What can be given for plantar fasciitis pain relief in a patient allergic to diclofenac and Toradol (ketorolac)?

Treatment for Plantar Fasciitis with NSAID Allergies

For plantar fasciitis in a patient allergic to diclofenac and ketorolac, start with acetaminophen (paracetamol) up to 4g daily combined with plantar fascia-specific stretching, and if inadequate, add naproxen as it has the best cardiovascular safety profile among oral NSAIDs. 1, 2

First-Line Treatment Approach

Non-Pharmacologic Core Therapy (Start Immediately)

• Plantar fascia-specific stretching exercises are the foundation of treatment and should begin immediately, as 80% of patients improve within 12 months with proper conservative management 3, 4
• Ice massage to the affected area 3, 5
• Viscoelastic heel cups or appropriate orthotics 6
• Activity modification to reduce repetitive loading of the plantar fascia 4

Pharmacologic Options (Given NSAID Allergies)

Step 1: Acetaminophen

• Start with acetaminophen (paracetamol) up to 4g daily for pain relief 7, 1
• This should be tried before any NSAID given the allergy history and general safety principles 1
• Regular dosing may be more effective than as-needed dosing 7

Step 2: Alternative Oral NSAID (if acetaminophen insufficient)

• Naproxen is the preferred oral NSAID in this situation, as it has better cardiovascular safety compared to other NSAIDs and is specifically mentioned as preferred for patients with cardiovascular risk factors 1, 2
• Use the lowest effective dose for the shortest duration 7, 1
• Must be prescribed with a proton pump inhibitor for gastroprotection 7
• Ibuprofen at lower doses (1.2g daily) is an alternative if naproxen is not available, as it has lower gastrointestinal risk 1

Important Caveat: Since the patient has documented allergies to diclofenac and ketorolac (both NSAIDs), there is a risk of cross-reactivity with other NSAIDs. If the allergy was anaphylactic or severe, avoid all NSAIDs entirely and proceed directly to other modalities 2

Second-Line Options for Inadequate Response

Night Splints

• Consider night dorsiflexion splinting, though evidence shows limited benefit over placebo in some studies 3, 4

Corticosteroid Injections (Highly Effective)

• Local corticosteroid injections are highly effective, especially when combined with controlled training (strength training and stretching) 7, 8
• The combination of corticosteroid injection plus training showed a 40-point improvement in Foot Function Index compared to training alone 8
• Effects may be short-lived and must be weighed against risks of fat pad atrophy and plantar fascia rupture 4
• Consider for moderate to severe pain 7

Opioid Analgesics

• Can be considered if NSAIDs are contraindicated and pain is severe 7
• Use cautiously given addiction potential

Third-Line for Recalcitrant Cases (>3 months)

• Ultrasonography-guided focal extracorporeal shock wave therapy for chronic plantar fasciitis 4
• Consider surgical endoscopic fasciotomy only after exhausting all nonoperative options 3

Critical Pitfalls to Avoid

• Do not use topical diclofenac given the documented allergy to diclofenac 9
• Do not combine multiple NSAIDs as this increases risk without additional benefit 1
• Do not prescribe conventional therapeutic shoes to heal plantar fasciitis—they are ineffective 7
• Avoid walking barefoot, in socks only, or in thin-soled slippers 7
• NSAIDs may delay natural healing as inflammation is necessary for tissue recovery 1

Evidence Quality Note

The recommendation for combined corticosteroid injection with controlled training is based on a 2019 randomized controlled trial showing clinically significant and sustained improvement at 2-year follow-up 8. However, a 2007 study showed NSAIDs (celecoxib) added to conservative treatment had only a trend toward benefit without statistical significance 6, supporting the prioritization of acetaminophen first given the allergy concerns.