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
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.
Mishra and Pavelko evaluated 20 patients with chronic severe elbow tendinosis who had persistent pain for a mean of 15 months despite nonoperative treatments and were considering surgical intervention.1 The patients received either a single percutaneous injection of PRP or bupivacaine. After eight weeks of treatment, their results showed 60 percent improvement in the visual analog scale pain scores for the PRP patients versus 16 percent improvement for the bupivacaine patients. They concluded treatment with PRP reduced pain significantly in patients with chronic elbow tendinosis and one should consider PRP before surgical intervention.
After six months of failed treatment or no treatment for plantar fasciitis, we deem the condition to be more chronic than acute. At this point, we present the patient with the option of performing more aggressive yet still non-invasive therapies. Our objective at that point is to stimulate an inflammation process at the insertion of the plantar fascia. The therapies we offer include: ESWT, monopolar capacitive-coupled radiofrequency, Coblation and PRP injections.
The PRP injection occurs in the office. We begin by collecting the blood from the patient’s cubital vein. A centrifuge separates the platelets from the plasma, which can take five to 20 minutes depending on the speed of the centrifuge and the concentration desired.
We inject local anesthetic into the surrounding skin, soft tissue and fascia. With ultrasound guidance, we advance the needle within the fascia. Using a peppering technique, we inject the growth factors over the entire region, traumatizing the fascia to some extent to allow the inflammatory response to increase.
Following injection, the patient wears a controlled ankle motion (CAM) walker boot to provide support and decrease stress on the plantar fascia. The patient wears the boot for two weeks while weightbearing as tolerated and then transitions into a stability/motion control running shoe, preferably with custom orthotics. The patient also receives instructions not to ice the area or take any non-steroidal anti-inflammatory drugs for the first two to three weeks post-injection.
At the University Foot and Ankle Institute, we have seen promising results with the use of PRP in plantar fasciosis for decreasing pain, improving function, increasing activity and decreasing recovery time. In our institute, we have found that 80 percent of patients with plantar fasciosis improve to the point of having minimal to no pain following two consecutive PRP injections spaced one month apart in comparison to 50 percent improvement following the primary injection. Therefore, we advise our patients on the benefits of a second injection if the first yields only partial relief of symptoms.
We have concluded PRP therapy to be an excellent as well as a non-invasive measure for the treatment of plantar fasciosis, preventing many of our patients from progressing to further surgical treatment post-injection.
Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Chandler is a Fellow at the University Foot and Ankle Institute in Los Angeles.
1. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006; 10(10):1-5.
2. Sampson S, et al. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med 2008; 1(3):165-174.
3. Marx RE. Platelet-rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 2001; 10(4):225-228.
4. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg 2012; 132(8):1065-70.
5. Barrett S, Erredge S. Growth factors for chronic plantar fasciitis. Podiatry Today 2004; 17(11):37-42.
6. Aksahin E, Dogruyol D, Yuksel HY, Hapa O, Dogan O, Celedi L, Bicimoglu A. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012; 132(6):781-5.
For further reading, see “Platelet-Rich Plasma: Can It Have An Impact For Plantar Fasciitis?” in the November 2012 issue of Podiatry Today.
By Patrick DeHeer, DPM, FACFAS
The allure of a magic bullet for the treatment of any pathology, the simple solution for a complex problem, is intoxicating. The reality is this magic bullet simply does not exist. We want it to be true so badly but with time, evidence-based medicine often pulls back the curtain to reveal the “wizard” is in fact just a hoax at worst and a marginal treatment option at best.
This is in fact the case with platelet-rich plasma (PRP) and the treatment of plantar fasciitis. The success of fibroblast-derived dermal substitutes is based on the premise that there are living dermal fibroblasts seeded on to a scaffold, which one then applies to the wound. These living dermal fibroblasts are able to secrete growth factors, deposit matrix proteins and facilitate epithelial cell migration.
Plantar fasciitis is the most common foot pathology we as caregivers of the foot and ankle treat. The literature is damning for this not-so magic bullet of PRP and I believe that PRP is not the answer for plantar fasciitis.
The article that has done the most damage to the magic bullet of PRP for plantar fasciitis was by Lee and colleagues in Foot and Ankle International in 2007.1 Their randomized study compared two treatments, PRP and corticosteroids, over a period of one year for patients who met the inclusion criteria of having plantar fasciitis for a period of at least six weeks with maximal tenderness over the medial plantar calcaneal tubercle. Both groups received the same volume of injections and 1% lidocaine HCl (PRP 1.5 mL mixed with 1 mL of lidocaine, or triamcinolone acetonide 0.5 mL with 2 mL of lidocaine). The total number of patients in the study was 61 with blinded follow-up visits at six weeks, three months and six months. Researchers measured the outcomes by the visual analog scale (VAS) (subjective exam) and a pressure algometer to measure tender threshold (objective exam).
The results showed a baseline measurement of the VAS for the PRP group of 7.3 ± 1.8 initially, which decreased to 3.6 ± 2.6 at six months post-injection.1 Results in the steroid group were 6.9 ± 1.7 initially, which decreased to 2.4 ± 3.0 at six months post-injection. The tender threshold results (higher number is a better result) initially for the PRP group was 3.1 ± 1.2, which increased to 6.5 ± 2.9 at six months post-injection. For the steroid group, the initial measurement was 3.7 ± 2.0, which increased to 8.6 ± 3.1 at six months post-injection. Although all patients found both injections painful, there were no complications in either group. The conclusion from this article was “Intralesional autologous blood injection is efficacious in lowering pain and tenderness in chronic plantar fasciitis, but corticosteroid is more superior in terms of speed and probably extent of improvement.”1
Aksahin and coworkers demonstrated similar outcomes in 2012.2 These authors concluded the following: “In this study, the effects of the corticosteroid and PRP injection in patients with plantar fasciitis were analyzed with clinical evaluation methods. Taking the possible regenerative effect of PRP into consideration, the results of the PRP injection group were expected to be more satisfactory in cases of plantar fasciitis since it is believed to be a regenerative process rather than an inflammatory reaction.”
This study did discuss “potential” complications associated with steroid injections and that PRP injections are safer with similar outcomes.2 The authors did not discuss the cost of the procedure and overstate the complications of steroid injections, given the corresponding literature, which Aksahin and coworkers note shows relatively rare complications associated with steroid injections for plantar fasciitis.
When evaluating the results of these studies, the question we must ask is: Is there is a role for PRP in the treatment of plantar fasciitis? Secondly, what role does the cost of PRP and blood draw and handling of the specimen play in the decision making process? In my opinion, the role of PRP alone in the treatment of plantar fasciitis is negligible.
I believe the reason for the outcome of this study is that plantar fasciitis is a multifactorial condition.2 Regardless of whether you think this an inflammatory versus a degenerative process, ignoring the biomechanical etiologies such as pronation syndrome, cavus deformity and equinus will not lead to consistent favorable outcomes. If there is an inflammatory condition, the reduction of the inflammation is critical to the successful treatment of plantar fasciitis. If there is progression into a degenerative process, the outcomes of this study indicate that, although the authors did not differentiate the acute inflammatory versus degenerative process, steroid injections are more efficacious than PRP injections.
The literature is replete with evidence-based medicine on the importance of equinus in the management of plantar fasciitis.3-10 Specifically, Digiovanni and colleagues say the tissue-specific plantar fascia stretching protocol for chronic plantar fasciitis can provide a long-term decrease in pain.3 Any treatment plan without equinus management when indicated by the diagnosis of equinus is an incomplete plan and the patient suffers.
There are similar findings regarding the role of biomechanical control in the treatment of plantar fasciitis.11-18 Fong and coworkers found a beneficial effect by combining rocker bottom soles and custom orthoses for patients with plantar fasciitis.11 Rome and colleagues found that for patients with plantar foot pain, orthoses provided a significant decrease in pain at four weeks.15
The literature has demonstrated the PRP magic bullet to be at best an adjunctive treatment alternative to established treatment protocols for plantar fasciitis. The treatment of plantar fasciitis is based on an accurate diagnosis derived from the patient history and physical examination. One must implement all components of treatment in a coordinated, well-structured treatment plan. At worst, the use of PRP injections for plantar fasciitis is an expensive, somewhat labor-intensive, marginally effective procedure.
Please do not be seduced by the glamor of this false magic bullet. Instead, trust in your knowledge base of podiatric medicine, specifically biomechanics, in the treatment of the most common foot and ankle pathology.
Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is in private practice in Indianapolis.
1. Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int 2007; 28(9):984–990.
2. Akşahin E, Doğruyol D, Yüksel HY, Hapa O, Doğan O, Celebi L, Biçimoğlu A. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132(6):781-5.
3. Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775-81.
4. Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. 2013;34(1):42-8.
5. Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. Foot Ankle Int. 2002;23(7):619-24.
6. Sheridan L, Lopez A, Perez A, John MM, Willis FB, Shanmugam R. Plantar fasciopathy treated with dynamic splinting: a randomized controlled trial. J Am Podiatr Med Assoc. 2010;100(3):161-5.
7. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int. 1994;15(10):531-5.
8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon). 2006;21(2):194-203.
9. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010;31(1):19-23.
10. Rompe JD, Cacchio A, Weil L Jr, Furia JP, Haist J, Reiners V, Schmitz C, Maffulli N. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92(15):2514-22.
11. Fong DT, Pang KY, Chung MM, Hung AS, Chan KM. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech (Bristol, Avon). 2012;27(10):1072-7.
12. Roos E, Engström M, Söderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27(8):606-11.
13. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10(1):12-8.
14. Martin JE, Hosch JC, Goforth WP, Murff RT, Lynch DM, Odom RD. Mechanical treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc. 2001;91(2):55-62.
15. Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. J Am Podiatr Med Assoc. 2006;96(3):205-11.
16. Rome K, Gray J, Stewart F, Hannant SC, Callaghan D, Hubble J. Evaluating the clinical effectiveness and cost-effectiveness of foot orthoses in the treatment of plantar heel pain: a feasibility study. J Am Podiatr Med Assoc. 2004;94(3):229-38.
17. Landorf KB, Keenan AM, Herbert RD. Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis. J Am Podiatr Med Assoc. 2004;94(6):542-9.
18. Hyland MR, Webber-Gaffney A, Cohen L, Lichtman PT. Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. J Orthop Sports Phys Ther. 2006;36(6):364-71.
Dr. DeHeer writes a monthly DPM Blog for Podiatry Today. To access it, visit http://www.podiatrytoday.com/deheerblog/feed  .