) injections have shown promising results for long-term pain relief in plantar fasciitis 8
• Acupuncture has demonstrated effectiveness for short-term pain relief (1 month) in plantar fasciitis 8
• Extracorporeal shock wave therapy (ESWT) can be considered for cases that don't respond to conservative treatment 2, 8

Weight Management

• Weight management has shown uniform positive effects on pain in osteoarthritis and should be considered as part of the comprehensive treatment plan 1

Common Pitfalls and Considerations

• Underestimation of pain severity often leads to inadequate treatment 4
• NSAIDs carry significant risks of drug-drug interactions, particularly in elderly patients 4, 5
• Many standard treatments for plantar fasciitis (like night splints) have not shown benefit over placebo in some studies 2
• Plantar fasciitis is not truly inflammatory (more accurately termed plantar fasciopathy), which may explain why anti-inflammatory medications sometimes have limited efficacy 2

Treatment Algorithm

1. Start with physical activity/exercise focused on stretching and strengthening
2. Add orthotics (custom foot orthoses) and manual therapy
3. For pharmacological management, begin with topical NSAIDs if not contraindicated
4. If additional pain control is needed, use acetaminophen or try a different NSAID than diclofenac
5. For persistent pain, consider advanced interventions like PRP injections, acupuncture, or ESWT
6. Surgical options should only be considered after exhausting non-operative treatments 2