Cath Lab Digest

Although night splints can be a valuable treatment for plantar fasciitis, their bulkiness can make patient adherence a challenge. There are also varying perspectives on the role of night splints within the armamentarium for plantar fasciitis. Accordingly, this author offers a closer look at these issues in facilitating relief for patients.

   Many DPMs include night splints as part of their standard of care for treating plantar fasciitis. The premise for such an approach is to maintain elongation of posterior and plantar structures including the Achilles tendon, triceps surae, intrinsic musculature and plantar fascia. This reduces tension on the medial calcaneal tubercle where the plantar fascia originates.

   Plantar fasciitis is an overuse injury, which causes inflammation at the origin of the plantar fascia. It is characterized by pain and inflammation secondary to strain on the intrinsic musculature and plantar fascia at their origin from the calcaneal tubercles. The classic physical examination finding is point tenderness at the anterior edge of the fascial attachment to the medial calcaneal tubercle. This usually coincides with a history of pain upon rising in the morning. Patients usually relate that the pain subsides during the day but returns after periods of non-weightbearing.¹

   Most commonly, treatment includes a combination of conservative modalities. Other ways of reducing the inflammation and associated pain include the use of heel pads, orthoses, padding, strapping, stretching, physical therapy, non-weightbearing, nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections. Even with appropriate treatment, plantar fasciitis sometimes becomes recalcitrant and may necessitate surgery.

   Despite the popularity of night splints, there is great variation in terms of how one prescribes plantar fascia night splints. There is also a disparity on where splints fit into treatment protocols, how patients receive instruction in their use, how long their use is recommended and the design of the devices themselves. There is also a multitude of procedural considerations that one must understand with respect to reimbursement by Medicare and other private third party carriers.

Understanding The Role Of Night Splints

   The therapeutic benefit of night splints is based on maintaining the length of the plantar fascia while the patient sleeps. Normally, muscle tone within the triceps surae causes the ankle joint to assume a plantarflexed position while at rest. With the foot in the plantarflexion position, the plantar fascia and intrinsic plantar musculature shorten, relax and adapt overnight to a nonfunctional state. The shortened, tight plantar fascia and intrinsic musculature would explain the phenomenon of post-static dyskinesia in which the first few steps after long periods of rest are extremely painful.

   The posterior night splint retains the tension within the plantar fascia and intrinsic musculature, maintaining their functional lengths and decreasing the sudden stress that ambulation places on the plantar aspect of the foot after periods of rest. One can position splints with the foot dorsiflexed at 5 to 15 degrees to the leg. In addition, podiatrists may add a pad to the anterior aspect of the night splints to maximize the stretching of the plantar fascia and intrinsic musculature.

   Night splints provide constant, consistent strain. This not only maintains functional length but eventually provides a net reduction of stress within the plantar fascia and intrinsic muscles.