The vast majority of Singaporean men have served, are serving, or will serve the country for between two to two-and-a-half years during their national service. Regardless of their vocation or service arm, these servicemen often face increased risks of injury due to their training and duties. Studies conducted on military personnel have shown that lower limb injuries can account for as high as 82% of injuries incurred during physical training.1
These injuries can have unexpected effects extending to other parts of the body as the human musculoskeletal system forms a closed kinetic chain for force propagation and stress distribution; unresolved lower limb issues can lead to a chain reaction throughout the body. For example, flat feet can affect the knees, hips and even the spine. Many enlistees go from a sedentary lifestyle to a highly active one, facing a dramatic increase of repetitive forces on the structures of their lower limbs. This can quickly cause new musculoskeletal pain, or exacerbate a pre-existing one.
What are the risk factors?
Active combat personnel frequently suffer from overuse injuries, which are injuries caused by repeated stress of the affected regions. These injuries are further aggravated by the strenuous and physically demanding training, as well as the heavy loads that these personnel are expected to handle while navigating uneven terrain in the jungle or hard surfaces like concrete. Those serving in the Civil Defence Force are also expected to handle heavy burdens such as fire-fighting equipment, life-saving equipment or those in need of medical assistance while navigating flights of stairs, narrow spaces or hard urban surfaces. Law enforcement officers spend much of their time on their feet while on patrol, leaving them at risk for lower limb muscle fatigue as well as long-term back pain and various musculoskeletal disorders.
Photo credited to official SCDF Facebook Page
Although those in combat or physically active vocations are more likely to suffer from injuries, those in support or service vocations may also suffer from injuries or develop conditions caused by their duties. Those in logistical support may suffer from trauma-induced injuries such as having a heavy object land on their foot, or stress-induced injuries such as tarsal tunnel or carpal tunnel syndrome which are caused by the excessive repetition of certain movements
In addition, many of these activities are conducted while wearing rigid footwear such as combat boots, leather shoes or work boots. While designed to provide protection for the user, these boots also add mass to the foot as well as restrict motion of both the foot and the ankle. These changes can result in increased loading at the ankle, knee, and hip joints, as well as decreased energy absorption during certain parts of the gait cycle, causing extra stress on the body.2
Photo credited to SAF Official Facebook Page
Many of these injuries are often ignored or neglected as it is not uncommon to be told that they should simply bear with the pain or to deal with it later. Doing so can often aggravate the condition, requiring more complex or painful treatments for a complete recovery.
What should we look out for?
Lower limb conditions come in many forms and their effects can reach beyond the lower half of our bodies. For example, an injury to your ankle can change your posture and gait as you favour the foot that is not injured. This puts stress on other parts of your body as the weight and pressure on your body is now redistributed to these other parts, resulting in injury or strain as they are unused to the changes. Keeping this in mind, these are some of the conditions presented by our patients who are active personnel.
Plantar Fasciitis is a painful condition caused by overuse of the plantar fascia or arch tendon of the foot. The plantar fascia is a broad, thick band of tissue that runs from under the heel to the front of the foot, which helps to support the arches of our feet.
- Sharp pain in the heel or bottom of the foot
- Pain is worse in the mornings when getting out of bed, standing after being seated for a long time, or after exercise
- Pain when pressing on the heel
- Stiffness or tenderness of the affected area
Plantar fasciitis can be caused by a multitude of reasons, including but not limited to –
- Sudden increase in level of physical activity
- Frequent and strenuous use of the lower limbs, particularly for running or jumping
- Being on your feet for long periods of time
Plantar fasciitis is common among those in active vocations as such personnel are frequently required to run, jump or undergo situations where their feet experience high stress forces.
The most basic remedy that you can try at home is the R.I.C.E treatment. Rest the injury by cutting back on daily activities. Ice the injury using an ice pack for 15 minutes several times a day. Ice calms down the damaged tissue and slows down blood flow to an injury, reducing swelling, inflammation and controlling the pain. Compression can be performed using an elastic wrap or bandage. Lastly, Elevate the affected limb to reduce the swelling. If you continue to experience pain, you should consult a foot specialist such as a podiatrist.
There are two parts to the treatment, the first is to address the pain, and the second is to treat the underlying causes responsible for your plantar fasciitis. The former can be addressed through a number of methods including extracorporeal shockwave therapy, phonophoresis, pain control medication or steroid injections. However, without addressing the underlying causes, these are only stop-gap measures and the condition is likely to be prolonged or worsen.
Tendionopathy, also known as tendonitis, occurs when there is damage to the tendon. Achilles tendinopathy is when there is an injury to your Achilles tendon, which joins your heel bone to your calf muscles. This tendon allows you to move forward when you walk, run or climb and is usually injured through overuse, particularly from running and jumping activities. For NS personnel, this injury may be worsened by the heavy footwear that they are required to wear on duty or during training.
- Pain and stiffness around the Achilles tendon, towards the back of your ankle
- Lifting the affected heel off the ground causes pain
- May feel tender or swollen to touch
The most common cause of Achilles tendonitis is the overuse of the tendon. High intensity running, jumping, and sports are frequent causes for overuse. If you are overweight or carrying heavy loads, your risks of developing this injury are also increased. Other contributing factors include poor technique, unsuitable footwear or the use of certain medicines.
Depending on the severity of your condition, RICE treatment or over-the-counter painkillers may be sufficient to soothe your pain; however, a full assessment by a podiarists is still advised as the underlying causes of your pain need to be addressed. Treatment options offered by your podiatrist can include extracorporeal shockwave therapy, ultrasound therapy, custom foot orthotics as well as sports taping.
This is the most common lower limb injury caused by sports or exercising. A sprain occurs when a joint is forced outside of its usual range of movement, causing the ligament around the joint to overstretch and suffer injury. Ankle sprains are typically separated into three categories, mild, moderate and severe. While mild and moderate sprains are likely to reach a full recovery within a few weeks or months, severe sprains may take much longer or even inflict permanent damage to the ankle. If you have already sprained your ankle, you are at higher risk of spraining it again in the next few years.3
- Swollen ankle
- Pain in the ankle that is worsened by movement or contact
- Redness and warm to touch
- Restricted movement or instability of the ankle
- Popping or tearing sound during injury
- Unable to put weight on your foot or walk
While there are many possible causes for ankle sprains, being highly active and on your feet means greater opportunity for you to suffer from injuries. In addition, those with high arches, weakened ligaments, or ankle instability are also at higher risk spraining their ankles.
Your first step should be to carry out the RICE treatment when the injury occurs. Many sprains require minimum treatment, but you should seek immediate healthcare attention if you are unable to put weight on your foot, if your foot appears deformed or there is breakage of the skin, if you experience discomfort or tenderness of the bone, or if the pain is severe. If your ankle continues to hurt after several days of home treatment, you should consult a podiatrist. The podiatrist will examine your ankle and lower limbs to offer you a diagnosis and suitable methods of treatment for your condition. Treatments can include using pulsed electromagnetic therapy to reduce swelling and pain and promote healing as well as custom orthotics to correct existing foot deformities and provide increased support, thereby reducing the risk of future sprains.
While it may be extremely uncomfortable, it is important to exercise your ankle joint during the healing process to prevent stiffness. More severe sprains may require you to immobilise your ankle with a brace or cast to provide support and protect your ankle from sudden movements.
Foot Rot is the Singaporean term for a condition that is more common known as Athlete’s Foot. It is caused by a fungal infection of the foot. It is contagious through direct skin contact and contact with contaminated surfaces. Singapore’s humid environment is very conducive for fungal growth and Foot Rot is a very common issue among active combat personnel.
- Cracking and peeling skin, particularly between the toes or on the sole
- Itchy blisters or rash
- Dry or crusty skin
- Itching, burning or stinging between the toes or on the sole
Aside from the humid environment, other causes include the water resistant boots which trap moisture and sweat, the extended periods of time that frontline personnel may spend in their boots during training, or the time they spend wandering around wet muddy conditions that allows water to seep into their boots. In addition, once someone sharing the same living space has a fungal infection, it is very easy for it to spread through contact in the bathroom or shower spaces as people often go barefoot in such areas.
If you think you may have foot rot, you should visit a healthcare professional immediately. Active personnel are particularly susceptible to this issue and the problem can escalate quickly, causing you pain and discomfort during training. Delaying treatment is also a risk as the fungus can spread to other parts of your body or to others around you. Treatments for fungal infections of the foot include topical and oral medication. If the fungal infection has also spread to the nails, your podiatrist may also prescribe you photodynamic therapy to remove the infection without harming your nails.
This condition usually affects the big toe and occurs when the side of the nail grows into the skin next to it. When a nail grows into the skin, the wound caused will not heal properly unless the spike is removed. It is important to treat the condition early as the injury offers another route for bacteria to enter your body, and the infection can spread if left untreated. Many patients tend to neglect this issue until it becomes incredibly painful, infected or impossible to ignore.
- Reddened and tender skin around the nail
- Painful and inflamed toe
- Pus or bleeding around the toe
Ingrown toenails can be caused by a number of factors including, but not limited to –
- Cutting your nails incorrectly or too short
- Overly tight footwear
- Sweaty feet
- Genetic predisposition
- Toenail injury
Many of these conditions are encountered by servicemen during duty and as a result, it is a common occurrence among service personnel.
While there are some home treatments available for ingrown toenails, they are usually only effective during the early stages. If treated before infection sets in, removal of the toenail may not be necessary. Treatments can include taping the nail to pull it away from the flesh, or separating the nail using dental floss or cotton. During later stages, partial or whole removal of the nail may be required. Partial toenail removal requires a shorter time for recovery and coupled with the right aftercare, has been found to be extremely effective in preventing the issue from recurring.
This general term covers a number of underlying issues including a condition also known as medial tibial stress syndrome. As the term suggests, it describes the pain felt along the front of your lower leg. This pain is concentrated in the lower leg between your knee and ankle and is caused by accumulated injury to the muscle, tendons or bone tissue around your shin. Active personnel are at greater risk of developing shin splints as they are engaged in strenuous physical activities.4 If left untreated, the pain can be so intense so as to restrict your ability to carry out physical activity.
- Tenderness or aching pain along the front or sides of your lower leg
- Pain occurs during strenuous activity and may ease off after the activity
- Swollen or warm to touch
- Muscle Pain
As shin splints can encompass a number of underlying conditions, the causes for the pain also vary widely. These can include –
- improper footwear
- inadequate stretching
- the type of surfaces encountered
- being overweight
- poor exercise technique
- lack of rest between exercise
- increase in physical intensity of activity
Depending on the severity of your condition, RICE treatment or over-the-counter painkillers may be sufficient to soothe your pain; however, a full assessment by a healthcare professional is still advised as the underlying causes of your pain need to be addressed. If you are experiencing bone tenderness or swelling of the lower limb, see a podiatrist immediately as you may have developed stress fractures. The treatment for shin splints is similar to some of the other conditions discussed previously as it is extremely important to treat the discomfort as well as the underlying causes for the condition. As shin splints cover an array of different conditions, a thorough assessment is required for generating accurate diagnosis and formulating an effective treatment plan. Treatment offered by a podiatrist can include extracorporeal shockwave therapy and ultrasound therapy to reduce pain and swelling, while custom foot orthotics and sports taping help to provide additional support and correction to your lower limbs to reduce and prevent the recurrence of the discomfort.
Why see a podiatrist?
Podiatrists specialise in the treatment of lower limb disorders, including your toes, feet, ankles, shins, knees, thighs, and hips. As previously mentioned, lower limb conditions can cause issues in seemingly unrelated areas of your body due to changes in gait or posture, consequently, podiatrists are also trained to identify and treat the conditions of the lower limb that are contributing factors to the pain or discomfort in other parts of your body. Podiatrists focus on utilising conservative treatments, avoiding the use of injuries, injections and surgery for their patients.
Photo credited to official SCDF Facebook Page
For those with pre-enlistment jitters, podiatrists are also able to assess you for any possible lower limb conditions, providing you with the opportunity to treat it before an injury occurs or before the condition is worsened by training or active duty.
For those who are currently in service, injuries are common and often neglected despite the best efforts of the various ministries and associated authority figures. Treating injuries early allows your healthcare professional to utilise less complex treatments and reduces the time needed for recovery.
In addition, podiatrists are better able to help you understand your condition, allowing you to have a clearer understanding of your injury or discomfort. Podiatrists are also able to assist with letters advising Medical Officers on their assessment and findings. Podiatrists work closely with doctors and other healthcare professionals, making them suitable for referring you to the relevant specialists for further investigation.
If you are experiencing lower limb pain or suspect you may be experiencing a lower limb injury or condition, see a podiatrist today. Don’t adopt a “wait and see” approach, this often encourages an injury to become more severe, especially due to a lack of rest and recovery, making treatment and recovery a much longer and more painful process.
1 Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31(8):1176–82. doi: 10.1097/00005768-199908000-00015.
2 Andersen, K. A., Grimshaw, P. N., Kelso, R. M., & Bentley, D. J. (2016). Musculoskeletal Lower Limb Injury Risk in Army Populations. Sports Medicine – Open, 2(1). doi:10.1186/s40798-016-0046-z
4Winters M, Eskes M, Weir A, et al; Treatment of medial tibial stress syndrome: a systematic review. Sports Med. 2013 Dec43(12):1315-33. doi: 10.1007/s40279-013-0087-0
Author: Benedict Khoo is a podiatrist with East Coast Podiatry, a group of private clinics based in Singapore with locations at Novena, Orchard and Kembangan. During his National Service, Benedict was a medic with the Republic of Singapore Navy. Today, as a podiatrist who focuses on sports-related conditions, Ben sees many patients who have suffered injuries during National Service.
*This post was originally published in March 2017 and was updated in August 2018.