What is the diagnosis and treatment for a 52-year-old male patient with intermittent right foot pain, high arches (pes cavus), and planned radiographic evaluation via X-ray of the right foot, with prescribed orthotic insoles and arch support?

From the Guidelines

For a 52-year-old male with migratory right foot pain and high arches, your management plan is appropriate, but it should be enhanced with NSAIDs for short-term pain relief and consideration of referral to a podiatric foot and ankle surgeon if no improvement occurs after six weeks, as suggested by 1 and 1. Ordering an X-ray is essential to rule out structural abnormalities like stress fractures or arthritis that could cause the shifting pain. Prescribing insoles and arch supports is a good first-line intervention as they can redistribute pressure and provide stability for high-arched feet, potentially alleviating pain. High arches (pes cavus) often lead to excessive pressure on the ball and heel of the foot, causing pain that can shift locations as the patient compensates in his gait. Consider adding an NSAID like ibuprofen (400-600mg three times daily with food) for short-term pain relief while waiting for the orthotic intervention to take effect, as initial treatment options may include NSAIDs, decreased activity, stretching exercises, and weight loss (if indicated) 1. The follow-up appointment is crucial to assess treatment efficacy and review imaging results. If X-rays are negative but symptoms persist, consider additional imaging such as MRI or referral to podiatry for specialized assessment, and if no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate, as suggested by 1. Also, recommend proper footwear with adequate cushioning and support to complement the insoles. Some key points to consider in the management plan include:

• Initial treatment options may include open-backed shoes, orthoses, accommodative padding; NSAID therapy; corticosteroid injections (avoiding the Achilles tendon), weight loss (if indicated), and physical therapy, as suggested by 1.
• If symptoms do not improve within six to eight weeks, other diagnoses may need to be considered, and patients should be referred to a podiatric foot and ankle surgeon.
• Initial treatments are continued, and an immobilization cast or fixed-ankle walker-type device may be added, and bursa injection may be considered, as suggested by 1.

From the Research

Patient Presentation and Treatment

The patient presents with right foot pain that moves from one place to another, and has high arches. Based on the symptoms, the following treatment options are considered:

• Ordering an X-ray of the right foot to confirm the diagnosis
• Prescribing insoles and arch support to help alleviate the symptoms
• Recommending a follow-up appointment to review the X-ray results and assess the effectiveness of the insoles

Diagnosis and Treatment of Plantar Fasciitis

Plantar fasciitis is a common cause of heel pain, and its diagnosis is generally made clinically 2. The treatment of plantar fasciitis ranges from conservative measures to surgical interventions, but most cases can be managed conservatively 2. Some studies suggest that combining corticosteroid injection and physical training (strength training and stretching) can result in a superior effect compared to each treatment separately 3.

Effectiveness of Orthotics and Other Treatments

Orthotics, both prefabricated and custom fitted, have been shown to reduce pain and improve function in adults with acute plantar fasciitis 4. Corticosteroid injection tends to be more effective for pain reduction than non-invasive treatments within 3 months 5. A study comparing the effectiveness of corticosteroid injection, extracorporeal shock wave therapy, and radiofrequency thermal lesioning found that all three options were safe and effective in treating chronic plantar fasciitis, with similar outcomes up to 1 year 6.

Key Points to Consider

• Plantar fasciitis is a common cause of heel pain, and its diagnosis is generally made clinically
• Combining corticosteroid injection and physical training can result in a superior effect compared to each treatment separately
• Orthotics can reduce pain and improve function in adults with acute plantar fasciitis
• Corticosteroid injection tends to be more effective for pain reduction than non-invasive treatments within 3 months
• All three options - corticosteroid injection, extracorporeal shock wave therapy, and radiofrequency thermal lesioning - are safe and effective in treating chronic plantar fasciitis, with similar outcomes up to 1 year 2, 3, 4, 5, 6