Multimodal Conservative Intervention Versus Surgery for Chronic Refractory Plantar Fasciopathy

Chronic refractory plantar fasciopathy is one of the most common causes of persistent heel pain and is associated with substantial disability, reduced quality of life, and limitations in daily and occupational activities. Although most patients respond to conservative management, a subgroup continues to experience symptoms despite prolonged treatment and may be considered for surgical intervention. However, evidence directly comparing optimized multimodal conservative care with surgical management remains limited.

This multicenter, non-randomized controlled trial has been designed to evaluate the comparative effectiveness of these two therapeutic strategies under real-world clinical conditions. Participants will be allocated to treatment groups according to their informed treatment preference following a standardized shared decision-making process.

The experimental group will receive a 6-week multimodal conservative intervention consisting of manual therapy techniques and ultrasound-guided percutaneous neuromodulation delivered in 12 supervised sessions. The control group will undergo endoscopic plantar fascial release followed by a standardized postoperative rehabilitation program.

The primary outcome measure is the change in the Foot Function Index (FFI) at 6 weeks after treatment initiation. Secondary outcomes include pain intensity measured using the Visual Analog Scale (VAS), health-related quality of life assessed with the EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L), treatment adherence, adverse events, and exploratory neurophysiological assessment through electromyography.

To minimize the effects of treatment selection bias inherent to the non-randomized design, analyses will include adjusted analysis of covariance (ANCOVA) and inverse probability of treatment weighting (IPTW). The findings of this study are expected to provide clinically relevant evidence to support shared decision-making and optimize treatment selection for patients with chronic refractory plantar fasciopathy.

Inclusion criteria

• Adults aged 30 to 65 years.
• Diagnosis of chronic refractory plantar fasciopathy with symptom duration greater than 6 months.
• Failure of at least two previous conservative treatments, each lasting at least 12 weeks.
• Foot Function Index (FFI) total score ≥45 points.
• Resting pain intensity ≥4/10 on the Visual Analog Scale (VAS).
• Plantar fascia thickness ≥4 mm at the calcaneal insertion confirmed by ultrasound.
• Ability to provide written informed consent and comply with study procedures.

Exclusion criteria

• Previous foot surgery on the affected side.
• Calcaneal stress fracture.
• Glycated hemoglobin (HbA1c) >7.5%.
• Inability or unwillingness to comply with study procedures or follow-up assessments.