Management of plantar heel pain: a best practice guide informed by a systematic review

Key points

1. 01Plantar fascia stretching and low-dye taping are first-line treatments supported by RCT evidence
2. 02Education covering load management, footwear advice, and pain monitoring is recommended alongside all physical interventions
3. 03Shockwave therapy (focused or radial) is recommended when the core approach fails, with positive evidence across short, medium, and long-term outcomes
4. 04Custom foot orthoses are the next step if shockwave therapy is insufficient, with moderate short-term evidence
5. 05Prefabricated orthoses, calf stretching alone, dry needling, and injection therapies lack adequate evidence of efficacy

How it was conducted

Design

Mixed-methods: systematic review of RCTs plus semi-structured expert interviews and online patient survey

Studies included

51 RCTs meeting PEDro score >=8/10 and risk-of-bias criteria

Participants (SR)

4351 participants across 51 trials; median sample size 75 (IQR 62); mean symptom duration 13 months; 49% female

Experts interviewed

14 international expert clinicians (physiotherapists, podiatrists, one rheumatologist) from 6 countries

Patient survey

40 people with plantar heel pain completed an online survey

Primary outcome

First step pain, overall pain, and foot-related function; short term 1 week to 3 months, medium term >3-6 months, long term >6 months

What they found

• Low-dye taping: moderate evidence of efficacy for first step pain at 1 week vs sham ultrasound (SMD 0.47, 95% CI 0.05 to 0.88)
• Plantar fascia stretching vs radial ESWT: moderate evidence of large effect for first step pain short term (SMD 1.21, 95% CI 0.78 to 1.63) and medium term (SMD 0.64, 95% CI 0.24 to 1.04); no difference long term (SMD -0.04, 95% CI -0.43 to 0.35)
• Focused ESWT: strong evidence for first step pain short term (OR 1.89, 95% CI 1.18 to 3.04); limited evidence medium term (SMD 1.31, 95% CI 0.61 to 2.01) and long term (SMD 1.67, 95% CI 0.88 to 2.45); moderate evidence for overall pain short term (SMD 0.36, 95% CI 0.11 to 0.61)
• Radial ESWT: moderate evidence for first step pain short term (OR 1.66, 95% CI 1.00 to 2.76) and long term (OR 1.78, 95% CI 1.07 to 2.96); pooled overall pain showed large but imprecise effect (SMD 1.64, 95% CI -1.06 to 4.33)
• Custom foot orthoses: strong evidence for overall pain short term vs sham (SMD 0.41, 95% CI 0.07 to 0.74); limited evidence medium term (SMD 0.55, 95% CI 0.09 to 1.02); moderate neutral evidence long term (SMD 0.04, 95% CI -0.37 to 0.45)
• Prefabricated orthoses: moderate neutral evidence for pain and function at all time points
• Dry needling: moderate neutral evidence for pain (SMD -0.33, 95% CI -0.76 to 0.10) and first step pain (SMD -0.42, 95% CI -0.85 to 0.02) short term
• Calf stretching: moderate neutral evidence for first step pain (SMD -0.39, 95% CI -0.80 to 0.03), pain (SMD 0.00, 95% CI -0.40 to 0.41), and function short term
• Patient survey: 95% of 266 treatment components mentioned by patients were consistent with the core approach derived from the review and expert interviews
• 48 of 50 domains in the 10 key trials had low risk of bias on the RoB-2 tool; a maximum of 2 had some concerns and none were high risk

Limitations

• Only 51 of 362 assessed trials met the high quality thresholds, so the evidence base for plantar heel pain overall is weak
• Most studies evaluated short-term outcomes only; only 27% reported medium-term and 13% long-term results
• Stepped-care sequencing in the best practice guide is extrapolated from expert opinion rather than from trials that required prior treatment failure as an inclusion criterion
• No placebo-controlled RCTs exist for corticosteroid or platelet-rich plasma injection therapy, leaving their efficacy inadequately tested

Why it matters

For patients

People with heel pain should start with daily plantar fascia stretching, low-dye taping, and footwear advice, and expect slow but positive recovery over weeks to months before considering further treatments like shockwave therapy.

For clinicians

This best practice guide supports a structured stepped-care pathway: core self-management first for 4-6 weeks, then shockwave therapy if recovery is suboptimal, then custom orthoses, enabling more consistent and evidence-informed management decisions.

For readers

The guide synthesises the highest-quality RCT evidence with expert reasoning and patient perspectives to produce a clear treatment hierarchy, though most evidence is of moderate strength and long-term comparative data remain limited.