Case Study – October 2016 – Arch Pain and Plantar Fasciitis

A 44 year old male has been seeing his Podiatrist for what he thinks is Plantar Fasciitis as the cause of his Arch Pain. He is a keen martial arts student and has been practicing Shotokan karate for 12 years, which he performs in his bare feet. He attends 3 times a week and each class is an hour long. His Arch Pain came on gradually over a period of 3 weeks and he reports that he strained his calf muscle in the same leg approximately 2 months prior to the pain developing. His physiotherapist was massaging his calf muscles and encouraging calf stretches following the strain and he sat out of karate for 6 weeks. When he returned to training, his leg did not feel 100% but he was able to complete the class with only slight pain. Stiffness in the muscles did persist and a reduced range of motion was apparent during training and walking. He had not made a connection between the calf problem and the Arch Pain but at this stage he is advised that they may be related.

He is otherwise a healthy individual with no other medical complaints and the only other foot problem he reports is a stress fracture to the 4th metatarsal of his other foot, 5 years ago.

This patient describes a sharp Arch Pain in the sole of his right foot, towards the right / outer edge. The area that he describes is along a line from the mid arch towards the cuboid bone, on the outer side of the foot. His Arch Pain is noticeable throughout his karate class and his podiatrist informed him that this is typical of Plantar Fasciitis. He does not feel much Arch pain in the mornings when he gets out of bed and the pain is very mild throughout the day when he is wearing his business shoes. When he wears his running shoes in the evenings and at weekends he does not feel any Arch Pain or Plantar Fasciitis pain at all. After his class has finished the patient drives home and struggles to walk from his car. He limps as his Arch Pain is quite severe and he believes that this is typical of Plantar Fasciitis. He finds relief from the pain when he applies an ice pack to his foot and he does this after each training session for approximately 30 minutes. He reports that the pain is present daily and he is becoming frustrated. He has a karate competition in 12 weeks and is anxious to partake.

Arch Pain Examination for Plantar Fasciitis

With the patient lying face up on the treatment table visual observation reveals swelling along the lateral edge of the foot, close to the cuboid bone. Firm pressure is applied to the arch of the foot from the heel, towards the toes, along the Plantar Fascia. There is pain when pressure is applied along the mid arch, approximately 3cm distal to the heel. The pain is not central as one would expect with Plantar Fasciitis but is more lateral towards the outer side of the foot, following the line of the long Peroneal tendon. Further pressure is applied to the tendon around the cuboid bone and this elicits a small jump response from the patient and he reports pain. The patient is asked if he ever feels pain along this outer side of his foot in addition to the Arch Pain and he confirms that this is definitely the case. He is under the impression that the pain on this side of his foot has been a result of compensation for the Arch Pain. He has been walking on the outer side of the foot to take load off the arch area. The patient is informed that the cause of his Arch Pain is not due to Plantar Fasciitis but more likely a result of tendonitis of the peroneus longus muscle. Peroneus longus is a muscle that runs down the outer side of the lower leg (fibula) and passes around the outer ankle into the sole of the foot. There is a short and a long tendon but they both pass the cuboid bone.

Arch Pain Treatment

The previous Podiatrist had been applying Shock Wave Therapy to the Plantar Fascia along the mid arch of the foot but this had not helped to reduce the patient’s Arch Pain. He had also arranged prefabricated, off the shelf, arch supports for the patient to use in his work shoes and trainers. Again, these had not helped the condition improve. The previous Podiatrist had also recommended heat packs be applied to the foot and although this was soothing, the long-term benefits were absent.

It was explained to the patient that because the cause of his Arch Pain was due to a peroneal tendonitis and not Plantar Fasciitis, it was important to unload the Peroneal tendon. He now understood why the Shock Wave Therapy had not helped. The probe had been used along the Plantar Fascia and not the Peroneal tendon. He was advised to stop applying heat packs but instead continue with ice, to reduce the inflammation within the tendon sheath.

To reduce the load on the Peroneal tendon, rigid sports tape was applied to the foot using a technique that lifts the cuboid bone, and creates a favourable arch on the lateral border of the foot. The patient is advised to leave the strapping in place for as long as possible and to expect it to remain for approximately 5 days.

Medium density padding is applied to the patients existing arch supports along the lateral border of the device in the area that will lift and support the cuboid bone, unloading the Peroneal tendon. The patient is advised that the tendon may take 4-8 weeks to heal completely.

Calf Stretches for Arch Pain

The patient is informed that his Arch Pain condition is likely to have been caused by his initial calf strain and hence he must restore normal range. He is instructed to perform the following calf stretches daily.

gastroc stretch and soleus stretch

Shock Wave Therapy for Arch Pain

A discussion surrounding the benefits of Shock Wave Therapy for Arch Pain takes place and the patient is advised to wait and return in one week to have his progress monitored. If there has been a significant improvement from the strapping, stretching and arch support modification, then Shock Wave Therapy will not be necessary.

The patient was reviewed at weekly intervals for 5 weeks and his strapping was replaced at each visit. He was compliant with the application of ice packs and stretching and hence he responded well to the treatment programme. No Shock Wave Therapy was needed and he was able to continue martial arts. His Arch Pain had gone completely by the 6th week and no further treatment was required.

Please be aware that the treatment for this patient should not be taken as general advice and if you are suffering with Arch Pain, Plantar Fasciitis or any other type of foot pain you may benefit from consulting a sports Podiatrist.