Plantar fasciitis, sometimes called plantar heel pain, is one of the most common causes of heel pain, particularly first thing in the morning or after periods of rest, and effective treatment depends on understanding what’s actually driving it. It involves the plantar fascia, a thick band of tissue running along the sole of the foot from the heel to the toes, becoming irritated and painful, often as a result of repetitive load or a sudden increase in activity.
Research plays a key role in shaping how physiotherapists manage conditions like plantar fasciitis, but that research does not always agree. Limitations and conflicting opinions are common in the evidence base, which can lead to different clinicians recommending different approaches. Two recent clinical practice guidelines for plantar heel pain have drawn genuinely different conclusions, which raises a fair question for anyone dealing with this condition: what does best practice actually look like.
What Is Plantar Fasciitis
Plantar fasciitis typically develops gradually, often linked to a sudden change in activity levels, prolonged standing, unsupportive footwear, or reduced calf and foot flexibility. It commonly presents as a sharp or aching pain under the heel that is worse with the first few steps in the morning and can ease with movement, only to return after periods of rest or at the end of a long day. While it is often labelled an inflammatory condition, current evidence suggests the underlying changes are more degenerative than inflammatory, which is part of why treatment approaches have shifted over time.
Two Guidelines, Two Different Approaches
The most recent guideline, published by Koc and colleagues in 2023 in the Journal of Orthopaedic and Sports Physical Therapy, is a revision of earlier clinical practice guidelines from 2014. It recommends manual therapy and stretching of the plantar fascia and calf complex as strong, evidence-backed interventions, along with taping for short term symptom relief and night splints for people with consistent first-step pain each morning. Therapeutic exercise involving resistance training for the foot and ankle, low-level laser therapy, and dry needling are supported with moderate level evidence. Foot orthoses are not recommended in isolation, though prefabricated or custom orthoses may help alongside other treatments.
This guideline has drawn some criticism. It places a large focus on manual therapy and low-level laser therapy, while offering comparatively little guidance on education and load management, both of which are widely considered central to managing heel pain well. Shockwave therapy was excluded entirely, as it was considered outside the typical physiotherapy scope of practice at the time the guideline was developed. Questions have also been raised about the strength of the evidence behind some of the specific recommendations, and the format of the guideline tends to tell clinicians what to include or exclude, rather than framing treatment as a shared decision made together with the patient.
A second, more recent guideline published by Morrissey and colleagues in 2021 in the British Journal of Sports Medicine takes a different approach. Rather than grading interventions individually, it was developed by combining a systematic review of the evidence with expert clinical reasoning and direct patient feedback. Its core recommendations centre on taping, stretching and individualised education as the foundation of treatment, with shockwave therapy and custom orthoses reserved for people who do not respond as expected to the initial approach.
This guideline also places more weight on individual factors that the 2023 guideline addresses less directly. It highlights the importance of load management to break up provocative activity and keep sport or daily activity at a manageable level, alongside helping patients understand their pain well enough to guide their own activity, sometimes using a simple traffic light approach based on pain levels. Footwear advice, such as choosing a shoe with a heel-to-toe drop that suits the individual’s symptoms, and support for related health factors such as Type 2 diabetes, are also included as part of a broader, more individualised approach. Progressive strength training features less prominently in this guideline than in typical practice with athletic populations, which reflects the more limited research evidence in that specific area rather than a rejection of its value.
What This Means for Your Plantar Fasciitis Treatment
Reading two guidelines that reach different conclusions can feel unhelpful if you are the one dealing with heel pain each morning. In practice, it means an individualised, patient centred approach matters more than picking a single guideline to follow to the letter. Good management typically draws on the strongest elements of both: manual therapy, stretching and taping in the early stages, load management and education throughout, and options like shockwave therapy or orthoses considered if the initial approach is not delivering the expected improvement. Guidelines are a valuable starting point, but they work best when adapted to how an individual patient is actually responding, not applied as a fixed recipe.
Common Questions
What Causes Plantar Fasciitis
Plantar fasciitis is usually linked to repetitive load on the plantar fascia, often from a sudden increase in walking, running or standing, tight calf muscles, unsupportive footwear, or a combination of these factors. It is common in both athletic and non-athletic populations, including people whose work involves long periods on their feet.
How Long Does Plantar Fasciitis Take to Heal
Recovery timelines vary considerably between individuals, and most guidelines emphasise that plantar fasciitis is generally a self-limiting condition that responds to a structured programme of stretching, load management and manual therapy over several weeks to a few months. Persistent cases may take longer and can benefit from a broader treatment approach, including shockwave therapy or orthoses.
Should I Rest or Keep Exercising with Plantar Fasciitis
Complete rest is rarely the best approach. Most current guidelines favour load management over rest, meaning activity is adjusted to a level the foot can tolerate rather than avoided altogether. A physiotherapist can help identify what level of activity is appropriate for your specific presentation.
Do I Need Orthotics for Plantar Fasciitis
Not always. Current evidence suggests foot orthoses are not recommended as a standalone treatment, but prefabricated or custom orthoses may help some people when used alongside manual therapy, stretching and load management, particularly if foot posture is a contributing factor.
How BeFit Can Help
Our physiotherapists stay across the current evidence base for conditions like plantar fasciitis, including guidelines that do not always agree with one another, so that your treatment plan reflects genuinely current best practice rather than a single fixed protocol. If you are experiencing plantar heel pain and want a clear diagnosis and a treatment plan built around your specific presentation, our physiotherapist at Edgecliff and Coogee can help.
Book an appointment at BeFit Training Physiotherapy — no referral needed.
Edgecliff: (02) 9327 7749 | Coogee: (02) 7205 2805
References
Martin RL, Davenport TE, Reischl SF, et al. Heel Pain-Plantar Fasciitis: Revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-A33.
Koc TA, Bise CG, Neville C, et al. Plantar Fasciitis/Heel Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy. J Orthop Sports Phys Ther. 2023;53(12):CPG1-CPG39.
Morrissey D, Cotchett M, Said J’Bari A, et al. Management of Plantar Heel Pain: A Best Practice Guide Informed by a Systematic Review, Expert Clinical Reasoning and Patient Values. Br J Sports Med. 2021;55(19):1106-1118.
Australian Physiotherapy Association. Clinical guidelines. physiotherapy.asn.au.
