A 45 year-old female presents to the clinic complaining of arch pain in her left foot. She reports that the pain came on after an intense session of tennis, just before returning to work as a hairdresser, after having an extended period of time off work. A thorough medical history reveals that she has had plantar fasciitis before, which was successfully treated with custom made prescription orthotics to control her poor biomechanical foot function, and reduce the strain on the plantar fascia. However, any further damage to the plantar fascia as a result of overuse injury, or over activity, can cause repeated inflammation in the arch and base of the heel, and hence can be the source of the arch pain she is experiencing now. However, arch pain is also a common symptom of Tibialis Posterior tendonitis and Peroneal tendonitis. She is otherwise healthy with no other significant medical history.
She has been experiencing this arch pain over 4 weeks now. She describes the pain as a constant sharp pain, with mild infrequent throbbing, especially at night times. When the pain first suddenly came on, she bought a new pair of sneakers and put her orthotics inside, hoping the pain will gradually go away. However, she reports that the arch pain has been getting progressively worse since. She has been advised to take some over the counter anti-inflammatories to reduce the pain in the arch of her foot, and has found this to be helpful. However, after a long day of work and being on her feet all day, the pain comes back, and the only way to relieve it is by resting and elevating her feet. However, due to the nature of her work, she is unable to rest her feet, and has to continue work through the pain.
After some research on the internet, she found some remedies to treat her arch pain at home. These included rolling her feet on a frozen bottle and pulling her toes back in an attempt to stretch the tight plantar fascia. She had also read online that putting heat packs on the arch can also be helpful. After trying these treatments at home for 2 weeks, she found the arch pain had gotten worse and decided to see a podiatrist.
Arch Pain Examination
A thorough physical assessment was conducted, where the origin of the plantar fascia from the base of the heel, through to its attachment to the base of the toes were firmly palpated to elicit any pain. The patient did not report pain on pressure to the plantar fascia.
Hence, the tendons which can also cause arch pain were assessed, and the patient reported pain when firm pressure was applied to the tibialis posterior tendon, along its attachment to the navicular and medial cuneiform bones of the foot. No swelling or redness was noted.
In order to understand the cause of her arch pain, the action of this tendon was explained to the patient, which is to hold up the arch and support the foot when walking. Hence, any injury to the tendon can cause it to become inflamed, or torn, consequently reducing its ability to provide stability and support for the arch – leading to arch pain as the inflammation in the tendon progressively increases.
The patient had a mild case of Posterior Tibial Tendon Dysfunction (PTTD).
Biomechanical Assessment for Arch Pain
The patient was asked to stand in her relaxed position. It became apparent that the left arch height was slightly lower than the right. This was confirmed when her arch heights were measured at 22mm for the left foot, and 26mm for the right foot. It was explained to the patient that once the tendon becomes inflamed or torn, the arch can slowly fall (collapse over time).
A few other examinations were conducted to confirm that the arch pain was a result of PTTD. These included the following:
- Single Leg Raises: Patient was asked to stand on her left foot on her tiptoes, and was unable to elevate her heel without pain.
- Limited range of motion of the ankle: This is tied to the tightness of the calf muscles – which further increase the pull going through the heel – exacerbating the arch pain.
- Over pronation due to muscle and tendon weakness.
The patient was also sent for an ultrasound, which confirmed that her arch pain was due to inflammation in the tibialis posterior tendon.
Arch Pain Treatment
In the short term, the patient’s foot was strapped with sports tape and she was fitted with an immobilisation boot to reduce her arch pain. This completely immobilises the foot and allows the inflamed tendon to heal, as she did not have the option of resting her feet due to work. Hence, she was still able to resume work as normal without experiencing any arch pain inside the boot. She was also advised to stop heat packs, and only apply ice packs to the area of the arch which was painful.
In the long term, she was instructed to do specific calf stretches which aimed to increase the range of motion at the ankle. She was also advised to do strengthening exercises of the tendon once her arch pain was completely gone.
At 6 weeks, she was reviewed and reported no pain in the mornings and when without the boot in general. She was also able to work a weekend without the boot, with no pain or discomfort. Firm pressure was applied to the mid-arch, where she initially experienced the arch pain, and no pain was reported.
As her previous orthotics were still firm and functional, they were still successfully able to control her foot function. Hence, she was asked to remove the boot and wear the orthotics in her new sneakers, which were also suitable for her foot type and function, at all times. This is to reduce the likelihood of a flare-up in the tendon, re-initiating her arch pain in the future.
An increase in the range of motion at the ankle was also noted, as she was consistent with her calf stretches. Light strengthening exercises of the tibialis posterior tendon were demonstrated and asked to be initiated, since her arch pain was now completely gone.
Please note: The information in this case study is specific to one particular patient and should not be taken as general advice. There are several cause of arch pain and if you are having foot problems you should consult with a Podiatrist or suitable healthcare practitioner.
Written by Karl Lockett