The guidelines from the New York State workers’ compensation board are here to support doctors, podiatrists, and healthcare experts in giving the right treatment for Plantar Heel Pain.
Healthcare professionals can rely on these guidelines from the Workers’ Compensation Board to figure out the best care for patients dealing with ankle and foot issues.
It’s important to note that these guidelines don’t replace the wisdom and expertise of healthcare professionals. The final decision about care should be a collaborative effort between the patient and their healthcare provider.
Plantar Heel Pain (“Plantar Fasciitis”)
The heel is the usual suspect when it comes to foot pain. Plantar fasciitis, or plantar heel pain, goes by various names like runner’s heel, painful heel syndrome, and more.
Plantar fasciitis typically brings on intense discomfort in the lower or plantar part of the middle heel. You might also feel pain towards the arch of the foot. It hits hardest during weight-bearing activities, especially that first step in the morning or after sitting for a while.
The good news is, over 90% of folks dealing with plantar fasciitis find relief without surgery within six to twelve months. Conservative care works like a charm for plantar heel pain.
We start with non-invasive treatments for plantar heel pain. In about six to twelve months, these methods work their magic for over 90% of cases. And here’s a reassuring tidbit: tell the patient that 95% of people with plantar fasciitis get relief within 12 to 18 months—crucial info for non-surgical treatment.
Diagnostic Studies for Plantar Heel Pain in workers compensation patients
Checking for Plantar Heel Pain with X-Rays When it comes to figuring out what’s causing your plantar heel pain, using X-rays is a good call, especially if there’s a chance of fractures.
Why: X-rays help us dig deeper into the root of heel pain, ruling out other potential causes like fractures or bone tumors. But here’s the scoop—just going for regular videos to spot heel spurs isn’t the way to go.
MRI for Pinpointing Plantar Fasciitis in Specific Cases If you’re dealing with persistent heel discomfort, getting an MRI is a smart move, especially for specific cases of plantar fasciitis.
When: If your heel isn’t getting any better, there’s a chance the plantar fascia is in trouble, or the talar dome is facing blood supply issues, or there’s a stress fracture in the talar neck.
Why: MRI helps us explore beyond just plantar fasciitis—things like calcaneal stress fractures, ruptured plantar fascia, fluid around the fascia, and heel spurs all show up on the radar. Plus, it’s a handy tool for spotting ganglion cysts, joint fluid, avascular necrosis of the talar dome, and stress-induced osteoid tumors and talar neck fractures.
SPECT-CT: Not the Go-To for Plantar Fasciitis Diagnosis When it comes to diagnosing plantar heel pain, SPECT-CT isn’t the recommended go-to method.
Ultrasound: A Smart Move for Pinpointing Plantar Fasciitis For those tricky cases of plantar fasciitis, ultrasound is the way to go.
When: If the diagnosis isn’t crystal clear or your heel isn’t getting better after a month-long conservative treatment, it’s time to bring in the ultrasound.
Why: Ultrasound helps in cases where there might be a suspected plantar fascia rupture or plantar calcaneal bursitis, especially if the symptoms linger after trying non-invasive treatments.
Medications for Plantar Heel Pain
First-Line Pain Relief: Ibuprofen, Naproxen, and Older NSAIDs
For most patients, starting with ibuprofen, naproxen, or other older NSAIDs is the go-to for tackling pain. If NSAIDs aren’t an option, acetaminophen (or paracetamol) could work, even though studies suggest it’s just slightly less effective than NSAIDs.
Proof points to NSAIDs being safer and equally effective as opioids like tramadol when it comes to managing pain.
Using NSAIDs for Plantar Fasciitis Pain
When it comes to dealing with acute, subacute, chronic, or postoperative pain from plantar fasciitis, the recommendation is NSAIDs.
When: NSAIDs are the go-to for all stages of plantar fasciitis pain, be it right after it hits or in the long-term recovery post-surgery. Start with over-the-counter meds to test the waters.
How Much/How Often: Take NSAIDs as needed, and many patients find this approach reasonable.
When to Stop: Stop if the foot or ankle discomfort fades away, if the medication isn’t working, or if side effects pop up that call for discontinuation.
NSAIDs for High-Risk Gastrointestinal Bleeding
For individuals at a higher risk of gastrointestinal bleeding, using NSAIDs should be done cautiously. It’s recommended to simultaneously use cytoprotective drugs like misoprostol, sucralfate, H2 receptor blockers, or proton pump inhibitors.
When: Consider cytoprotective drugs for those at a high risk of gastrointestinal bleeding who also need NSAIDs, especially if the treatment plan is long-term. This is crucial for patients with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers.
How Much/How Often: Follow the dosage recommendations for H2 blockers, misoprostol, sucralfate, and proton pump inhibitors. Generally, there’s no significant difference in their effectiveness in preventing gastrointestinal bleeding.
When to Stop: Discontinue if there’s intolerance, unwanted effects emerge, or if the NSAID is no longer needed.
Addressing Cardiovascular Risk with NSAIDs
When it comes to patients at risk for cardiovascular issues, opting for acetaminophen or aspirin as the first line of defense seems to be the safest bet in terms of heart health. If needed, non-selective NSAIDs are suggested over COX-2-specific medications.
To make sure an NSAID doesn’t interfere with the protective effects of low-dose aspirin used for cardiovascular disease prevention, take the NSAID at least 30 minutes after or eight hours before the daily aspirin.
Using Acetaminophen for Pain Relief
When it’s about tackling acute, subacute, or chronic plantar fasciitis pain, especially in folks with medical conditions that rule out NSAIDs, acetaminophen is the way to go.
When: This is for patients dealing with various stages of foot and ankle pain.
How Much/How Often: Follow the manufacturer’s guidelines; use it as needed. Just be cautious as exceeding 4 g/day can lead to liver issues.
When to Stop: Once the pain is gone, if side effects pop up, or if you can’t tolerate it anymore.
Infliximab: Not the Solution for Plantar Fasciitis
For acute, subacute, or chronic plantar fasciitis, using infliximab is not recommended.
Opioids: Not the Answer for Plantar Fasciitis Pain
When it comes to managing acute, subacute, or chronic plantar fasciitis pain, steering clear of opioids is the way to go.
Managing Post-Op Pain with Opioids
For those recovering from surgery, using opioids for post-op plantar fasciitis is advised but only for a brief period in the initial days following the procedure, not exceeding seven days.
When: This is specifically for controlling postoperative pain.
How Much/How Often/For How Long: Stick to the manufacturer’s recommendations for frequency and dosage, whether taking it on schedule or as needed. Typically, it’s suggested for short courses, tapering to nighttime use if necessary, and then stopping altogether.
When to Stop: Discontinue following the recommended frequency and dosage guidelines. The general idea is short-term use, with tapering down to nighttime usage and eventual discontinuation.
Why: There’s no solid evidence supporting the use of opioids for acute, subacute, or persistent plantar heel pain. Most patients with plantar fasciitis don’t experience pain intense enough to justify the risks associated with opioids. However, for those not finding adequate relief with NSAIDs, using opioids cautiously in the immediate postoperative period, especially at night, might be beneficial for sleep and early rehabilitation.
Skipping Glucocorticosteroids for Heel Pain
Oral or intramuscular glucocorticosteroids aren’t recommended for treating acute, subacute, or chronic heel pain.
Why: The evidence supporting their use in this context is lacking, despite their efficacy in various other treatments.
Lidocaine Patches: Not the Answer for Plantar Fasciitis Pain
When it comes to dealing with postoperative, chronic, subacute, or acute plantar fasciitis, using lidocaine patches is not recommended.
Why: The evidence doesn’t support their effectiveness in treating plantar fasciitis.
Using Topical NSAIDs for Plantar Fasciitis Pain
For dealing with acute, subacute, or chronic plantar fasciitis pain, turning to topical NSAIDs is a recommended approach.
When: This is suitable for mild, moderate, or severe cases, and it’s especially helpful for patients who can’t take oral medication.
How Much/How Often: Follow the frequency suggested by the manufacturer. Typically, topical NSAIDs are applied for one to three weeks.
When to Stop: Discontinue when the pain is resolved, if there’s intolerance or unfavorable outcomes, or if the benefits are not noticeable.
Why: Topical NSAIDs are a good call for treating acute, subacute, and chronic plantar fasciitis or plantar heel pain, particularly for those who can’t or shouldn’t take oral medication.
Avoiding Topical NSAIDs After Surgery
When it comes to postoperative plantar fasciitis, using topical NSAIDs is not recommended.
Why: The evidence or support for their effectiveness in treating plantar fasciitis post-surgery isn’t there.
Ruling Out Casting for Persistent Plantar Fasciitis
Casting isn’t advised as a solution for dealing with chronic plantar fasciitis.
Opting for Night Splints for Persistent Plantar Heel Pain
For persistent or subacute plantar heel discomfort, using night splints is recommended. This is particularly useful for brief relief from pain and stiffness associated with subacute or chronic plantar fasciitis.
How Often/How Long: Use night splints every night, as long as they prove effective, measured by improvements in symptoms and function with medical attention.
When to Stop: Discontinue when the splints are no longer effective, if there are side effects, intolerance, or if there’s noncompliance with the treatment.
Rehabilitation for Plantar Heel Pain
Rehabilitation After Work-Related Injury
Rehabilitation following a work-related injury should focus on restoring functional abilities necessary for the patient’s daily and work responsibilities, aiming to bring them back to their pre-injury status as much as practically possible.
Active therapy involves the patient actively participating in specific activities or tasks, requiring internal effort. In contrast, passive therapy involves modalities administered by a therapist without the patient exerting effort.
It is important to prioritize active interventions over passive ones, as active therapy programs are seen as more effective in achieving objective functional gains.
As part of the ongoing healing process, patients should be encouraged to continue both active and passive therapy at home to maintain improvements. The use of assistive technology can be considered as an additional step to promote functional enhancements.
Magnets for Plantar Heel Pain
Using magnets for sudden, gradual, or persistent plantar heel pain relief is not recommended.
Stretching Exercises for Plantar Fasciitis
Stretching exercises are recommended for the treatment of plantar fasciitis, whether it is chronic, subacute, or acute.
How Often/How Long: No specific time limit is set, but three ten-minute sessions per day are suggested.
When to Stop: Discontinue if the exercises prove ineffective, if there are side effects, intolerance, or if there’s noncompliance with the recommended routine.
Heel Taping for Plantar Fasciitis or Heel Pain
Heel taping is recommended as a temporary measure for acute or subacute plantar fasciitis or heel pain.
When: This is suitable for patients without adhesive allergies.
How Often/How Long: Apply tape daily for one to four weeks.
When to Stop: Discontinue when the issue is resolved, if negative consequences arise, if there’s a failure to comply, or upon completing a four-week treatment course.
Heel Taping for Persistent Plantar Fasciitis or Heel Pain
Using heel taping is recommended for treating persistent plantar heel discomfort or fasciitis, but it’s important to note that its effectiveness provides only minimal short-term pain relief. Due to the risk of skin irritation, degradation, and sensitization, taping is typically suggested for short-term use. It is advised as a temporary measure to be used alongside alternative non-surgical therapies.
Acupuncture for Plantar Fasciitis
Acupuncture is not recommended as a treatment for immediate, short-term, or persistent plantar fasciitis.
Low Frequency Electrical Stimulation for Plantar Fasciitis
Low-frequency electrical stimulation is not recommended for acute, subacute, or chronic plantar fasciitis.
Extracorporeal Shockwave Therapy (ESWT) for Persistent Plantar Fasciitis
ESWT is recommended for individuals with chronic plantar fasciitis who haven’t responded to other treatments. The patients usually experience at least six months of discomfort and have not found relief through active and passive exercise, NSAIDs, and glucocorticosteroid injections. The decision to use ESWT is not influenced by the presence or absence of a heel spur.
Frequency/Duration: Several therapy procedures are available, and one to three sessions may be appropriate and effective.
When to Stop: Discontinue in case of disputes, tolerance issues, or noncompliance.
Extracorporeal Shockwave Therapy for Acute or Subacute Plantar Fasciitis
ESWT is not recommended for treating acute or subacute foot fasciitis.
Ultrasound or Fluoroscopy Guidance for Shockwave Therapy for Plantar Fasciitis
Using ultrasound or fluoroscopy guidance for shockwave therapy for plantar fasciitis is not recommended.
Local Anesthesia with High Shockwave Therapy for Plantar Fasciitis
Using local anesthesia with high shockwave therapy is recommended for the treatment of plantar fasciitis when combined with high-energy ESWT.
Local Anesthesia with Low or Medium Shockwave Therapy for Plantar Fasciitis
Using local anesthesia with low or medium shockwave therapy is not recommended for treating plantar fasciitis.
Radial Extracorporeal Shockwave Therapy for Chronic Plantar Fasciitis
Radial extracorporeal shockwave therapy is not recommended for the treatment of chronic plantar fasciitis.
Radial Extracorporeal Shockwave Therapy for Acute or Subacute Plantar Fasciitis
Radial extracorporeal shockwave therapy is not recommended for the treatment of acute or subacute plantar fasciitis.
Iontophoresis with Glucocorticosteroid or Acetic Acid for Plantar Fasciitis
Using iontophoresis with glucocorticosteroid or acetic acid is not recommended for treating chronic, subacute, or acute plantar fasciitis.
Low-level Laser Therapy for Plantar Fasciitis
Low-level laser therapy is not recommended for treating chronic or subacute plantar fasciitis.
Manipulation for Plantar Heel Pain
Manipulation is not recommended for managing postoperative, chronic, or subacute plantar heel pain.
Massage and Soft Tissue Mobilisation for Plantar Fasciitis
Using massage and soft tissue mobilization is not recommended for the treatment of postoperative, chronic, subacute, or acute plantar fasciitis.
Phonophoresis for Plantar Heel Pain
Phonophoresis is not recommended for the management of surgical, chronic, or subacute plantar heel pain.
Therapeutic Ultrasound for Plantar Fasciitis
Therapeutic ultrasound is not recommended for treating postoperative, chronic, subacute, or acute plantar fasciitis.
Low-dose Radiation (Radiotherapy) for Chronic Plantar Heel Pain
Using low-dose radiation (radiotherapy) is not recommended to alleviate persistent plantar heel pain.
Injection Therapy for Plantar Heel Pain
Autologous Blood Injection for Plantar Fasciitis
Using autologous blood injection is not recommended for treating chronic or subacute plantar fasciitis.
Botulinum Toxin A Injection for Plantar Fasciitis
Botulinum toxin injection is not recommended as a remedy for persistent plantar fasciitis.
Glucocorticoid Injections for Chronic Plantar Fasciitis
Using glucocorticoid injections is recommended for short-term relief in cases of severe or difficult-to-treat plantar fasciitis, especially when other non-operative therapies have failed.
Indications: Failures with stretching, exercise, and other non-operative therapy for moderate to severe plantar fasciitis.
Frequency/Duration: A second injection may be considered if the problem is incapacitating, all other treatment options have been exhausted, and the patient is aware of and agrees to the possible complication of rupture, which may necessitate surgery.
Glucocorticosteroid Injections for Acute or Subacute Plantar Fasciitis
Using glucocorticosteroid injections is not recommended for treating acute or subacute plantar fasciitis.
Guidance of Steroid Injection with Ultrasound or Scintigraphy
Guiding steroid injection with ultrasound or scintigraphy is not recommended; instead, palpation is suggested.
Hyperosmolar Dextrose Injections for Plantar Fasciitis
Using hyperosmolar dextrose injections is not recommended for treating plantar fasciitis.
Platelet Rich Plasma (PRP) Injections for Plantar Fasciitis
Using platelet-rich plasma (PRP) injections is not recommended for treating plantar fasciitis. However, there is some support for the use of PRP in the treatment of plantar fasciitis.
Surgery for Plantar Heel Pain
Surgery for Chronic Recalcitrant Plantar Fasciitis
Surgery is recommended for select cases of chronically resistant plantar fasciitis. No specific method is favored over another procedure.
Indications: Patients with moderate to severe chronic plantar fasciitis persisting for at least six to twelve months, having exhausted numerous non-surgical treatments without success. Prior attempts at NSAIDs, plantar fascia stretching, injections, and other conservative treatments should have been unsuccessful.
Rationale for Recommendations: Surgery is advised as an intervention when other nonoperative treatments have been utilized for at least six months, and the severity of the patient’s symptoms justifies the risks associated with surgery. It is important for patients to be well-informed about the potential outcomes and limitations of surgery.
Surgery for Acute or Subacute Plantar Fasciitis
Surgery is not recommended for treating plantar fasciitis that is either acute or subacute.
Other
Orthotic Devices for Plantar Heel Pain
Orthotic devices are recommended for managing sudden, gradual, or persistent plantar heel discomfort.
Indications: Suitable for patients with plantar fasciitis.
Duration/Frequency: Daily use for two to three months is recommended. Discontinuation can occur if there is resolution, adverse effects, or noncompliance.
Custom Orthoses for Plantar Fasciitis
Custom orthoses are not recommended for acute, subacute, or chronic plantar fasciitis.
Orthoses for Prevention of Plantar Fasciitis or Lower Extremity Disorders
Using orthoses for the prevention of lower extremity problems, including plantar fasciitis, is not recommended.
Cryosurgery for Plantar Heel Pain
Cryosurgery is not recommended for alleviating persistent plantar heel pain.
Intracorporeal Pneumatic Shockwave Therapy (IPST) for Select Chronic Plantar Fasciitis
IPST is recommended for the treatment of select chronic plantar fasciitis, serving as an alternative to surgical treatment for stubborn cases.
Indications: Advised for patients with visible heel spurs who have not responded to various non-operative treatments such as NSAIDs, injections, stretching, and other exercises (including night splinting).
Percutaneous Calcaneus Fenestration for Chronic Plantar Heel Pain
Percutaneous calcaneus fenestration is not recommended for alleviating persistent plantar heel pain.
Radiofrequency Microtenotomy for Chronic Plantar Fasciitis
Radiofrequency microtenotomy is not recommended for the treatment of chronic plantar fasciitis.
