SLR - May 2016 - Tamer Younan

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

Reference: Mahindra P, Yamin M, Selhi HS, Singla S, Soni A. Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo. Orthopedics. 2016 Mar 1;39(2):e285-e289.

Scientific Literature Review

Reviewed By: Tamer Younan, DPM
Residency: Cedars-Sinai Medical Center, Los Angeles, CA

Podiatric Relevance: Plantar fasciitis is one of the most common causes of heel pain. It is a debilitating disease, especially in its chronic form. Therefore, it is vital that the most effective treatment options for this condition are employed in podiatric practice. Various treatment options are available, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, orthoses, physiotherapy, surgical management, as well as multiple other options. Local injection of platelet-rich plasma is an emerging concept in treating recalcitrant tendon and ligament pathologies, including plantar fasciitis. The authors of this publication aimed to compare the effects of local platelet-rich plasma (PRP), corticosteroid, and placebo injections in the treatment of chronic plantar fasciitis.

Methods: The study was a prospective randomized, controlled trial performed at two different centers in India. Included patients had persistent, incapacitating symptoms and physical exam findings consistent with plantar fasciitis (heel pain and tenderness over the plantar-medial aspect of the calcaneal tuberosity). These patients also had not responded to at least three months of conservative therapy, including physical therapy, NSAIDs, bracing, and orthotics. In this double-blind study, patients were divided randomly into three groups: local injections of platelet-rich plasma, corticosteroid, or normal saline were given. Treatment with NSAIDs was discontinued one week before injection.

For the PRP cohort, 27 mL of blood was withdrawn from the cubital vein. 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. In the corticosteroid cohort, 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 four to five penetrations of the fascia. Patients were instructed not to use NSAIDs for one month after the procedure. After the injection, patients were advised to continue to ice as necessary and wear comfortable shoes with cushions. All patients had physical therapy to stretch the calf muscle and plantar fascia.

Clinical outcome measures consisted of scores from the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot questionnaire, and the visual analog scale (VAS) for pain, activity, and patient satisfaction. Subjects were assessed prior to injection, at three weeks and at three-month follow-up.

Results: Mean VAS score in the PRP and corticosteroid groups decreased from 7.44 and 7.72 pre-injection to 3.76 and 2.84 at three-weeks follow-up, as well as to 2.52 and 3.64 at three-month follow-up, respectively. Mean AOFAS score in the PRP and corticosteroid groups improved from 51.56 and 55.72 pre-injection to 83.92 and 86.6 at three-weeks follow-up, as well as to 88.24 and 81.32 at three-month follow-up, respectively. There was a significant improvement in VAS and AOFAS scores in the PRP and corticosteroid groups at three weeks and at three-month follow-up. There was no significant improvement in VAS or AOFAS scores in the placebo group at any stage of the study.

Comparison of the PRP and corticosteroid groups showed no significant difference in VAS and AOFAS scores before injection. At three weeks of follow-up, the corticosteroid group had better outcome (low VAS score and high AOFAS score) compared with the PRP group, but the difference was not significant. At three months of follow-up, the PRP group had a significantly higher AOFAS score than the corticosteroid group, but the difference in VAS score was not significant.

Conclusions: Based on their findings, the authors of the study concluded that local injection of PRP or corticosteroid is an effective treatment option for chronic plantar fasciitis. PRP injection is as effective as or more effective than corticosteroid injection in treating chronic plantar fasciitis according to their results. Some limitations of the study were that the sample size was small (n=75) and there was a lack of commentary on their post injection protocol which can play role in final outcomes. There was mention of patients partaking in physical therapy and wearing comfortable shoes but no details were given.

The process of administering corticosteroids versus PRP may be less involved and more effective in the treatment of inflammatory processes; however, as prior literature has indicated that chronic plantar fasciitis is more of a degenerative process on the histologic level, PRP may be the more appropriate treatment option for addressing the physiologic process while also treating symptoms. Another limitation of this study was the short follow up time (three months). Plantar fasciitis is usually not only chronic in nature but also recurs frequently even after resolution of symptoms. A study with longer follow-up may be more helpful in assessing the long-term efficacy of corticosteroid versus platelet-rich plasma injections.

Educational Opportunities