Platelet-Rich Plasma: Can It Have An Impact For Plantar Fasciitis?
How The Author Utilizes PRP For Chronic Heel Pain
I have found promising results using PRP for those patients with chronic, recalcitrant plantar fasciitis. Patients who have failed conservative treatments (including RICE, functional foot orthotics, physical therapy and cortisone injections) after four to six months may be candidates for PRP.
Clinicians can confirm their diagnosis using ultrasound and/or MRI. Use a skin marker to identify the site of the most pain on palpation. Provide an initial anesthetic block at the site. Draw 60 cc of whole blood using a collection tube and butterfly needle. Calcium chloride activates the PRP. In order to keep the PRP in liquid form for injection, do not use thrombin.
Once the PRP is prepared, using the preferred method, clinicians can employ a 10 cc syringe and 22- or 18-gauge needle to inject the patient with 5 cc to 8 cc of PRP from the 60-cc whole blood collection. This yields a concentration that is a 10 to six times over baseline respectively. It is important to use a large gauge needle for injection. A 22-gauge or even 18-gauge needle is preferable. Smaller gauge needles may lyse the platelets. Of note, I have found that as the concentration increases, the patient’s post-injection pain increases.
Perform the injection with ultrasound guidance. Place several 0.25-cc pulsed injections, while peppering the needle, in the medial plantar fascial band starting at the point of maximum tenderness. In many of the patients, during the injection, one can appreciate the fibrosis of the ligament by a crepitus that is tangible and audible as the needle passes in and out of the fascial tissue. After completing the injection, perform continued peppering of the fascia, using the needle to further aggravate the tissue.
Restrict the patient from using any anti-inflammatories or modalities for up to three months after the treatment. Advise patients to use acetaminophen or narcotics for pain as needed. I have found better results with a post-injection protocol of a walking boot and crutches with no weightbearing for three to five days, and then walking in the boot for two to three weeks. Activity begins gradually around the third or fourth week in an athletic shoe and functional foot orthotic, and increases over a four-week period.
Some patients have benefited from a second injection when the first yielded only some relief in symptoms. One would give this injection about six weeks after the first one. Those patients who have no change in their symptoms after the first injection rarely benefit from a follow-up injection.
I have been using PRP over the last three years in the treatment of plantar fasciitis. The results have been increasingly promising with regard to decreased pain, increased activity, improved function, faster recovery and increased strength. The use of PRP in the clinical setting may be advantageous for its ease of use, relative availability, lack of side effects and improved tolerability in comparison to more invasive techniques.
Although the theory behind the use and effectiveness of PRP and some positive clinical evidence are promising, it is evident that additional well-designed prospective studies on PRP are needed to measure its true effectiveness in treating chronic foot and ankle pathology, specifically plantar fasciitis.
Dr. Soomekh is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery. He is a faculty member at the University Foot and Ankle Institute in Los Angeles. Dr. Soomekh is also a Foot and Ankle Specialist for the Los Angeles Ballet.