Painful Arch

Evaluation

Important items to consider in the history:

• Etiology/onset (acute, gradual)

• Shoe gear/activity level

• Family history

• Functional loss?

• Foot type (not a diagnosis!)

  • pes planus: (low arch/over-pronator)

    • flexible: unstable, good accommodation to shock

    • rigid: tarsal coalition, surgical problem

  • pes cavus: (high arch/supinator)

    • flexible: stable, not good shock absorber

    • rigid: consider neurological problems

Differential diagnosis:

Trauma

• Plantar fascial tear

• Posterior tibialis tendon rupture (acute loss of arch)

• LisFranc’s fracture dislocation

Overuse

• Plantar fasciitis

• Posterior tibial tendonitis

Other

• Infection (puncture wound)

• Tarsal coalition

Physical exam

• Look for fracture first.  

• Examine for edema and deformity.  

• Check specifically for LisFranc’s fracture/dislocation, a significant injury with a poor prognosis, especially in patients who are unable to weight bear.  

• Dislocation can result with spontaneous reduction so x-ray may be unremarkable. 

• Severe pain may also suggest a possible compartment syndrome - check for good perfusion by pulses and capillary refill and check sensation.  

• Ecchymosis may be present with LisFranc’s injury, plantar fascial tear, or posterior tibial tendon rupture.  

• Plantar fasciitis exhibits pain on rising and after rest in the plantar medial heel / arch.  

• Posterior tibial tendon rupture will result in the inability to invert the foot.  

• Lack of range of motion of the rearfoot may indicate a tarsal coalition. 

• Isolated infection in the arch is unlikely without a puncture wound.

Treatment

Trauma

• Plantar fascial tear

  • Initial anti-inflammatory regiment

  • Followed by aggressive stretching

  • Shoe inserts may be required for long-term support

• Posterior tibial rupture (acute loss of arch)

  • surgical repair of posterior tibialis tendon

  • follow by 8 – 12 weeks of immobilization

  • shoe inserts for long-term support

• LisFranc’s fracture/dislocation

  • requires surgical reduction and correction

Overuse

• Plantar fasciitis

  • anti-inflammatory therapy (NSAIDs, ice massage)

  • stretching

  • shoe inserts (orthotics)

  • if intractable, corticosteroid injections, night splints, possible plantar release

• Posterior tibial tendon dysfunction

  • shoe inserts to prevent excessive pronation

Other

• Infection

  • oral antibiotics with/without IM/IV antibiotics

  • surgical I&D and packing (puncture wounds) may be necessary

Christopher Kardohely, DPM and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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