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

Platelet Rich Plasma Injections for Foot and Ankle Pathologies have Significantly Higher Complications Compared to Hyaluronic Acid injections, Saline Injections, and Dry Needling: A Systematic Review

PURPOSE

To investigate complications of platelet rich plasma (PRP) injections for foot and ankle pathologies to better inform clinical decision-making.

METHODS

A systematic review following PRISMA guidelines of PubMed, Embase, Web of Science, and Cochrane databases was conducted to identify randomized controlled trials (RCTs) documenting complications following PRP injections for foot and ankle pathologies. Condition studied, demographics, and complications were extracted. Complication rates and number needed to harm (NNH) were calculated, and random-effects models were generated to compare complications using odds ratios, with a p-value < 0.05 indicating significance.

RESULTS

Sixteen studies assessing Achilles tendon injuries, plantar fasciitis, ankle osteoarthritis, and osteochondral lesions of the talus were identified, with 674 patients receiving PRP, and 749 patients received alternatives (corticosteroids, saline, dry needling, hyaluronic acid, prolotherapy, and stromal vascular fraction). Twelve studies reported no complications. Four studies reported 277 (rate of 41.1%) complications in the PRP group and 249 (rate of 33.7%) in the comparison group (p < 0.01). Treatment site pain was the most common complication, occurring at a significantly higher rate in the PRP group (14.5% vs. 10.1%, respectively, p < 0.01), and meta-data showing higher odds of pain following PRP (OR 2.23 I2 = 0.0%, p <0.01). The NNH for PRP was 13. One patient receiving PRP injections for Achilles tendinopathy experienced severe pain that resolved with surgical debridement. No other serious complications or infections occurred.

CONCLUSION

PRP injections of the foot and ankle have significantly higher rates of post-injection pain versus comparison treatments, and an estimated 13 patients need to receive PRP injections to experience any complication over an alternative injection. Only one patient experienced an event that necessitated surgical intervention. Future studies investigating PRP should aim to report complications to allow clinicians to appropriately counsel patients.

LEVEL OF EVIDENCE

Level II, Systematic Review of RCTs.

Platelet-rich plasma and corticosteroid injection for tendinopathy: a systematic review and meta-analysis

OBJECTIVE

In this systematic review and meta-analysis, we evaluated and compared the efficacy and safety of platelet-rich plasma injection into corticosteroid injection in the treatment of tendinopathy.

METHODS

We searched PUBMED, EMBASE, Cochrane Library, SCOPUS, and Web of Science to identify randomized controlled trials on the PRP injection versus CS injection in treatment of tendinopathy.The meta-analysis was performed using the Revman 5.4 software.

RESULT

We found 27 RCT studies with a total of 1779 patients enrolled. 8 rotator cuff injuries, 7 humeral external epicondylitis, 10 plantar fasciitis, and 2 tenosynovitis. The results of the meta-analysis showed that there were no significant group differences in the results of patients with rotator cuff injury comparing the pain visual analog scale score and functional measures at 1 month after receiving injection treatment. After three months of receiving PRP treatment, the VAS scores showed greater improvement compared to the CS group(OR = -1.64,95%CI [-2.97,-0.31],P = 0.02), while there was no statistically significant difference in shoulder joint function between the two groups at the 3-6 month post-treatment mark. Patients with plantar fasciitis showed no significant differences in VAS and AOFAS scores after receiving PRP or CS injections at 1 and 3 months. However, at the 6-month mark, the PRP group demonstrated significantly better VAS and AOFAS scores compared to the CS group(OR = -1.41,95%CI [-1.88,-0.44],P < 0.00001; OR = 7.19,95%CI [2.41,11.91],P = 0.003). 1 month after CS injection in patients with tenosynovitis, the VAS score was lower than that of the PRP group; patients with elbow epicondylitis had better improved upper limb function rating scale scores 1 month after CS injection compared to the PRP group. In patients with tenosynovitis, the VAS scores were superior to the CS group six months after PRP treatment(OR = -0.72,95%CI [-1.04,-0.40],P < 0.00001); similarly, patients with lateral epicondylitis exhibited better VAS, DASH scores than the CS group three and twelve months post-PRP treatment(OR = -9.76,95%CI [-10.89,-8.63],P = 0.0002; OR = -0.97,95%CI [-1.87,-0.06],P < 0.0001; OR = -18.03,95%CI [-31.61,-4.46],P = 0.009).

CONCLUSION

PRP can effectively improve pain and functional impairment in patients with tendinopathy, and its mid-term efficacy is superior to that of corticosteroids. However, the long-term efficacy remains to be further clinically verified.

Therapeutic efficacy and safety of botulinum toxin A injection in plantar fasciitis: A systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis was to evaluate the therapeutic efficacy and safety of botulinum toxin A (BTA) injections for treatment of plantar fasciitis (PF).

METHODS

This review adhered to the PRISMA guidelines, conducting a comprehensive search of the PubMed, Web of Science, EMBASE, and Cochrane Library databases for eligible studies from their inception to December 30 2023. The inclusion criteria were limited to randomized controlled trials (RCTs) comparing BTA injections with control interventions in terms of pain reduction, functional improvement, or the occurrence of adverse events in treating patients with PF were extracted for meta-analysis. Relevant data were extracted using an electronic spreadsheet and analyzed with Stata 16.0 software. The quality of included studies was assessed using the Cochrane Collaboration's tool.

RESULTS

A total of 655 studies were retrieved and subsequently screened. Seven RCTs, comprising 305 participants, met the eligibility criteria and were included in the meta-analysis. The pooled results indicated that BTA injections led to significant pain reduction only at 1-month posttreatment (SMD = -1.72, 95% CI [-3.10, -0.34], p = 0.01]) and sustained functional improvement over twelve months (SMD = 25.10, 95% CI [9.67, 40.53], p = 0.001) compared to the control group. There was no significant difference in the occurrence of adverse events between the BTA and control interventions (OR = 0.16, 95% CI [-1.00, 1.32], p = 0.79).

CONCLUSION

This meta-analysis suggested that BTA injection could be an effective and safe therapeutic strategy for plantar fasciitis. However, further larger-scale, rigorously designed RCTs are needed to validate these findings and determine the optimal injection dosage and site for BTA in the treatment of plantar fasciitis.

New Infiltration Technique in the Treatment of the Plantar Fascia Syndrome Based on Platelet-Rich Plasma

Pain in the attachment of the plantar fascia in the calcaneus represents 10% of all sports injuries, affects 10% of foot runners, and will affect around 20% of the world population. There is no effective conservative treatment for it. This paper justifies a new definition and name for this pathology, Plantar Fascia Syndrome (PFS), presents a methodology for its diagnosis, and presents the clinical and functional effectiveness of a new conservative treatment based on platelet-rich plasma (PRP). In total, 25 patients (from an initial sample of 260) diagnosed with recalcitrant PFS lasting for more than 12 months were treated with a single infiltration of 2 mL of PRP, according to a new technic proposed. The study was approved by the ethical committee for clinical research of the reference hospital. The patients were controlled after 15, 30, 90, and 180 days, reviewing on each occasion pain, thickness of the plantar fascia, and active extension of the ankle joint. A total of 15 days after infiltration, 85% of patients had no clinical signs requiring treatment. After 90 days of infiltration, no patients showed clinical signs. This improvement in the patients' condition lasted for 180 days. All patients after treatment can fully resume normal activity with no pain.

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.

Current Status and Advancements in Platelet-Rich Plasma Therapy

Platelet-rich plasma (PRP) as a treatment modality has been around for the last four decades, but only truly gained popularity over the last 10 to 15 years in medicine, in a variety of fields ranging from regenerative medicine to infertility treatment. It has gained popularity, especially in treating musculoskeletal conditions where the bulk of research has been performed and published. There is level I evidence available supporting its efficacy in the treatment of osteoarthritis (OA), epicondylitis, bursitis, compressive neuropathy, plantar fasciitis, muscular injuries and osteochondral lesions. Most published research with regards to PRP has been focused on knee OA (limited research in shoulder, elbow, and foot and ankle OA), lateral epicondylitis and carpal tunnel syndrome, whereas spinal and hand conditions have limited research available. Tendinopathies and partial tendon tears have conflicting evidence available, with level I evidence supporting PRP's use in rotator cuff tendinopathies and tears, with contradictory level I evidence discouraging its use in patella and Achilles tendinopathies and tears. The available evidence regarding the use of PRP continues to produce conflicting results, but despite this, there is an ongoing increase in the popularity and use of PRP in patients with musculoskeletal conditions.

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.

The role of corticosteroid injections in treating plantar fasciitis: A systematic review and meta-analysis

BACKGROUND

Plantar fasciitis is a recurrent cause of heel pain and is often treated by corticosteroid infections (CSI). The current study reviewed and analysed the role of CSI with platelet rich plasma (PRP), and CSI with extracorporeal shock wave therapy (EWST) for plantar fasciitis treatment.

METHODS

PubMed, Medline, Web of Science, Embase, Cochrane, and Google Scholar databases were searched for relevant studies. Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA) guidelines were used to search relevant studies published from infinity to April 2021. The risk of bias was performed using Cochrane Collaboration's tool. GRADE assessment was used for quality of evidence. Data analysis was performed with the use of R software and P < 0.05 was considered statistically significant. CSI was compared with PRP and EWST.

RESULTS

Eighteen studies comprising 1180 patients were included in this meta-analysis. When compared to PRP, CSI with lignocaine/lidocaine had significantly higher mean difference on visual analogue scale (VAS) pain scores at 3 months (0.62 [0.13; 1.12], P = 0.01) and 6 months (MD = 1.49 [0.22; 2.76], P = 0.02). At 6 months, VAS scores were higher in the CSI group than the ESWT group (MD = 0.8 [0.38; 1.22], P = 0.1). At 6 months, a significant reduction in the American Orthopaedic Foot and Ankle Score (AOFAS) was observed in the CSI group compared to PRP (MD = - 11.53 [- 16.62; - 6.43], P < 0.0001).

CONCLUSION

Patients suffering from plantar fasciitis, PRP achieved better VAS scores compared to CSI at 3 and 6-month follow-up. In addition, ESWT had better VAS score outcomes at 6 months compared to CSI. Regarding AOFAS score, PRP was more efficacious than CSI at 6 months of follow-up. Only through the development of high-quality, large-scale longitudinal studies, will the findings and conclusions of this meta-analysis be strengthened and influence our clinical practice in the treatment of plantar fasciitis.

LEVEL OF CLINICAL EVIDENCE

II.

Effects of therapeutic interventions on pain due to plantar fasciitis: A systematic review and meta-analysis

OBJECTIVE

To determine the effects of different therapeutic interventions that have ever been evaluated in randomized controlled trials on pain due to plantar fasciitis.

METHODS

We searched different electronic databases until September 2022. Mean differences (MDs) and 95% confidence intervals (CIs) were calculated. The Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the overall certainty evidence.

RESULTS

A total of 236 studies met the study criteria, including 15,401 patients. Botulinum toxin MD -2.14 (CI: -4.15, -0.14), micronized dehydrated human amnion/chorion membrane injection MD -3.31 (CI: -5.54, -1.08), dry needling MD -2.34 (CI: -4.64, -0.04), low-dye taping MD -3.60 (CI: -4.16, -3.03), low-level laser therapy MD -2.09 (CI: -2.28, -1.90), myofascial releases MD -1.79 (CI: -2.63, -0.94), platelet-rich plasma MD -2.40 (CI: -4.16, -0.63), radiofrequency MD -2.47 (CI: -4.65, -0.29), and stretching MD -1.14 (CI: -2.02, -0.26) resulted in being effective treatments for pain when compared to the control in the short term. In the medium and long term, only extracorporeal shock wave therapy MD -0.97 (CI: -1.13, -0.81)/MD -2.49 (CI: -3.17, -1.82) was effective for improving pain when compared to the control.

CONCLUSIONS

Considering the available studies, this systematic review and meta-analysis showed that different therapeutic interventions seem to be useful strategies for improving pain in patients with plantar fasciitis. In the medium and long term, only extracorporeal shock wave therapy was effective in improving pain when compared to the control.

The Statistical Fragility of Platelet-Rich Plasma as Treatment for Plantar Fasciitis: A Systematic Review and Simulated Fragility Analysis

Background

Plantar fasciitis (PF) is the most common cause of heel pain and can be a source of extensive physical disability and financial burden. Platelet-rich plasma (PRP) offers a potentially definitive, regenerative treatment modality that, if effective, could change the current paradigm of PF care. However, randomized controlled trials (RCTs) on the clinical benefits of PRP for refractory PF offer inconsistent conclusions, potentially because of the broader limitations of using P value thresholds to declare statistical and clinical significance. In this study, we use the Continuous Fragility Index (CFI) and Quotient (CFQ) to appraise the statistical robustness of data from RCTs evaluating PRP for treatment of PF.

Methods

RCTs comparing outcomes after PRP injection vs alternative treatment in patients with chronic PF were evaluated. Representative simulated data sets were generated for each reported outcome event using summary statistics. The CFI was determined by manipulating each data set until reversal of significance (α=0.05) was achieved. The corresponding CFQ was calculated by dividing the CFI by the sample size.

Results

Of 259 studies screened, 20 studies (59 outcome events) were included in this analysis. From these simulations, the median CFI for all events was 9, suggesting that varying the treatment of 9 patients would be required to reverse trial significance. The corresponding CFQ was 0.177. Studies with reported P value <.05 were more statistically fragile (CFI=10, CFQ=0.122) than studies with reported P value >.05 (CFI=5, CFQ=0.179). Of 36 outcome events reporting lost to follow-up data, 10 events (27.8%) lost ≥9 patients.

Conclusion

Our findings suggest that, on average, the statistical fragility of RCTs evaluating PRP for nonoperative PF therapy is at least comparable to that of the sports medicine literature. However, several included studies had concerningly low simulated fragility scores. Orthopaedic surgeons may benefit from preferentially relying on studies with higher CFI and CFQ values when evaluating the utility of PRP for chronic PF in their own clinical practice. Given the importance of RCT data in clinical decision making, fragility indices could help give context to the stability of statistical findings.

Level of Evidence

Level I, systematic review.

Interventional Imaging Techniques as Alternative to Surgery of the Foot and Ankle

A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided intervention, the joints, soft tissues, and osseous structures may be accessible using various percutaneous techniques as a potential alternative therapeutic tool, avoiding the need for surgery with its associated risks and morbidity. This article discusses the potential range of image-guided interventional treatments. Injections, aspiration, biopsies, cryoablation, and radiofrequency ablation are described. Newer novel treatments are also covered. Finally, the common pathologies of Morton's neuroma, Achilles tendinopathy, and plantar fasciitis are addressed.

Comparison of Platelet-Rich Plasma Treatment and Partial Plantar Fasciotomy Surgery in Patients with Chronic Plantar Fasciitis: A Randomized, Prospective Study

Platelet-Rich Plasma (PRP) injection has become a desirable alternative to Partial Plantar Fasciotomy (PPF) surgery and steroid injection for patients with chronic plantar fasciitis (CPF) due to its potential for shorter recovery times, reduced complications, and similar activity scores. As such, we compared PRP treatment to PPF surgery in patients with CPF. Between January 2015 and January 2017, patients were randomly divided into two groups, a PRP treatment group, and a PPF group. All procedures were performed by a single foot and ankle fellowship-trained specialist surgeon. Visual Analog Score (VAS) and Roles-Maudsley Scale (RM) were collected during the preoperative visit and 3, 6, and 12 months postoperatively. The patients were also closely followed by a physiotherapist. There were 16 patients in each group after four patients refused to participate. Patients in the PPF had low Roles-Maudsley Scale (RM) scores compared to the PRP group one-year after treatment (3.77 vs. 2.72, p < 0.0001). Both procedures showed a reduction in RM scores during the follow-up year (9 to 1.62 for PPF and 8.7 to 2.4 for PRP). There was no significant change in VAS pain between the two groups (p = 0.366). Patients treated with PRP injection reported a significant increase in their activity scores, shorter recovery time, and lower complication rates compared to PPF treatment. Moreover, with respect to existing literature, PRP may be as efficient as steroid injection with lower complication rates, including response to physical therapy. Therefore, PRP treatment may be a viable option before surgery as an earlier line treatment for CPF. Level of Clinical Evidence: II.