If pain isn’t settling, what should you do next

Months after the original trigger—often a single match, a new training block, or simply more time on hard floors—pain can still be dictating choices: walking pace, shift work, sleep, or whether training happens at all. By the 8–12 week mark, many people have already tried the standard first steps (relative rest, basic exercises, simple analgesia), and the frustration tends to be less about “what is this?” and more about “why is this not moving on?”

In practical terms, escalation is not a jump straight to injections or surgery. It is usually a decision to tighten the diagnosis and the loading plan: checking whether the pain pattern truly fits the initial label, identifying the specific movements and volumes that repeatedly flare it, and building rehabilitation that is progressive rather than just “do these stretches”. In some conditions—such as plantar heel pain—most cases improve over several months with conservative care, which is why evidence-based frameworks tend to reserve more invasive options for symptoms that persist despite a properly optimised programme.[1]

The sections that follow compare four common situations where the “next step” can feel unclear even after good effort: (1) plantar fasciitis that has not settled after around 6 months, (2) deep groin pain in a young adult where a labral tear or femoroacetabular impingement is suspected, (3) planning a return to running after an Achilles rupture, and (4) rotator cuff tears in active adults over 40 deciding between physiotherapy and surgery.

A consultant-led MSK assessment (for example, within the MSK Doctors team) typically focuses on a careful history, targeted examination, and imaging only when it is likely to change the plan—then a stepwise pathway that starts with getting rehabilitation right, and only then considers injections or surgery where the evidence and the person’s goals align.

Plantar fasciitis still bad after 6 months

Six months of plantar heel pain that is still limiting walking or running is often the point to stop simply “resting” and instead re-check whether the plan is genuinely optimised. Most plantar fasciitis improves within several months with conservative care, so persistent, disabling symptoms beyond roughly 6–12 months tend to prompt a structured review rather than an automatic jump to surgery.[1]

“Optimised basics” usually means more than occasional stretching. Evidence-based frameworks emphasise a blend of plantar fascia–specific and calf stretching, progressive strengthening/loading (not only passive treatments), and practical supports such as taping, footwear changes and orthoses; night splints are also commonly considered as an adjunct, particularly when first-step pain on waking is prominent.[1]

Two common “six‑month” patterns lead to different next steps. A runner who can manage daily life but flares with speedwork often needs a tighter loading plan (volume, hills, surfaces) and a more structured strength progression; in contrast, a retail worker on hard floors for 8-hour shifts may improve most by changing cumulative standing load plus footwear/orthoses and a consistent night-splint trial. Both scenarios can still turn around after month 6 when the load drivers are identified and rehab is made progressive.[1]

When progress has genuinely plateaued despite good-quality rehab, extracorporeal shockwave therapy (ESWT) is commonly positioned as a next, non-surgical step for chronic recalcitrant cases, typically delivered over several sessions. Reviews describe ESWT as an option to reduce pain in longer-standing plantar fasciitis before considering injections or surgery.[1,2]

Injection choices sit on a trade-off between speed of pain relief, durability, and risk. Corticosteroid injections can reduce pain in the short term, but reviews warn about recognised complications such as plantar fascia rupture and heel fat-pad atrophy, so repeated injections are generally discouraged.[1]

Orthobiologic injections (for example PRP) are usually framed as second- or third-line in chronic cases: a 2024 meta-analysis of 21 RCTs (1,356 patients) reported greater long-term pain improvement with PRP than ESWT, corticosteroid injection, or placebo, while functional differences were often modest. Reviews also emphasise that the evidence base is heterogeneous and that cost and availability matter in real-world decision-making.[1,2]

• A simple escalation ladder used in many pathways is: optimise loading/strength + supports (stretching/orthoses/taping/night splint trial) → consider ESWT if stalled → consider a single, carefully selected injection option → reserve surgery for persistent, function-limiting cases after many months of well-delivered conservative care.[1]

Deep groin pain and whether an MRI will help

Deep, hard-to-point-to groin pain in a 25–40-year-old runner or field-sport athlete often raises the same worry: “Is this a labral tear, and does that mean an MRI and surgery?” The pattern that most commonly fits an intra‑articular hip problem is a deep anterior “C‑shaped” ache, worse with hip flexion and rotation—long car journeys, deep squats, uphill running, or cutting and pivoting—sometimes with clicking, catching, stiffness, and a sense of reduced hip movement (especially internal rotation).[3]

Two labels tend to come up in this scenario. A labral tear refers to damage or fraying in the labrum—the rim of cartilage around the hip socket that helps with stability and load distribution. Femoroacetabular impingement syndrome (FAIS) describes a situation where the ball-and-socket shape (often described as cam or pincer morphology) can pinch on that rim or nearby cartilage during certain movements. These are mechanical problems of movement and load, not a simple “scan = fix” diagnosis.[3]

Some presentations need faster assessment because they are not the usual stable FAIS/labral picture. Red-flag features commonly used in clinical triage include:

• Fever, night sweats, or feeling systemically unwell alongside hip pain (infection/inflammation needs consideration).
• Inability to weight-bear after a fall/tackle or a sudden “pop” with severe pain (fracture or significant acute injury needs exclusion).
• Significant night pain that is progressive and not behaving like a load-related sports injury.
• New neurological symptoms (for example, numbness, weakness, or bladder/bowel disturbance), especially if back pain is also present.

In most sports-related cases, diagnosis starts with a detailed history and a hands-on examination: hip range of motion (often limited internal rotation), plus provocative manoeuvres such as FADIR (flexion–adduction–internal rotation) and sometimes FABER. A positive test supports the pattern of intra‑articular irritation, but it does not, by itself, prove a labral tear.[3]

Imaging is most helpful when it changes the plan. In suspected FAIS/labral presentations, the usual pathway begins with plain X‑rays to look for cam/pincer morphology and to check for arthritis. MRI (or MR arthrogram) is then mainly used when symptoms and examination still strongly suggest intra‑articular pathology after a proper trial of rehabilitation (often at least a few months of supervised, strengthening‑based physiotherapy and activity modification), or when an operation is genuinely being considered.[3,4]

A crucial reason MRI is not automatically the “next step” is that it can show labral tears and variants in people without hip symptoms—so the scan finding must match the story and exam rather than driving decisions on its own.[3]

Practical bottom line: when MRI is most vs least useful

• MRI is most useful when: pain remains clearly groin/anterior hip and function-limiting after months of good rehab; X‑rays show impingement morphology; and the results will be used to plan next-step options (including possible arthroscopy), or to rule out other intra‑articular pathology.[3,4]
• MRI is least useful when: symptoms are steadily improving with physiotherapy and load modification, because an MRI-detected “tear” rarely mandates surgery by itself.[3,4]

When advanced imaging does add value, access and image quality can matter—particularly for people who struggle in standard scanners. In Lincolnshire, MSK Doctors’ Open MRI in Sleaford (NG34) is one option for obtaining the scan that supports a decision-making conversation, rather than simply generating a label.

Running again after an Achilles rupture

After an Achilles rupture, the most helpful shift is often from asking whether the “right” treatment was chosen to asking what needs to be true in the calf and tendon before running load goes back in. In a 2022 multicentre NEJM randomised trial (n=526), patient-reported function and physical performance at 12 months were similar with modern nonoperative care, open repair, and minimally invasive repair, even though the risk profile differed between options.[5]

That trade-off is worth understanding because it influences how cautiously progression is managed in the early months. In the NEJM trial, re-rupture occurred in 6.2% of the nonoperative group versus 0.6% in each surgical group, while surgical pathways carried more procedure-related complications (for example, nerve injury being more frequent after minimally invasive repair). Systematic reviews describe the same broad pattern: similar medium-term function, with re-rupture risk higher without surgery and wound/nerve risks higher with surgery.[5,6]

Rehabilitation has also moved away from long periods in plaster. Contemporary protocols commonly use a controlled-ankle-motion boot with heel wedges and early functional rehabilitation, typically progressing from partial to full weight-bearing over roughly 4–6 weeks, while gradually increasing dorsiflexion as heel lifts are reduced. Evidence-based reviews link prolonged rigid immobilisation with more stiffness and slower recovery, which matters when the end goal is a return to impact.[6]

Timeframes are only rough guides, but published rehab guidance is fairly consistent about the broad “windows”. Light jogging is rarely appropriate before about 12 weeks, and more commonly begins somewhere in the 3–6 month range once strength and impact tolerance are rebuilding; full return to cutting, pivoting and jumping sports is often in the 6–12 month range. Even at 12 months, measurable calf strength deficits are common, which is one reason return-to-sport is usually framed as criteria-based rather than calendar-based.[5,6]

Practical milestones often used before starting or progressing running include:

• controlled double-leg heel raises, then controlled single-leg heel raises (quality and endurance matter as much as the count)
• improving left–right symmetry in calf size and strength, plus steady balance and control on single-leg tasks
• tolerance of lower-impact plyometric drills (for example, skips or gentle hops) without a next-day flare-up, before faster running or hills are added[6]

Pain guidance is usually framed around response to load rather than “zero discomfort”. Rehabilitation literature commonly uses a 24‑hour rule: mild discomfort during or after activity that settles within about 24 hours, without increasing swelling or worsening limp, is generally considered acceptable; sharper pain, a sense of “giving way”, or pain that lingers or is worse the next day suggests overload and is a cue to reduce intensity or volume. These thresholds are largely based on expert consensus and tendon-loading principles rather than RCT-defined cut-offs, so they are usually individualised—especially in the higher-risk phases of return to impact.[6]

Rotator cuff tears in active over‑40s

Being told there is a “rotator cuff tear” on ultrasound or MRI can sound like a clear instruction to operate, but the more useful question in an active person over 40 is whether the tear is the main driver of pain and loss of function now, and whether those problems are changing with a proper rehab plan.

Two broad patterns tend to guide urgency. Degenerative tears often come on gradually over months, sometimes with a slow drift in overhead strength or aching that is worse after activity. Acute traumatic tears are different: a fall, sudden heavy lift, or a sharp “rip” sensation followed by an immediate drop in function (for example, being unable to lift the arm away from the body) is the scenario where an earlier surgical opinion is more commonly discussed in active patients.[7]

When physiotherapy-only can be a reasonable first plan

For many over‑40s—particularly when symptoms are improving and day-to-day function is trending in the right direction—clinicians often start with a structured rehabilitation programme rather than making the scan finding the decision-maker. The goal is to improve load tolerance and function (rotator cuff strength, scapular control, and graded return to pressing/pulling/overhead work), while monitoring whether weakness, pain and disability are actually resolving.

When surgery becomes the more predictable—or safer—route

Surgery is more commonly prioritised when there is a clearly traumatic loss of function in an otherwise healthy, active patient, or when there is persistent weakness and pain despite high-quality rehabilitation in a tear considered repairable.[7]

When a tear is massive/irreparable with established cuff‑tear arthropathy, reverse shoulder arthroplasty can give substantial pain relief and functional improvement in published series, but it carries notable complication and revision rates—so it is usually reserved for older, lower-demand patients after less invasive options have failed.[7]

How MSK Doctors can help you decide your next step

Across the four scenarios above, the turning point is rarely a single scan result or a “magic” treatment at week 6; it is the moment persistent symptoms (often at the 3–6 month mark) justify a more exact diagnosis and a more measurable plan. The emphasis here stays with those decision rules—what is most likely to change management—rather than a booking script or a list of products.

A consistent pathway tends to hold up in clinic, whether the problem is heel pain, deep groin pain, a post‑rupture calf, or an aching shoulder in an active over‑40: clarify the diagnosis; optimise conservative care with clear load targets; consider targeted injection or biologic support where it is genuinely likely to add value; and reserve surgery for situations where it offers a clearer advantage in pain relief, function, or safety. When uncertainty remains after a good rehab attempt, the practical question becomes “what would change if the diagnosis were more precise?”—because not every image, injection, or operation changes the next 12 weeks.

MSK Doctors supports that decision-making through consultant-led assessment in Lincolnshire, with access in Sleaford (NG34) and Grantham (NG31). Where imaging is likely to influence the plan—such as complex hip or shoulder presentations—an Open MRI pathway can be paired with onMRI™ analysis to help interpret findings in context. Where biomechanics and load tolerance are the key issue—such as stubborn plantar heel pain or return‑to‑running after Achilles injury—MAI Motion® can add objective movement measures to complement physiotherapy progress markers. For patients weighing an injection or an operation, Consent Plus is used to document risks, alternatives, and realistic expectations.

A first specialist consultation is usually most productive when it includes:

• previous imaging reports (for example an MRI from 2023–2026) and any physio notes
• a short timeline (the “week 1–2 trigger”, the “week 8 plateau”, the “month 6 concern”)
• 2–3 concrete goals (for example “walk the dog for 30 minutes”, “return to 5 km running”, or “manual work overhead”)

Appointments can be booked online at mskdoctors.com without a referral if that route is helpful; the more important closing point is that stubborn symptoms often need better problem‑solving—not simply more rest, and not automatically surgery.

1. [1] Review of femoroacetabular impingement syndrome. (2024). https://doi.org/10.1093/jhps/hnae034 https://doi.org/10.1093/jhps/hnae034