A study to compare the efficacy of corticosteroid therapy with platelet-rich plasma therapy in recalcitrant plantar fasciitis: a preliminary report

Botulinum toxin A versus platelet rich plasma ultrasound-guided injection in the treatment of plantar fasciitis: A randomised controlled trial

BACKGROUND

Platelet-rich plasma (PRP) and botulinum toxin type A (BTX-A) injections have proven effective in clinical trials for plantar fasciitis treatment but have not been directly compared. We aimed to compare clinical outcomes in patients undergoing PRP or BTX-A injections.

METHODS

We performed a randomised controlled trial (59 patients; 1-year follow-up) to assess efficacy, using pain and functional scales (VAS, AOFAS Hindfoot-scale and FAAM questionnaire) and fascia thickness reduction, in control and single ultrasound-guided BTX-A or PRP injection groups.

RESULTS

The BTX-A group showed better results at 1-month after treatment. Conversely, the PRP injection was more effective in the long-term, with significant pain reduction and functional improvement. Plantar fascia thickness significantly reduced from months 1 and 3 in the PRP and BTX-A groups, respectively.

CONCLUSION

PRP and BTX-A injections are effective in patients with plantar fasciitis with BTX-A achieving better short-term pain reduction and PRP better long-term results.

LEVEL OF EVIDENCE

Level I; Randomised Controlled Trial.

Platelet-rich plasma injections as a treatment for Achilles tendinopathy and plantar fasciitis in athletes

Platelet-rich plasma (PRP) injections represent a growing interest in the use of biologic therapies for treatment of musculoskeletal injuries. One possible application of PRP is in the management of overuse injuries commonly experienced by athletes. The aim of this review is to evaluate and summarize existing evidence regarding the efficacy of PRP in the treatment of Achilles tendinopathy and plantar fasciitis in athletes. Although many lower quality single-armed studies have demonstrated clinical improvement in athletes treated for Achilles tendinopathy with PRP, higher quality randomized controlled trials (RCTs) have shown no clear benefit in athletes. Existing data suggest PRP significantly improves clinical outcomes for plantar fasciitis in the general population, but very few studies and no RCTs are available that specifically analyze outcomes in athletic populations. More research is needed to evaluate how platelet concentration, leukocyte and erythrocyte presence, and sport type may interact to affect clinical outcomes in athletes.

Comparative study of local injections of autologous platelet rich plasma versus corticosteroid in management of chronic plantar fasciitis

Background

Plantar fasciitis is a known degenerative pathology and is a common cause of heel pain. We intend to evaluate the efficacy between locally injected Corticosteroids and autologous PRP in the management of chronic plantar fasciitis patients.

Materials and methods

In this prospective randomized controlled study, 70 chronic plantar fasciitis with failed conservative management for 3 months were randomly selected into 2 groups of 35 patients each. Group A received a local autologous platelet rich plasma injection of 3 ml and group B received a local corticosteroid injection of 2 ml. The Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores were compared between the groups at 15 days, 1 month, 3 months and 6 months.

Results

No improvement in pain between autologous PRP and corticosteroids study subjects was noted in the initial period up to 15 days whereas after 1 month, 3 months and 6 months duration, it is seen that autologous PRP injected study subjects showed significant relief in pain compared to corticosteroids.

Conclusion

PRP was more effective in chronic plantar fasciitis patients compared to corticosteroids with pain relief coming after first 1st, 3rd and 6th month of the injection.

Level of evidence

Level 2.

Extracorporeal Shockwave Therapy Versus Platelet Rich Plasma Injection in Patients of Chronic Plantar Fasciitis: A Randomized Controlled Trial From a Tertiary Center of Eastern India

Introduction Plantar fasciitis is a degenerative condition of the plantar fascia that leads to heel and sole pain. Physical modalities, physiotherapy, medication, and orthoses have been tried before as treatments. Extracorporeal shockwave therapy (ESWT) and the injection of autologous platelet-rich plasma (PRP) are generally effective in the treatment of plantar fasciitis, which might be resistant to other conservative measures. The present study compares the efficacy of ESWT and PRP injection in respect of symptomatic relief, functional improvement, and change in plantar fascia thickness (PFT). Methods Seventy-two patients were enrolled and randomized into two groups. Patients in the first group received ESWT, whereas patients in the second group received PRP injections. Patients were evaluated using the Visual Analog Scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) score, along with PFT measurement (using ultrasonography) before the treatment and at days 15, 30, and 90 after the treatment. The X² test was used to compare qualitative variables, and the paired T-test was used to evaluate quantitative data. Quantitative variables had a normal distribution with a standard deviation, and the significance level was set at P-value=0.05. Results On day 0, the mean VAS of the ESWT and PRP groups were 6.44±1.11 and 6.78±1.17, respectively (p=0.237). On day 15, the mean VAS of the ESWT and PRP groups were 4.67±1.45 and 6.67±1.35, respectively (p<0.001). At day 30, the mean VAS of the ESWT and PRP groups were 4.97±1.46 and 4.69±1.39, respectively (p=0.391). On day 90, the mean VAS of the ESWT and PRP groups were 5.47±1.63 and 3.36±0.96 (p<0.001). On day 0, the mean PFTs of the ESWT and PRP groups were 4.73±0.40 and 5.19±0.51, respectively (p<0.001). At day 15, the mean PFT of the ESWT and PRP groups were 4.64±0.46 and 5.11±0.62, respectively (p<0.001) which changed to 4.52±0.53 and 4.40±0.58 at day 30 (p<0.001), and to 4.40±0.50 and 3.82±0.45 at day 90 (p<0.001). The mean AOFAS of the ESWT and PRP groups were 68.39±5.88 and 64.86±8.95 on day 0 (p=0.115), 72.58±6.26 and 67.22±10.47 on day 15 (p=0.115), 73.22±6.92 and 74.72±7.52 on day 30 (p=0.276), and 72.75±7.90 and 81.08±6.01 on day 90, respectively (p<0.001). Conclusion Both PRP injection and ESWT are very effective methods to improve pain and cause reduced plantar fascia thickness in patients with chronic plantar fasciitis non-responsive to other conservative measures. PRP injection is more effective at a longer duration as compared to ESWT.

Similar Benefits Seen After Radial Extracorporeal Shockwave Therapy or Autologous Blood Injection in Patients With Chronic Plantar Fasciitis-A Retrospective Cohort Study

OBJECTIVE

To compare the outcomes for patients with chronic plantar fasciitis after extracorporeal shockwave therapy (ESWT) or autologous blood injection (ABI).

DESIGN

Cohort study-retrospective analysis of prospectively collected data.

SETTING

Hospital-based Sports Medicine Outpatient Clinic.

PATIENTS

One hundred two consecutive patients with chronic plantar fasciitis, treated with either radial-ESWT (rESWT) (n = 54) or ABI (n = 48), with minimum 3-month follow-up and 96% (98/102) having 6-month follow-up. Mean age 49.5 years and mean duration of symptoms 37.5 months before treatment.

INTERVENTIONS

Patients received either 3 sessions of radial ESWT (one session per week for 3 weeks), or a single ultrasound-guided dry needling and ABI (3 mL whole autologous blood). All patients received standardized after-care, including progressive structured home exercise program of flexibility, strengthening, and proprioception exercises.

MAIN OUTCOME MEASURES

0 to 10 numerical rating scale (NRS) for self-reported "average pain" and "average stiffness" values. Secondary outcome measures included assessments of local foot function [including Manchester-Oxford Foot Questionnaire (MOXFQ), revised-Foot Function Index] as well as markers of mental health functioning (HAD), global health (EQ-5D-5L), and physical activity (International Physical Activity Questionnaire).

RESULTS

This study demonstrated statistically significant improvements in self-reported measures of pain and local foot function after either procedure at 6 weeks, 3 months, and 6 months, but no statistically significant differences were seen between groups at any time-period studied. At 6 months, the average pain using a 0 to 10 NRS was improved from 6.8 ± 1.8 to 4.0 ± 2.7 (P < 0.001) after ESWT and from 7.1 ± 1.6 to 3.8 ± 2.7 (P < 0.001) after ABI. At 6 months, significant improvements were seen following either group using a number of different validated patient-rated outcome measures assessing local foot pain and function, eg, the total score for MOXFQ improved from 56.1 ± 12.8 to 42.5 ± 16.6 (P < 0.001) after ESWT and from 58.8 ± 13.2 to 44.2 ± 19.2 (P < 0.001) after ABI. However, measures of physical activity or wider aspects of patient functioning did not consistently improve from baseline values to follow-up periods.

CONCLUSIONS

Patients with chronic plantar fasciitis improved to statistically significant extent after either rESWT or ABI procedures, with no significant differences seen between groups. The lack of randomization in this pragmatic study is noted, which may have influenced the outcome seen. Potentially larger and more robust studies are required to investigate this treatment comparison further.

The 2020 NBA Orthobiologics Consensus Statement

This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.

Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Chronic Plantar Fasciitis: A Systematic Review and Meta-analysis of Prospective Comparative Studies

Plantar fasciitis is a common cause of heel pain, which often results in a significant limitation of daily activity. The objective of this review was to compare platelet-rich plasma injection (PRP) and corticosteroids injection in the treatment of chronic plantar fasciitis. MEDLINE, PubMed, Web of Science, EMBASE, and the Cochrane library of clinical trials were searched in March 2019. Inclusion criteria were prospective comparative studies reporting functional scores or pain score with a minimum follow-up of 1 month. We excluded studies with patients younger than 18 years and patients with a history of surgical intervention, infection, or rheumatological disease. First author, publication year, sample size, type of intervention, outcome measures, and follow-up period were recorded. The American Orthopaedic Foot & Ankle Society score was significantly better in the PRP group at 6 months' follow-up, with a lower visual analogue scale at 6- and 12-month intervals. The Foot and Ankle Disability Index and Roles-Maudsley score were similar in the 2 treatments at 3 and 6 months. PRP injection in the treatment of chronic plantar fasciitis is considered safe, with a favorable functional outcome and pain control at intermediate and long-term follow-up in comparison to corticosteroid injection.

Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis

BACKGROUND

Plantar fasciitis is a common cause of heel pain. Corticosteroid injections are commonly used and proven to be effective, and lately platelet-rich plasma (PRP) has been used with mixed results.

PURPOSE

To perform a systematic review and meta-analysis comparing intralesional injections of PRP and steroid infiltration.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of Medline, Embase, Scopus, and Google Scholar including all level 1 and 2 studies from 2010 to 2019 was perfomed. American Orthopaedic Foot and Ankle Society and visual analog scale for pain scores were used as outcome variables. Publication bias and risk of bias was assessed with the Cochrane Collaboration tools. The Grading of Recommendations, Assessment, Development and Evaluations system was used to assess the quality of the body of evidence. Heterogeneity was assessed with χ² and I² statistics.

RESULTS

Fifteen studies were included in the analysis. Nine studies had a high risk of bias. There was 1 study with high quality, 9 with moderate, 2 studies with low, and 3 with very low quality. The pooled estimate for the American Orthopaedic Foot and Ankle Society score demonstrated nonsignificant differences at 1 month (P = .4) and 3 months (P = .076). At 6 months (P = .009) and 12 months (P = .009), it indicated significant differences in favor of PRP. The pooled estimate for visual analog scale demonstrated nonsignificant differences at 1 month (P = .653). At 3 months (P = .0001), 6 months (P = .002), and 12 months (P = .019), it yielded significant differences in favor of PRP.

CONCLUSION

The results of this systematic review and meta-analysis suggest that PRP is superior to corticosteroid injections for pain control at 3 months and lasts up to 1 year. In the short term, there is no advantage of corticosteroid infiltration. However, the low study quality, high risk of bias, and different protocols for PRP preparation reduce the internal and external validity of these findings, and these results must be viewed with caution.

Prospective Randomized Evaluation of Local Injection of Allogeneic Growth Factors in Plantar Fasciitis

BACKGROUND

The aim of this study was to evaluate the efficacy and safety of injection of allogeneic growth factors in patients with plantar fasciitis.

METHODS

This study included 150 patients who were randomly divided into 2 equal groups; the patients were locally injected with allogeneic growth factors (GFs) (treatment group) or with saline 0.9% (control group). The patients were assessed using visual analog scale (VAS) and Foot Function Index-Revised short form (FFI-Rs) scores preinjection and 1, 3, 6, and 12 months postinjection. The patients were questioned about their satisfaction. Any adverse effects were recorded.

RESULTS

At baseline, there was no significant difference between both groups regarding the mean VAS and FFI-Rs scores. At 3-month follow-up, the reduction in mean VAS score was 87% in the treatment group and 55% in the control group (P < .001), and the reduction in mean FFI-Rs score was 62% in the treatment group and 40% in the control group (P < .001). Treatment group and study visit were significant factors affecting both VAS and FFI-Rs scores. Overall, 92% were satisfied in the treatment group, and 78.2% in the control group. Postinjection pain occurred in 5 patients in the treatment group.

CONCLUSION

This study provides Level I evidence regarding the efficacy and safety of allogeneic GF injection in patients with plantar fasciitis. However, additional studies are needed to evaluate their adverse effects, immunogenicity, and microbiological safety.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled case series.

Role of Platelet Rich Plasma in Chronic Plantar Fasciitis: A Prospective Study

INTRODUCTION

Autologous platelet rich plasma (PRP) local injection has been recently proposed as a treatment of plantar fasciitis. The autologous PRP does not have much side effects compared to steroid injections. So far PRP injections have shown promising results in various studies. This study assessed the efficacy of a single local injection of PRP in chronic unilateral plantar fasciitis through a prospective case series.

METHODOLOGY

A hospital-based prospective case series of 30 unilateral plantar fasciitis patients with symptom duration of 6 months or more were included in the study. All patients included in the study were assessed clinically and by visual analogue score for heel pain, AHS component of AOFAS and FADI scores before injection and at 6 and 12 week follow-up. USG measurement of plantar fascia thickness was done at pre-injection and at 12 weeks follow-up. All patients were observed for 12 weeks.

RESULTS

The mean age was 39 years (range 20-55 years). The pre-injection VAS score for heel pain was 6.5 ± 1.1 which improved to 2.7 ± 0.5 and 1.8 ± 0.8 at 6 and 12 week respectively and difference was significant (p < 0.001). The baseline FADI and AHS component of AOFAS scores were 53.1 ± 9.0 and 72.2 ± 5.7 which improved to 65.5 ± 5.3 and 76.1 ± 4.5 at 6 weeks and, 77.9 ± 4.4 and 85.7 ± 4.6 at 12 weeks respectively which was significant (p < 0.001). The baseline mean plantar fascia thickness was 4.9 ± 0.3 mm which was significantly (p < 0.001) reduced to 3.9 ± 0.3 mm at 12 weeks post PRP injection. All pairwise comparisons by the post-hoc Wilcoxon signed rank test with p-value adjustment were also significant.

CONCLUSION

The short-term results of single dose PRP injections shows clinical and statistically significant improvements in VAS for heel pain, functional outcome scores and plantar fascia thickness measured by USG. This study concludes that local PRP injection is a viable management option for chronic plantar fasciitis.

Outcomes of platelet-rich plasma for plantar fasciopathy: a best-evidence synthesis

BACKGROUND

Plantar fasciopathy (PF) is a very common disease, affecting about 1/10 people in their lifetime. Platelet-rich plasma (PRP) had been demonstrated to be useful in achieving helpful effects for plantar fasciopathy. The purpose of this study was to compare the pain and functional outcomes between PRP and corticosteroid (CS) or placebo for plantar fasciopathy through meta-analysis and provide the best evidence.

METHODS

Literature was searched systematically to explore related studies that were published in Cochrane Library, PubMed, Embase, Medline, SpringerLink, OVID, and ClinicalTrials.gov . Articles regarding comparative research about the outcomes of PRP therapy and CS or placebo injection were selected. Data of pain and functional outcomes was extracted and imported into Reviewer Manager 5.3 to analyze.

RESULTS

Thirteen RCTs were included and analyzed. Analysis results showed significant superiority of PRP in outcome scores when compared with CS (VAS: MD = - 0.85, P < 0.0001, I² = 85%; AOFAS: MD = 10.05, P < 0.0001, I² = 85%), whereas there is no statistical difference in well-designed double-blind trials (VAS: MD = 0.15, P = 0.72, I² = 1%; AOFAS: MD = 2.71, P = 0.17, I² = 0%). In the comparison of the PRP and the placebo, the pooled mean difference was - 3.76 (P < 0.0001, 95% CI = - 4.34 to - 3.18).

CONCLUSIONS

No superiority of PRP had been found in well-designed double-blind studies, whereas it is implied that the outcomes of PRP are better than placebo based on available evidence.

Comparison of midterm results of Platelet Rich Plasma (PRP) versus Steroid for plantar fasciitis: A randomized control trial of 118 patients

BACKGROUND

Plantar fasciitis, which is a common cause of heel pain, often results in significant morbidity. In cases who are not responsive to initial conservative treatment, invasive procedures, often in the form of local infiltration of steroid are required. These procedures are associated with significant complications. Local Platelet Rich Plasma (PRP) infiltration is an emerging addition to these treatments. However, whether it is more effective in reducing pain and improving function than other treatments (such as steroid injections or whole blood) remains controversial.

METHODS

Skeletally mature patients with plantar fasciitis who had failed conservative therapy were randomized using envelope method into 2 groups: PRP and Steroid group. The participants were assessed for pain using Visual Analog Scale on the day of presentation, and then after therapy at 2 weeks, 4 weeks, 3 months, and 6 months. They were additionally assessed on final follow-up using AOFAS hind-foot Score.

RESULTS

118 patients were randomized into 2 groups: 58 patients to the PRP group and 60 to the Steroid group. PRP was associated with greater improvement in VAS score and resulted in superior AOFAS score at 6 months as compared to steroid injection. The authors did not find any local or systemic complications in any of the groups. The result and difference were more pronounced as the time from injection increased and maximal benefit was observed at 6 months follow-up. None of the patients needed a repeat injection at 6 months.

CONCLUSION

Our study expands on the previous studies to provide a better evidence for superiority of PRP over local injection of steroid in plantar fasciitis, and the authors conclude that PRP provides better pain relief and function as compared to steroid injection.

LEVEL OF EVIDENCE

Level 1 Prospective Randomized Control Trial (RCT).

Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis

BACKGROUND

Platelet-rich plasma (PRP), as a promising alternative to traditional corticosteroid (CS), is now increasingly used in the treatment of elbow epicondylitis (EE) and plantar fasciitis (PF). To date, however, the synthesis of information on the clinical efficacy of PRP versus CS is limited with divergent conclusions.

PURPOSE

To compare the clinical efficacy of PRP and CS injections in reducing pain and improving function in EE and PF.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Online databases were searched from inception to October 2018 for prospective studies evaluating PRP versus CS injections for EE or PF. Independent reviewers undertook searches, screening, and risk-of-bias appraisals. The primary outcomes of interest were pain and function in both the short term (1-3 months) and the long term (≥6 months).

RESULTS

Twenty trials with 1268 participants were included. For EE, PRP provides a statistically and clinically meaningful long-term improvement in pain, with a very large effect size of -1.3 (95% CI, -1.9 to -0.7) when compared with CS, but the evidence level was low. For EE, there was moderate evidence that CS provides a statistically meaningful improvement in pain in the short term, with a medium effect size of 0.56 (95% CI, 0.08-1.03) as compared with PRP; this improvement might not be clinically significant. For PF, there was low evidence that PRP provides a statistically and clinically meaningful long-term improvement in function (American Orthopedic Foot & Ankle Society score), with a very large effect size of 1.94 (95% CI, 0.61-3.28). There were no significant differences between the groups in improvement in function in EE and pain and short-term function in PF, but the quality of the evidence was low.

CONCLUSION

The use of PRP yields statistically and clinically better improvement in long-term pain than does CS in the treatment of EE. The use of PRP yields statistically and clinically better long-term functional improvement than that of CS in the treatment of PF.

Platelet Concentrates in Musculoskeletal Medicine

Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.

Is Platelet-rich Plasma Injection more Effective than Steroid Injection in the Treatment of Chronic Plantar Fasciitis in Achieving Long-term Relief?

Introduction: Plantar fasciitis is characterised by pain in the heel, which is aggravated on weight bearing after prolonged rest. Many modalities of treatment are commonly used in the management of plantar fasciitis including steroid injection. Many studies show that steroid injection provides pain relief in the short term but not long lasting. Recent reports show autologous platelet-rich plasma (PRP) injection promotes healing, resulting in better pain relief in the short as well as long term. The present study was undertaken to compare the effects of local injection of platelet-rich plasma and Corticosteroid in the treatment of chronic plantar fasciitis. Materials and methods: Patients with the clinical diagnosis of chronic plantar fasciitis (heel pain of more than six weeks) after failed conservative treatment and plantar fascia thickness more than 4mm were included in the study. Patients with previous surgery for plantar fasciitis, active bilateral plantar fasciitis, vascular insufficiency or neuropathy related to heel pain, hypothyroidism and diabetes mellitus were excluded from the study. In this prospective double-blind study, 60 patients who fulfilled the criteria were divided randomly into two groups. Patients in Group A received PRP injection and those in Group B received steroid injection. Patients were assessed with visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score. Assessment was done before injection, at six weeks, three months and six months follow-up after injection. Plantar fascia thickness was assessed before the intervention and six months after treatment using sonography. Results: Mean VAS in Group A decreased from 7.14 before injection to 1.41 after injection and in Group B decreased from 7.21 before injection to 1.93 after injection, at final follow-up. Mean AOFAS score in Group A improved from 54 to 90.03 and in Group B from 55.63 to 74.67 at six months' follow-up. The improvements observed in VAS and AOFAS were statistically significant. At the end of six months' follow-up, plantar fascia thickness had reduced in both groups (5.78mm to 3.35mm in Group A and 5.6 to 3.75 in Group B) and the difference was statistically significant. Conclusion: Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long lasting beneficial effect.

Unexpected sequelae of plantar fasciitis: Iatrogenic calcaneal osteomyelitis following plantar heel injection

The injection of a local anesthetic in combination with a corticosteroid is an accepted choice in the treatment of plantar fasciitis with recalcitrant heel pain. When the injection is performed properly, post-injection infection is extremely rare. We are reporting a rare case of chronic calcaneal osteomyelitis that developed secondary to a local corticosteroid injection. A 56-year-old lady diagnosed with right plantar fasciitis presented with a 6-month history of pain and a persistent sinus with serous discharge of her right heel following a local infiltration of a corticosteroid. A Magnetic Resonance Imaging demonstrated right calcaneal osteomyelitis with intramuscular abscess. Surgical drainage and debridement were done, followed by antibiotic therapy. A recurrence of infection was not detected throughout the duration of follow-up. It is suggested that a plantar heel injection be done in a more controlled environment, such as in operating theatre, to reduce the risk of infection and to avoid injecting a steroid as compared to platelet-rich plasma (PRP) in view of their safety profiles. However, such an injection should only be offered after conservative treatment has failed, as 80% of patients recover well after initial conservative management.

Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial

BACKGROUND

When nonoperative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporary pain reduction but no healing. Platelet-rich plasma (PRP) has proven to be a safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries.

PURPOSE

To determine the effectiveness of PRP as compared with corticosteroid injections for chronic plantar fasciitis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients with chronic plantar fasciitis were allocated to have steroid injection or PRP. The primary outcome measure was the Foot Function Index (FFI) Pain score. Secondary outcome measures were function, as scored by the FFI Activity, FFI Disability, and American Orthopaedic Foot & Ankle Society, and quality of life, as scored with the short version of the World Health Organization Quality of Life (WHOQOL-BREF). All outcomes were measured at baseline and at 4, 12, and 26 weeks and 1 year after the procedure.

RESULTS

Of the 115 patients, 63 were allocated to the PRP group, of which 46 (73%) completed the study, and 52 were allocated to the control group (corticosteroid injection), of which 36 (69%) completed the study. In the control group, FFI Pain scores decreased quickly and then remained stable during follow-up. In the PRP group, FFI Pain reduction was more modest but reached a lower point after 12 months than the control group. After adjusting for baseline differences, the PRP group showed significantly lower pain scores at the 1-year follow-up than the control group (mean difference, 14.4; 95% CI, 3.2-25.6). The number of patients with at least 25% improvement (FFI Pain score) between baseline and 12-month follow-up differed significantly between the groups. Of the 46 patients in the PRP group, 39 (84.4%) improved at least 25%, while only 20 (55.6%) of the 36 in the control group showed such an improvement (P = .003). The PRP group showed significantly lower FFI Disability scores than the control group (mean difference, 12.0; 95% CI, 2.3-21.6).

CONCLUSION

Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.

REGISTRATION

NCT00758641 (ClinicalTrials.gov identifier).

Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial

No consensus has been reached about the best treatment method of plantar fasciitis and the results of the treatment methods have been inconsistent. The objective of the present study was to compare the therapeutic effects of extracorporeal shock wave therapy, platelet-rich plasma injection, local corticosteroid injection, and prolotherapy for the treatment of chronic plantar fasciitis using a randomized, controlled, prospective study. We performed a randomized controlled prospective clinical study of 4 groups. The first group received extracorporeal shock wave therapy, the second group received prolotherapy, the third group received platelet-rich plasma injection, and the fourth group received a local corticosteroid injection. The study included 158 consecutive patients with a diagnosis of chronic plantar fasciitis with a symptomatic heel spur. The clinical outcomes were assessed using the visual analog scale and Revised Foot Function Index. At the end of the follow-up period, the mean visual analog scale scores for all 4 groups were similar to the mean visual analog scale scores before treatment. At the end of the follow-up period, no significant improvement was noted in the Revised Foot Function Index score in any of the groups. The corticosteroid injection was more effective in the first 3 months and extracorporeal shock wave therapy was an effective treatment method in the first 6 months in regard to pain. The corticosteroid injection lost its effectiveness during the follow-up period. The effect of prolotherapy and platelet-rich plasma was seen within 3 to 12 months; however, at the 36-month follow-up point, no differences were found among the 4 treatments.

Platelet-Rich Plasma

Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated.

Current Clinical Recommendations for Use of Platelet-Rich Plasma

PURPOSE OF REVIEW

This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications.

RECENT FINDINGS

Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.

Thickness of plantar fascia is not predictive of functional outcome in plantar fasciitis treatment

OBJECTIVE

The aim of this study was to define a quantitative parameter to indicate which cases of plantar fasciitis will benefit from local corticosteroid injection or ESWT and to compare the efficacy of two different treatment modalities.

METHODS

Seventy patients (mean age: 49.10; range: 41-58) with chronic plantar fasciitis unresponsive to conservative treatment for 3 months were treated with either betamethasone injection or extracorporeal shock wave therapy (ESWT). Correlation between AOFAS scores, fascia thickness, duration of symptoms, age and calcaneal spur length were assessed.

RESULTS

Degree of fascial thickening (mean 4.6 mm for all patients) did not influence baseline AOFAS scores (r = -0.054). Plantar fascia thickness significantly decreased in both groups after treatment (1.2 mm for steroid, 1.2 mm for ESWT) (p < 0.01 for both groups). Percentage of change in AOFAS scores (68% for steroid and 79% for ESWT, p = 0.069) and fascial thickness (24% for steroid and 26% for ESWT, p = 0.344) were similar between two groups. Functional recovery was not correlated with baseline fascial thickness (r = 0.047) or degree of fascial thinning after treatment (r = -0.099). Percentage of change in AOFAS scores was correlated only with baseline AOFAS scores (r = -0.943).

CONCLUSIONS

Plantar fascia thickness increases significantly in plantar fasciitis and responds to treatment. Both ESWT and betamethasone injection are effective in alleviating symptoms and reducing plantar fascia thickness in chronic plantar fasciitis. However, the only predictive factor for functional recovery in terms of AOFAS scores is patients' functional status prior to treatment. Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Comparison of effects of low-level laser therapy and extracorporeal shock wave therapy in plantar fasciitis treatment: A randomized, prospective, single-blind clinical study

Objectives

The aim of this study is to compare the efficacy of extracorporeal shock wave therapy (ESWT) and low-level laser therapy (LLLT) in terms of fascia thickness, heel pain, and foot functions in patients with plantar fasciitis (PF).

Patients and methods

Between April 2015 and October 2015, a total of 34 patients (5 males, 29 females; mean age 51.5±10.8 years; range, 18 to 65 years) with PF were randomized into two treatment groups to receive either ESWT or LLLT using closed envelope method. The patients were evaluated before and after treatment and one month after treatment using the visual analog scale (VAS)-pain, Foot Function Index (FFI), and plantar fascia thickness measured by ultrasonography.

Results

A significant improvement in the VAS-pain and FFI scores and plantar fascia thickness was observed in both groups after treatment and one month after treatment, compared to pre-treatment values (p<0.05). Changes over time in these outcome parameters were not different between study groups (p>0.05).

Conclusion

Our study results suggest that both ESWT and LLLT seem to be effective on pain, foot functions, and fascia thickness in the treatment of PF.Presented at the 26th National Congress of Physical Medicine and Rehabilitation, April 25-29, 2017 Antalya, Turkey.

Effects of platelet-rich plasma in the treatment of plantar fasciitis: A meta-analysis of randomized controlled trials

BACKGROUND

Plantar fasciitis is a common cause of heel pain, which often results in significant morbidity. There have been several treatment options that are used for plantar fasciitis, including nonsteroidal anti-inflammatory drugs, orthoses, physical therapy, and steroid injections.

OBJECTIVES

The aim of this meta-analysis was to compare the effects of platelet-rich plasma (PRP) and other treatments in patients with plantar fasciitis.

SEARCH METHODS

Medline, Web of Science, and Embase were systematically searched to identify relevant trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared the effects of PRP and other treatments on plantar fasciitis were included.

DATA COLLECTION AND ANALYSIS

The main outcomes included changes from baseline in visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society Score (AOFAS), and Roles-Maudsley score (RMS). Results were expressed as weight mean difference (WMD) with 95% confidence interval (95% CI). The meta-analysis was performed using a fixed-effects or random-effects model according to heterogeneity.

MAIN RESULTS

Ten RCTs involving a total of 445 patients with plantar fasciitis were included. Among these studies, 9 compared PRP with steroid, and 1 compared PRP with whole blood.Four studies were categorized as being at low risk of bias, and the remaining 6 as being at unclear risk of bias.Pooled estimates suggested that PRP had greater changes in VAS and AOFAS scores than other treatments. However, it had no benefit effect in the RMS.Subgroup analysis for VAS and AOFAS showed that PRP had superior effect than other treatments at 12 months, but not at the 1, 3, 6 months.Subgroup analysis based on treatment regimens demonstrated that PRP was more effective than steroid in the change from baseline in AOFAS, but not in VAS and RMS scores.

AUTHORS' CONCLUSION

PRP was as effective as other treatments in reducing pain and improving function in patients with plantar fasciitis. Subgroup analysis indicated that PRP had better effect than steroid in AOFAS Score and its effect was durable in a long term. However, considering the potential limitations in this study, more large-scale RCTs are needed to confirm the current findings.

Intratissue Percutaneous Electrolysis vs Corticosteroid Infiltration for the Treatment of Plantar Fasciosis

BACKGROUND

Corticosteroid infiltration (CI) is commonly used for treatment of plantar fasciosis. In recent years, however, interest has grown in the use of intratissue percutaneous electrolysis (EPI) for the treatment of tendinopathies. The aim of our study was to compare the effectiveness of the above techniques in the treatment of plantar fasciosis.

METHODS

The results achieved over a period of 1 year following the use of these techniques to treat plantar fasciosis were examined. There were 64 patients; 32 of whom were treated with ultrasound-guided EPI and 32 with ultrasound-guided CI. A clinical examination was performed and ultrasound taken before treatment and at 3, 6, and 12 months. Clinical assessments were made using a visual analog scale (VAS) to record pain and the Foot and Ankle Disability Index (FADI) to evaluate function. Ultrasound was used to determine the thickness of the plantar fascia.

RESULTS

Both the ultrasound-guided EPI and CI techniques were associated with significant clinical and echographic improvements at 12 months post-treatment ( P < .001).

CONCLUSION

Both techniques were effective in the treatment of PF, providing excellent VAS pain and FADI results at 12 months. However, CI required fewer patient visits and appeared to provide somewhat better VAS and FADI results.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Regenerative efficacy of therapeutic quality platelet-rich plasma injections versus phonophoresis with kinesiotaping for the treatment of chronic plantar fasciitis: A prospective randomized pilot study

BACKGROUND:

Plantar fasciitis (PF) a common chronic musculoskeletal pain routinely diagnosed and treated in rehabilitation practices. When conservative management fails in this degenerative disease, local injections of corticosteroids, platelet rich plasma (PRP), botulinum toxin, extracorporeal shockwave therapy, surgical release are used. In our prospective randomized pilot study we compared the regenerative efficacy of Platelet Rich Plasma vs Kinesiotaping with phonophoresis who were resistant to conservative management of PF.

MATERIALS AND METHODS:

Sixty-four chronic plantar fasciitis patients nonresponding to conservative management were evaluated for two interventions.36 patients received ultrasound guided 2.5 ml autologous platelet rich plasma (PRP) injection and 28 participant received phonophoresis and total10 Kinesiotaping on alternate days. 54 participants 33 in PRP intervention group and 21 in KT group were analyzed, by Numerical Rating Scale (NRS), plantar fascia thickness (ultrasound guided) and disability and activity limitation measured by foot function index in every two weeks up to 6 months.

RESULTS:

Post intervention assessment at 2 weeks revealed improvement in pain relief was better in Kinesiotaping group (NRS-4.619) as compared to PRP group (NRS- 6.061). But evaluation at 12 and 24 weeks showed statistically significant improvement in NRS and Foot function index in PRP group than in Kinesiotaping. Similarly, at the end of 24-week improvement in foot function index (FFI) was more in PRP group (P<0.0001). At end of 12 and 24 weeks there was significant reduction in plantar fascia thickness in PRP group (p<0.0001) as compared to KT group (p<0.05).

CONCLUSION:

Our study concluded that therapeutic quality autologous PRP injection (1x10⁶ platelets/μl) has regenerative effect with long and better efficacy in pain management of chronic recalcitrant plantar fasciitis than Phonophoresis and Kinesiotaping.

Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials

BACKGROUND

Recently, platelet-rich plasma (PRP) has been used as an alternative therapy for plantar fasciitis (PF) to reduce heel pain and improve functional restoration. We evaluated the current evidence concerning the efficacy and safety of PRP as a treatment for PF compared with the efficacy and safety of steroid treatments.

METHODS

Databases (PubMed, EMBASE, and The Cochrane Library) were searched from their establishment to January 30, 2017, for randomized controlled trials (RCTs) comparing PRP with steroid injections as treatments for PF. The Cochrane risk of bias (ROB) tool was used to assess the methodological quality. Outcome measurements were the visual analogue scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopedic Foot and Ankle Society (AOFAS) scale, and the Roles and Maudsley score (RMS). The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS

Nine RCTs (n = 430) were included in this meta-analysis. Significant differences in the VAS were not observed between the 2 groups after 4 [weighted mean difference (WMD) = 0.56, 95% confidence interval (95% CI): -1.10 to 2.23, P = .51, I = 89%] or 12 weeks of treatment (WMD = -0.49, 95% CI: -1.42 to 0.44, P = .30, I = 89%). However, PRP exhibited better efficacy than the steroid treatment after 24 weeks (WMD = -0.95, 95% CI: -1.80 to -0.11, P = .03, I = 85%). Moreover, no significant differences in the FADI, AOFAS, and RMS were observed between the 2 therapies (P > .05).

CONCLUSION

Limited evidence supports the conclusion that PRP is superior to steroid treatments for long-term pain relief; however, significant differences were not observed between short and intermediate effects. Because of the small sample size and the limited number of high-quality RCTs, additional high-quality RCTs with larger sample sizes are required to validate this result.

Plantar Fasciitis-A Comparison of Treatment with Intralesional Steroids versus Platelet-Rich Plasma A Randomized, Blinded Study

BACKGROUND

Many treatment options for plantar fasciitis currently exist, some with great success in pain relief. The objective of our study was to compare the use of intralesional steroids with platelet-rich plasma (PRP), using pain scales and functional evaluation, in patients with plantar fasciitis who did not respond to conservative treatment.

METHODS

A controlled, randomized, blinded clinical assay was performed. Patients were assigned to one of the two groups by selecting a sealed envelope. The steroid treatment group received 8 mg of dexamethasone plus 2 mL of lidocaine as a local anesthetic. The PRP treatment group received 3 mL of PRP activated with 0.45 mL of 10% calcium gluconate. All of the patients were evaluated at the beginning of the study, and at 2, 4, 8, 12, and 16 weeks post-treatment with the Visual Analog Scale (VAS), Foot and Ankle Disability Index (FADI), and American Orthopedic Foot and Ankle Society (AOFAS) scale.

RESULTS

The right foot was the most frequently affected foot (63%). The average age of the patients was 44.8 years (range, 24-61 years). All scales used (VAS, FADI and AOFAS) showed that the difference was not statistically significant between the two groups.

CONCLUSIONS

We can conclude that the use of PRP is an effective treatment method for patients with plantar fasciitis who do not respond to conservative treatment because PRP demonstrates an efficacy equal to that of steroids. However, the cost and the time for preparation the PRP are two of the disadvantages of this treatment.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

BACKGROUND

Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases.

METHODS

A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded.

RESULTS

A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product.

CONCLUSIONS

Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

The use of platelet-rich plasma to treat chronic tendinopathies: A technical analysis

Platelet-rich plasma (PRP) is blood plasma with a high concentration of autologous platelets which constitute an immense reservoir of growth factors. The clinical use of PRP is widespread in various medical applications. Although highly popular with athletes, the use of PRP for the treatment of tendinopathies remains scientifically controversial, particularly due to the diversity of products that go by the name of "PRP." To optimize its use, it is important to look at the various stages of obtaining PRP. In this literature review, we take a closer look at eight parameters which may influence the quality of PRP: 1) anticoagulants used to preserve the best platelet function, 2) the speed of centrifugation used to extract the platelets, 3) the platelet concentrations obtained, 4) the impact of the concentration of red and while blood cells on PRP actions, 5) platelet activators encouraging platelet degranulation and, hence, the release of growth factors, and 6) the use or nonuse of local anesthetics when carrying out infiltration. In addition to these parameters, it may be interesting to analyze other variables such as 7) the use of ultrasound guidance during the injection with a view to determining the influence they have on potential recovery.

Comparative Effectiveness of Radial Extracorporeal Shockwave Therapy and Ultrasound-Guided Local Corticosteroid Injection Treatment for Plantar Fasciitis

BACKGROUND

We compared the long-term clinical and ultrasonographic effects of radial extracorporeal shockwave therapy (rESWT) versus ultrasound-guided corticosteroid injection treatment in patients with plantar fasciitis unresponsive to conservative therapy.

METHODS

Seventy-two patients with unilateral plantar fasciitis were randomized to receive either rESWT (three times once per week) (n = 36) or corticosteroid treatment (a single 1-mL dose of betamethasone sodium plus 0.5 mL of prilocaine under ultrasound guidance by injection into the plantar fascia) (n = 36). The primary outcome measures were visual analog scale (VAS) and Foot Function Index (FFI) scores. Secondary outcome measures included the heel tenderness index (HTI) score and plantar fascia thickness (PFT) as obtained by ultrasound examination. All of the assessments were performed at baseline and 1, 3, and 6 months after treatment.

RESULTS

Significant improvements were observed in the rESWT group in VAS, HTI, and FFI scores and PFT at the end of treatment and were maintained during follow-up. Posttreatment improvements in VAS, HTI, and FFI scores and PFT were also seen in the corticosteroid group but were not maintained for VAS and FFI scores after the completion of therapy and were lost at 1 and 6 months, respectively. No serious treatment-related complications occurred.

CONCLUSIONS

Both rESWT and corticosteroid injection therapy are effective modalities for treatment of chronic plantar fasciitis. However, rESWT seems to be superior to corticosteroid injection therapy due to its longer duration of action.

A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy

PURPOSE

To determine whether platelet-rich plasma (PRP) injections are associated with improved pain and function scores when compared with corticosteroid injections for plantar fasciopathy.

METHODS

A systematic review of published literature was performed for studies comparing PRP injections and corticosteroid injections for plantar fasciopathy. Studies were assessed using the Cochrane Risk of Bias Tool and the Newcastle Ottawa Scale (NOS). The primary endpoint was pain and function score at three and six month follow-up. Sensitivity analysis was performed for high quality studies and randomised studies.

RESULTS

Ten studies totalling 517 patients were included. Seven studies were randomised. All studies included patients who had failed conservative measures and excluded patients with systemic illness and other causes of foot pain. Studies reported outcomes using the visual analogue score (VAS) and American Orthopaedic Foot and Ankle Score (AOFAS). At 3-month follow-up, PRP injections were associated with improved VAS scores (standard mean difference [SMD], -0.66; 95% CI, -1.3 to -0.02; p = 0.04) and AOFAS scores (SMD, 1.87; 95% CI, 0.16-3.58; p = 0.03). At 6-month follow-up, there was no difference in VAS score (SMD, -0.66; 95% CI, -1.65 to 0.3; p = 0.17) or AOFAS scores (SMD, 1.69; 95% CI, -1.06 to 4.45; p = 0.23). No studies reported adverse event rates or cost analysis. There was no difference in pain or function score at one, six- or 12-month follow-up. Sensitivity analyses of high-quality studies showed no differences between the PRP and steroid group at any of the follow-up points.

CONCLUSIONS

PRP injections are associated with improved pain and function scores at three month follow-up when compared with corticosteroid injections. Information regarding relative adverse event rates and cost implications is lacking. Further, large-scale, high-quality, randomised controlled trials with blinding of outcome assessment and longer follow-up are required.

Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies

INTRODUCTION

local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

Effectiveness and relevant factors of platelet-rich plasma treatment in managing plantar fasciitis: A systematic review

Background:

Plantar fasciitis (PF) is a common foot complaint, affects both active sportsmen and physically inactive middle age group. It is believed that PF results from degenerative changes rather than inflammation. Platelet-rich plasma (PRP) therapy has been introduced as an alternative therapy for PF. This study is aimed to systematically review to the effectiveness and relevant factors of PRP treatment in managing PF.

Materials and Methods:

A search was conducted in electronic databases, including PubMed, Scopus, and Google Scholar using different keywords. Publications in English-language from 2010 to 2015 were included. Two reviewers extracted data from selected articles after the quality assessment was done.

Results:

A total of 1126 articles were retrieved, but only 12 articles met inclusion and exclusion criteria. With a total of 455 patients, a number of potentially influencing factors on the effectiveness of PRP for PF was identified. In all these studies, PRP had been injected directly into the plantar fascia, with or without ultrasound guidance. Steps from preparation to injection were found equally crucial. Amount of collected blood, types of blood anti-coagulant, methods in preparing PRP, speed, and numbers of time the blood samples were centrifuged, activating agent added to the PRP and techniques of injection, were varied between different studies. Regardless of these variations, superiority of PRP treatment compared to steroid was reported in all studies.

Conclusion:

In conclusion, PRP therapy might provide an effective alternative to conservative management of PF with no obvious side effect or complication. The onset of action after PRP injection also greatly depended on the degree of degeneration.

Beneficial effects of platelet-rich plasma on improvement of pain severity and physical disability in patients with plantar fasciitis: A randomized trial

BACKGROUND

The present study aimed to clinically examine the effects of platelet-rich plasma (PRP) on improvement of plantar fasciitis and its related manifestations.

PATIENTS AND METHODS

This single-blind randomized controlled trial was performed on 32 consecutive patients with the final diagnosis of plantar fasciitis that were randomly assigned to the case group (that received PRP, n = 16) and the control group (that received corticosteroid as methylprednisolone 1 ml plus lidocaine 1 ml, n = 16). The endpoints in the present study were changes in the visual analog scale score and the modified Roles and Maudsley score (RMS) from baseline, 1-month, 3 months, and 6 months follow-up. Plantar fascia was also assessed by B-mode sonography before and also 3 months after primary assessment.

RESULTS

Regarding the pain severity, the PRP group had significantly higher mean pain score at 3 time points of before injection, as well as 1 and 3 months after PRP use when compared to the corticosteroid group (P < 0.05); however, the control group experienced significantly higher pain severity than the PRP group at 6 months after interventions. Also, RMS was lower in PRP group than in corticosteroid group at baseline as well as at 1 and 3 months after injections (P < 0.05). In sonography assessment, no difference was revealed.

CONCLUSION

Administration of PRP leads to significant improvement in pain severity and physical limitation in patients with plantar fasciitis. This healing effect may be begun at least 3 months after injection.

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

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.

Plantar fascia rupture in a professional soccer player

We report the case of a 29-year-old male professional soccer player who presented with symptoms of plantar fasciitis. His symptoms occurred with no remarkable triggers and gradually worsened despite conservative treatments including taping, use of insoles, and physical therapy. Local corticosteroid injection was given twice as a further intervention, but his plantar fascia partially ruptured 49 days after the second injection. He was treated conservatively with platelet-rich plasma, and magnetic resonance imaging showed regenerative change of the ruptured fascia. Five months after the rupture, he returned to his original level of training. If professional athletes find it difficult to refrain from athletic activity, as in the present case, the risk of rupture due to corticosteroid injection should not be overlooked.

Autologous platelet-rich plasma compared with whole blood for the treatment of chronic plantar fasciitis; a comparative clinical trial

BACKGROUND

Intralesional injection of autologous blood-derived products has recently gained attention as a potential treatment for plantar fasciitis (PF). We compared platelet-rich plasma (PRP) and whole blood (WB) for the treatment of chronic PF.

MATERIALS AND METHODS

Patients with chronic PF received either an intralesional injection of 3 cc PRP prepared by double centrifuge technique or WB (n = 17 in each group). Overall, morning and walking pain severity were assessed by 11-point numerical rating scale, and function was assessed by the Roles and Maudsley score (RMS) at baseline and 1-month and 3 months after treatment. Ultrasonography was performed to measure plantar fascia thickness at baseline and 3 months after treatment.

RESULTS

Pain scores were reduced over the study in the PRP (mean change = -5.00 ± 1.17 to -5.47 ± 1.46) and WB groups (mean change = -5.29 ± 2.56 to -6.47 ± 2.83), with no difference between groups (P > 0.05). One month and 3 months after treatment, successful treatment (RMS of ≤ 2) was respectively observed in 29.4% and 82.3% of the PRP and in 47.1% and 76.4% of the WB groups (P > 0.05). Also, fascia thickness was decreased in both the PRP and WB groups (mean change = -1.74 ± 1.11 vs. -1.21 ± 0.73 mm, respectively, P = 0.115).

CONCLUSIONS

Significant improvement in pain and function, as well as decrease in plantar fascia thickness, was observed by intralesional injection of the PRP and WB in patients with chronic PF. The study results indicate similar effectiveness between PRP and WB for the treatment of chronic PF in short-term.

Long-Term Outcome of Open Plantar Fascia Release

BACKGROUND

Plantar fasciitis is thought to be a self-limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and surgery may be indicated. Partial plantar fascial release is reported to have a short-term success rate of up to 80%, but anecdotally this was not thought to represent our local experience.

METHODS

An audit of long-term patient-reported outcomes following open partial plantar fascia release was performed. A total of 30 patients (33 feet) were identified over a 10-year period and case notes were reviewed. Patients were contacted by letter and invited to complete 2 validated patient-reported outcome score questionnaires (Visual Analog Scale-Foot and Ankle [VAS-FA] and Manchester Oxford Foot Questionnaire [MOXFQ]). Responses were received from 24 patients (26 feet). The average ages were 42.4 (range 24-61) for male and 46.2 (range 33-60) for female patients, with a female/male ratio of 2.7:1. The average duration of treatment prior to operative intervention was 3.1 years (range 1-5). Preoperatively, our cohort underwent a range of conservative measures. All patients were reviewed postoperatively, and average time from surgery to completion of questionnaires was 80 months (range 14-130).

RESULTS

The outcomes were worse in patients who had received preoperative steroid injections and this was found to be statistically significant. The mean MOXFQ score was 33.6 ± 3.9 (0-64). Mean VAS-FA score was 57.8 ± 4.9 (24-100).

CONCLUSION

This study found a negative correlation between duration of follow-up and outcome, in both MOXFQ and VAS-FA, showing that patients continued to improve many years postoperatively. The authors also found worse outcomes with preoperative steroid injections, better outcomes in older patients, and a weak gender bias, suggesting results in men were better than those in women. A prolonged recovery period and generally poor outcomes leads the authors to suggest that open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery.

LEVEL OF EVIDENCE

Level III, comparative study.

Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study

INTRODUCTION

Intractable plantar fasciitis can be a difficult condition to treat. Early results of platelet rich plasma (PRP) injection have been promising. We compared PRP to traditional cortisone injection in the treatment of chronic cases of plantar fasciitis resistant to traditional nonoperative management. The aim of the study was to compare the efficacy of PRP to that of Steroid at 3, 6 and 12 months after injection.

METHODS

60 heels with intractable plantar fasciitis who had failed conservative treatment were randomised to receive either PRP or Steroid injection. All patients were assessed with the Roles-Maudsley (RM) Score, Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Data was collected prospectively on the cohort, pre-treatment, at 3, 6 and 12 months post injection and the results were compared.

RESULTS

Pre-injection, the two groups were well matched with no statistically significant difference. At 3 months, all three outcome scores had significantly improved from their pretreatment level in both groups. The scores in the Steroid arm were marginally better than in the PRP arm, but this difference was not statistically significant. At 6 months, there was no statistically significant difference between the two groups, though there was a trend for the PRP scores to become better than the Steroid scores. At 12 months, the RM, VAS and AOFAS scores in the PRP arm (1.9, 3.3 and 88.5) were significantly better than the Steroid arm (2.6, 5.3 and 75) with P values of .013, .028 and .033, respectively.

CONCLUSIONS

PRP is as effective as Steroid injection at achieving symptom relief at 3 and 6 months after injection, for the treatment of plantar fasciitis, but unlike Steroid, its effect does not wear off with time. At 12 months, PRP is significantly more effective than Steroid, making it better and more durable than cortisone injection.

Ultrasound-guided intervention in the ankle and foot

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery

PURPOSE

To summarize clinical studies after platelet-rich plasma (PRP) therapy for tendinopathy, plantar fasciopathy, and muscle injuries; to review PRP formulations used across studies; and to identify knowledge deficits that require further investigation.

METHODS

After a systematic review in PubMed, we identified clinical studies assessing PRP efficacy in tendon and muscle during the past decade. We standardized data extraction by grouping studies based on anatomic location; summarized patient populations, PRP formulations, and clinical outcomes; and identified knowledge deficits that require further investigation.

RESULTS

Overall, 1,541 patients had been treated with PRP in 58 clinical studies; of these, 26 addressed upper limb tendinopathies and 32 addressed the lower limb (810 patients and 731 patients treated with PRP, respectively). The quality of research is higher for the upper limb than for the lower limb (23 controlled studies, of which 17 are Level I, v 19 controlled studies, of which 6 are Level I, respectively). Patients have been treated mostly with leukocyte-platelet-rich plasma, except in the arthroscopic management of the rotator cuff. The safety and efficacy of PRP for muscle injuries has been addressed in 7 studies including 182 patients. Differences across results are mainly attributed to dissimilarities between tissues and different stages of degeneration, numbers of PRP applications, and protocols.

CONCLUSIONS

Given the heterogeneity in tendons and tendinopathies, currently, we are not able to decide whether PRP therapies are useful. Despite advances in PRP science, data are insufficient and there is a clear need to optimize protocols and obtain more high-quality clinical data in both tendinopathies and muscle injuries before making treatment recommendations.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial)

INTRODUCTION

Knee osteoarthritis (OA) is the most common articular disease. Different methods are used to alleviate the symptoms of patients with knee OA, including analgesics, physical therapy, exercise prescription, and intra-articular injections (glucocorticoids, hyaluronic acid [HA], etc). New studies have focused on modern therapeutic methods that stimulate cartilage healing process and improve the damage, including the use of platelet-rich plasma (PRP) as a complex of growth factors. Due to the high incidence of OA and its consequences, we decided to study the long-term effect of intraarticular injection of PRP and HA on clinical outcome and quality of life of patients with knee OA.

METHOD

This non-placebo-controlled randomized clinical trial involved 160 patients affected by knee OA, grade 1-4 of Kellgren-Lawrence scale. In the PRP group (n = 87), two intra-articular injections at 4-week interval were applied, and in the HA group (n = 73), three doses of intra-articular injection at 1-week interval were applied. All patients were prospectively evaluated before and at 12 months after the treatment by Western Ontario and McMaster Universities Arthritis Index (WOMAC) and SF-36 questionnaires. The results were analyzed using SPSS 16.1 software (RCT code: IRCT2014012113442N5).

RESULTS

At the 12-month follow-up, WOMAC pain score and bodily pain significantly improved in both groups; however, better results were determined in the PRP group compared to the HA group (P < 0.001). Other WOMAC and SF-36 parameters improved only in the PRP group. More improvement (but not statistically significant) was achieved in patients with grade 2 OA in both the groups.

CONCLUSION

This study suggests that PRP injection is more efficacious than HA injection in reducing symptoms and improving quality of life and is a therapeutic option in select patients with knee OA who have not responded to conventional treatment.