Plantar Heel Pain Best Practice Guidelines: How to Apply Them in Everyday Clinical Care

Plantar heel pain is one of the most common and disabling foot conditions in rehabilitation settings. Clinicians are likely to see this complaint frequently when treating recreational runners, active older adults, or those with a sedentary lifestyle. Despite its prevalence, plantar heel pain can present diagnostic and management challenges. Fortunately, recent plantar heel pain best practice guidelines offer a roadmap for evidence-based care. 

In this article, we’ll explore how clinicians can apply the latest heel pain guidelines to optimize assessment and treatment. The focus is on practical implementation, bridging the gap between research and everyday clinical care.

Why best practice guidelines matter

The American Academy of Orthopaedic Physical Therapy (AAOMPT) has published Clinical Practice Guidelines (CPGs) for heel pain since 2009, with the latest revision released in 2023. This update integrated findings from over 100 new studies, including high-quality randomized clinical trials and systematic reviews.

While CPGs offer a clear synthesis of current evidence, they are not rigid "recipes." CPGs should guide, not replace, individualized clinical reasoning. By applying these guidelines systematically, clinicians can:

• Improve diagnostic accuracy 

• Optimize examination strategies 

• Select interventions with proven effectiveness 

• Track patient outcomes using validated measures 

• Enhance patient-centered, functional care

Understanding plantar heel pain

Plantar fasciitis is an overuse injury involving inflammation or degeneration of the plantar fascia, a thick band of connective tissue that runs along the bottom of the foot, supporting the arch and absorbing shock. It typically causes pain at the medial plantar heel, especially with the first steps after rest. 

Plantar fasciitis alone affects approximately 10 percent of the general population, with 83 percent of these cases occurring in active working adults between the ages of 25 and 65.¹ This highlights both the broad prevalence and the significant functional impact of plantar heel pain on the working-age population.

However, plantar fasciitis is just one contributor to the broader diagnosis of plantar heel pain. Clinicians must remain vigilant for other causes, including fat pad atrophy, nerve entrapment, and systemic conditions, and be prepared to tailor their evaluations accordingly. A thorough understanding of pathomechanics, risk factors, differential diagnosis, and the application of plantar heel pain best practice guidelines is essential to effective care.

Differential diagnosis: Identifying the source of heel pain

Accurate diagnosis begins with careful differential diagnosis. The Heel Pain - Plantar Fasciitis Clinical Practice Guidelines stress the importance of ruling out other potential causes of heel pain that may require alternative management strategies or referral to another provider. Conditions to consider include:²

• Radiculopathy from lumbar spine involvement, which can produce referred heel pain or paresthesia.

• Autoimmune conditions (e.g., ankylosing spondylitis, reactive arthritis), which may present with heel pain as an early symptom of systemic disease. 

• Gout, which can cause acute, intense pain in the heel or other foot structures due to crystal deposition.

• Fractures, particularly calcaneal stress fractures or traumatic fractures, which require different treatment pathways. 

• Peripheral nerve entrapments, such as tarsal tunnel syndrome or entrapment of the first branch of the lateral plantar nerve, which can mimic plantar fasciopathy. 

Findings that support a diagnosis of plantar heel pain due to plantar fasciopathy include:

• Medial plantar heel pain, often worst with first steps after inactivity. 

• Pain onset following increased weight-bearing activity or changes in footwear. 

• Tenderness at the proximal plantar fascia insertion on the medial calcaneus. 

• Limited ankle dorsiflexion range of motion, which can increase plantar fascia strain.

• A positive Windlass test and a negative Tarsal Tunnel test, helping differentiate from neural involvement.

Using a structured physical examination ensures a comprehensive, evidence-based approach to diagnosis and helps clinicians rule out serious conditions while establishing a working diagnosis of plantar fasciopathy, consistent with the principles outlined in the plantar heel pain best practice guidelines.

Understanding pathomechanics and risk factors

Biomechanical models of plantar heel pain provide essential insights for developing effective treatment plans. The current guidelines emphasize two primary models that explain how tissue overload and pain develop:²

• Limited ankle dorsiflexion and weak intrinsic/extrinsic foot muscles: Involve increased strain on the plantar fascia and surrounding structures, contributing to tissue overload, microtrauma, and persistent pain.

• Excessive heel loading (acute or chronic): Involves sustained or repeated high loads on the heel fat pad, leading to irritation, degeneration, localized discomfort, altered gait mechanics, and functional limitations.

Risk factors for plantar heel pain can be grouped into two broad categories:

• Intrinsic factors: Include abnormal foot posture, limited joint mobility, high body mass index (BMI), muscle weakness, and fear-avoidance behaviors. These elements can alter gait mechanics and increase repetitive strain on the plantar fascia. 

• Extrinsic factors: Include sudden increases in activity level, improper footwear, and walking or running on hard surfaces. External loading conditions can significantly influence tissue stress and recovery capacity.

Identifying and addressing modifiable risk factors plays a key role in both preventing plantar heel pain and optimizing treatment outcomes.

Evidence-based treatment approaches for plantar heel pain

The plantar heel pain best practice guidelines provide graded recommendations for intervention based on the strength of supporting evidence:²

Strongly recommended interventions

• Manual therapy to improve ankle and foot mobility

• Stretching exercises (such as the standing bilateral gastrocnemius stretch with step and the seated plantar fascia stretch) targeting the plantar fascia and Achilles tendon. 

• Taping techniques (such as Low-Dye taping) for arch support. 

  Foot orthoses, particularly prefabricated devices, for short- to medium-term symptom relief.

Moderately recommended

• Night splints for patients with symptoms persisting beyond six months. 

• Strengthening exercises for foot intrinsic muscles and proximal hip and lower limb musculature.

Less supported or adjunctive

• These approaches involve modalities such as ultrasound, laser therapy, and dry needling. Given the limited supporting evidence, these modalities may be adjuncts but should not replace active, evidence-based interventions. 

Patient education as a foundation for effective care

Beyond targeted interventions, patient education provides the foundation for sustained recovery and long-term self-management. It helps patients adopt positive behaviors that reinforce treatment gains and prevent recurrence. Priority areas to address include:

• Activity modification: Help patients adjust daily and recreational activities to minimize aggravating loads while supporting continued mobility. 

• Footwear selection: Guide patients toward supportive, well-cushioned footwear that optimizes biomechanics and reduces tissue strain. 

• Long-term self-management: Encourage home-based stretching, strengthening, and activity progression. Address psychosocial factors that may impact recovery. 

Empowering patients with clear, actionable education enhances both clinical outcomes and long-term resilience against plantar heel pain.

Using patient-reported outcome measures in heel pain management

Systematic outcome measurement is critical to evaluating treatment effectiveness, guiding clinical decisions, and promoting patient engagement in the rehabilitation process. The plantar heel pain best practice guidelines recommend the use of validated patient-reported outcome measures (PROMs) such as:²

Foot and Ankle Ability Measure (FAAM)

A self-reported questionnaire with 21 items related to activities of daily living (ADL) and 8 items on sports function. Provides a total score out of 100 for each subscale, helping clinicians monitor both everyday and athletic functional status. Sensitive to meaningful clinical changes.

Foot Function Index (FFI)

Originally a 23-item tool (with revised and short-form versions), the FFI assesses pain, disability, and activity limitation using either visual analog scales or Likert scales. It is particularly useful for capturing the multidimensional impact of heel pain on quality of life. 

Lower Extremity Functional Scale (LEFS)

A 20-item questionnaire evaluating overall lower limb function, rated on a 5-point Likert scale. Broadly applicable across lower extremity conditions, making it a valuable tool for tracking global progress, especially in patients with multiple lower limb impairments. 

Visual Analog Scale (VAS)

A simple and highly sensitive measure of pain intensity, especially well-suited for monitoring first-step pain, a hallmark symptom of plantar heel pain. Patients mark their pain level on a continuum, allowing for easy comparison over time. 

Clinical application: Using outcome measures to guide care

A 48-year-old recreational runner sought care for a three-month history of medial plantar heel pain. The patient described the pain as sharp and localized to the medial heel, most pronounced during first-step weight-bearing in the morning and after prolonged standing throughout the day. No neurological symptoms or systemic concerns were reported. 

Initial evaluation revealed tenderness at the proximal plantar fascia insertion, limited ankle dorsiflexion, a positive Windlass test, and a negative Tarsal Tunnel test. Baseline outcome measures reflected functional limitations: FAAM-ADL score of 62/100, LEFS score of 52/80, and first-step pain rated at 7/10 on the VAS.

The patient’s presentation was consistent with plantar fasciopathy. The treatment plan included manual therapy to improve ankle and foot mobility, stretching exercises targeting the plantar fascia and gastrocnemius-soleus complex, prefabricated foot orthoses, and patient education on activity modification and appropriate footwear selection. 

At a six-week follow-up, the patient reported significant improvements in both function and pain. The FAAM-ADL improved to 82/100, the LEFS increased to 68/80, and first-step VAS decreased to 3/10. Systematic tracking of these outcome measures guided the progression of the exercise program and supported ongoing clinician-patient discussions about treatment goals and long-term self-management. 

Applying evidence to everyday clinical care

The plantar heel pain best practice guidelines provide a strong foundation for care. To further enhance outcomes, clinicians can integrate these recommendations within a holistic, patient-centered approach that addresses each individual’s unique needs and goals. The following principles can help guide this process:

Treat guidelines as a clinical compass, not a checklist

While best practice guidelines synthesize current evidence, they are meant to inform, not dictate, care. Individual patient factors such as personal goals, comorbidities, and psychosocial considerations should always shape the treatment plan. 

Prioritize active care strategies

Evidence consistently supports active, functionally focused interventions (including manual therapy, targeted exercise, and education) as the foundation of effective treatment. Passive modalities may serve as adjuncts but should not displace active patient engagement.

Adopt a whole-person approach

Addressing plantar heel pain requires more than biomechanical correction. Psychosocial factors, lifestyle habits, and patient beliefs all influence recovery. A comprehensive approach that integrates these dimensions fosters better outcomes and stronger therapeutic alliances.

Use outcome measures as a clinical tool

Regularly tracking validated patient-reported outcomes helps guide treatment decisions and supports transparent communication about progress. PROMs also empower patients by making their improvements visible and reinforcing active participation in care.

Set realistic recovery expectations

Recovery timelines vary, particularly in cases of chronic symptoms. Establishing clear expectations about the recovery process and emphasizing the importance of consistency and self-care can improve adherence and patient satisfaction.

Emphasize long-term self-management and prevention

As patients progress, shift the focus toward strategies for sustaining improvement and preventing recurrence, including maintaining mobility and strength, selecting appropriate footwear, and managing training loads.

By thoughtfully applying these principles, clinicians can translate the latest guidelines into practical, effective care that meets each patient’s individual needs.

Enhancing care for plantar heel pain

Plantar heel pain management is evolving. Moving beyond passive modalities and fragmented care toward a function-first, evidence-based approach allows clinicians to provide treatment that restores mobility, reduces pain, and supports lasting improvements in activity and quality of life.

The plantar heel pain best practice guidelines offer a valuable foundation for delivering high-quality, individualized care. Combined with clinical reasoning and a holistic, patient-centered approach, these guidelines can help clinicians support optimal outcomes for every patient.

To learn more about applying a function-first approach to plantar heel pain care, explore the course Heel Pain: Pathomechanics, Examination, and Outcomes Measures. This first course focuses on intervention recommendations from the 2023 clinical practice guidelines update, covering pathomechanics, clinical examination, differential diagnosis, and patient-reported outcomes measures, helping you integrate evidence-based strategies into your clinical practice. 

You can also continue building your expertise by exploring the next course in the series, Heel Pain: Prevention and Interventions.

References

1. Buchanan, B. K., Sina, R. E., & Kushner, D. (2024). Plantar fasciitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431073/

2. Koc, T. A. Jr., Bise, C. G., Neville, C., Carreira, D., Martin, R. L., & McDonough, C. M. (2023). Heel pain – plantar fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy, 53(12), CPG1–CPG39. https://doi.org/10.2519/jospt.2023.0303