Are you dealing with foot arch pain that you know is not plantar fasciitis? While plantar fasciitis is the most common condition affecting the arch of the foot, but there certainly are other conditions that can lead to foot arch pain.
The foot and ankle are surprisingly complex structures, and as such, there is a large variety of injuries or conditions that can occur to that area. Some of these may involve the bones and joints, others are more specific to muscles and tendons, and nerve problems can also be present.
In this article, we will discuss some other relatively common conditions that can cause foot arch pain that are not plantar fasciitis, including a brief description of the pathology and general treatment methods used in the rehab of these conditions.
Stress fractures are small fractures in a bone that are commonly associated with repetitive use in high impact sports, such as long distance running, repeated jumping like volleyball, or a variety of high impact repetition such as in gymnastics, rather than an acute traumatic episode like a fall from a height, and tend to affect females more than males. Stress fractures can often cause foot arch pain that is not related to plantar fasciitis.
Given that stress fractures typically results from impact activities, they are much more common in weight bearing bones than non-weight bearing bones. As such, the tarsals, such as the navicular bone located on the inner foot, and metatarsal bones in the foot, are very common locations for these stress fractures (Rizzone et al, 2017). The tibia and fibula, which are the two shin bones that form the top of the ankle joint, are also common locations for stress fractures, especially in runners.
The main symptom of a stress fracture is pain local to the area of the fracture. If performing a repeated activity like running, pain from a stress fracture will continue to increase throughout the activity, and may ultimately force the patient to discontinue that activity. The pain is typically alleviated with substantial rest, but will return with activity if the fracture does not heal fully with rest.
Other symptoms may include swelling and inflammation in the area of the stress fracture, and palpating the area will likely be quite tender. Muscles around the area may also feel weak or stiff due to the interference of pain or altered loading. While these signs and symptoms can suggest a high suspicion of a stress fracture, the diagnosis is typically confirmed via x-ray imaging (Schneiders et al, 2012).
Initial treatment for a stress fracture will include substantial offloading in order to allow the fracture to heal. This doesn’t necessarily mean laying on your back all day, but rather, reducing the forces exerted on the area by using crutches or a walking boot. The patient may still engage in fitness activities like upper body workouts, non-weight bearing lower body strengthening, and low-impact cardiovascular activities like swimming (Patel et al, 2011).
Once the fracture appears healed on imaging and cannot be provoked by palpation, the next step will be to improve strength and mobility in the area, with a heavy focus on strength. For stress fractures that cause foot arch pain, strengthening the small intrinsic muscles of the foot, as well as larger muscles that provide dynamic support to the arch of the foot, such as tibialis posterior, can help take some of the load off the bones while engaging in activity, thus helping to prevent recurrence of this injury.
Other treatment strategies can include improving footwear to wearing shoes that offer good arch support, stretching muscles around the area before and after activity, and potentially using medications to help with any lingering pain or inflammation. Visiting a physiotherapist is a great idea if you’re dealing with a stress fracture causing foot arch pain, as they will be able to guide your activity modification and provide you with confidence when it comes to rehab and returning to activity.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome can be a source of foot arch pain that’s not plantar fasciitis, but it is often overlooked or mistaken with plantar fasciitis, especially if you or the healthcare professional you are consulting with is not familiar with these specific musculoskeletal conditions.
The tarsal tunnel is located on the inside of the ankle and is an area of passage for numerous structures that can become irritated. Tarsal tunnel syndrome usually affects the posterior tibial nerve, and this nerve continues to branch off in the sole of the foot, which can cause fairly pronounced heel pain and/or foot arch pain and inflammation.
If the posterior tibial nerve is becomes irritated or inflamed as it passes through this narrow tarsal tunnel, it can refer pain and other symptoms down to the bottom of the foot. The pain is sometimes characterized as burning, and there may be associated numbness and tingling in the area as well (Kiel and Kaiser, 2018).
Treatment for irritation of the posterior tibial nerve due to impingement by the tarsal tunnel and/or other structures within the tunnel usually involves some level of range of motion exercises. This can help improve the mobility of the ankle, particularly on the medial side, allowing for improved mobility of the structures within the tarsal tunnel and can also help relieve pain over time.
Specific tibial nerve sliders may also assist in recovery, which are mobility exercises that allow the nerve to slide back and forth along its course without being tensioned (Kavlak and Uygur, 2011).
Additionally, as symptoms settle, a physiotherapist may incorporate different functional strength and stability exercises, especially if the cause of the tarsal tunnel syndrome is mechanical, such as fallen arches, excessive rearfoot valgus in standing, or excessive pronation during walking. Any of these biomechanical factors can result in the appearance of flat feet, which make one more vulnerable to stressing the structures that pass through the area.
A consult with a physiotherapist will be able to provide exercises specific to these mechanical issues with the goal of reducing the stress on the tunnel caused by these issues, and may include, but are not limited to, exercises such as short foot doming, toe curls, calf raises with a tibialis posterior bias, and special types of squats that help recruit other muscles that support the bottom and inside of the foot and ankle.
As with many foot arch issues, wearing supportive shoes to help with flat feet, particularly with good medial arch support, is key. This can be guided by an orthotist, physiotherapist, or a shoe store that specialized in running.
In addition to the recommendation to wear supportive shoes or insertable arch supports, other treatment options may include manual therapy, such as soft tissue release or ankle joint mobilizations. If the problem is really severe and foot arch pain is not settling, then more invasive approaches, such as injections or even surgical release, can also assist in recovery.
The tarsal tunnel also includes a variety of tendons, including tibialis posterior, flexor digitorum longus, and flexor hallucis longus, all of which can also be sources of foot arch pain not related to plantar fasciitis. When researching these tendons, you may see them referred to as “Tom, Dick, and Harry”, which is a strategy that many medical and physiotherapy students use to remember what tendons pass through the tarsal tunnel.
We will discuss these structures separately in subsequent sections, and while we will be more specific with these tendon conditions, do know that they are often involved to some degree in tarsal tunnel syndrome.
Tendinopathy is an overuse injury that results in degeneration and disorganization of the collagen fibers that make up the tendon. The most common form of tendinopathy in the lower body is Achilles tendinopathy, but this can occur to any tendon if the person’s task demands and biomechanics align such that a particular tendon is more exposed to forces that it has trouble withstanding.
Tibialis posterior tendinopathy is also relatively common, which makes sense given it has some similar functions to the Achilles tendon. Tibialis posterior is often considered the core of the lower leg, as it sits deep to the calf muscles, assists in ankle plantarflexion which is the calf muscles’ main action, and its tendon wraps around the medial malleolus to connect to the navicular bone on the inside of the foot and continues to fan out along the sole of the forefoot.
All in, tibialis posterior helps with ankle plantarflexion, ankle inversion, and by way of its insertion, also acts as one of the main dynamic supports for the medial arch of the foot. If the tibialis posterior tendon is irritated, it can often lead to foot arch pain not associated with plantar fasciitis, and the pain can be felt on the inside of the ankle, inside of the foot, or anywhere along the arch of the foot, and may sometimes occur in combination with plantar fasciitis.
While stretching may provide very temporary relief for pain in the arch of the foot, the main form of conservative treatment for tibialis posterior tendinopathy is strengthening. More specifically, exposing the tendon to direct loading in a controlled manner with specific dosing will allow the tendon to heal properly and become more robust.
Throughout this type of physical therapy treatment, patients will typically report being able to do more with their familiar foot pain, or can do an activity for a longer amount of time before experiencing foot pain, and as treatment continues, that foot pain will eventually settle over time.
Eccentric exercises are quite popular for any form of tendinopathy. Eccentric strengthening involves loading a muscle and its tendon while elongating the tendon. For example, with the Achilles tendon, the lowering part of a calf raise can be considered the eccentric portion. This is different from passive stretching, as the tendon is being actively loaded via the associated muscle contraction, and the stretch is controlled through movement while sustaining the load.
While much of this research involves the patellar tendon or Achilles tendon, applying these techniques to tibialis posterior has shown some promise in clinical settings and various case studies (Samardzic and Zlaticanin, 2022). Additionally, simply strengthening the muscle, whether eccentrically, isometrically (stationary), or concentrically (contracting + shortening), can all have positive effects in terms of reducing pain caused by tendinopathy.
Other muscles and tendons in the area of the medial arch that help provide support to the arch include flexor digitorum longus, which runs from the inside portion of the back of the main shin bone (tibia) all the way to the bottoms of the toes (excluding the big toe), as well as flexor hallucis longus, which runs from the back of the other shin bone (fibula) all the way down to the bottom of the big toe.
A diagnosis of flexor digitorum longus tendinopathy and/or flexor hallucis longus tendinopathy is much less common, but can happen, and as such, it’s worth keeping these structures in mind. Treatment will be similar to tibialis posterior tendinopathy, but strengthening may involve more emphasis on the toes and smaller intrinsic foot muscles.
A Lisfranc injury can be quite debilitating and often results in significant pain in the arch of the foot not related to plantar fasciitis. A Lisfranc injury refers to broken bones in the middle of the foot, or sprained ligaments in the middle of the foot that help support these bones and joints. Pain from a Lisfranc injury is often more concentration on the top of the foot, but can also be felt in the bottom of the foot as foot arch pain.
Additionally, there is a Lisfranc ligament on the bottom of the foot close to the area where the plantar fascia inserts, and as such, some people can mistake Lisfranc ligament pain with plantar fasciitis, but the respective mechanisms of injury are quite different.
A Lisfranc injury can occur with trauma, such as a crush injury from something falling on the foot, or falling from a height. The trauma can also be less intense, but still considered “high energy”, as is seen in many Lisfranc injuries that occur in contact sports, especially football. In these cases, there is some form of impact to the foot and ankle that happens while the ankle is in a plantarflexed position. It can also happen by twisting the foot, especially external rotation, while there is axial compression through the foot joints (Chan et al, 2021).
Diagnosing this injury can actually be fairly tough given that the entire foot and sometimes ankle will be very irritable after injury. However, combining the patient’s subjective history (e.g. their account of the injury and associated symptoms), along with careful and diligent palpation of the foot, may be enough to yield a high level of suspicion for a Lisfranc injury.
An x-ray may also be ordered, particularly one that is done with the patient in a weight bearing position, as this may allow the radiologist to see if there is any shifting of the bones relative to each other, or even any discrete fractures.
Unfortunately, treatment for a Lisfranc injury is often surgical, whereby pins are used to realign and fixate the compromised joints. Even if it’s not surgical, a period of non-weight bearing is often mandatory, often for approximately 8 weeks, and a walking boot may be recommended to immobilize the foot and ankle while it heals and allow for some level of protection and function (Grewal et al, 2020).
Once the surgeon has provided clearance to initiate physiotherapy, ankle range of motion is usually prescribed first, which will help reintroduce active motion to the foot and ankle while not over-doing it. Then, just like an ankle sprain, progressive strengthening of the foot and ankle muscles will be necessary in order to provide support to the area, restore function to the foot and ankle, and reduce the risk of future injuries.
Strengthening will often begin with resistance band exercises, again to allow for a proper foundation to build on with more functional exercises without provoking foot pain. These functional exercises will then be in weight bearing positions, and will challenge balance and proprioception to ensure full function is restored will minimizing foot pain in the process.
While we recommend in-person physical therapy consultation for any injury, including foot pain, post-operative rehabilitation is even more highly recommended to be guided by a physiotherapist, as they will have the knowledge of what is safe to do, when you are ready to progress, and they can also provide education on what to avoid and what to expect moving forwards.
While plantar fasciitis is the most common condition to cause foot arch pain, there are many other conditions and injuries that result in pain to the arch of the foot that are not plantar fasciitis. The above conditions are some of the most common I encounter in the clinic, but this is not an exhaustive list. As such, in-person consultation with a physiotherapist is always recommended for foot pain in general, but we hope this article helps to shed light on possible diagnoses of foot arch pain not related to plantar fasciitis.
Chan, J. J., Geller, J. S., Chen, K. K., Huang, H. H., Huntley, S. R., Vulcano, E., & Aiyer, A. (2021). Epidemiology of severe foot injuries in US collegiate athletes. Orthopaedic journal of sports medicine, 9(4), 23259671211001131.
Grewal, U. S., Onubogu, K., Southgate, C., & Dhinsa, B. S. (2020). Lisfranc injury: a review and simplified treatment algorithm. The Foot, 45, 101719.
Kavlak, Y., & Uygur, F. (2011). Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. Journal of manipulative and physiological therapeutics, 34(7), 441-448.
Kiel, J., & Kaiser, K. (2018). Tarsal tunnel syndrome. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2022. PMID: 30020645.
Patel, D. S., Roth, M., & Kapil, N. (2011). Stress fractures: diagnosis, treatment, and prevention. American family physician, 83(1), 39-46.
Rizzone, K. H., Ackerman, K. E., Roos, K. G., Dompier, T. P., & Kerr, Z. Y. (2017). The epidemiology of stress fractures in collegiate student-athletes, 2004–2005 through 2013–2014 academic years. Journal of athletic training, 52(10), 966-975.
Samardžic, V., & Zlaticanin, R. (2022). Eccentric exercise in the treatment of tibialis posterior tendinopathy: A case report. International Journal of Medical Reviews and Case Reports, 6(14), 72-76.
Schneiders, A. G., Sullivan, S. J., Hendrick, P. A., Hones, B. D., McMaster, A. R., Sugden, B. A., & Tomlinson, C. (2012). The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy, 42(9), 760-771.
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