Point-Counterpoint: Is PRP Beneficial For Chronic Plantar Fasciitis?
Noting the literature and their own success with platelet rich plasma (PRP), these authors say PRP is an effective non-invasive treatment that can obviate further surgery for plantar fasciosis.
By Babak Baravarian, DPM, FACFAS, and Lindsay Mae Chandler, DPM
Plantar fasciosis is heel pain caused by deterioration of the plantar fascia, which occurs as a result of repetitive stress and chronic plantar fasciitis. This is the term used for the non-inflamed phase of plantar fasciopathy. It is much more difficult to treat plantar fasciosis when healthcare providers fail to recognize it as the non-inflamed phase of the condition.
In plantar fasciitis, there is adequate blood supply to the problematic area as well as an inflammatory response that happens to be painful. In plantar fasciosis, the fascia has a decreased or absent inflammatory response, a reduction in the growth/healing factors, and chronic scar tissue that prevents the healing process.
Treatments such as dry needling, extracorporeal shockwave therapy (ESWT), monopolar capacitive-coupled radiofrequency, Coblation and platelet rich plasma (PRP) focus on increasing the inflammation response rather than suppressing it. When a patient presents with symptoms of plantar fascia pain for six months or longer, we must stimulate the inflammatory and healing cascade.
The basis of PRP technology is to provoke a supraphysiologic release of growth factors in an attempt to jumpstart the healing of a chronic injury.1 Increased concentrations of autologous platelets yield high concentrations of growth factors, subsequently leading to intensified healing of soft tissue on a cellular level.
Blood is comprised of red blood cells, white bloods cells, plasma and platelets. Platelets have a lifespan of seven to 10 days and aggregate at the site of an injury. The platelet is responsible for hemostasis, assembly of new connective tissue and revascularization.2 The ability to concentrate platelets and white blood cells within a fibrin clot at the injury site results in a controlled inflammatory response and the following proliferative healing response is the body’s natural reparative mechanism. Platelets and white blood cells dominate the proliferative healing response by releasing growth factors, recruiting stem cells and supporting tissue regeneration.3
What The Research Reveals
There has been extensive research, both animal and human studies, with widespread applications revealing the efficacy and safety of PRP. Recently, there has been a focus in the literature on the beneficial effects of PRP for chronic non-healing tendon injuries such as plantar fasciitis and lateral epicondylitis.
Ragab and Othman looked at 25 patients who received PRP for chronic plantar fasciitis.4 In their prospective study, they had a mean follow-up of 10.3 months with patients’ pain decreasing from an average of 9.1 to 1.6 on the visual analogue scale post-PRP injection. They reported that 88 percent of patients were completely satisfied.
Barrett and Erredge investigated the use of PRP for plantar fasciitis in nine patients.5 The authors used ultrasound of the fascia before and after treatment with the patients’ pain scale determining the efficacy. They found that six of the nine patients achieved complete resolution of symptoms after two months. It took a second injection for one patient to have complete resolution. The authors noted that 77.9 percent of their patients had no symptoms after one year of treatment. They also concluded that ultrasound measurements of the thickness of the plantar fascia post-injection showed reduced thickness.
Aksahin and colleagues compared 30 patients treated with PRP versus 30 patients treated with corticosteroid injection.6 Over a six-month period, they found both groups of patients to have significant improvement in symptoms but there were no statistical differences between the groups. The authors felt PRP to be safer than corticosteroid injection with the same effectiveness.