Table of Contents    
ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 135-139  

Evaluating the efficacy of platelet rich plasma injection for the treatment of chronic plantar fasciitis


1 Institute of Orthopaedics and Traumatology, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
2 Institute of Orthopaedics and Traumatology, CMCH, Vellore, Tamil Nadu, India

Date of Submission05-Nov-2019
Date of Decision25-Dec-2019
Date of Acceptance15-Jan-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
Vetrivel Chezian Sengodan
Institute of Orthopaedics and Traumatology, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_199_19

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   Abstract 


Background: Plantar fasciitis is a common and recurring cause of heel pain in adults. Platelet-rich plasma (PRP) derived from autologous blood contains a high concentration of growth factors necessary for tissue healing and offer potential treatment for plantar fasciitis. Materials and Methods: The study was conducted in Coimbatore medical college hospital as a day care procedure. Between May and September 2017, 100 patients with chronic plantar fasciitis with a mean age of 40 years were included in this prospective study and were treated with single autologous PRP injection. All patients were assessed for the pain on the visual analog scale (VAS) and the American orthopedic foot and ankle score (AOFAS) both preinjection and postsingle injection of PRP. Results: The average pain perception before injection as assessed using VAS was observed to be 9.1. Before PRP injection, 72% of patients had severe limitation of activities and 28% of patients had moderate limitation of activities. Following the administration of PRP, VAS decreased to 1.6. Eighty-eight patients were completely satisfied; eight patients were satisfied with reservation, whereas four patients were unsatisfied with the treatment outcome. AOFAS improved from 52 to 90, thus establishing its therapeutic efficacy both at 8 weeks and 3 months posttreatment. Conclusion: The results of this study support that injection of autologous PRP is safe, does not affect the biomechanical function of the foot and is efficacious in improving plantar fasciitis.

Keywords: American orthopedic foot and ankle score, plantar fasciitis, platelet-rich plasma, visual analogs scale


How to cite this article:
Sengodan VC, Thiagarajan N, Raajendiren IP. Evaluating the efficacy of platelet rich plasma injection for the treatment of chronic plantar fasciitis. J Nat Sc Biol Med 2020;11:135-9

How to cite this URL:
Sengodan VC, Thiagarajan N, Raajendiren IP. Evaluating the efficacy of platelet rich plasma injection for the treatment of chronic plantar fasciitis. J Nat Sc Biol Med [serial online] 2020 [cited 2020 Oct 23];11:135-9. Available from: http://www.jnsbm.org/text.asp?2020/11/2/135/290485




   Introduction Top


Plantar fasciitis is a common cause of heel pain in adults.[1],[2] Pain is usually caused due to collagen degeneration at the origin of the plantar fascia. The cause of degeneration is suggested to be due to repetitive microtears of the plantar fascia that limits the body's self-repair process.[3] The classic sign of plantar fasciitis includes intense pain associated with the first few steps in the morning or at the beginning of any physical activity, which lessens as the tissue warms up. In severe cases of plantar fasciitis, the pain will worsen and fail to subside with the tissue warm-up.[4]

In general, plantar fasciitis is a self-limiting disease with a tissue resolution time of 6–18 months, which can lead to frustration among patients and physicians. Conservative lines of treatment, including nonsteroidal anti-inflammatory drugs, heel pads or orthotics, physical therapy, stretching exercises, corticosteroid injections, and extracorporeal shockwave therapy are regarded as the mainstay of treatment and provide substantial to transient relief in about 80% of the patients.[5]

The advancements in orthobiologics or injectable preparations to promote healing through the use of the patient's own biological tissues are seen as a new frontier in the treatment of orthopedic injuries. For the past two decades, Platelets-rich plasma (PRP) has been utilized in a number of medical fields, including orthopedics, sports medicine, neurosurgery, urology, and maxillofacial surgery. PRP is promoted as an ideal autologous blood-derived biological product, which can be exogenously applied to various tissues where it enhances tissue healing by releasing high concentrations of platelet-derived growth factors[6] Although several studies have documented therapeutic efficacy of PRP in tissue healing, most of the literature to date is limited to small pilot or anecdotal studies. Hence, this prospective study was designed to clinically evaluate the efficacy of PRP treatment in plantar fasciitis by injecting PRP directly into the origin of the plantar fascia.


   Materials and Methods Top


This study was conducted between May and September 2017 in Government Coimbatore Medical College Hospital, India, as a day care procedure. One hundred and twelve patients with chronic plantar fasciitis (100 females and 12 males) were recruited. The principal objective of the current study was to define the improvement in the intensity of pain in patients with plantar fasciitis at 8 weeks and 3 months postinjection of PRP using the visual analog scale (VAS) for pain and American orthopedic foot and ankle score (AOFAS). The secondary objective was to assess the consequence of PRP on foot and ankle functions in day-to-day activities before and after PRP injection. The hypothesis tested in this study was PRP is effective in decreasing pain in patients with plantar fasciitis and can improve the foot and ankle function. Ten patients were excluded from this study as per eligibility criteria (outlined below) and two patients did not agree to participate. All the consenting patients were evaluated clinically to rule out pain related to other plantar pathologies.[7] The study finally comprised 100 patients with plantar fasciitis who gave willingness by providing written consent. These patients underwent demographic and basic surveys initially and were staged using VAS, AOFAS after managing them conservatively for two months. All these patients were given PRP injection, and they were evaluated at 8 weeks and 3 months postinjection [Figure 1].
Figure 1: Single-entry-point needle placement technique

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Inclusion criteria

  • Patients aged >18 years with chronic plantar fasciitis after the failure of conservative treatment for at least 3 months
  • Patients should be able to understand the informed consent, and
  • The VAS pain in the morning higher than 5.


Exclusion criteria

  • Patients who received local steroid injection within 6 months, physical therapy within 6 weeks, or nonsteroidal anti-inflammatory within 1 week
  • Active bilateral plantar fasciitis
  • Previous surgery for plantar fasciitis
  • Vascular insufficiency or neuropathy related to heel pain
  • Diabetics or other painful or function limited disorders of the foot and ankle
  • Pregnancy
  • History of severe anemia (hemoglobin <5)
  • Significant cardiovascular, renal, or hepatic disease.


Platelet-rich plasma preparation and injection procedure

Autologous PRP was prepared using the standard method. Initially, 30 ml of the patient's whole blood was collected under aseptic conditions into acid citrate dextrose tubes and subjected to centrifugation at 2000 rpm (soft spin). The whole blood was separated into three layers. The supernatant layer of plasma and buffy coat were separated and subjected to second centrifugation at 3000 rpm (hard spin). In the final end product, the upper two-thirds of the tube which containing platelet poor plasma was discarded, and the lower one-third which was PRP enhanced with the superficial buffy coat was used for injection. An orthopedic surgeon performed the procedure.

The procedure was executed as an op technique. All pain management methods, including oral and injections of pain medication, were avoided. Patients follow-up was done by attending orthopedic surgeon at 8 weeks and 3 months postinjection using VAS for pain and AOFAS. Patients were asked about adverse events and this information was verified by their surgeon and by the review of their medical records.

The primary outcome was changed in pain severity, measured using VAS at 8 weeks and 3 months post-PRP injection. Patients had to think their worst pain in their shoulder for the past 24 h on a 10-cm vertical scale, with “0” indicating no pain at all and “10” indicating the maximum pain the patient could imagine using a series of smilies. The VAS is a simple and sensitive measure that can detect minor changes in an individual's perception of pain severity and easy to understand. Secondary outcome measures included the AOFAS at 8 weeks and 3 months post-PRP injection, as well as recording the incidence of surgeries and adverse events.

Injection technique

The injection was performed as an outpatient procedure under complete aseptic condition. A 5cc autologous platelet concentrate was injected into the most tender area of the plantar fascia by a peppering technique (a single skin portal and 4 or 5 penetrations to fascia) using a 22G needle attached to a syringe. The patient was observed for 15–20-min post-PRP injection and then discharged.

Postinjection protocol

The use of nonsteroidal anti-inflammatory drugs or any type of foot orthosis was prohibited. To avoid discomfort experienced by the patient at the site of the injection for up to 48 h post-PRP injection, the patients are encouraged to use ice pack on the injection site, elevate the limb, and modify activities. Immediately after injection, the patients are kept in the sitting position without moving the foot for 15 min. Patients were discharged with instructions to limit their activities for 48 h and use acetaminophen for pain control if necessary. After 2 days of PRP injection, patients were referred to a physiotherapist to start stretching exercises for 2 weeks and strengthening exercises for additional 2 weeks. At 4 weeks postinjection, the patients are allowed to start normal recreational activities.

Using the VAS, patients were evaluated for preprocedure pain and pain perceived at each postinjection visit. All patients in the study completed a questionnaire at preinjection, 8 weeks postinjection and 3 months follow-up visit. This questionnaire included the following; (1) pain level using VAS when getting out of bed, at rest, and after activity in treating this difficult condition. (2) Effect of the procedure on patient condition; and (3) patient satisfaction. Statistical analysis was performed using the Student's t-test. A value of P < 0.05 was considered to be statistically significant. AOFAS were evaluated using the following questionnaire.


   Results Top


The mean duration of follow-up was for 3 months. Using the VAS, the average preinjection pain was 9.1 (range 8–10) [Table 1] and [Table 2]. As per the patient's response to the questionnaire, 72% of the patients had a severe limitation in activities, and 28% of patients had moderate limitation in activities before injection of PRP. Post-PRP injection, using the same scale the pain decreased to an average of 1.6 (range: 0–6) (P < 0.001). Sixty patients (60%) had no functional limitations postinjection, and only thirty-two patients (32%) had minimal functional limitations [Table 1]. Only eight patients (8%) had moderate functional limitation postoperatively. Eighty-eight patients (88%) were completely satisfied, eight patients (8%) were satisfied with reservations, and four patients (4%) were unsatisfied with the therapeutic outcome of PRP injection. AOFAS improved from 52 to 90 showing significant improvement (P < 0.001) at the end of 8 weeks. The main adverse events identified were: (1) pain and (2) dizziness immediately post PRP injection; although both these adverse outcomes were not specific to this study procedure.
Table 1: Ankle-Hindfoot scale (100 points total)

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Table 2: Visual analog scale for pain and activity improvement perception among patients

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   Discussion Top


The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of the calcaneus and runs forward to form the longitudinal foot arch. The function of the plantar fascia is to provide static support of the longitudinal arch and is a tool for dynamic shock absorption. Plantar fasciitis is the most common condition treated by podiatric foot and ankle specialist. Although the true etiology of plantar fasciitis is still unknown, several etiological factors have been suggested. There are many treatment methods available and when the conservative treatments are nonsatisfactory, the patient often becomes interested in treatment options other than surgery.[8] Steroid injection is a popular method of treating plantar fasciitis; however, its benefits are limited and for short term.[9] Moreover, the treatment with steroids has a high frequency of relapse and recurrence, probably because intrafascial injection may lead to permanent adverse changes within the structure of the fascia and patients tend to overuse the foot after injection as a result of direct pain relief.[10] Since the early 1990s, extracorporeal shock wave therapy (ESWT) was used for the treatment of chronic plantar fasciitis. The benefits from ESWT are mixed and highly variable. Success rates from ESWT are reported to range from 48% to 77%. The underlying working mechanism of ESWT on the plantar fascia is not completely understood, although an analgesic effect and a stimulating effect on tissue regeneration are suggested as possible mechanisms. The major limitation of ESWT includes its contraindications in neuropathic patients, the potential destruction of muscle tissue, development of compartment syndromes, and the cost of treatment.[11]

Several studies have reported that PRP has four to six times the normal level of growth factors, which results in fibrocytes migration and induction of neurovascular growth. In a recent study Peerbooms et al.[12],[13] reported a positive effect of PRP injection on the lateral epicondylitis. In this study, a single injection of PRP improved pain and function significantly superior to corticosteroid injection. Further, the improvements achieved by PRP injection were sustained over a longer period without any complications. One of the significant benefits of PRP injection was that the patient used their own blood for the procedures. The use of autologous sources eliminates all kinds of potential problems, including disease transmission and tissue reaction. The therapeutic use of autologous PRP is not new as it is a vital part of natural healing cascade to any injury or surgical intervention. The benefits of PRP injection relies on endogenous factors delivered to the healing site.[14] Successful tissue healing and regeneration require a scaffold or matrix, undifferentiated cells and signal proteins, and adhesion molecules (growth factors). It is well known that platelets affect the mitogenic activity of cells such as osteoblast, chondroblast, or tenoblast and hence facilitate tissue repair. Injection of PRP into the affected tissues augments the healing process and reverses the degenerative process at the base of the plantar fascia. The various cytokines present in the platelet granules are shown to enhance fibroblast migration/proliferation, vascularization, and increase collagen deposition to facilitate tissue repair process in chronic plantar fasciitis.[15],[16] Transforming growth factor 1 is one such cytokine shown to significantly increase type I collagen production by tendon sheath fibroblast. In addition, many of the other cytokines are also likely to work in a dose-dependent manner to improve tissue repair and healing.

There is greater interest in evaluating the efficacy of PRP for several orthopedic conditions, and hence large controlled, double-blind scientific studies to validate its effectiveness are needed. To date, the literature is limited to pilot studies with a small sample size to evaluate the efficacy of treatment of plantar fasciitis. These pilot studies although useful to establish a proof of concept are not sufficient to validate and clinically translate the application of new scientific treatment methodology. In our study, we did not use local anesthetic, as it could lead to bias, indeed an injection with local anesthetic alone can lead to improvement in plantar fasciitis. Furthermore, we noted little changes in the lateral band thickness because these patients demonstrated the typical type of plantar fascial pain, which is located more medially at the medial calcaneal tubercle.

Although the use of autologous PRP is safe, it is contraindicated in patients with coagulopathies, concurrent anticoagulant therapy, active infection, tumor, and pregnancy. Theoretically, several systemic complications may be associated with the use of PRP, as a result of the systemic increase in growth factors, the injection of PRP could potentially initiate cancer like the effect, but no studies to date have found any data to support this concern. In our study, we did not observe any complications following autologous PRP injection. At the end of the follow-up period, 88% patients had complete resolution of pain and were satisfied with therapeutic outcomes. Our results are comparable to the results from the lateral epicondylitis study and are superior to the results from other procedures used for the treatment of chronic plantar fasciitis such as steroids injection or ESWT. Further, autologous PRP injection cannot impair the biomechanical function of the foot, unlike other invasive procedures that transect or resects part of the plantar fascia. In our study, only eight patients were dissatisfied and had moderate limitation of function.


   Conclusion Top


The study results validate that the injection of autologous PRP for the treatment of chronic plantar fasciitis is very efficacious, leading to a very satisfactory resolution of symptoms. Hence, injecting PRP as a commonly used modality in the treatment of chronic plantar fasciitis can be considered. Certainly, the injection of PRP is safe, economical, cannot impair the biomechanical function of the foot, and none of our patients experienced any complications. This study succeeded in demonstrating that those patients receiving PRP injections have decreased pain, promoted optimal healing and achieved superior functional outcomes. Nevertheless, the molecular mechanisms of benefits from PRP warrant further investigation to refine this therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
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Apalset I, Myhre T, Finsen V. Operative treatment of plantar fasciitis. Foot 2000;10:87-9.  Back to cited text no. 4
    
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Tatli YZ, Kapasi S. The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Curr Rev Musculoskelet Med 2009;2:3-9.  Back to cited text no. 10
    
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van Leeuwen MT, Zwerver J, van den Akker-Scheek I. Extracorporeal shockwave therapy for patellar tendinopathy: A review of the literature. Br J Sports Med 2009;43:163-8.  Back to cited text no. 11
    
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Soomekh DJ. Current Concepts for the Use of Platelet-Rich Plasma in the Foot and Ankle. Clin Podiatr Med Surg [Internet]. 2011;28:155-70.   Back to cited text no. 12
    
13.
Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38:255-62.  Back to cited text no. 13
    
14.
Barrett S, Erredge S. Growth Factors For Chronic Plantar Fasciitis? Pod Today 2004;17:37-42.   Back to cited text no. 14
    
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Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:638-46.  Back to cited text no. 15
    
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    Figures

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    Tables

  [Table 1], [Table 2]



 

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