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Physical Therapy Reviews 2000; 5: 147-54
EFFECTIVENESS OF TENSION NIGHT SPLINTS IN
TREATING PLANTAR FASCIITIS: A REVIEW
JOHN P. RYAN and TOM J. OVEREND
School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
ABSTRACT
The purpose of this review was to investigate the effectiveness of tension night splints for treating
plantar fasciitis. A computerized literature search (Medline 1966-2000; CINAHL 1982-2000)
using the key words plantar fasciitis, tension night splints and treatment yielded nine studies on
the use of tension night splints as either primary or adjunct treatments for plantar fasciitis. Most
of the research was descriptive in nature. Six studies, including one randomized clinical trial,
suggested that tension night splints, in conjunction with other techniques, willresolve symptoms
in patients who have failed other courses of treatment. A randomized clinical trial has also
shown that tension night splints are effectiveas a solo treatment. Tension night splints have been
shown to be effective in overweight and chronic patients, however, more research is needed to
determine the effectiveness in patients with acute plantar fasciitis.
INTRODUCTION
Plantar fasciitis is the most common cause of plantar
heel pain and accounts for
7-9%
of all running
injuries.! It also affects participants in tennis, basket-
ball, soccer, gymnastics, or any other sport involving
jumping and push-off actions. Each year, more than
two million Americans alone are diagnosed with
plantar fasciitis. Most of these patients will respond to
conservative management. However, some will go on
to need surgery.2-SAs many patients will seek physio-
therapy assistance, therapists must be aware of all the
treatment options available. Tension night splints are
a recent form of adjunct therapy used in the treatment
of plantar fasciitis with a biologically plausible ration-
ale supporting their use. Thus, the purpose of this
paper was to review the literature on the effectiveness
of tension night splints in treating plantar fasciitis. The
review will first provide a brief description of the
functional anatomy, pathophysiology, clinical fea-
tures, predisposing factors and treatment of plantar
fasciitis, and then examine the limited body of know-
ledge relating to tension night splints.
© W. S. Maney & Son Ltd 2000
ANATOMY AND FUNCTION OF THE
PLANTAR FASCIA
The plantar fascia is a multi-layered fibrous apo-
neurosis.
6
Of the three distinct portions, the central
portion is the most dominant and attaches to the
medial calcaneal tubercle.
6-8
The central portion
becomes thin in the forefoot and divides into five
bands, each with a superficial and deep component.
The superficial bands anchor to the plantar skin and
the deep bands attach to the proximal phalanx via the
flexor tendons. The medial portion provides a covering
for abductor hallucis, and the lateral portion for
abductor digiti minimi.
6,7
The plantar fascia helps to absorb shock as the foot
pronates from heel strike to mid-stance. The plantar
fascia is further tightened as the toes dorsiflex between
the midstance and push-off phases of gait. This
tightening assists the foot in supinating and becoming
a rigid structure for propulsion. The ability of the
plantar fascia to absorb stress and maintain the
longitudinal arch -as the toes are extended has been
compared to a windlass.
6
This mechanism has also
148
J.
P. RYAN AND T.
J.
OVEREND
been compared to a bowstring tensing on the plantar
surface of the foot.7
PATHOPHYSIOLOGY
Plantar fasciitis may be the result of repetitive micro-
trauma overload injury at the area of its origin at the
medial calcaneal tubercle.9It may also result from an
acute injury8,10In both instances, the result is a pull
on the calcaneal tubercle that may be strong enough
to detach the periosteum and cause bleeding, inflam-
mation, and the laying down of new connective tissue.
This new tissue may go on to become cartilaginous
and ossify. A calcaneal spur may develop that projects
painfully into the neighbouring tissue with weightbear-
ing.11 Histological samples have revealed collagen
necrosis, angiofibroblastic hyperplasia, chondroid
metaplasia and matrix calcification.
6
CLINICAL FEATURES
Patients most frequently complain of severe pain with
their first steps in the morning or after prolonged
sitting.
5
,12,13 Pain may be localized to the medial
plantar aspect of the calcaneal tubercle,12,13or present
anywhere along the plantar fascia.14 Pain is likely to
increase with dorsiflexion of the toes or ankle and
decrease with plantarflexion.13,14 Patients may also
present with tight or weak plantarflexors. Symptoms
may increase initially with activity and then subside
after the plantar fascia becomes more flexible.5,15
Swellingmay be observed, and there may be a palpable
nodule.2,17The presence of a heel spur on X-ray may
or may not be significant,18 as many asymptomatic
patients will have a heel spur,19 and the presence of a
heel spur has not been correlated with a worse
outcome.20 The pain may arise from plantar fascial
tendinitis and not the heel spur itself.6Tinel's sign
(radiating pain and numbness when the posterior tibial
or medial calcaneal nerve are percussed) would norm-
ally be absent, unless the patient also suffers from
tarsal tunnel syndrome.21 In acute cases, such as if the
patient stepped into a hole, there may be a sprain in
the spring ligament, which attaches the talus to the
navicular. 21
Videotaping of running or walking is helpful,8and
analysis may indicate adaptations including toe-run-
ning, decreased stride length or walking on an inverted
foot.9Important information can also be obtained
from examining the patient's shoes for inadequate
support, a tight toe box or abnormal wear.8Blood
tests may be performed to exclude gout, Reiter's
disease, ankylosing spondylitis, psoriatic arthritis or
rheumatoid arthritis, which may be the underlying
cause. Patients with these conditions will most likely
have bilateral complaints.7,17,21
BIOMECHANICAL FACTORS
A wide range of factors have been implicated in the
development of plantar fasciitis. Perhaps the most
frequently cited predisposing factor is excessiveprona-
tion. 5,6,17,19,22Excessive pronation places strain on the
plantar fascia from heel-strike to midstance, and
because the forefoot does not fully resupinate, it is
placed under further stress at toe-off.23This prolonged
stretching may cause depression of the arches.6
Flat feet may give rise to plantar fasciitis, as the
plantar fascia is placed under greater strain to com-
pensate for weak ligaments.6,16As with the pronated
foot, the flexible flat foot is not locked for propulsion,
and the plantar fascia is placed under abnormal
strain.6,24Plantar fasciitis is also often seen with the
rigid cavus fOOt.15,17,20The high-arched foot is
ineffective in absorbing ground reaction forces,6thus
increased load from shock absorption and force dis-
sipation is transmitted to the plantar fascia.
A tight Achilles tendon has been implicated as a
mechanism for plantar fasciitis as it creates a valgus
position of the calcaneus and causes excessive prona-
tion.6,7,lo,25A tight Achilles tendon is often seen with
a rigid cavus foot or with excessive pronation.21 A
valgus heel may also cause the medial calcaneal
tubercle to absorb a greater load.6Other predisposing
factors include training errors, improper footwear7,8
and obesity.12,18,26
TREATMENT
The majority of patients suffering from plantar fasciitis
will respond to conservative therapy.5,21,27,28
Treatment in the short term is aimed at reducing
inflammation. Inflammation is reduced by NSAIDs,
ultrasound, ice, rest and activity modification.6,16,21
Athletes may need to reduce the duration, intensity or
frequency of the aggravating activity.7,16,17,21
Alternative activities such as cycling, pool running and
swimming should be considered, to allow healing and
maintain conditioning.7,17,21
In the early stages of rehabilitation, strengthening
exercise of the plantar and dorsiflexors can be per-
formed isometrically or with rubber tubing.9Later,
these may be followed by more functional activities
such as heel raises. Proprioceptive training with a
wobble board is also recommended at this time.9
Stretching of the Achilles tendon is another important
EFFECTIVENESS OF TE SION NIGHT SPLINTS
149
part of therapy.6.9,16,18.21Milder forms of plantar
fasciitis may respond to transverse frictional
massage.21
Taping is often used to limit range of motion and
allow the plantar fascia to heal. 9If taping is successful
at reducing symptoms, an orthotic may also be benefi-
cial. Orthotics have been shown to keep the foot in a
neutral position and limit excessive pronation.29 A
randomized clinical trial by Lynch and colleagues 30
demonstrated that custom foot orthotics were more
effective in treating plantar fasciitis than anti-inflam-
matories or heel cups. In contrast, Pfeffer and col-
leagues4showed that a prefabricated shoe insert was
more likely to produce relief than a custom-made
orthotic. Batt and TanjF recommended that custom-
made orthotics be reserved for those who do not
respond to other conservative measures, as they are
relatively expensive. Heel raises or heel cups that help
to cushion or disperse the load on the calcaneal
tuberosity are also used7,12,17and may be particularly
useful for an obese population, where heel fat pad
atrophy is sometimes present. 7
Prevention of recurrence focuses on proper foot-
wear, training surfaces and running technique.7,9
Shoes should be designed with a firm heel counter,
good heel cushioning and good arch supports8,16as an
ill-fitting, worn-out or excessively rigid shoe may also
lead to plantar fasciitis.8Runners should also consider
running on a softer surface.1Functional rehabilitation
should focus on the entire kinetic chain, including
foot, ankle, knee and hip.7,9 Progression of exercises
and return to activity must be gradual to avoid
recurrence.
Some patients will not respond to conservative
measures, and their symptoms prevent them from
returning to athletic activity. Others may even have
pain with walking or even standing.17 Corticosteroid
injections should be reserved for recalcitrant cases, as
injections have been associated with degeneration and
acute rupture of the plantar fascia.2,16,21·Aperiod of
rest must follow the injections, to allow recovery from
steroid-induced changes to the plantar fascia.21
Surgery may be considered if symptoms last for more
than one year,16or have not responded to conservative
measures. 17Surgery is performed to release the plantar
fascia from the os calcis and excise degenerated
tissue.17Sometimes a heel spur is removed as well.7
RATIONALE FOR TREATMENT WITH
TENSION NIGHT SPLINTS
During sleep, particularly in supine position, both
gravity and muscle tone in the triceps surae can cause
the ankle to assume a plantarflexed position,
7,25,26
thus shortening the gastroc-soleus complex. This in
tum puts the plantar fascia in a shortened, non-
functional position. The signature symptom of sharp
pain with the first few steps in the morning is caused
by the return of the plantar fascia to functional
weightbearing length. This may contribute as well to
the chronic nature of plantar fasciitis, as overnight
healing at the enthesis and in the plantar fascia is
disrupted every morning by the return to functional
length.31 Tension night splints serve to maintain a
neutral or dorsiflexed position of the ankle, allowing
the plantar fascia to heal in a more functional posi-
tion.7,25,26A splint designed to maintain toe extension
in addition to ankle dorsiflexion will further tension
the plantar fascia during sleep,31perhaps enhancing
effectiveness of the device.
Tension night splints exert their effect via stress
relaxation, defined as the decrease in stress over time
once a material under load has deformed to a constant
length.32Stress relaxation results from the viscoelastic
nature of all biological tissues. With the splint on, the
plantar fascia is kept in a dorsiflexed, stretched posi-
tion and the phenomenon of stress relaxation occurs,
reducing tension in the lengthened plantar fascia and
intrinsic muscles of the foot.7,33 Additionally,
increased range of motion in the triceps surae allows
the calcaneus to assume a more midline position,
thereby reducing the excess strain placed on the
plantar fascia with pronatory gait.33
EFFECTIVENESS OF TENSION NIGHT
SPLINTS
A computerized literature search (Medline 1966-2000;
CINAHL 1982-2000) was carried out using the key
words plantar fasciitis, tension night splints and treat-
ment. A secondary, manual search of the reference
lists of all identified articles was also conducted. The
primary search yielded a total of nine studies on the
use of tension night splints as either primary or adjunct
treatments for plantar fasciitis. The studies included
one single-subject case study,1° three retrospective
studies,12,13,18two case series14,25and three random-
ized controlled studies.26,31,34They are reviewed in
chronological order.
The first report of the use of tension night splints
was a case series by Wapner and Sharkey in 1991,25
which included 14 patients ( 18 heels) diagnosed with
recalcitrant plantar fasciitis. None of the patients had
experienced relief of symptoms with their previous
treatments, including activity modification, NSAIDs,
orthotics, steroid injections and physical therapy. All
patients were prescribed a custom-moulded
ankle-foot orthotic (AFO), which extended beyond
150
J.
P. RYAN AND T.
J.
OVEREND
the toes and held the ankle in five degrees of dorsi-
flexion. The patients were instructed to wear the splints
nightly for the first three months, then gradually to
reduce the wearing schedule to every second night,
every third night, every fourth night and finally, on an
as-needed basis. The patients were also asked to
maintain their previous physical therapy programmes,
NSAIDs, heel cups and shoe liners. Fifteen (11
patients) out of the 18 heels treated had complete
resolution of symptoms within four months of treat-
ment, with no incidence of recurrence. Patients
reported a period of discomfort and disturbed sleep
that lasted the initial week. If the AFO was not used
for a night during the first month, symptoms were
increased the next morning. Of the three heels that did
not respond, one patient did not comply with the
treatment, one patient was found to have medial
calcaneal nerve entrapment, and another was
60 pounds over her ideal body weight. Wapner and
Sharkey concluded that the tension night splint was a
useful adjunct in the treatment of chronic recalcitrant
plantar fasciitis.
The next report was a single-subject case study by
Pezzullo10 in which a 34-year-old male recreational
soccer player was treated with a night splint. The client
had reported hearing a 'pulling and tearing' in his foot
at the time of injury, 8-12 weeks prior to being given
the night splint. Pain had prohibited him from
returning to play. Previous physiotherapy treatment,
which had failed to resolve the condition, consisted of
rest, ice, stretching, ultrasound and transverse friction
massage. The tension night splint constructed for him
was made with a stockinette, cast padding, casting
tube, moleskin and velcro. The foot was held in a
subtalar neutral position or slightly everted. The client
was instructed to continue stretching the gastrocnem-
ius and soleus muscles, as well as the plantar fascia.
After one month of nightly use, the client reported
substantial relief of pain and improved function. He
went on to increase his activity and reduce the number
of nights wearing the splint, and seven months later he
expressed '100% satisfaction' with the night splint. At
that time, he was continuing to do the stretching
exercises and wore the tension night splint only on an
occasional basis for prophylactic purposes. Pezzullo
concluded that this promising case study indicated the
need for larger studies regarding effectiveness of the
night splint.
Wolgin and colleagues12 reviewed, by telephone
survey, 100patients from the practices of three ortho-
paedic surgeons with the intent of revealing the natural
history of plantar fasciitis when managed non-operat-
ively. All 100 subjects had a minimum follow-up
period of two years, had been treated conservatively
with recommendations for rest and Achilles stretching,
and had been given handouts about other treatments
including ice, heat, orthotics, NSAIDs, night splints
and injections. Outcomes were rated as good (no
symptoms), fair (continued symptoms but no activity
restriction either at work or in sport), or poor (con-
tinued symptoms limiting activity). Eighty-two
patients recovered completely. There was a signific-
antly higher percentage of overweight people in the 18
patients with fair (n
=
15) or poor outcomes. Although
only three patients actually tried the night splints, they
all reported improvement of symptoms.
The first large-scale report on the effectiveness of
tension night splints was a retrospective report by
Ryan in 1995,18who reported successwith 30patients,
although there was no mention of the total number of
patients treated. Ryan's stepwise approach to treating
plantar fasciitis included initial instruction in stretch-
ing, followed by strengthening, orthotics or heel pads,
and sometimes NSAIDs. If no relief was reported
within three weeks, a tension night splint was pre-
scribed. If relief was not found within another three
weeks, a corticosteroid injection was administered.
The night splint used was made inexpensively out of
fibreglass casting tape and wetted elastic wrap, and
held the foot in maximum dorsiflexion. In a five-year
period at Ryan's institution, not one corticosteroid
injection was required following the prescription of
tension night splints. Ryan concluded that, in view of
the low cost and potential for complications, night
splinting was a reasonable alternative to invasive
treatments such as injection or surgery.
A case series by Mizel and colleagues14involved 57
patients (71 heels) diagnosed with plantar fasciitis
(average duration of symptoms, 10 months). One
hundred and twenty-seven patients were offered a
removable cast brace or a metatarsal ankle-foot
orthosis (MAFO) as a night splint. The MAFO was
prefabricated and set the ankle in a neutral position.
In addition, patients were given a shoe modification
consisting of a steel shank and anterior rocker bottom.
The steel shank was bonded into the sole of the shoe
and a crepe sole was contoured to increase the height
under the metatarsal heads to create a rocker bottom.
Previous treatment included orthotics, injection,
NSAIDs and physical therapy. The only concurrent
treatment consisted of silicone heel pads ( 13heels) and
NSAIDs (4 heels). At an average follow-up of
16months (range 0.5-39), symptoms were resolved in
59% of the feet, improved in 18%, unchanged in 15%,
and worse in 7%. Problems included cost, weight of
the modified shoe and three instances of broken steel
shanks. The authors concluded that this combined
treatment (night splint and shoe modification) was
reliable, useful and successful in compliant patients.
EFFECTIVENESS OF TE SIO NIGHT SPLINTS
151
The first randomized clinical trial of the tension
night splint was performed by Batt and colleagues in
1996,31 after a pilot study that showed 80% resolution
of symptoms.
7
Following a formal sample size ana-
lysis, 40 patients with plantar fasciitis were randomly
assigned by computer to two groups. Thirty-two
patients (one with bilateral pathology) completed the
study (average duration of symptoms, 12.7 months).
The control group
(n
=17) received anti-inflammator-
ies, soft heel cushions and a stretching programme for
gastrocnemius and soleus. The treatment group
(n
=
15) received the identical treatment, in addition to a
tension night splint constructed from stockinette,
cotton padding and casting tape. The night splints
were designed to keep the ankle in maximum dorsi-
flexion while also extending the toes. Patients were
assessed every four weeks for pain (Visual Analog
Scale), activity level, ankle range of motion, plantar
fascial discomfort and compliance with treatment.
Patients were considered cured and discharged from
the study if they reported minimal or no discomfort
and had resumed normal activity. Patients deemed
failures from the control group were crossed over to
the splint group after
8-12
weeks.
No significant difference was found between groups
including self-reported severity or length of symptoms,
age, gender, extent of prior treatment or lower limb
malalignment. Sixteen out of 16 feet were cured in the
splint group in an average time of 12.5 weeks. Six out
of 17 patients in the control group were deemed cured
after an average of 8.8 weeks. Following crossover of
the remaining 11 patients into the splint group, eight
were deemed cured after an average of 13weeks. In
total, 30 out of 33 patients were cured. Two of the
three patients who did not heal were severely over-
weight. Chi square analysis indicated that the tension
night splint protocol was significantly (p
<
0.05) more
efficacious. There were no adverse side effects.
Limitations of the study included a possible selection
bias towards those with prior treatment and longer
duration of prior symptoms, and a lack of multiple
reliable end-points. The authors concluded that ten-
sion night splints were a highly effective form of
treatment when combined with a viscoelastic heel pad,
stretching programme and NSAIDs.
Martin and colleagues
13
conducted a retrospective
study (chart reviews and mailed survey) of 237 patients
(157 responses) diagnosed with plantar fasciitis (no
coexisting symptomatic foot or ankle problem) and
treated with a standard protocol. All patients had been
given a prescription for an oral NSAID, a single
physical therapy session where they were taught a
home exercise programme consisting of Achilles ten-
don and plantar fascia stretching exercises, a resting
dorsiflexion night splint, and either a custom orthotic
or a heel cup. Outcomes of treatment were categorized
as good (no pain), fair (intermittent pain) and poor
(constant pain). The combined therapy produced
complete relief in 51% of the subjects, with 81. 8%
satisfied with outcome. Although no direct conclusion
can be made regarding the effectiveness of the tension
night splints owing to the multiple treatments, 18.8%
of the patients perceived the night splint to be the most
beneficial form of treatment, which was comparable
with exercise (18.8%), and orthoses or heel cup
(20.8%). The night splint treatment had the highest
degree of compliance (70.5%), and night splints were
the only treatment that showed a statistically signific-
ant correlation between compliance (wearing the night
splint seven days a week) and outcome (p =0.046).
The authors, while recognizing the limitations of their
experimental design, concluded that patients with
chronic conditions who complied with the use of
tension night splint as part of a non-surgical treatment
programme had a better outcome.
The second prospective randomized clinical trial
was conducted by Powell and colleagues,26who evalu-
ated a dorsiflexion night splint in 37 patients (52 feet)
as a cost-effective treatment for chronic plantar fasci-
itis. Patients were admitted into the study if they had
been diagnosed with plantar fasciitis by a physician or
podiatrist, had heel pain for more than six months
(range 6-108), had severe morning pain with the first
steps, were tender to palpation of the medial calcaneal
tubercle, and had failed previous treatments such as
NSAIDs, orthotics, heel cups, activity modification,
weight loss, steroid injections, casting or taping.
Subjects were excluded due to previous surgery or
additional unrelated foot or ankle problems. Thirty-
seven patients were randomly assigned (computer-
generated random numbers) to two groups. Group A
(n=22) wore the splints for the first month, group B
(n= 15) wore the splints for the second month, and
neither group wore splints for months three to six. All
subjects were told to discontinue all other forms of
therapy during the study. The night splints were
constructed with polypropylene and kept the ankle in
five degrees of dorsiflexion. A wedge was included to
maintain 30 degrees of dorsiflexion at the metatarsal
phalangeal joints.
Outcome measures included a pain scale (1 to 10,
with 10 representing severe disabling pain and one
representing a dull ache), foot type assessments,
radiographs and two hindfoot rating systems (Mayo
Clinical Scoring System, MCSS: Ankle-Hindfoot
Rating System, AHRS) both scored out of 100. After
an initial visit, subjects were reassessed at 30, 60 and
180 days. Data were incomplete in seven subjects who
were regarded as 'failures' of splinting for statistical
152
J.
P. RYAN AND T.
J.
OVEREND
analysis. Only four of these subjects actually were
unable to tolerate the night splints.
There were no significant differences between the
groups for age, weight or foot type. Both males (30%)
and females (52%) were well over predicted ideal body
weights. Heel spurs were detected on radiographs in
85% of the feet. At the final follow-up (180 days),
there was an average improvement of 5.9 points on the
10-point pain scale, with 36.4% reporting no pain at
all. Twenty-two out of 37 patients stated that they
were satisfied, fivewere satisfied with reservations, and
four were dissatisfied (three of whom had bilateral
involvement). Despite the randomization procedure,
Group A had significantly greater scores on both
hindfoot rating systems throughout the study.
However, both groups responded to treatment in the
same way. Significant improvements on both the
MCSS and AHRS were noted for Group A in month
one and for Group B in month 2, corresponding to the
times that each group used the night splints. At six-
month follow-up, both groups maintained a significant
improvement (on both scales) compared with initial
scores, even though neither group was using the brace
at this time. The authors concluded that dorsiflexion
night splints were an effective treatment for recalcit-
rant plantar fasciitis. The splints were also cost-
effectivewhen measured against the cost of six months
of conservative treatment.
The most recent randomized clinical trial was con-
ducted in 1999by Probe and colleagues,
34
who studied
116 patients with plantar fasciitis (duration less than
12months, average 19weeks) to determine the effect-
iveness of tension night splints as an adjunct therapy
for relieving acute symptoms. Inclusion criteria
included positive clinical diagnosis, early-morning
pain (minimum 3 on a 10-point scale) and age between
18 and 65 years. Subjects were excluded if they had
prior hindfoot surgery, any systematic illness or heel
pain due to other causes. Computer-generated num-
bers were used to divide the subjects randomly into
conventional and conventional +night splint treat-
ment groups. Conventional treatment consisted of
three months of ankle dorsiflexion stretches and
30 days of an NSAID (first month). Shoes with
supportive arches and cushioned heels were recom-
mended. However, compliance with this recommenda-
tion was not recorded. The experimental group
received the same conventional treatment programme
along with a tension night splint (five degrees of ankle
dorsiflexion) which was to be worn nightly for the
three months. Patients were assessed at presentation,
and at four, eight and 12 weeksby an examiner blinded
to the group assignment, and again via a questionnaire
at between 12 and 28 months post-study (mean
19months). Pain was assessed based on a four-level
subjective scale: none, mild, moderate and severe.
Patients also completed the Health Status Short Form
36 disease-impact questionnaire.
No significant differences were noted between
groups in age, prior symptom duration, bilateral
involvement, radiographically evident heel spurs, or
number undergoing prior treatment. Sixty-eight per
cent of the patients recorded an improvement of at
least one pain grade after 12 weeks with most improve-
ment noted in the first four weeks. Fewer older patients
(>45 years) improved compared with younger
patients. Seventy-fiveper cent of the subjects returned
the final follow-up questionnaires, with 84% reporting
symptom improvement. There was no additional bene-
fit resulting from use of the tension night splint. Short
Form 36scores were symmetric between groups as was
pain grade improvement rate. The authors concluded
that night splints did not affect improvement when
added to a conventional non-operative protocol in
patients with plantar fasciitis of relatively short dura-
tion. They recommended the continuation of trials of
night splinting for treatment of recalcitrant plantar
fasciitis.
DISCUSSION
Only nine studies on the effectiveness of tension night
splints for treating plantar fasciitis were identified in
our literature search. The study designs ranged from
retrospective surveys to randomized clinical trials.
Although most of the early work was descriptive in
nature and thus difficult from which to draw conclu-
sions, the recent work is characterized by a higher
degree of methodological rigour
26•31,34
and hence
permits more confidence in the results.
Most patients with plantar fasciitis respond well to
conservative treatment.
12,13,28
However, this review
has indicated that tension night splints may work
where other treatment options have failed.
1o,25,26
In
the study by Wapner and Sharkey,
25
only three of 14
patients did not report relief; one was 60 pounds over
her ideal body weight, one was non-compliant with
treatment, and one went on to have surgery for nerve
entrapment. Although 11patients did report complete
resolution of symptoms, the tension night splints were
used in combination with other treatment measures;
thus, this study did not demonstrate the effectiveness
of tension night splints as a sole treatment technique.
With only 14 subjects, the study lacked statistical
power, and as the study population consisted of only
people with chronic conditions, the effectiveness of the
splints in a more acute population could not be
determined.
EFFECTIVENESS OF TENSION NIGHT SPLINTS
153
Martin and colleagues13 included a larger subject
population, but also included multiple treatment tech-
niques. Thus, although many patients perceived the
tension night splints to be the most effective form of
treatment, it is not possible to determine which
treatment or combination of treatments led to the
success. The study did demonstrate a high rate of
compliance with the tension night splints, and that the
level of compliance correlated with outcome. The
authors also mention the problem of bias associated
with mailed surveys. Only 66% of their subjects
returned the surveys, and the effect on the results of
the outcome of those who did not is unknown.
The study by Mizel and colleagues,14which showed
success in 77% of the subjects, again included other
treatments. The use of the rocker bottom shoe and
tension night splint did prove effective where other
treaments had failed. This study included fewer vari-
ables, however, as only a small percentage of subjects
used medication, orthotics or performed exercises.
The studies by Ryan, Mizel, Wapner, Wolgin and
Martin and their respective colleagues12-14,18,25were
primarily descriptive in nature, and all lacked control
groups. In addition, the use of combined treatments
makes it impossible to attribute treatment effects to
any specific treatment protocol. The retrospective
studies12,13 suffer from additional methodological
problems associated with this research design, includ-
ing no true control group, little control over internal
validity, limited return rate for questionnaires,
response bias and reliability of self-reports.
The study by Batt and colleagues31 was well
designed, with an a priori sample size calculation
based on 80% statistical power, a cross-over feature to
increase effectivesample size,consistent and standard-
ized treatment, and successful randomization. Their
night splint differed from other studies, incorporating
a toe dorsiflexion component which acts to stretch the
plantar fascia further. The results of this study suggest
that tension night splints are an effective adjunct
treatment in the chronic plantar fasciitis population.
Tension night splints were also shown to be effective in
overweight people, as only three of 14 overweight
patients were treatment failures. Two of these three
were severely obese. Weight has previously been
identified as contributing to less satisfactory treatment
outcomes. 12
The study by Powell and colleagues26is noteworthy
because it is the only one to date that assessed the
isolated effect of tension night splints for treating
plantar fasciitis, again in a chronic sample. This study
was also well designed with randomized group selec-
tion and statistical control for multiple comparisons.
However, no information was provided regarding the
statistical power of their comparisons. This study
indicated that tension night splints are effective in the
treatment of recalcitrant plantar fasciitis.
Improvement was demonstrated with multiple out-
come measures, including the AHRS, MCSS and a
numeric pain scale. The positive effect elicited in the
one-month treatment period was also maintained for
five months after treatment stopped. Although the
average patient in this study was obese, there was no
relationship between obesity index and clinical
outcome.
The results of the randomized clinical trial of Probe
and colleagues34conflicted with most of the previous
papers, showing no effect of the tension night splint
when used as an adjunct treatment. This discrepancy
seems to be most likely due to the more acute nature
of plantar fasciitis in the study population. In contrast
to previous studies, participation was restricted to
patients with symptoms of less than 12 months' dura-
tion. This suggests that tension night splints may be
more effective in treating chronic plantar fasciitis.
CONCLUSION
Although many of the reviewed studies had small
sample sizes and lacked control groups, the balance of
evidence in this review indicates that tension night
splints may be effective in treating plantar fasciitis.
Two randomized clinical trials indicated that tension
night splints are effective in primary and adjunct
treatment of overweight and chronic patients with
plantar fasciitis. The splints seem to be tolerated well
by most patients, but more research is needed to
determine their effectiveness in an acute population.
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