Plantar Fasciitis When Extracorporeal Shockwave Therapy Has Not Worked
This protocol applies to patients with plantar fasciitis who have completed a course of extracorporeal shockwave therapy (ESWT) targeted to the most tender point over the medial calcaneal tubercle, but have not achieved adequate symptom control or the expected structural changes on imaging.
Previous Treatment & Failure Criteria
Extracorporeal shockwave therapy is considered to have failed when — at 3 to 4 months post-procedure — the patient has not reached a VAS pain score below 2 out of 10, has not demonstrated reduction in plantar fascia thickness on ultrasonography, or the plantar fascia lesion has not become isoechoic or hyperechoic on imaging. When these targets are not met, clinical escalation is warranted.
Next-Line Approach
The escalated pathway involves an image-guided injection-based intervention. Which specific approach is selected depends on the clinical findings and individual patient profile. The complete eligibility criteria, selection criteria, and procedural guidance are within the full protocol.
Treatment goals: VAS pain score below 2 out of 10, and a measurable reduction in plantar fascia thickness on ultrasonography at 3 to 4 months following the procedure.
References
DOI: 10.47102/annals-acadmedsg.2023211
- Injection of platelet-rich plasma is not a first-line treatment, and it may only be considered if the following conditions are met: I. No improvement or worsening of symptoms for at least 3 months after one or more courses of shockwave therapy II. Evidence of partial plantar fascia tear contributing to plantar heel pain III. Counselled for off-label use, based on current Ministry of Health guidelines
- Perifascial corticosteroid injection under ultrasonography guidance may be considered if the patient has persistent severe plantar heel pain and has failed other conservative therapies.
- If performed, corticosteroid injection is recommended to be limited to a single course and to individuals not engaged in any explosive, weight-bearing lower limb activities.
- The response to treatment can be monitored via ultrasonography between 2 to 4 weeks and 3 to 4 months post-procedure.
View source ↗