Secrets To Patient Adherence With Night Splints

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.

   Patient adherence with these splints can be a challenge. Most patients will tolerate them for about two weeks. At this point, some patients get uncomfortable and may start removing them at night. Wearing night splints may adversely affect patients’ sleeping habits and consequently their lives and work productivity. In these cases, patients often prefer to abandon the splints.1

   To gauge the range of treatment options utilized by experienced podiatrists, various practitioners provided feedback. These DPMs use a large volume of night splints in their practice and some are Fellows of the American Academy of Podiatric Sports Medicine (AAPSM). The results reveal broad differences of opinion in terms of how and when DPMs use night splints.

When And How Long Should You Prescribe Night Splints?

   Pedram Aslmand, DPM, uses splints as a first line of treatment along with NSAIDs. Matthew Werd, DPM, uses splints as an adjunct in an early phase of plantar fasciitis. He also uses splints for tendo-fasciits (posterior-plantar heel) and insertional Achilles pathology

   Robert Conenello, DPM, says splints are a useful adjunct for patients with heel pain and Achilles tendonitis. He notes that patients with such pathologies must understand the role of flexibility in their treatment.

    “The problem with ‘routine active stretching programs’ is a patient’s compliance,” he cautions. “(Patients) either perform the stretches incorrectly or opt not to perform them at all. Night splints offer a passive solution to this dilemma.”

   Dr. Conenello’s patients wear the devices for at least two weeks and he monitors their improvement.

   Paul Langer, DPM, uses splints for runners who are looking for options that allow them to keep active. When determining if patients need splints, he says the severity and duration of pain are less relevant than resistance to other conventional therapies. For Dr. Langer, patients should wear splints until they have achieved satisfactory improvement for their condition.

   For Alex Kor, DPM, the duration of pain is more important than the severity. Dr. Kor says he will suggest a splint if typical conservative therapy has not had an effect in three months. He finds patients benefit most from splints if they have had severe pain in the morning.

   Lawrence Huppin, DPM, only uses splints for patients who have had plantar fasciitis of several months’ duration. He has long-term patients wear the splints for three to four weeks.

   In contrast, David Davidson, DPM, does not prescribe night splints.

    “They are uncomfortable to sleep in and only minimize the first step out of bed pain,” maintains Dr Davidson.

Inside Insights On Night Splint Types

   Are posterior or dorsal splints preferable? Dr. Werd has tried most types of splints, including the sock, posterior and anterior splints. He says patient preference varies based on the tolerance level.

   Dr. Conenello prefers the Strassburg Sock. He says it has a simple design, is patient friendly and comfortable. Dr. Conenello notes the sock also provides the patient the ability to increase or decrease the amount of stretch easily. In addition, he says patients can easily remove it if they need to get out of bed at night.

   Ashkan Soleymani, DPM, prefers using dorsal night splints for younger patients as they tolerate the devices better. Dr. Huppin also favors dorsal splints.

   Physicians must also consider whether or not to alter the degree of dorsiflexion of the night splint. Dr. Langer starts the angle at 90 degrees. He demonstrates how to change the angle, emphasizing to the patient that the calf muscles will spasm if the angle is too aggressive.

Keys To Effective Patient Education

   When dispensing night splints, it is also important to give instructions to patients on proper usage.

    “This thing is uncomfortable at first but if you use it even for a few hours a night, it makes a huge difference,” Dr. Aslmand tells patients. He finds that after wearing the splint for the first night and waking up with less pain, patients are more eager to use the splints going forward.

   Dr. Werd advises patients that while they are sitting or sleeping, the foot and ankle should be in a relaxed plantarflexed position. He says this allows the plantar and posterior soft tissue structures to tighten. Ideally, one can diminish the tightening and alleviate post-static dyskinesia by splinting the foot and ankle in a neutral/slightly dorsiflexed position, according to Dr. Werd. Matthew Barkoff, DPM, notes that the night splint does not stretch the fascia but rather splints the fascia in a better anatomic position.

   Dr. Kor advises patients to put on the splint before they go to sleep and try to wear it all night. If patients have to get out of bed during the night, since they cannot apply weight to the splint, they should remove it. He also advises patients to wear the splint while sitting for lengthy periods of time.

   Dr. Werd also tells patients that if they cannot tolerate wearing the splint all night, they should at least wear it while sitting, watching TV or reading. Similarly, for the first week, Dr. Soleymani discourages patients from using it as a “night” splint, recommending they wear it as a “lazy” splint in their spare relaxation time. After patients wear splints for a week during the day, they can start wearing them at night. As he notes, once patients become accustomed to the splint, they will have better nocturnal adherence.

    “Most patients that avoid night splints are the ones that lose sleep because of it. If they get aggravated throughout the night, chances are that they will not put it on again the next night,” says Dr. Soleymani.

   For patients with plantar fasciitis that has lasted for several months, Dr. Huppin suggests that they wear the splint during the day with a walking boot.

Other Considerations In Treating Plantar Fasciitis

   In addition to night splints, Drs. Langer and Kor will use icing, stretching, shoe modifications and orthotics. Dr. Kor notes that patients have usually already tried NSAIDs or undergone at least two cortisone injections prior to presenting to his office.

   After determining that a patient has plantar fasciitis or fasciosis, and if there is acute pinpoint pain, Dr. Davidson will provide a local injection of lidocaine and dexamethasone via a medial approach. He also prescribes stretching for gastrocsoleus equinus and advises massaging the fascia. If a patient does not have acute pain, he only prescribes stretching.

   After two weeks of follow-up, if the patient has not improved, Dr. Davidson will tweak the stretching program. If there is minimal improvement, he will prescribe NSAIDs and over-the-counter inserts like the Polysorb (Spenco). After that, if a patient still only has minimal improvement, he will prescribe physical therapy. If the patient is only slightly better after a month, Dr. Davidson will use custom orthotics.

   Dr. Huppin will utilize splints as a second- or third-line treatment after first using OTC insole/orthotic therapy, changes in footwear, stretching, NSAIDs and modifying activities. He notes splints are an alternative to cortisone injections or physical therapy for those who do not want to pursue such options. Dr. Huppin will consider dry needling if the patient does not improve. For patients with a short duration of plantar fasciitis, Dr. Huppin will use prefabricated inserts, NSAIDs and icing.

   As Dr. Levine notes, night splints and stretching are important to the overall treatment plan and he will explain the benefits of the modalities to patients. He tries as many conservative treatments as he can to reduce inflammation and support the foot.

   In regard to follow-up, David Levine, DPM, CPed, checks for progress after a few weeks. He concurs with others that some patients will keep using splints while others do not. Dr. Langer tells patients to use the devices until they are satisfied and then keep the splint around for possible flare-ups of the plantar fasciitis.

   Dr. Conenello will use splints following shockwave or Topaz (Arthrocare) treatment.

In Conclusion

   Night splints offer podiatrists an effective treatment modality for the treatment of plantar fasciitis. There is a broad difference of opinion on how and when the devices are indicated. However, studies determine that splints can be therapeutically effective as part of a comprehensive plan of care including one of more of the following: icing; shoe recommendations; corticosteroid injections; prefabricated inserts; custom orthotics; stretching exercises; and prefabricated walking casts.

   In addition to seeing how more experienced practitioners utilize night splints in their practices, reviewing coverage guidelines by Medicare and other third-party payers may help podiatrists integrate night splints into their practices.

Dr. White is the President/Founder of SafeStep. He is the Chairman of the American Podiatric Medical Association DME Sub-Committee.

Dr. White thanks Pedram Aslmand, DPM, Matthew Barkoff, DPM, Robert Conenello, DPM, David Davidson, DPM, Larry Huppin, DPM, Alex Kor, DPM, MS, Paul Langer, DPM, David Levine, DPM, CPed, Ashkan Soleymani, DPM and Matthew Werd, DPM.

For further reading, see “Offloading The Plantar Fascia: What You Should Know” in the November 2005 issue of Podiatry Today.

References:

1. Jimenez A, Goecker R. Night splints: conservative management of plantar fasciitis. Biomechanics 1997;4(9):29-33. Additional References 2. Batt BE, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sports Med 1996; 6(3):158-162. 3. Forman WM, Green MA. The role of intrinsic musculature in the formation of inferior calcaneal exostosis. Clin Podiatr Med Surg 1990; 7(2):217-223. 4. Frank C, Ameil D, Woo SL-Y, Akeson W. Normal ligament properties and ligament healing. Clin Orthop 1985; 196:15-25. 5. Pezzullo DJ. Using night splints in the treatment of plantar fasciitis in the athlete. J Sports Rehab 1993; 2:287-297. 6. Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot: clinical biomechanics, vol. 2. Clinical Biomechanics Corp., Los Angeles, 1977, p. 174. 7. Ryan J. Use of posterior night splints in the treatment of plantar fasciitis. Am Fam Phys 1995; 52(3):891-898. 8. Valmassy RL. Clinical biomechanics of the lower extremities. St. Louis: Mosby Yearbook, St. Louis, 1996, pp. 23, 76.