PRP. Sharing insights from the research as well as clinical experience, this author says the one-time treatment and regenerative potential make platelet-rich plasma a more practical option for treating plantar fasciitis in younger, healthy patients.
By James Ratcliff, DPM, FACFAS, FAAPSM
Is platelet-rich plasma (PRP) more effective than extracorporeal shock wave therapy (ESWT) for plantar fasciitis? In my clinical experience, I would say yes but let us take a closer look at the evidence as well.
While platelets are primarily known as the blood clotting cells in the body, they also contain growth factors that accelerate tissue repair. Platelet-rich plasma is a sample of autologous platelets at concentrations above physiologic baseline values in a small volume of plasma.
Not all PRP treatments are the same. Leukocyte-rich PRP is the most appropriate for tendinopathy.1,2 The growth factors and cytokines within the PRP promote angiogenesis, increase blood flow, and also remove the cellular waste and debris that forms following injury. Platelet-rich plasma injections harness the natural functions of one’s own platelets to stimulate and augment tissue healing.1
What Comparative Studies Reveal
Two studies have compared PRP and ESWT in the treatment of plantar fasciitis. In one Egyptian study involving 60 patients (48 female and 12 male), Soliman and colleagues compared a one-time PRP injection to three consecutive weekly ESWT treatments for plantar fasciitis.3 Both groups showed pain improvement in the visual analog scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) scale at one month. The PRP group had decreased plantar fascia thickness at the one- and three-month marks. However the authors found minimal difference between the two groups in terms of VAS pain scale and AOFAS ankle-hindfoot scale improvements.
In another study, Chew and coworkers detailed a study that consisted of 54 patients with plantar fasciitis.4 The three treatment groups included: 19 patients who had PRP and conventional therapy (eccentric stretching, etc.); 19 patients who had ESWT and conventional therapy; and 16 patients who had only conventional therapy. Both the PRP and ESWT cohorts had better VAS and AOFAS scores than the group that only had conventional therapy. However, the authors noted no difference in VAS or AOFAS scores between the ESWT and PRP groups.4
In a 2018 study, Ugurlar and colleagues compared VAS scores and the Revised Foot Function Index for patients receiving ESWT, PRP, corticosteroid injection or prolotherapy (injection of dextrose with needling) for the treatment of chronic plantar fasciitis.5 Patients receiving corticosteroid injection showed the best improvement in VAS scores at one month but there was a loss of this improvement noted after one month. Platelet-rich plasma had the best long-term VAS result at 36 months.
Practical Considerations In Determining The Efficacy Of PRP Over ESWT
Is PRP better than ESWT for all patients with plantar fasciitis? Not necessarily. In my experience, PRP is best in younger, athletic patients who have failed conventional treatments such as stretching, taping, physical therapy and orthotics. I started using PRP in 2006 and began using ESWT in 2008. I have had great success anecdotally with both modalities for plantar fasciitis. That said, in my experience, older patients appear to have more success with ESWT. One recent study from 2019 found a correlation between increased age and less growth factors associated with PRP.6 Platelet-rich plasma is also more invasive than ESWT and therefore may not be appropriate for older patients with comorbidities.
However, one of the advantages of PRP over ESWT is that it involves one treatment session whereas ESWT usually requires one treatment a week for three consecutive weeks. Both treatments reportedly have similar efficacies at three months.3-5
There is also evidence that PRP can have superior results in comparison to corticosteroid injections. In a 2019 study comparing PRP to corticosteroid injections for plantar fasciitis, Peerbooms and coworkers found that PRP was effective in 84 percent of those studied in comparison to only 55 percent of those treated with corticosteroid injection.7 Additionally, many researchers believe that plantar fasciitis is a degenerative condition and the regenerative potential of PRP may prove to be beneficial in this regard. The concentrated growth factors with PRP can increase collagen production by tendon sheath fibroblasts, which is likely to occur in chronic plantar fasciitis, which is a degenerative condition.8
One of the problems in the comparison of these two treatments is the many different companies that provide PRP and ESWT. Is one company’s product superior to another product? Many companies claim to have a higher yield of platelets from the blood with their PRP product but do not have evidence to prove their contention. There are also different types of ESWT (i.e. focused shockwave versus radial shockwave).
Additionally, one must consider many other factors when treating plantar fasciitis and determining the best treatment. These factors include high body mass index (BMI), foot structure and the patient’s medical history, all of which will impact the efficacy of any intervention.
Having both modalities available gives the practitioner more options from which to choose. However, with so many different products on the market, there is definitely a need for more randomized controlled trials to determine which products are truly superior. Head-to-head studies of the different shockwave systems and PRP products are necessary. Young, healthy patients will have higher levels of growth factors in their PRP, likely yielding better results. For older patients with more medical problems, I believe it would best for them to try ESWT.
Ideally, utilizing both modalities should improve efficacy. In my experience, applying ESWT to the area before injecting PRP and then applying several ESWT treatments post-injection for several weeks should improve outcomes in patients with plantar fasciitis.
Unfortunately, PRP and ESWT may not be options for many patients as both are not typically covered by traditional insurance plans in my experience. Many of my patients use flexible health-care spending accounts or health savings accounts to cover the cost. Hopefully, with more evidence-based trials, insurance companies will start covering both of these promising treatments.
Although each of these modalities has benefits and drawbacks, PRP’s less invasive application, the potential for a single treatment and promising efficacy in the literature make it a wise choice in the right patient population.
Dr. Ratcliff is Chief of Podiatry Services at Stanford Health Care in Palo Alto, Calif., and is a Fellow of the American College of Foot and Ankle Surgeons. He is a Fellow and current President of the American Academy of Podiatric Sports Medicine. Dr. Ratcliff is in private practice in Los Gatos and Menlo Park, Calif.
ESWT. Noting significant pain reduction, minimal activity restrictions and the lack of serious adverse events, this author says low-energy extracorporeal shockwave therapy (ESWT) provides a viable treatment alternative for patients with chronic plantar fasciitis.
By Erika Schwartz, DPM, FACFAS
Plantar fasciitis is for many podiatrists the most common issue bringing patients into the office. While the term plantar fasciitis implies an inflammatory condition, there is much evidence that this heel pain disorder stems from degenerative changes in the fascia and change within the abductor digiti minimi muscle. Especially when plantar fasciitis continues for many months, experts largely agree that this condition is certainly not an inflammatory issue.1
Early treatments include modalities such as stretching, physical therapy, non-steroidal anti-inflammatory medications, corticosteroid injections, shoe changes and orthotics that are often utilized simultaneously or in combination. These modalities resolve the issue for the majority of our patients.
However, for the 10 to 20 percent of patients who do not achieve pain relief for plantar fasciitis within four to six months, other options exist.1 Where surgery was likely the next step years ago, extracorporeal shockwave therapy (ESWT), platelet-rich plasma (PRP) and amniotic stem cell allograft may provide alternatives. These regenerative-based treatment options all show promise in the treatment of many musculoskeletal disorders, including plantar fasciitis. For the treatment of the chronic form of plantar fasciitis, often termed plantar fasciosis, I believe ESWT is the best choice.
While the exact mechanism of action is unknown at this time, there are several thoughts on what happens with the use of ESWT. During ESWT, the amount of energy and the frequency of application influences the biological effect on the target tissue. The administration of sound waves creates vibration, which transmits through the tissue and causes local injury. There is a subsequent increase of blood flow and migration of growth factors to the area of treatment.2 There may be fragmentation with increased pressure in areas of calcium deposition, induction of an inflammatory response leading to an inflammatory-mediated healing process and neovascularization with increased blood flow to the treated site.2
Multiple studies of ESWT demonstrate destruction of sensory unmyelinated nerve fibers, neovascularization and the creation of collagen within degenerated tissue.3 There is also the belief that the nerve hyperstimulation may inhibit pain perception.2
High-energy extracorporeal shock wave therapy (ESWT) is widely used for lithotripsy in urology. Generally, when clinicians utilize high-energy ESWT in the musculoskeletal system, in my experience, they usually do so in a surgical setting and the procedure can be painful and expensive. In contrast, I have found one can perform low-energy ESWT in an outpatient setting and there is comfortable tolerance by patients. High-energy ESWT requires one 20-minute treatment and regional anesthesia for the patient whereas low-energy ESWT requires three to four applications but no anesthesia.4
The low-energy ESWT systems can be focused shockwave (FSW) or radial shockwave (RSW). There is more diffuse application with radial shockwave while focused shockwave is more concentrated to the direct tissue region, focusing energy on a small region at a maximum level, which can subcutaneously penetrate a few centimeters.3 Radial shockwave delivers shockwaves at the skin surface and radially distributes energy into larger tissue areas.3
The ideal method for applying shockwave therapy is not clear. Some studies associate a higher rate of success with focused shockwave while other studies point to increased benefit with radial shockwave’s ability to treat a larger area of tissue.3,5 Trials in the literature vary in regard to intensity and frequency of the sound waves, the duration of treatment, and the number and timing of treatments.
What The Research Reveals About The Potential Superiority Of ESWT
Multiple researchers have reported improvement at eight and 12 weeks after ESWT with the best results occurring after 12 weeks of use.8 Kudo and colleagues showed good or excellent outcomes in 43 percent of patients with chronic plantar fasciitis that did not improve with conservative therapy for at least six months.7 Malay and team found 43 percent of their patients treated with shockwaves reported a 50 percent decrease in pain from baseline at 12 weeks.8 A 2018 study published in The Journal of Foot and Ankle Surgery showed clinically relevant and statistically significant efficacy of ESWT in patients with chronic plantar fasciitis, noting a 63 and 79 percent reduction of pain in active and non-active duty military populations with a mean follow-up of 42 months.6
Researchers did not note similar results in trials that involved ESWT use in newer onset plantar fasciitis or when clinicians used local anesthesia during treatment. In patients having symptoms of plantar fasciitis for only six weeks, Buchbinder and colleagues found no significant improvement in pain with ESWT in comparison to placebo.9 Employing three sessions of focused shockwave (and local anesthetic) in the treatment of plantar fasciitis in comparison to placebo, Haake and team found no statistically significant difference in success rates.10
While many data points are subjective in regard to pain relief in trials involving ESWT, Vahdatpour and colleagues examined the ultrasonographic appearance of plantar fascial thickness in their 2012 study.11 After three weekly treatments of focused shockwave therapy, the authors noted significantly decreased plantar fascial thickness in the ESWT group and slightly increased plantar fascial thickness in the placebo group. Both treatment groups noted improvement of pain but there was significantly more pain reduction exhibited in the ESWT group.
In a 2020 study that included 60 patients with plantar fasciitis, Soliman and coworkers looked at PRP injection versus ESWT.12 While both treatment groups had significant improvement of pain and function, the study authors concluded that ESWT led to this improvement earlier in the study points and was more effective in patients who had a noted calcaneal spur.12
There are multiple regenerative alternatives to surgery for plantar fasciosis. I would argue that ESWT is preferable over the others as it is noninvasive, has a fast recovery time and provides convenience to continue activities of daily life.3 Studies involving different types of ESWT (focused and radial) all find no serious adverse with the treatment.3 There are patients with documented discomfort, pain, swelling and bruising during or following treatment, but these issues appear to be consequences of the intensity of modality use and not adverse events.3
Whether one is using focused or radial shockwave modalities, the practitioner has the ability to move the applicator though multiple areas and adjust frequency, energy and time of treatment. This allows for far more flexibility in treatment than with any modality based on substance injection for plantar fasciitis.
There are no activity restrictions for patients during the time of treatment and patients treated with focused or radial shockwave therapy can continue with orthotics and stretching to reinforce good habits for the future.
An effective modality that does not involve injection or incision appeals to the majority of our patients.
Dr. Schwartz is the Scientific Conference Chair and a Past President of the American Association for Women Podiatrists. She is board-certified in foot surgery by the American Board of Foot and Ankle Surgery, and is in private practice with Foot and Ankle Specialists of the Mid-Atlantic in Washington, DC and Chevy Chase, MD.
1. Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current clinical recommendations for use of platelet-rich plasma. Curr Rev Musculoskelet Med. 2018;11(4):624-634.
2. Jiang G, Wu Y, Meng J, et al. Comparison of leukocyte-rich platelet-rich plasma and leukocyte-poor platelet rich plasma on Achilles tendinopathy at an early stage in a rabbit model. Am J Sports Med. 2020;48(5):1189-1199.
3. Soliman SG, Labeeb AA, Abd Allah EA, Abd- Ella TF, Abd- El Hady Hammad EA. Platelet rich plasma injection versus extracorporeal shockwave therapy in treatment of plantar fascia. Menoufia Med J. 2020;33(1):186-190.
4. Chew KTL, Leong D, Lin CY. Comparison of autologous conditioned plasma injection, extracorporeal shockwave therapy and conventional treatment for plantar fasciitis: a randomized trial. Phys Med Rehabil. 2013;5(12):1035-1043.
5. Ugurlar M, Sonmez MM, Urgurlar OY, Adiyeke L, Yildirim H, Eren OT. Effectiveness of four different treatment modalities of chronic plantar fasciitis during a 36 month follow up period: a randomized controlled trial. J Foot Ankle Surg. 2018;57(5):913-918.
6. Taniguchi Y, Yoshioka T, Sugaya H, et al. Growth factor levels in leukocyte-poor platelet-rich plasma and correlations with donor age, gender and platelets in the Japanese population. J Exp Orthop. 2019;6:4.
7. Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive effect of platelet-rich plasma on pain in plantar fasciitis: a double-blind multicenter randomized controlled trial. Am J Sports Med. 2019;47(13):3238-3246.
8. Yang WY, Han YH, Cao XW, et al. Platelet-rich plasma as a treatment for plantar fasciitis: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2017;96(44):e8475.
9. Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic plantar fasciitis. Foot Ankle Int. 2014;35(4):313-318.
10. Mishra A, Pavelko, T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34(11):1774- 1778.
1. Schmitz C, Csaszar N, Rompe J, Chaves H, Furia J. Treatment of chronic plantar fasciopathy with extracorporeal shock waves (review). J Orthop Surg Res. 2013;8:31.
2. Carulli C, Tonelli F, Innocenti M, Gambardella B, Muncibi F, Innocenti M. Effectiveness of extracorporeal shockwave therapy in three major tendon diseases. J Orthop Traumatol. 2016;17(1):15-20.
3. Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis. Medicine (Baltimore). 2017;96(15):e6621.
4. Wilson M, Stacy J. Shock wave therapy for Achilles tendinopathy. Curr Rev Musculoskelet Med. 2010;4(1):6-10.
5. Malliaropoulos N, Crate G, Meke M, et al. Success and recurrence rate after radial extracorporeal shock wave therapy for plantar fasciopathy: a retrospective study. Biomed Res Int. 2016;2016:9415827.
6. Purcell R, Schroeder I, Keeling L, Formby P, Eckel T, Shawen S. Clinical outcomes after extracorporeal shock wave therapy for chronic plantar fasciitis in a predominantly active duty population. J Foot Ankle Surg. 2018;57(4):654-657.
7. Kudo P, Dainty K, Clarfield M, Coughlin L, Lavoie P, Lebrun C. Randomized placebo-controlled double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracorporeal shockwave therapy (ESWT) device; a North American confirmatory study. J Orthop Res. 2006;24(2):115- 123.
8. Malay DS, Pressman M, Assili A, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized placebo-controlled double-blinded multicenter intervention trial. J Foot Ankle Surg. 2006;45(4):196-210.
9. Buchbinder R, Prasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis; a randomized controlled trial. J Am Med Assoc. 2002; 288(11):1364-1372.
10. Haake M, Buch M, Schoeliner C, et al. Extracorporeal shock wave therapy for plantar fasciitis; randomized controlled multicenter trial. BMJ. 2003;357(7406):75.
11. Vahdatpour B, Sajadieh S, Bateni V, Karami M, Sajjadieh H. Extracorporeal shock wave therapy in patients with plantar fasciitis. A randomized, placebo-controlled trial with ultrasonographic and subjective outcome assessments. J Res Med Sci. 2012;17(9):834- 838.
12. Soliman SG, Labeeb AA, Abd Allah EA, Abd- Ella TF, Abd-El Hady Hammad EA. Platelet rich plasma injection versus extracorporeal shockwave therapy in treatment of plantar fascia. Menoufia Med J. 2020;33(1):186-190.