What is the recommended treatment for a patient with bilateral foot pain in the arch of the foot, with pain radiating to the left foot (LFT) ankle and right leg?

Treatment for Bilateral Foot Pain in the Arch with Radiating Pain

The most effective initial treatment for bilateral foot pain in the arch with radiating pain to the ankle and leg is a combination of conservative measures including NSAIDs, orthotic devices, stretching exercises, and activity modification. 1

Diagnostic Considerations

The presentation of bilateral arch pain with radiation to the left ankle and right leg suggests several possible diagnoses:

1. Plantar fasciitis - Most common cause of heel and arch pain
2. Neurologic pain - Suggested by the radiation pattern to ankle and leg
3. Achilles tendinopathy - May present with posterior heel and arch pain

Key Physical Examination Findings to Look For:

• Tenderness at the plantar fascia origin on the medial calcaneal tubercle
• Pain with dorsiflexion of the toes (windlass test)
• Pain with compression of the calcaneus
• Tenderness along the medial or lateral plantar nerve pathways
• Achilles tendon tenderness or thickening

Treatment Algorithm

First-Line Treatment (0-6 weeks):

1. Patient-directed measures:

   • Regular plantar fascia-specific stretching exercises (superior to Achilles tendon stretching) 2
   • Calf muscle stretching
   • Cryotherapy (ice massage) for 15-20 minutes, 3-4 times daily
   • Over-the-counter arch supports and heel cushions
   • Weight loss if indicated
   • Activity limitation and avoidance of flat shoes/barefoot walking

2. Medication:

   • NSAIDs for pain and inflammation (may enhance pain relief when combined with other conservative measures) 3

3. Physical therapy interventions:

   • Cross-friction massage of the plantar fascia 4
   • Gastrocsoleus complex stretching 4
   • Deep transverse friction massage to reduce pain 1

Second-Line Treatment (if no improvement after 6 weeks):

1. Referral to podiatric foot and ankle surgeon
2. Continue initial treatment measures plus:
   • Customized orthotic devices
   • Night splinting in dorsiflexion
   • Limited corticosteroid injections (caution: risk of fat pad atrophy and plantar fascia rupture) 5
   • Casting or fixed-ankle walker-type device during activity

Third-Line Treatment (if no improvement after 2-3 months):

1. Cast immobilization (if not previously used)
2. Consider:
   • Extracorporeal shock wave therapy 1
   • Surgical intervention (plantar fasciotomy) as last resort

Special Considerations for Radiating Pain

The radiation of pain to the ankle and leg suggests possible neurologic involvement. If neurologic heel pain is suspected:

• Consider referral for diagnostic testing (electromyography, nerve conduction studies, MRI)
• Podiatric foot and ankle surgeon may manage local conditions
• Referral to neurology may be required for problems originating in the lumbar area 1

Important Caveats

1. Avoid corticosteroid injections near the Achilles tendon as they can lead to tendon rupture 1

2. Watch for red flags suggesting more serious conditions:

   • Night pain unrelieved by position change
   • Systemic symptoms (fever, weight loss)
   • History of trauma
   • Swelling or erythema

3. Conservative treatment is ultimately effective in approximately 90% of patients with plantar fasciitis, though resolution may take 6-12 months 6

4. The plantar fascia-specific stretching program is superior to standard Achilles tendon stretching for treating chronic plantar fasciitis 2

5. Manual therapy interventions including manipulation of the foot and ankle combined with cross-friction massage have shown positive effects on range of motion and pain perception 4