Bilateral Plantar Pain in Patient on Clonazepam: Interim Management and Medication Review
This patient's bilateral plantar pain with radiation to the knees is most consistent with plantar fasciitis rather than a clonazepam side effect, and you can safely initiate conservative treatment while the provider evaluates for potential clonazepam tapering if other indications warrant it.
Immediate Assessment and Reassurance
The FDA label for clonazepam lists common side effects as drowsiness, problems with walking and coordination, dizziness, depression, fatigue, and memory problems—but does not include foot or leg pain as a recognized adverse effect 1. The patient's symptoms of bilateral plantar pain worse in the morning and at end of day, lasting over a month, are classic for plantar fasciitis rather than medication-related 2, 3.
Key clinical features to confirm over the phone:
- Pain location: proximal medioplantar surface of the foot, particularly at the anteromedial calcaneus 2, 3
- Timing: stabbing pain with first steps in the morning that improves with activity, then worsens at end of day 2, 3
- Bilateral involvement: note that bilateral plantar fasciitis is a negative prognostic indicator requiring more intensive management 4
Interim Management You Can Provide Today
Initiate the following conservative treatment immediately (effective in 80% of patients within 12 months) 2:
- Ice massage: Apply ice directly to the painful heel area for 15-20 minutes, 3-4 times daily 2, 3
- NSAIDs: Ibuprofen 400 mg three times daily (maximum 3200 mg/day) for pain control 2, 3
- Plantar fascia stretching: Instruct patient to perform gentle stretching exercises—pulling toes upward toward shin while keeping knee straight, holding 30 seconds, repeating 10 times, 3 times daily 2, 3
- Activity modification: Reduce prolonged standing and high-impact activities temporarily 3
Clonazepam Discontinuation Considerations
Do not abruptly discontinue clonazepam as the FDA label explicitly warns that "stopping clonazepam tablets suddenly can cause serious problems" including seizures that will not stop (status epilepticus), hallucinations, shaking, and severe withdrawal symptoms 1.
If the provider determines clonazepam should be tapered:
- The evidence-based protocol involves reducing by 0.5 mg per 2-week period until reaching 1 mg/day, then decreasing by 0.25 mg per week 5
- This gradual taper over 4 months successfully discontinues clonazepam in 68.9% of patients with minimal withdrawal symptoms 5
- Common mild withdrawal symptoms include anxiety, tremor, nausea, insomnia, sweating, tachycardia, headache, and muscle aches—but not specifically plantar pain 5
Provider Follow-Up Recommendations
The provider should evaluate for:
- Physical examination with palpation of the medial plantar calcaneal region and passive ankle/first toe dorsiflexion to reproduce pain 2, 3
- Assessment of risk factors: obesity, excessive foot pronation, prolonged standing 3
- Consideration of bilateral involvement as a marker for potentially more refractory disease requiring extended treatment 4
If pain persists beyond 3 months despite conservative treatment, the provider should consider 2, 3:
- Ultrasonography to confirm diagnosis (showing increased plantar fascia thickness >4mm)
- Physical therapy referral
- Foot orthotics
- Night splinting
- Corticosteroid injections for recalcitrant cases
Critical Safety Point
The patient's attribution of foot pain to clonazepam likely reflects her searching for explanations rather than an actual drug effect 1. However, never dismiss her concerns—validate her experience while redirecting toward the more likely diagnosis of plantar fasciitis, which requires specific treatment 6. The CDC guidelines emphasize that communication with patients about their symptoms is critical, and providers should address concerns about medications openly 6.