Plantar fasciitis: Outcome evaluation of plantar fasciitis treated with PRP against steroid injection

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O)Plantar fasciitis: Outcome evaluation ofplantar fasciitis treated with PRP against steroid injection Abdul Rahim*, Mukesh TiwariDept. of Orthopedics, NIMS Hospital and College, Shobhanagar, Jaipur, India *Corresponding author email: [email protected] to cite this article: Abdul Rahim, Mukesh Tiwari. Plantar fasciitis: Outcome evaluation ofplantar fasciitis treated with PRP against steroid injection. IAIM, 2015; 2(2): 46-51.Available online at www.iaimjournal.comReceived on: 16-01-2015 Accepted on: 24-01-2015AbstractPlantar fasciitis is the most common cause of heel pain which seems difficult to treat in its mostchronic and severe forms. Earlier treatments, including orthoses, non steroidal anti-inflammatorydrugs, and steroid injections are paucity of supportive clinical evidence but carry the potential forserious complication and permanent disability. Platelet-rich plasma (PRP) has recently beendemonstrated to be helpful in managing chronic severe plantar fasciitis when other techniques havefailed. The purpose of this study was to assess the safety and preliminary clinical results of platelet-rich plasma injections for treating chronic plantar fasciitis. 163 consecutive patients with chronicplantar fasciitis receiving injections of PRP and 158 patients for steroid injections into the plantarfascia were assessed 12 months after the procedure. The visual analogue scale (VAS) for pain wasused to evaluate the clinical results. According to criteria VAS score, at 12 months of follow-up,results were rated as excellent in all PRP injected patients, good and poor in steroid injectedpatients. In PRP injection, VAS (mean) for pain was significantly decreased from 8.6 before treatmentto 0.3 at the last follow-up. PRP injection has safety and efficiency as treatment for plantar fasciitiswith no side effects and complications.Key wordsPlantar fasciitis, PRP, Steroids.Introduction before proceeding across the transverse bands of the deep transverse metatarsal ligaments toThe plantar fascia is a durable, longitudinal insert along the proximal phalanges. It functionsbundle of thick fibrous bands that originate off using a windlass mechanism to support andthe medial tubercle of the calcaneus. These cushion the foot during gait while efficientlybundles condense to form the arch of the footInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 46Copy right © 2015, IAIM, All Rights Reserved.

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)converting potential energy to kinetic energy awareness of platelets and their role in theduring toe-off [1, 2]. healing process has lead to the concept of therapeutic applications. There is emergingPlantar fasciitis is diagnosed on patient history literature on the beneficial effects of PRP forand physical examination. Patients have local chronic non-healing tendon injuries includingpoint tenderness along the medial tuberosity of lateral epicondylitis and plantar fasciitis [9, 10].the calcaneum, pain on weight bearing and/orpain on first steps. It is especially evident upon The findings of existing clinical trials provideddorsiflexion of the patients’ metatarso- some support for the use of corticosteroidphalangeal joint, which further stretches the injection in the short term management ofplantar fascia or windlass mechanism. So any plantar fasciitis [11, 12]. However, a recentactivity that would increase stretch of the systematic review concluded that theplantar fascia, such as walking barefoot without effectiveness of this treatment has not beenany arch support, climbing stairs, or toe walking, sufficiently established [13].can worsen the pain. The diagnosis is usuallyclinical and rarely needs to be investigated by Material and methodsimaging or electromyographically. A comparative study was done in 321 patientsChronic plantar fasciitis is the commonest cause from June 2013 to December 2014 for PRP andof foot complaints in India. The incidence of steroid injections for treatment of plantarplantar fasciitis peaks in people between the fasciitis. Patients of plantar fasciitis in presenceages of 40 to 60 years with no bias towards of other systemic disease like diabetes mellitus,either sex [3]. The underlying condition that rheumatoid arthritis, gout etc, history of anemiacauses plantar fasciitis is a degenerative tissue (hemoglobin < 5.0), and physical/occupationalcondition that occurs near the site of origin of therapies within 4 weeks were excluded fromthe plantar fascia at the medial tuberosity of the this study. Tenderness in the heel on weightcalcaneous [4]. bearing and firm pressure with thumb by palpation especially at the medial side of heelAccording to the World Health Organization were two main criteria for the diagnosis. A(WHO), musculoskeletal injuries are the most lateral X-ray of calcaneum of both heels wascommon cause of severe long-term pain and taken to demonstrate the presence or absencephysical disability, and affect hundreds of of a spur in normal and painful heel for all cases.millions of people around the world [5]. The treatment consisted of steroid injections and PRP injection. The Medical EthicalThe use of autologous PRP was first used in 1987 Committee of The NIMS Medical College andby Ferrari, et al [6]. Platelet-rich plasma (PRP) is Hospital had approved the study design,a bioactive component of whole blood with procedures and informed consent.platelet concentrations elevated above baseline Platelet concentrate preparationand containing high levels of various growthfactors [7]. The rationale for PRP benefit lies in To generate 3 ml of PRP, 20 ml whole blood wasreversing the blood ratio by decreasing redblood cells (RBC) to 5%, which are less useful in drawn. The blood was prepared according to thethe healing process, and increasing platelets to94% to stimulate recovery [8]. An increased GPS system instructions (Cell Factor Technologies, Warsaw, Ind). Platelet concentrate was obtained for each patient. Autologous platelet concentrate containedInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 47Copy right © 2015, IAIM, All Rights Reserved.

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)concentrated white blood cells and platelets patient's reported pain using a scale of 0-10,which were suspended in plasma. The platelet where 0 was pain-free and 10 was the worstconcentrate must be buffered to increase the pH pain imaginable. The scale was 10 centimeterto normal physiologic levels as an acidic line beginning with 0 and ending with 10, theanticoagulant was introduced to the whole score was marked at the point on the line thatblood. The resulting buffered platelet corresponded with the patient response.concentrate contained approximately a 6 to 8times concentration of platelets compared to Follow upbaseline whole blood. No activating agent was All patients had been followed up at 4, 8, 12, 26used. The total time from blood draw to and 52 weeks with complete VAS scores.injection in the patients was about 30 minutes.No specialized equipment, other than the GPS Resultsmachine, was required. The results were obtained on mean VAS in bothInjection technique groups. The cortisone group had a pretreatmentInitially, local block was infiltrated into the skin mean VAS score of 8.5, which initially improvedand subcutaneous tissue of both groups. to 1.1 at 12 weeks post treatment but decreasedApproximately 0.5 cc was also injected directly to 4.9 at 26 weeks, and then continuousinto the area of maximum tenderness. Then, 3 increased to near baseline levels of 8.4 at 52ml platelet concentrate prepared or 5 to 6 cc weeks. In contrast, the PRP group started withcorticosteroid (2 cc steroid + 4 cc normal saline) an average pretreatment 8.6 score, whichwas injected using a 22 g needle into the plantar decreased to 3.4 at 12 weeks, remainedfasciitis maximum tenderness point. declining to 1.2 at 26 weeks and 0.3 at 52 weeks. (Chart – 1)Post-procedure protocol DiscussionImmediately after the injection, for 15 minutespatient was kept in sitting position. After that Surgical treatments for chronic severe plantarpatients were sent to physiotherapist to learn fasciitis, including plantar fasciotomy with andstretching exercises. Patients were sent home without neurolysis of the calcaneal branches ofwith instructions to limit their use hydrocodone the tibial nerve, have demonstrated conflictingor acetaminophen for pain of the feet for late clinical results with pain and disabilityapproximately 48 hours. After 48 hours, patients persisting in many patients [14, 15].were given a standardized stretching protocol tofollow for 2 weeks. A formal strengthening The most common secondary level treatmentprogram was initiated after this stretching. At 4 for plantar fasciitis is the use of corticosteroidweeks after the procedure, patients were injections. Critical reviews of cortisone injectionallowed to proceed with normal sporting or therapy have yielded equivocal short-termrecreational activities as tolerated. findings and disappointing long-term results [16, 17].Corticosteroid Reported benefits of this include provision ofThe type of steroid that was used during the temporary pain relief, dilution of potentiallystudy was depomedrol (methyl prednisolone) 40 harmful corticosteroid crystals (acetates only),mg/ml. We did used VAS score to evaluate the and confirmation of accurate solution depositresults of study. The score recorded theInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 48Copy right © 2015, IAIM, All Rights Reserved.

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)[18]. Hence, Crawford, et al. [19] concluded that takes place, fibrinocytes move in and start layingsteroid injections can provide short-term relief. down new collagen to heal and reinforce the plantar fascia. Other healing components of theHowever, a number of complications were blood, such as stem cells migrate into the area,noted including plantar fascial rupture, plantar rebuilding and strengthen the tissue. PRP hasfat pad atrophy, lateral plantar nerve injury none of the side effects as seen in repeatedsecondary to injection, and calcaneal steroid injections, especially no breakdown ofosteomyelitis and in iontophoresis, burning of tissue and recurrence of plantar fasciitis, as seenthe underlying skin [20]. in our study. Platelet rich plasma therapy results in tissue regeneration. As with all injectionLong-term sequelae of plantar fascia rupture procedures, there can be damage towere found in approximately one half of the neurovascular structures, infection and pain butpatients with plantar fascia rupture, with in our study no such side effects were seen.longitudinal arch strain accounting for morethan one half of the chronic complications [21, Conclusion22] in steroid injection. In PRP therapy, healing of the damaged,Results of a Cochrane review showed that inflamed plantar fascia. PRP injection has safetycorticosteroid injection therapy has short-term and efficiency as treatment for plantar fasciitisbenefit compared to control, and the with no recurrence, side effects andeffectiveness of treatment is not maintained complications.beyond six months [12]. ReferencesRagab and Othman [23] examined a larger group 1. Neufeld SK, Cerrato R. Plantar fasciitis:of 25 patients who were injected with PRP and Diagnosis and treatment. J Am Acadwere then followed up for an average of 10.3 Orthop Surg., 2008; 16: 338–346.months after treatment. VAS scores improvedfrom 9.1 pretreatment to 1.6 post treatment. 2. Gill LH. Plantar fasciitis: Diagnosis andBefore treatment, 72% of patients noted severe conservative treatment. J Am Acadactivity limitations, whereas 28% were Orthop Surg., 1997; 5: 109–117.moderately limited. After PRP treatment, 60%had no functional limitations, 32% had mild 3. Taunton J, Ryan M, Clement D,limitations, and 8% noted moderate limitations. McKenzie D, Lloyd-Smith D, Zumbo B. AUltrasonography was completed before and retrospective case-control analysis ofafter PRP treatment and demonstrated 2002 running injuries. Br J Sports Med,decreased plantar fascial Thickening. By 2002, 36: 95-101.combining eccentric exercise and cyclic plantarfascia–specific stretching with PRP injection, 4. Buchbinder R. Clinical practice. Plantarenhanced and accelerated healing with excellent fasciitis. N Engl J Med, 2004, 350: 2159-long-term results can be achieved in refractory 2166.cases [24, 25]. 5. Woolf AD, Pfleyer B. Burdon of majorInitially PRP induces slightly more inflammation, musculoskeletal conditions. Bull Worldpart of the healing process, but then the action Health Organ., 2003; 81: 646–56. 6. Ferrari M, Zia S, Valbonesi M. A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiacInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 49Copy right © 2015, IAIM, All Rights Reserved.

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P)surgery. Int J Artif Organs., 1987; 10: 47– ISSN: 2394-0034 (O) 18. Jacobs J. How to perform local soft-50. tissue glucocorticoid injections. Best7. Hall MP, Brand PA, Meislin RJ, et al. Pract Res Clin Rheumatol, 2009; 23: 193-Platelet-rich plasma: Current concepts 219.and application in sports medicine. J Am 19. Crawford F, Atkins D, Young P, EdwardsAcad Orthop Surg., 2009; 17: 602–609. J. Steroid injection for heel pain:8. Marx R, Garg A. Dental and craniofacial evidence of short-term effectiveness. Aapplications of platelet-rich plasma. randomized controlled trial.Carol Stream: Quintessence Publishing Rheumatology (Oxford, England), 1999;Co, Inc.; 2005. 38(10): 974–7.9. Mishra A, Pavelko T. Treatment of 20. Gudeman SD, Eisele SA, Heidt RS, Jr,chronic elbow tendinosis with buffered Colosimo AJ, Stroupe AL. Treatment ofplatelet-rich plasma. Am J Sports Med., plantar fasciitis by iontophoresis of 0.4%2006; 10(10): 1–5. dexamethasone. A randomized, double-10. Barrett S, Erredge S. Growth factors for blind, placebo-controlled study. Am Jchronic plantar fascitis. Podiatry Today, Sports Med., 1997; 25(3): 312–6.2004; 17: 37–42. 21. Acevedo JI, Beskin JL. Complications of11. Buchbinder R. Plantar fasciitis. N Engl J plantar fascia rupture associated withMed, 2004; 350: 2159-66. corticosteroid injection. Foot Ankle Int.,12. Crawford F, Thomson C. Interventions 1998; 19: 91–7.for treating plantar heel pain. Cochrane 22. Sellman JR. Plantar fascia ruptureDatabase Syst Rev, 2003; 3: CD000416. associated with corticosteroid injection.13. Landorf K, Menz H. Plantar heel pain and Foot Ankle Int., 1994; 15: 376–81.fasciitis. Clin Evid, 2008; 2: 1111. 23. Ragab EM, Othman AM. Platelet rich14. Woelffer KE, Figura MA, Sandberg NS, et plasma for treatment of chronic plantaral. Five-year follow-up results of instep fasciitis. Arch Orthop Trauma Surg.,plantar fasciotomy for chronic heel pain. 2012; 132: 1065–1070.J Foot Ankle Surg., 2000; 39: 218–223. 24. Monto RR. Platelet rich plasma15. Conflitti JM, Tanquinio TA. Operative treatment for chronic Achillesoutcome of partial plantar fasciectomy tendinosis. Foot Ankle Int., 2012; 33:and neurolysis to the nerve of the 379–385.abductor digit minimi muscle for 25. Virchenko O, Aspenberg P. How can onerecalcitrant plantar fasciitis. Foot Ankle platelet injection after tendon injuryInt., 2004; 25: 482–487. lead to a stronger tendon after 4 weeks?16. Crawford F, Atkins D, Young P, et al. Interplay between early regenerationSteroid injections for heel pain: evidence and mechanical stimulation. Actaof short-term effectiveness. A Orthop., 2006; 77: 806–812.randomized controlled trial.Rheumatology, 1999; 38: 974–977.17. Tsai WC, Hsu CC, Chen CP, et al. Plantarfasciitis treated with local steroidinjection: Comparison betweensonographic and palpation guidance. JClin Ultrasound., 2006; 34: 12–16.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 50Copy right © 2015, IAIM, All Rights Reserved.

Outcome evaluation of plantar fasciitis treated with PRP ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Chart – 1: Follow up v/s mean VAS score of patients treated with PRP and steroid injections.VAS SCORE (MEAN) PRP VS STEROID INJECTIONS. PRP Steroid 10 9 8 7 6 5 4 3 2 1 0 0 4 8 12 26 52 WEEKSSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 51Copy right © 2015, IAIM, All Rights Reserved.