Not All Arch Pain Is Plantar Fasciitis

When runners experience arch pain, plantar fasciitis is the first condition that comes to mind — and it is the most common cause. But several other distinct conditions produce arch pain in runners, and misdiagnosis leads to ineffective treatment and prolonged suffering. Understanding the distinguishing characteristics of each condition allows runners to seek appropriate care rather than spending months on generic plantar fasciitis treatment that isn’t addressing their actual problem.

Plantar Fasciitis: The Classic Arch and Heel Pain

Plantar fasciitis produces heel pain with the start-up pattern (worst in the morning and after sitting) and arch aching during and after running that worsens with mileage. The pain is primarily at the heel insertion of the plantar fascia (95% of cases), though the entire fascial band may be tender. Risk factors: tight calves, sudden mileage increase, cushioned shoes with inadequate arch support, and high body weight. The combination of stretching, custom orthotics, and load management resolves most cases within 3–6 months.

Posterior Tibial Tendinopathy (PTTD): Inner Ankle and Arch

The posterior tibial tendon runs behind the inner ankle and inserts on the navicular and plantar arch — its failure is the primary driver of adult flat foot deformity. In runners, tendinopathy presents as inner ankle and arch pain that is worse with push-off and downhill running. The key distinguishing physical finding: single-leg heel rise is painful and may be impossible, while the standard single-leg heel rise test for plantar fasciitis is usually possible (though painful). Early PTTD in runners responds well to orthotics, modified training, and targeted eccentric strengthening — but progression is rapid without treatment.

Spring Ligament Sprain

The spring ligament (plantar calcaneonavicular ligament) can be sprained during a sudden pronation injury or through chronic overload in pronating runners. Pain is located at the medial arch, directly beneath the navicular bone — slightly more anterior than typical plantar fasciitis pain. There is no significant morning start-up pain pattern. MRI is required to assess ligament integrity, as spring ligament injury can progress to arch collapse without proper management.

Plantar Fascia Mid-Substance Tear

A partial or complete mid-substance tear of the plantar fascia — particularly in runners who have received corticosteroid injections for plantar fasciitis — presents with acute onset severe arch pain during a run, often with a “pop” sensation. Subsequent arch aching, swelling, and a flat-footed gait with reduced push-off capacity follow. MRI confirms the extent of the tear. Treatment: protected weight-bearing followed by progressive rehabilitation; arch support orthotics are essential during recovery.

Flexor Hallucis Longus Tendinopathy

The FHL tendon runs along the medial arch from behind the ankle to the great toe. Tendinopathy produces pain along the medial arch and under the great toe during the push-off phase — particularly in runners who have increased speed training or hill work. Pain with passive great toe extension while the ankle is dorsiflexed (the “stretch test” for FHL) is positive. Eccentric loading and gait modification are the primary treatments. Contact Balance Foot & Ankle at (810) 206-1402 for accurate arch pain diagnosis and runner-specific treatment planning.

Foot or Ankle Pain? We Can Help.

Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.