Causes of Plantar Fasciitis There are a number of different things that can cause plantar fasciitis. It can develop from an overuse or an acute injury to the fascia. This can be due to doing a lot of running or a running sport, especially if you have recently or suddenly increased the intensity of the activity. This can result in small tears in the plantar fascia, which will then lead to pain and inflammation. Another cause of plantar fasciitis is said to be poor foot mechanics with walking or running and an excess in inward pronation. This is believed to be a cause because it increases the stretch and pull on the plantar fascia, which then leads to an increase in the damage to the tissue. It is said that the injury is more common in those who have an abrupt change in weight, due to pregnancy or obesity, since there is greater pressure on the foot. Finally, a change in the surface that you are walking on or wearing different, less supportive shoes can both impact the development of plantar fasciitis.
Understanding Plantar Fasciitis Plantar fasciitis is a common condition that causes pain in the heel. It is inflammation of the plantar fascia, which is a band of tissue that runs from the heel to the toes. The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. It is commonly associated with long periods of weight bearing or sudden changes in weight bearing. It is also quite often seen in runners and other athletes. Although there are no specific races that have been proven to have a higher incidence of plantar fasciitis, it is seen in both men and women. Plantar fasciitis can develop in anyone. It is most commonly seen in active individuals between the ages of 40 and 70. It is particularly common in soldiers and people with other forms of arthritis.
Understanding Plantar Fasciitis
Plantar fasciitis is a condition often explained as one of the most common causes of heel and foot pain. The plantar fascia is a band of tissues, similar to a ligament, which runs from your heel bone to the ball of your foot. This tissue supports the arch of the foot and absorbs shock or pressure. If too much tension or pressure is placed on the fascia, damage and irritation can be caused. The damage to the tissue may or may not be inflamed, but results in sharp pain. Common movements, including walking or running, can cause small tears to occur to the fascia which leads to immediate pain. This is due to the tension of body weight and pressure placed on the foot. The condition can affect the way you walk and can cause further damage to surrounding muscles, due to the change in the way you shift your body weight to relieve foot pain.
Causes of Plantar Fasciitis
It is something that causes physical pain to the sufferer and can be prevented through simple exercises or, in more serious cases, physical aids such as foot supports and orthotics.
Plantar fasciitis is more common in runners. People who are overweight and those who wear shoes with inadequate support also have an increased risk of plantar fasciitis. It can result from lack of physical activity or overactivity, high arches, flat feet, one leg being longer than the other, and tight Achilles tendons. All of these can increase your risk of plantar fasciitis.
Plantar fasciitis commonly causes stabbing pain that usually occurs with your first steps in the morning. As you get up and move, the pain normally decreases, but it might return after long periods of standing or after rising from sitting.
Plantar fasciitis is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of your foot and connects your heel bone to your toes (plantar fascia).
Symptoms of Plantar Fasciitis
Plantar fasciitis may cause weight bearing on the inside of the foot due to the discomfort on the heel and inside, leading to overpronation as a compensation injury. This overstretching of the fascia and the flatness of the foot combined can cause the plantar fascia to become overstretched and lead to development of plantar fasciitis. Having oversensitive or tight calf muscles can also be a contributing factor as there is a tightness in the tendo-achilles, which pulls continuously on the back of the heel and increases the likelihood of damaging the plantar fascia. In rare occasions, it is a possibility that some may have a single episode of damage to the area, which was not severe but then developed into a chronic issue a few weeks later as a result of further overuse.
The predominant complaint of those with plantar fasciitis is pain at the bottom of the heel, which is often described as sharp or tearing. This is most prevalent when taking the first steps in the morning or after extended sitting. As you get up and move, the pain normally decreases, but it might return after long periods of standing or after rising from sitting. As the day progresses, the soreness might change in intensity, often turning into a dull ache and then, with increased activity, transforming into a sharp, persistent pain. If the plantar fascia is stressed excessively, small tears can develop in the fascia. As the fascia heals following each episode of overuse, it can develop scarring in the area of a tear and the tension of the fascia on its insertion can damage the surrounding tissues, causing more pain. An area on the inside of the heel towards the arch may also hurt because that is where the fascia is attached.
Diagnosing Ankle Pain
Posterior tibialis tendon problems – Degeneration, tear or inflammation of the posterior tibialis tendon may cause pain on the inner aspect of the ankle and into the arch of the foot. This often occurs with activities involving the ankle and the foot and can result in dealing with flatfoot deformity.
Ankle impingement – This is a condition where an individual has pain when the ankle is put through a range of motion. Often this is accompanied with stiffness and sometimes a feeling that the ankle “gives way”. There are two types of ankle impingement – bony and soft tissue impingement. Diagnostic tests may have to be performed in order to distinguish between the two.
Osteochondritis dissecans – A condition where a piece of cartilage, along with a thin layer of the bone beneath it, comes loose from the end of a bone. This often occurs in the ankle joint and the “free floating” fragment can cause pain and may not heal without treatment.
Ankle sprain – The most common cause for ankle pain is a history of an inversion sprain of the ankle. Repeated damage to the ligaments associated with a sprain can result in chronic ankle pain and weakness.
Some common causes of ankle pain include:
Common Causes of Ankle Pain
Common Causes of Ankle Pain
Next, subtalar arthritis. The subtalar joint is a joint of the foot which is formed by the articulation of the talus and calcaneus. The joint is responsible for the inversion and eversion of the foot. Cartilage covers the end of the bones to provide a smooth gliding surface for movement and acts as a cushion to absorb shock placed upon the foot. Arthritis is a condition where the cartilage of a joint breaks down and ultimately causes the bones to rub together. Subtalar arthritis is where the cartilage in the subtalar joint has worn out. This can cause deep aching pain in the ankle or a feeling of pain or grinding sensation when moving the foot from side to side.
Another common cause of ankle pain is posterior impingement. Posterior impingement syndrome, also known as “footballer’s ankle,” is a condition characterized by chronic or recurrent ankle pain in activities involving maximum plantar flexion. This movement may be standing on tiptoes, going up stairs, running, or kicking. When the foot is in the position of maximum plantar flexion, this is when the tibia has a tendency to ram back into the ankle joint. This results in an impingement of bony or soft tissues in the back of the ankle joint and can cause pain, swelling, and stiffness.
The most common cause of ankle pain is an ankle sprain. An ankle sprain is an injury to the ligaments in the ankle. Ligaments are bands of tissue, like rubber bands, that connect the bones together. Ankle sprains occur when the foot twists or rolls beyond its normal range of motion. This can happen when walking on an uneven surface or taking an awkward step off a curb. The most common types of sprains occur when the foot turns inward, damaging the ligaments of the outer/lateral side of the ankle.
Physical Examination for Ankle Pain
Special tests may be done for ligament sprains and chronic instabilities; the most common of these being talar tilt and anterior drawer testing. These tests are often not very sensitive, and the best of these tests have been shown to be close to 80% sensitive and 80% specific. The relatively low utility of these tests has prompted the establishment of clinical prediction rules for ankle fractures and lateral ligament ruptures, which are based on combining the most sensitive and specific pieces of the history and physical exam.
After the clinician has noted the abnormalities seen with inspection, palpation may then be used to further define the areas of tenderness, noting the exact location and how site-specific it is to the injury. This is critical as many injuries are overlooked due to diffuse tenderness and the lack of localization of the injury site.
Inspection is often the most revealing aspect of the exam. Deformity such as that seen with an ankle fracture or ligament rupture is usually apparent. Swelling is an important finding and should be compared to the uninjured ankle. Swelling isolated to the anterior or posterior aspect of the ankle may give a clue to the involved tissue. Muscle atrophy is often apparent, and ecchymosis may still be present around the ankle from a prior injury. The pattern of gait may point to a chronic problem such as an ankle instability.
The physical examination of the patient with ankle pain is often very similar among all health care providers. Because of the repetitiveness of the exam, the clinical diagnosis often becomes apparent, and little objective data is gathered. Ideally, the provider will develop a strategy for the examination, beginning with inspection, followed by palpation, and finally performing special tests to confirm the suspicions raised during the history taking.
Diagnostic Tests for Ankle Pain
Diagnostic tests are utilized to identify ankle pain and its underlying cause. The exact tests ordered vary depending on the condition presented and the duration of symptoms. X-rays are often ordered first. X-rays are best for identifying bone problems such as a break or arthritis. If the problem is deemed to be soft tissue related, then an MRI may be ordered. MRIs use magnetization and radio waves to create an image of the interior of the body. They are particularly useful in identifying problems within the tendons, ligaments, and muscles. If bone problems are not thought to be the cause, then a CT scan may be ordered. CT scans are often used to further investigate an abnormality found on an X-ray. If a doctor suspects a systemic problem such as gout or rheumatoid arthritis, then blood tests may be ordered. These are often used in conjunction with the other imaging studies to further identify the exact cause of pain.
Ankle Pain Treatment Options
A patient seeking treatment for chronic ankle pain will often be looking for ways to manage their pain in the long term. Rheumatologic conditions such as osteoarthritis and rheumatoid arthritis in the ankle joint are often best managed with long-term NSAID use and weight reduction. Osteoarthritis can also be helped with lifestyle changes such as an increase in exercise involving low impact activities and weight loss, as well as a specific type of physiotherapy called musculoskeletal physiotherapy. When considering treatment options for the more chronic conditions, it is always best that the patient has a discussion with a healthcare professional on the suitable options and guidance on the severity of their condition. A healthcare professional could be anyone from a general practitioner to a medical specialist.
Once the common causes of ankle pain have been identified and a diagnosis has been reached, treatment should then be considered. The type of treatment for ankle pain can vary greatly depending on the problem. Problems such as fractures and severe sprains are best managed by using the R.I.C.E regimen (rest, ice, compression, elevation) and reducing the amount of weight bearing. Foot and ankle surgeons believe that it is best to use this type of regimen in the first 24-48 hours after injury/pain occurs. Medications may also be recommended to reduce the pain and inflammation related to the injury. If a problem is identified as an acute injury of the musculotendinous or ligamentous structures of the ankle, then it is likely that immobilization of the ankle is required through the use of a walking boot and/or crutches. This will allow the structures to heal without the risk of further damage. When an underlying mechanical condition or an acute inflammatory arthritic condition is identified, treatment can range from the use of nonsteroidal anti-inflammatories and/or joint and soft tissue injections.
Treatment Options for Plantar Fasciitis
In cases where symptoms of fasciitis become unbearable, surgeons may choose to perform a plantar fascia release. This is a last resort for patients who have had symptoms for more than 6-12 months and have failed to respond to less invasive treatments. This procedure involves cutting part of the plantar fascia ligament in order to release tension. Studies on this treatment and its outcomes have shown positive results, and many patients remain satisfied. With this being said, due to the plantar fascia playing an important role in maintaining the arch of the foot, there is always the potential for over-release which can lead to the loss of function in the arch and a flat foot.
If after 12 weeks of continuous treatment there has been no improvement, the next stage of treatments will be sought. One option is corticosteroid therapy. Direct injection of corticosteroids in labeled areas has shown to have minor immediate effects relative to placebos, but with little to no long-term effects. The next step is the use of Extracorporeal Shock Wave Treatment (ESWT). This is a non-surgical procedure that is now becoming known as a second-line treatment. Its effectiveness has not yet been proven, but the use of high or low doses has shown positive results for both. ESWT works by applying a local anesthetic then using an imaging plan to find the heel spur. High doses have a success rate of 64% with one treatment and can almost reach the 91% success rate of those who use 3 treatments. Low dose ESWT involves less energy and can have the same success rate if performed from 9-12 times. This is perceived to be less painful and has positive long-term outcomes.
Conservative treatments for plantar fasciitis, such as the use of a simple nonprescription orthotic or a change in footwear, are often all that’s required. These treatments will most likely be prescribed by a doctor, however, it can also be arranged by yourself with what can be bought over the counter. In the case of an orthotic, a recent study has shown that by using a simple and cheap 6mm flat or domed orthotic, 4 out of 5 patients with plantar fasciitis will have decreased symptoms. Specific exercises or stretches relevant to the plantar fascia can also be helpful. Usually under the prescription of a therapist, taping or massage of the plantar fascia may be advised to promote increased blood flow to the affected area.
Conservative Treatments for Plantar Fasciitis
A more effective method of providing the foot with padding and support is the use of silicone heel cups and custom-made orthoses. Silicone heel cups have been proven to be effective in providing cushioning and support in more severe cases of plantar fasciitis. Orthoses, or shoe inserts, are designed by taking an impression of the foot with correction of the foot biomechanics. This has been shown to be effective in curing plantar fasciitis by providing the foot with correct support and an equal distribution of load on the foot to prevent overstressing the plantar fascia.
Padding in the form of a simple insole is an easy way to provide the foot with a padding layer between it and the ground. This again will help limit the load and work on the plantar fascia, and in particular, it will limit the amount of time that the foot is under duress during long-duration weight-bearing activities. This may eliminate the pain and prevent the severe onset of plantar fasciitis.
By strapping or taping the foot, it will help provide the anatomical support that the foot lacks, especially the foot arch, and will help alleviate the stress on the plantar fascia. This will support the foot and limit the amount of load and work the foot has to do.
The main reason for plantar fasciitis is a lack of muscle training in the feet, legs, hips, and key muscle groups around the associated areas. But when it comes to treatment for the condition, it becomes evident that the best way to resolve the problem is to try and fix it with conservative methods such as support, padding, strapping, icing, and anti-inflammatory medications.
Physical Therapy for Plantar Fasciitis
Exercise therapy is often a good start. Your doctor may send you to a physical therapist. He or she may have you start with stretching exercises for your calf muscles. This is very important, particularly for people with tight Achilles tendons. People who have a tight Achilles tendon are more likely to develop plantar fasciitis. The same is true for people with flat feet. If people are not sure if they have a flat foot, just look at the footprint made by your bare foot. If it shows a very wide band between the heel and the toes, you have a flat foot. If you develop plantar fasciitis, you will experience pain. If you’re worried that stretching has the potential to cause even more pain, don’t worry, stretching is usually painless. Other exercises may include strength training or coordination and balance. Your physical therapist may give you a flexibility assessment and if you do have plantar fasciitis, any of these areas is a reasonable starting point for rehabilitation. In summary, you should expect your therapist to go through your current history, perform an assessment, provide you with a clinical diagnosis and design an appropriate treatment plan. It is also important for your therapist to provide you with education on your condition and set a realistic time frame for your rehabilitation. This is very important in order to manage your own expectations. With the correct treatment plan in place, successful rehabilitation for plantar fasciitis can take up to 6-8 weeks but this can be longer if you have had the condition for a long period of time.
Medications for Plantar Fasciitis
Corticosteroids, cortisone, or steroids are terms used to describe a class of drugs that are powerful anti-inflammatory drugs. Plantar fasciitis is often caused by inflammation in the thick band of tissue that runs from your heel to your toes, the plantar fascia. Corticosteroid drugs are powerful anti-inflammatory drugs. Corticosteroid drugs are very powerful anti-inflammatory medications. Oral corticosteroids, such as prednisone, are very useful in cases of acute or chronic plantar fasciitis, but we are using them less frequently due to potential systemic side effects. Side effects from systemic corticosteroids may include increased appetite, weight gain, changes in mood, and repeated infections. Corticosteroid drugs can be very destructive to the tissues of the body, and the effects of corticosteroid drugs in an attempt to treat HPI may make the situation even worse. Short-term benefits usually outweigh these long-term risks, and these decisions must come from a patient and his/her physician weighing the risks of HPI left untreated or the symptoms that remain if plantar fasciitis symptoms do not completely resolve. Corticosteroids used in the form of an injection use the power of the medication directly at the desired site of action and are particularly useful in treating plantar fasciitis. A single and often relatively small dose of cortisone at the site of inflammation will reduce pain and the inflammatory process in most cases. Corticosteroid injections such as prednisone, cortisone, and others can rapidly relieve pain and reduce inflammation. Corticosteroids may raise blood sugar levels in diabetics and non-diabetics alike. You should talk to your doctor about this if you have a concern. Local effects of the corticosteroid injection are often amazing, and this pain relief, especially when combined with the other conservative therapies, leads towards successful resolution of symptoms. Tissue located at the Calcaneal Attachment is often relieved and improved upon with a single cortisone injection. High volume image-guided injection is a potential adaptation of a sonographically guided technique and is extremely effective in eradicating pain with a consistent effort with physical therapy exercises. This is likely a successful method to this common problem that thus far was only helped with regimens of medication.
The use of oral non-steroidal anti-inflammatory drugs (NSAIDs) is commonly used to treat plantar fasciitis. Examples include over-the-counter products such as ibuprofen (e.g. Motrin or Advil) or prescription strength drugs such as Celebrex. Use of NSAIDs is usually taken for a short period of time, but longer-term use is also possible. While the use of NSAIDs for plantar fasciitis has been theoretical given the unclear inflammatory component, it has been an anchor drug in the treatment of plantar fasciitis.
Surgical Interventions for Plantar Fasciitis
Surgical treatment of plantar fasciitis is usually directed at repairing damage to the plantar fascia, generally before it tears. In determining the type of surgery a patient requires, the surgeon will consider a variety of factors, including the patient’s level of pain and ability to function. While many types of surgery can help correct plantar fasciitis, the ultimate goal is to prevent the recurrence of this ailment. The patient’s willingness to comply with post-operative therapy and regular activity restrictions to ensure adequate healing is also a factor in determining the type of surgery. Ruptures are acute injuries and are treated as such. Approximately 2 weeks in a splint or cast and the patient can ease into weight-bearing activities. After the splint or cast, it is also a good idea to tape the foot, securing the arch. This will allow extra support for a patient who is both trying to return to activities/work or simply trying to get rid of an acute rupture. A patient can tape his/her foot independently and usually no professional skill is needed. A tear is often treated like a rupture. Finally, after failed attempts to fix chronic plantar fasciitis, a surgeon may finally perform a gastrocnemius recession. This is because the calf muscles are a significant contributor to plantar fasciitis and tightness in these muscles will prevent healing. By lengthening the calf, the surgeon will relieve stress on the plantar fascia. This needs to be done with complete care to not create an actual Achilles’ tendon rupture, considering there are two tendons near the incision site in this area of the leg.
Seeking Treatment in Singapore
Medical treatment for plantar fasciitis foot pain in Singapore is one of the best in Asia, especially in the area of orthopedic research. With the increasing rate of musculoskeletal disorders among the population in Singapore and globally, Singapore has risen to the challenge by setting up facilities catered to the treatment of such disorders. One of the most established facilities is the Singapore General Hospital. The Department of Orthopaedic Surgery has an established foot and ankle service which deals specifically with such disorders. The National University Hospital is also another established medical facility which provides excellent treatment for plantar fasciitis foot pain. Both medical institutions are highly reputable and have some of the best foot and ankle specialists in Singapore. Other notable medical facilities in the area would be Raffles Hospital, Tan Tock Seng Hospital, and Changi General Hospital. Patients seeking treatment for plantar fasciitis in Singapore have a wide array of foot and ankle pain specialists to choose from. Some notable specialists in the area of foot and ankle pain would be Dr. Kevin Lee, Dr. Sean Ng, Dr. Tan Ken Jin, and Dr. Tay Kae Sian. All are well-established foot and ankle specialists in Singapore with vast experience in the treatment of various foot and ankle disorders. Seeing a specialist in foot and ankle pain diagnosis is highly recommended as compared to other countries, the level of knowledge, expertise, and treatment provided by a foot and ankle specialist in Singapore is relatively higher.
Medical Facilities in Singapore
There are also two main specialist centres that specialize in sports medicine and orthopaedics: the Sports Medicine Centre and the Singapore Orthopaedic Centre. The types of services provided include physiotherapy, podiatrist services, pain relief injections, and surgical options. One of the key components to managing plantar fasciitis is physiotherapy, and many patients like Kevin will find it reassuring that there are quality services available and covered by insurance. Physiotherapy sessions may also span over several months and possibly be the most costly portion in the long-term treatment of this chronic condition. High-quality physiotherapy services are also available in numerous private clinics, and a podiatrist service is rather common and can be fairly easy to make a booking compared to our public health sector. Overall, those seeking medical treatment in Singapore will have vast options to choose from different medical facilities and service types to best suit their needs for treating this chronic foot condition.
Those living in the southern part of Peninsula Malaysia and the neighboring Indonesian islands will find Singapore to be the most convenient option for medical care. The Singapore Health Services (2004) attribute to the quality of care is availability of advanced technology, state-of-the-art medical facilities, and trained medical professionals. Singapore is recognized as a regional medical center and many foreign patients, particularly from Indonesia and the Middle East, seek treatment in Singapore. There are several major private and public hospitals that house the latest in medical technology and house trained orthopaedic surgeons and podiatrists. Some of the public hospitals include Changi General Hospital, National University Hospital, and Tan Tock Seng Hospital. Some private hospitals include Mount Alvernia Hospital and Gleneagles Hospital. The treatment of plantar fasciitis in these hospitals is generally fully equipped to provide the latest minimally invasive surgical techniques, shock wave therapy machines, and navigational systems (2011 Singapore Health Services).
Specialists in Foot and Ankle Pain
The majority of orthopaedic surgeons with subspecialty training in foot and ankle surgery are with the public sector; however, there are several in private practice. General charges for consultation and treatment are higher in the private sector, but the overall service and attention you receive may be more thorough. It is also easier to book an appointment, and waiting times are greatly reduced. If you have health insurance, a portion of your medical bills may be claimable. Do call your insurance provider to find out whether this is so.
There are many orthopaedic surgeons and neurosurgeons in Singapore that treat plantar fasciitis through various methods. Apart from general orthopaedic or neurosurgery training, many have chosen to pursue further specialist training in the sub-specialty of foot and ankle surgery. Such specialists are likely to possess more specific knowledge about your condition and may be able to provide treatment options that are more suited to your needs.
Cost of Treatment in Singapore
The actual cost of treatment in Singapore may vary, depending on the duration of treatment and type of therapy provided. A rough range of cost will be: For non-invasive treatment, the cost may range between SGD 60 to 80 per session. Medication, orthoses and other medical supplies will require another SGD 100 to 200. A typical amount of physiotherapy sessions would be 4 to 8 times. A conservative costing will be: Bi-weekly sessions for a month, SGD 50 to 80 per session. Weekly sessions for two months, SGD 200 to 320. This adds up to an estimated range of SGD 500 to 900 or more. For a more severe case, increased duration of sessions will escalate the cost. It is worthwhile to consult with the physiotherapist the expected duration of treatment. For invasive and surgical treatment, it is hard to estimate cost due to the varying nature of presented cases. The individual will be best advised to consult their specialist or surgeon on the cost and type of treatment. This would include: Injections – SGD 300 to 400. Extracorporeal shock wave therapy – SGD 1000 to 1400. Surgery may be required for chronic cases, it ranges between SGD 5000 to 10000 or more.
