Orthopedics

Feature Article 

Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo

Pankaj Mahindra, MS; Mohammad Yamin, MS; Harpal S. Selhi, MS; Sonia Singla, MD; Ashwani Soni, MS

Abstract

Plantar fasciitis is a common cause of heel pain. It is a disabling disease in its chronic form. It is a degenerative tissue condition of the plantar fascia rather than an inflammation. Various treatment options are available, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, orthosis, and physiotherapy. This study compared the effects of local platelet-rich plasma, corticosteroid, and placebo injections in the treatment of chronic plantar fasciitis. In this double-blind study, patients were divided randomly into 3 groups. Local injections of platelet-rich plasma, corticosteroid, or normal saline were given. Patients were assessed with the visual analog scale for pain and with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score before injection, at 3 weeks, and at 3-month follow-up. Mean visual analog scale score in the platelet-rich plasma and corticosteroid groups decreased from 7.44 and 7.72 preinjection to 2.52 and 3.64 at final follow-up, respectively. Mean AOFAS score in the platelet-rich plasma and corticosteroid groups improved from 51.56 and 55.72 preinjection to 88.24 and 81.32 at final follow-up, respectively. There was a significant improvement in visual analog scale score and AOFAS score in the platelet-rich plasma and corticosteroid groups at 3 weeks and at 3-month follow-up. There was no significant improvement in visual analog scale score or AOFAS score in the placebo group at any stage of the study. The authors concluded that local injection of platelet-rich plasma or corticosteroid is an effective treatment option for chronic plantar fasciitis. Platelet-rich plasma injection is as effective as or more effective than corticosteroid injection in treating chronic plantar fasciitis. [Orthopedics. 2016; 39(2):e285–e289.]

Abstract

Plantar fasciitis is a common cause of heel pain. It is a disabling disease in its chronic form. It is a degenerative tissue condition of the plantar fascia rather than an inflammation. Various treatment options are available, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, orthosis, and physiotherapy. This study compared the effects of local platelet-rich plasma, corticosteroid, and placebo injections in the treatment of chronic plantar fasciitis. In this double-blind study, patients were divided randomly into 3 groups. Local injections of platelet-rich plasma, corticosteroid, or normal saline were given. Patients were assessed with the visual analog scale for pain and with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score before injection, at 3 weeks, and at 3-month follow-up. Mean visual analog scale score in the platelet-rich plasma and corticosteroid groups decreased from 7.44 and 7.72 preinjection to 2.52 and 3.64 at final follow-up, respectively. Mean AOFAS score in the platelet-rich plasma and corticosteroid groups improved from 51.56 and 55.72 preinjection to 88.24 and 81.32 at final follow-up, respectively. There was a significant improvement in visual analog scale score and AOFAS score in the platelet-rich plasma and corticosteroid groups at 3 weeks and at 3-month follow-up. There was no significant improvement in visual analog scale score or AOFAS score in the placebo group at any stage of the study. The authors concluded that local injection of platelet-rich plasma or corticosteroid is an effective treatment option for chronic plantar fasciitis. Platelet-rich plasma injection is as effective as or more effective than corticosteroid injection in treating chronic plantar fasciitis. [Orthopedics. 2016; 39(2):e285–e289.]

Plantar fasciitis is a common cause of heel pain. The diagnosis is primarily based on history and clinical findings, and further investigations are rarely required. Prolonged weight bearing, obesity, and reduced plantar flexion are well-described risk factors.1 Nonsurgical treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), night splints, ice packs, plantar fascia stretching exercises, corticosteroid injections, and extracorporeal shock wave therapy. In more than 80% of patients, symptoms resolve with these nonoperative measures.2 In 10% of cases, patients do not improve with conservative measures and the disease becomes chronic.3 Delay in starting treatment, obesity, and bilateral disease are risk factors for chronic disease.4

Local injection of platelet-rich plasma is an emerging concept in treating recalcitrant tendon and ligament pathologies, including plantar fasciitis. Platelet-rich plasma injection delivers platelets and growth factors in high concentrations directly to the site of injury, which otherwise is inaccessible to growth factors as a result of hypovascularity and hypocellularity.5 To the best of the authors' knowledge, no study has evaluated the effect of platelet-rich plasma in chronic plantar fasciitis with a placebo control group. Although previous studies compared platelet-rich plasma and corticosteroid injection with variable results, comparison with a placebo control group is important in showing that the improvement is the result of treatment only and not the routine course of disease. This study is the first prospective randomized double-blind placebo control study to compare the effectiveness of platelet-rich plasma and corticosteroid in chronic plantar fasciitis.

Materials and Methods

Institutional review board approval was obtained, and all patients provided informed consent. The study included 75 patients with chronic plantar fasciitis. Patients were diagnosed on the basis of history and physical examination, including heel pain and tenderness over the plantar-medial aspect of the calcaneal tuberosity, near the insertion of the plantar fascia. In patients with bilateral planter fasciitis, only the right heel was included in the study. Patients had not responded to at least 3 months of conservative therapy, including physical therapy, NSAIDs, bracing, and orthotics. Treatment with NSAIDs was discontinued 1 week before injection. Participants were randomly divided by computer-derived random charts into 3 groups. Group A was assigned to receive platelet-rich plasma, group B was assigned to receive corticosteroid, and group C was assigned to receive normal saline.

For preparation of platelet-rich plasma in group A, 27 mL of blood was withdrawn from the cubital vein and placed in a glass tube containing 3 mL of citrate dextrose solution. Citrate dextrose solution was used to prevent clotting. The blood was centrifuged at 3200 rpm for 12 minutes, and 2.5 to 3 mL of platelet-rich plasma was obtained by this method. No activating agents were used. Only 5 mL of blood was extracted from patients in groups B and C. Patients did not know the amount of blood extracted. In group B, 2 mL of 40 mg of methylprednisolone was used for injection.

The injection was given at the point of maximum tenderness in the heel with a 22-g needle using a peppering technique. This technique involved use of a single skin portal and 4 to 5 penetrations of the fascia. During injection, a screen was placed between the patient's face and the injection area so that the patient could not see the syringe or the content of the injection. Injections were given under aseptic conditions as a day procedure. Patients were instructed not to use NSAIDs for 1 month after the procedure. After the injection, patients were advised to apply ice for pain relief if required and to continue to wear comfortable shoes with cushions. All patients had physical therapy to stretch the calf muscle and plantar fascia.

Patients were assessed before injection and during follow-up at 3 weeks and 3 months by a blinded observer working in the authors' department as a resident physician. Assessment was conducted with the visual analog scale for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score.

In groups A, B, and C, preinjection visual analog scale and AOFAS scores were compared with visual analog scale and AOFAS scores at 3 weeks of follow-up with paired 2-tailed Student's t test. Similarly, preinjection visual analog scale and AOFAS scores were compared with visual analog scale and AOFAS scores at 3 months of follow-up using paired 2-tailed Student's t test. Visual analog scale and AOFAS scores in groups A and B were compared with unpaired 2-tailed Student's t test. P<.05 was considered significant.

Results

Mean age of the patients in groups A, B, and C was 30.72, 33.92, and 35.48 years, respectively (Table 1). Mean visual analog scale score in groups A, B, and C before injection was 7.44, 7.72, and 7.56, respectively, which improved to 3.76, 2.84, and 7.12, respectively, at 3 weeks and 2.52, 3.64, and 7.44, respectively, at 3 months of follow-up. Mean AOFAS score in groups A, B, and C before injection was 51.56, 55.72, and 50.28, respectively, which improved to 83.92, 86.6, and 53.88, respectively, at 3 weeks of follow-up and 88.24, 81.32, 50.84, respectively, at 3 months of follow-up.


Patient Demographic Characteristics

Table 1:

Patient Demographic Characteristics

Mean visual analog scale and AOFAS scores improved over time after injection in groups A and B. In group A, visual analog scale score decreased significantly from preinjection level at follow-up of 3 weeks (P=0) and 3 months (P=0). Compared with the preinjection level, AOFAS score improved significantly at follow-up of 3 weeks (P=0) and 3 months (P=0). Similarly, in group B, visual analog scale score decreased significantly from pre-injection level at follow-up of 3 weeks (P=0) and 3 months (P=0). The AOFAS score improved significantly at follow-up of 3 weeks (P=0) and 3 months (P=0) in group B. In group C, no significant difference was seen between preinjection visual analog scale score and visual analog scale score at 3 weeks (P=.11) or between preinjection visual analog scale score and visual analog scale score at 3 months (P=.41). No significant difference was seen between preinjection AOFAS score and AOFAS score at 3 weeks (P=.06) or between pre-injection AOFAS score and AOFAS score at 3 months (P=.39) (Table 2).


Change in Visual Analog Scale and American Orthopaedic Foot and Ankle Society Scores at Follow-up

Table 2:

Change in Visual Analog Scale and American Orthopaedic Foot and Ankle Society Scores at Follow-up

Comparison of groups A and B showed no significant difference in visual analog scale and AOFAS scores before injection (visual analog scale score, P=.37; AOFAS score, P=.20). At 3 weeks of follow-up, group B had better outcome (low visual analog scale score and high AOFAS score) compared with group A, but the difference was not significant (visual analog scale score, P=.35; AOFAS score, P=.33). At 3 months of follow-up, group A had a significantly higher AOFAS score than group B, but the difference in visual analog scale score was not significant (visual analog scale score, P=.22; AOFAS score, P=.00) (Table 3).


Comparison Between Groups A and B

Table 3:

Comparison Between Groups A and B

Discussion

Many authors consider plantar fasciitis a degenerative tissue condition rather than inflammation at the site of origin of the plantar fascia at the medial tuberosity of the calcaneous.6,7 Degeneration of collagen occurs at the site of the lesion because of microtears of the fascia that do not heal. The histologic features of chronic plantar fasciitis show no inflammatory cell invasion at the site of the lesion, and the normal fascia and surrounding tissue are replaced by angiofibroblastic hyperplastic tissue.7,8 Platelet-rich plasma injection delivers platelets with growth factors in high concentrations directly to the site of the lesion, which otherwise is inaccessible to growth factors because of hypovascularity and hypocellularity.9 The cytokines in platelet alpha granules affect the healing stages necessary to reverse chronic plantar fasciitis by enhancing fibroblast migration and proliferation, increase vascularization, and improve collagen deposition.10

Previous studies described platelet-rich plasma injection as an effective treatment option for chronic plantar fasciitis (Table 4).11–20 Monto11 found that platelet-rich plasma injection was more effective and durable than corticosteroid injection at 2 years of follow-up in a study of 40 patients.


Previous Studies of Platelet-Rich Plasma Treatment in Chronic Plantar Fasciitis

Table 4:

Previous Studies of Platelet-Rich Plasma Treatment in Chronic Plantar Fasciitis

Shetty et al12 compared the effectiveness of platelet-rich plasma and corticosteroid injections in 60 patients and found no significant difference at 6 months of follow-up. Peerbooms et al13 performed a randomized controlled multicenter trial of 120 patients comparing platelet-rich plasma and corticosteroid injections, but the results were not published. When Aksahin et al14 compared intralesional corticosteroid and platelet-rich plasma injections for plantar fasciitis, the treatments were found to be equally effective. In a prospective randomized study, Lee and Ahmad15 compared intralesional autologous blood injection with corticosteroid injection in patients with chronic plantar fasciitis. At 6 weeks and 3 months of follow-up, the corticosteroid group had significantly lower visual analog scale scores than the autologous blood group, but the difference was not significant at 6 months. The corticosteroid group had a significantly higher tenderness threshold than the autologous blood group at 6 weeks, 3 months, and 6 months of follow-up.15

The current study found that local platelet-rich plasma and corticosteroid injections were effective at 3 weeks and 3 months of follow-up, with significant improvement in visual analog scale and AOFAS scores. This was not the case with placebo injection. Comparison of platelet-rich plasma and corticosteroid injections showed no significant difference at 3 weeks of follow-up. At 3 months of follow-up, platelet-rich plasma injection had significantly better outcomes compared with corticosteroid injection, based on AOFAS score, but both procedures had the same outcomes, based on visual analog scale score.

Platelet-rich plasma was administered at the point of maximum tenderness of the heel. Some studies advocate an ultrasound-guided technique for administering injection in plantar fasciitis.21,22 However, Kane et al23 reported no significant difference in their comparative study between ultrasound-guided and palpation-guided injection techniques in the management of idiopathic plantar fasciitis. In previous studies, platelet-rich plasma injection was administered with a peppering technique where the fascia was injected at multiple sites through a single skin portal.13,17–19 Other authors used a medial approach to administer platelet-rich plasma.14,16 It is not known whether either technique is superior. In the current study, the peppering technique was used.

Platelet concentration in platelet-rich plasma varies depending on the method of preparation. Preparations with a high concentration of platelets have a greater level of restorative growth factors. There is no final consensus regarding the threshold concentration of platelets in platelet-rich plasma. In addition, the superiority of leukocyte-reduced or leukocyte-rich platelet-rich plasma is debatable.24,25 In the current study, leukocytes were not separated from platelet-rich plasma.

Limitations

The sample size in the current study was small, and further study with a larger sample is required to confirm the results.

Conclusion

Local injection of platelet-rich plasma or corticosteroid is an effective treatment option for chronic plantar fasciitis. The authors believe that platelet-rich plasma injection is as effective as or more effective than corticosteroid injection at 3 months of follow-up.

References

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Patient Demographic Characteristics

CharacteristicGroup A (n=25)Group B (n=25)Group C (n=25)Pa
Age, mean±SD, y30.72±7.4233.92±8.6135.48±9.54.14
Sex, male:female8:1712:1311:14

Change in Visual Analog Scale and American Orthopaedic Foot and Ankle Society Scores at Follow-up

Score/GroupPreinjection3 Weeks3 Months
Visual analog scale score, mean±SD
  Group Aa7.44±1.043.76±1.532.52±1.71
  Group Ba7.72±1.172.84±1.463.64±1.62
  Group Cb7.56±1.157.12±1.127.44±1.04
American Orthopaedic Foot and Ankle Society score, mean±SD
  Group Aa51.56±11.1083.92±12.1288.24±8.76
  Group Ba55.72±11.7986.6±6.7781.32± 6.39
  Group Cc50.28±11.0153.88±11.8150.84±10.76

Comparison Between Groups A and B

Score/GroupPreinjection3 Weeks3 Months
Visual analog scale score, mean±SD
  Group A7.44±1.043.76±1.532.52±1.71
  Group B7.72±1.172.84±1.463.64±1.62
  P.37.35.22
American Orthopaedic Foot and Ankle Society score, mean±SD
  Group A51.56±11.183.92±12.1288.24±8.76
  Group B55.72±11.7986.6±6.7781.32±6.39
  P.20.33.00

Previous Studies of Platelet-Rich Plasma Treatment in Chronic Plantar Fasciitis

StudyDesignDoses of Platelet-Rich PlasmaAssessment MethodFollow-upConclusion
Shetty et al12 (2014)Comparison between PRP injection and corticosteroid injection (60 patients)1VAS score FADI AOFAS score3 moNo significant difference between PRP and corticosteroid injection
Monto11 (2014)Comparison between PRP injection and corticosteroid injection (50 patients)1AOFAS scorePreinjection; 3, 6, 12, 24 moPRP more effective and durable than corticosteroid injection
Martinelli et al16 (2013)PRP injection in 14 patients3VAS score Roles and Maudsley score12 moPRP injection effective in treatment
Kumar et al17 (2013)PRP injection in 44 patients (50 heels)1VAS score AOFAS score Roles and Maudsley score6 moPRP injection effective in treatment
Wilson et al18 (2014)PRP injection in 12 patients (24 heels)1FAAM score Foot-SANE score SF-12v24, 8, 16, 32, 52 wkPRP injection effective in treatment
Aksahin et al14 (2012)Comparison between PRP injection and corticosteroid injection (60 patients)1VAS score Modified Roles and Maudsley score3 wk; 6 moPRP injection as effective as corticosteroid injection
Ragab and Othman19 (2012)PRP injection in 25 patients1VAS score UltrasoundPreinjection; 2, 6 wk; 6, 12 moPRP injection effective in treatment
Peerbooms et al13 (2010)Comparison between PRP injection and corticosteroid injection (120 patients)1VAS score AOFAS score4, 8, 12, 26 wk; 1 yResults not available
Lee and Ahmad15 (2007)Comparison between autologous blood injection and corticosteroid injection (61 patients)1VAS score Tenderness thresholdPreinjection; 6 wk; 3, 6 moBetter results in corticosteroid injection group
Barrett and Erredge20 (2004)Autologous blood injection in 9 patients1Ultrasound1 wk; 1, 2, 3, 12 moAutologous blood treatment effective in treatment
Authors

The authors are from the Department of Orthopaedics (PM, MY, HSS, SS), Dayanand Medical College and Hospital, Ludhiana; and the Department of Orthopaedics (AS), Guru Gobind Singh Medical College and Hospital, Faridkot, India.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Ashwani Soni, MS, Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, House No 172, Park Ave, Faridkot 151203, India ( asoniortho@gmail.com).

Received: March 27, 2014
Accepted: June 24, 2014

10.3928/01477447-20160222-01

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