Are Night Splints a Good Treatment Option?
Hands up if you like wearing a night splint... No? Me neither! But they do offer a fantastically effortless way of reducing the dreading morning pain that most plantar fasciitis sufferers experience. Night splints prevent the overnight shortening of the calf muscles and plantar fascia whilst we sleep. During sleep, your feet naturally fall into a plantarflexed position. This means the feet are pointing downwards. This causes the calf muscles which are attached to the Achilles tendon to shorten and increases tension on the Achilles tendon which results in tightening of the plantar fascia.
When you awake in the morning and put your feet down to the ground to get out of bed the Achilles tendon and plantar fascia suddenly have to stretch back to the ankles neutral position in order for you to get your heel to make contact with the ground (otherwise you would be walking around on tip toes). This rapid change in tendon and fascia length over such as short period causes pain in the plantar fascia which is why you get an immediate sharp, unrelenting pain response and hobble to the toilet like a 90 year old!
How does a night splint work?
Because the night splint holds the ankle in its neutral position it does not allow the calf muscles or the plantar fascia to shorten overnight therefore when you put your feet down to the ground first thing in the morning the plantar fascia only has to stretch a minimal amount thus significantly reducing the pain and preventing damage. Some designs available also pull the toes backwards as well as keeping the ankle in a neutral position. This provides added benefit by stretching the plantar fascia as well as the calve muscles. A night splint is designed to be worn whilst you sleep at night. If you're lucky enough to get a magic 8 hours sleep, this means the night splint is doing all the hard work over a long period of time whilst you enjoy your well deserved rest. When it's time to get out of bed in the morning, you simply take off the splint, put your foot down to the ground, and feel sheer relief that you don't feel as if you've just stood on 50 pieces of Lego. So that's how it works. Sounds easy right? Well this is all well and good in theory, but do night splints actually help plantar fasciitis morning pain? Let's take a look at what the research tells us.
There have been a number of studies published looking at the effectiveness of night splints for plantar fasciitis which I have detailed below:
The Journal of Foot and Ankle Surgery published a study in 2002 which compared 2 groups of patients with plantar fasciitis;
group 1 wore a night splint but did not complete a stretching programme for the calf muscles and group 2 only completed a stretching programme but did not wear a night splint.
The researchers wanted to compare the results between these groups for reducing plantar fasciitis pain. Stretching exercises are a well established treatment for plantar fasciitis, therefore the night splint group were being compared to a treatment already considered to be effective.
Group 1 results – All but two of the patients treated with night splints recovered within 8 weeks (97.8%)
Group 2 results – only 57.7% of these patients that utilized the stretching protocol recovered within 8 weeks.
The researchers concluded “The night splint treatment group had a significantly shorter recovery time compared to the stretching group” (Barry et al 2002). Despite the promising result here for the night splint group, it is important to point out that there were limitations to this study including adjunctive (additional) treatments and a short term follow up (just 8 weeks).
Another and recent study compared two different night splint designs:
An anterior night splint - this means the material of the splint covers the front of the shin bone
a posterior night splint - this means the material of the splints covers the calf muscle on the back of the leg
The results indicated that both night splints were effective at treating plantar fasciitis. The anterior night splint was found to be more effective in the treatment of plantar fasciitis. It was also proven to be better tolerated and more comfortable than the posterior night splint (Attard & Singh 2012).
A prospective randomised control trial (this means good quality research) was conducted by Roos et al (2006).They studied the effects of foot orthoses (insoles) and night splints, alone or combined, in a trial with a 1 year follow-up.
Group 1 - orthoses and night splint(15 patients)
Group 2 - orthoses only (13 patients)
Group 3 - night splint only (15 patients)
The results demonstrated that at 12 weeks, all groups improved significantly in all outcomes evaluated. There was a pain reduction of 30% to 50% compared to patients pain scores before treatment across all groups. At 1 year follow-up, pain reduction of 62% was seen in the two groups using orthoses compared to 48% in the night splint only group. In conclusion, the study found that orthoses and anterior night splints were effective both short-term and long-term in treating pain from plantar fasciitis. However, orthoses were better overall in the long term due to better compliance with this device.
Finally, the American Physical Therapy Association (APTA) published clinical practice guidelines for plantar fasciitis. They graded the overall evidence strength of different treatments ranging from A (highest strength) to F (lowest strength). night splints were graded as an A (APTA 2014).
What are the risks of using night splints?
A night splint is a safe treatment option for plantar fasciitis with no common associated risk. It's hard to go wrong with a night splint. Ensure the night splint is fitted correctly and not fitted too tight to prevent adverse effects such as reducing circulation.
In my opinion, the night splint is an incredibly effective device at eliminating heel pain first thing in the morning which is what almost every patient with plantar fasciitis suffers with. The reasons for this are explained above. I have prescribed many of my patients with night splints and achieved very successful results over the years. It is one of the most readily available, cheap, and effective treatment options for plantar fasciitis as it reduces pain when the patient gets out of bed in the morning. This breaks the pain cycle and promotes faster recovery time from plantar fasciitis. In addition to this, there is moderate quality research evidence to support the use of night splints in the management of plantar fasciitis.
Which is the best night splint?
This is dependent on patient preference. Most people find posterior night splints very bulky, uncomfortable and difficult to wear whilst sleeping. Posterior night splints have been shown to be less effective than anterior night splints and I do not recommend them. Anterior night splints are less bulky and more comfortable than posterior night splints. A limitation of the anterior night splint, however, is that it does not pull the toes back, it only keeps the ankle joint in a neutral position. It has been clinically proven that dorsiflexion (pulling the toes back) of the toes in combination with dorsiflexion of the ankle provides a maximum stretch on the plantar fascia and Achilles tendon (Carlson et al 2000; Flanigan 2007). The most recent night splint design, the sock design is not made from plastic and is the most comfortable of the three designs for most people. The sock design night splint provides dorsiflexion of the toes in a combination of dorsiflexion of the ankle, providing the most effective stretch whilst sleeping. Due to improved clinical effectiveness and improved comfort the sock design night splint is considered the best option.
Thanks for reading. Comments welcome.