Making a Tension Night Splint for Plantar Fasciitis
Michael J. Petrizzi, MD, and Mark G. Petrizzi, MD, with Robert J. Roos
Department Editor: William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 6 - JUNE 98
This is the first of several how-to articles on casting and splinting that will appear intermittently in coming months. Many kinds of splints and casts can be made from a few simple materials, reducing the need to keep prefabricated products on hand. The authors find that making their own splints and casts pays dividends in patient satisfaction and cost savings.
Plantar fasciitis, a painful inflammation of the plantar fascia along the sole of the foot, is a common and often disabling overuse injury in runners, walkers, and other athletes. One measure that provides significant improvement for many patients is the use of a tension night splint (1).
The splint maintains ankle dorsiflexion and toe extension during sleep, thus applying a constant, mild stretch to the plantar fascia. This allows the fascia to heal at a functional length and may reduce the repetitive microtears that cause reinflammation. Without use of this splint, the fascia tends to heal in a shortened position because the foot normally assumes a plantar-flexed position during sleep.
The plantar fascia is a multilayered band of tough connective tissue that originates at the bottom of the heel and extends forward to the metatarsal heads, separating into branches in the forefoot. It helps maintain the arch. In plantar fasciitis, pain occurs chiefly on the bottom of the heel; it is usually worse when taking the first steps in the morning or after sitting and at the beginning of a run or other athletic activity.
Standard treatments for plantar fasciitis include relative rest, ice, nonsteroidal anti-inflammatories, and stretching. Other measures include running shoes with excellent heel support, plastic heel cups, and arch supports.
For recreational athletes, we generally prescribe the standard conservative measures for the first 2 to 4 weeks, and then add the night splint if there is little improvement. But for high-demand athletes, we consider starting the patient on use of the night splint immediately. It makes sense to try the night splint before considering corticosteroid injections, which may increase the risk of rupture of the plantar fascia.
Constructing the Splint
Tension night splints are relatively simple to make. Materials needed include a splint roll or package with padding on both sides (such as Ortho-Glass, Smith & Nephew, Inc, Charlotte, North Carolina), elastic wrap, and tape. First, with the patient's knee flexed 90° and the ankle in neutral, determine the length of the splint by extending padding or a tape measure from just below the fibular head along the posterior leg and sole to just beyond the toes (figure 1). Then, measure and cut the splint material and secure it to the leg and foot with elastic wrap (figure 2). The wrap should not extend beyond the metatarsal heads. With 6-in.-diameter wrap, one length is usually sufficient.
Next, separate the padding from the fiberglass at the distal end of the splint. At the third toe, make a 1-in. cut into the fiberglass (figure 3) and then extend this cut laterally to the little toe. This feature allows the splint to promote maximum extension at the great toe while minimizing the chance of causing cramping. In our experience, this increases comfort and promotes patient compliance.
Now, remove the splint and moisten the fiberglass. After wiping off any excess water, reapply the splint with the knee flexed and the foot maximally dorsiflexed. Knee flexion is important because it allows the gastrocnemius muscle to stretch to its maximal length. Make sure the great toe is also dorsiflexed.
To help maintain this position until the fiberglass hardens, run tape from the back of the leg to the ball of the foot and back to the leg in a figure-eight pattern, and repeat this several times (figure 4). By twisting the tape in the middle, the desired degree of dorsiflexion can be induced.
It's important to make sure the cast has hardened before you remove it. If warm water is used, this should take no more than 15 minutes. Then, cut the tape and remove the elastic wrap. To make sure the patient knows how to put on the splint, have him or her demonstrate reapplication of the splint and elastic wrap. The completed splint is shown in figure 5.
Codes used in filing for reimbursement for this procedure include ICD-9 728.71 for plantar fasciitis, CPT A4570 for a custom-made short leg splint, and CPT A4460 for elastic wrap.
The patient should be instructed to wear the splint in bed every night until a follow-up visit in 1 to 2 weeks. Using the splint with stretching exercises, NSAIDs, and, if appropriate, a heel cup, will usually make the technique more effective. In our experience, the condition has taken anywhere from 1 to 8 weeks to resolve.
Skin breakdown with use of the splint is uncommon because it is worn only at night. Vascular compromise is also uncommon, but patients who have peripheral vascular disease or diabetes should be assessed individually.
The splint can break down at the crease behind the heel or under the great toe. If necessary, a new splint can be made at the follow-up visit.
Dr Michael Petrizzi is director of the family practice residency program at Hanover Family Physicians in Mechanicsville, Virginia, an associate professor of family medicine at the Medical College of Virginia in Richmond, and a charter member of the American Medical Society for Sports Medicine. Dr Mark Petrizzi is on the faculty of the residency program at Hanover Family Physicians and is an assistant professor of family practice at the Medical College of Virginia. Mr Roos is a senior editor at The Physician and Sportsmedicine. Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, medical director of the Twin Cities Marathon, and an editorial board member of The Physician and Sportsmedicine.
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