11/14/2014    Ira Baum, DPM

Bilateral Night Splints

Chronic inflammatory or degenerative changes to
the plantar fascia, I think, are a continuum of
the process of plantar fasciitis/fasciosis. I
understand there have been studies that “prove”
plantar fasciitis is not inflammatory but
degenerative, but those studies have limitations
particularly based on timing of the pathological
evaluation.

Having said that, placing the foot and ankle in
an extended position places passive tension on the
plantar fascia. As we all know, the fibers of the
plantar fascia are oriented longitudinally
extending from heel to its insertions. Chronic
inflammation or degeneration of the fibers over
time change the character and orientation of the
fibers. If you will , they become disoriented
into an amorphic contracted mass (not size) of
tissue.

By placing passive tension on the plantar fascia,
Wolfe’s Law comes into play, and over time the
fibers will reorient more longitudinally.
Instead of newly formed disoriented fibers being
re-injured by weight bearing causing the
disoriented fibers to abruptly realign, the newly
formed fibers are more longitudinally oriented.
The newly formed longitudinally oriented fibers
are not re-injured and the AM pain is less.

From my perspective, abnormal stress to the
plantar fascia over time contributes to the
condition. Most of the time it is due to a
functionally inefficient foot combined with stress
applied to the foot over a time. I don’t think
abnormal foot function causes the plantar fascia,
the foot must be exposed to abnormal stress over
time.

In my opinion, that’s why use of night splints
without addressing an inefficient functioning foot
and/or modifying the stress (activity) to the
plantar fascia is inefficient and most times,
contributes to prolonged symptoms. I will add for
completion, that the use of anti-inflammatory
medication is important to control the body’s
chemical reaction to the injury and is an integral
part of the care.

Ira Baum, DPM, Miami, FL, ibaumdpm@bellsouth.net

Other messages in this thread:

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11/12/2014    Keith Gurnick, DPM

Bilateral Night Splints

Dr. Perry asked if it is acceptable to dispense
and bill for 2 night splints when a patient has
bilateral plantar fasciitis and Dr. Kesselman
responded to Dr. Perry that he needs to separate
medical necessity and reimbursement policy from
practicality. I don't totally agree with
Dr. Kesselman. I would rather he had written to do
what you feel is best for each patient on a case
by case basis but if the patient needs two night
splints explain the costs and any possible
reimbursement or insurance payment concerns in
advance so that the patient is aware and can
make decisions about any potential out of pocket
costs.

Dr. Perry seemed to be asking more about insurance
reimbursement and Dr. Kesselman seemed to be
responding our of a fear of patient non-compliance
with the use of two night splints introduced at
one patient encounter. Oh, the external pressures
we all face on a daily basis that effects our
medical decision making and patient treatment.

If one feels that b/lat night splints are
medically indicated for a patient with b/lat
plantar fasciitis, it may be improper
to dispense only 1 splint with the instructions to
alternate the use of the splint on the left and
right side every other day, because of the fear of
whether an insurance company will or won't
reimburse for 2 night splints. If you feel the
patient really needs 2 night splints, get the
patient 2 night splints and bill the patient or
the insurance company for 2 night splints.

There are however other reasons why you might want
to initially dispense only one night splint and
then dispense the 2nd splint on a later
visit (i.e. staged treatment). Irrespective of the
style of the night splint and I have tried them
all (rigid posterior, rigid anterior, dynamic
anterior or the soft elastic sleeves) we are aware
that there can be a high non-compliance rate with
these products even when only 1 night splint is
dispensed. Patients, for the most part, really
don't like to wear anything in bed on any part of
their body that can and does interfere with their
sleeping habits, even when it is prescribed for
the benefit of improving their health.

Asking the patient to "begin" treatment with only
1 splint and then assess how the patient responds
may be the better technique to improve patient
compliance and then also not seeing the patient
return to you 2 partially unused night splints on
the next visit. I have found patient compliance
with night splints to be directly proportional to
the following:

1) The more the patient pays out of pocket (up
front) for the night splint the more they use it.
2) The more time I take to properly fit, and teach
the patient how and when to use the night and
adjust it, the more they use it.
3) When I really take the time to discuss that it
takes time to get used to night splints and a
gradual break in period may be required, the
failure rate is markedly minimized.
4) When I have a patient who I feel needs 2 night
splints who I feel will comply with 2 night
splints, I will fit them for 2 night splints.

If I get the feeling they may be a challenging
patient, I will dispense 1 splint only with the
instructions to wear it every night on the worse
side, or one side only if both are identically
painful and see how they did on the next visit
and they move forward (or backwards) from there.

Keith Gurnick, DPM, Los Angeles, CA,
KEITHGRNK@AOL.COM