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

[Translated article] Subchondral bone damage has no influence in 12-week clinical outcome in patients with knee osteoarthritis treated with intraarticular platelet-rich plasma: A retrospective study

OBJECTIVE

To determine if subchondral bone damage can influence the clinical results of intraarticular platelet-rich-plasma (PRP) treatment in knee osteoarthritic patients.

MATERIAL AND METHODS

A retrospective review of patients treated with intraarticular PRP injections for knee osteoarthritis who previously underwent a magnetic resonance (MR) of the knee was performed. Visual Analogic Score (VAS) was assessed for pain, whereas WORMS MR score was adapted to assess the damage to the subchondral bone (WORMSsc score).

RESULTS

Sixty-one patients were treated with 3 weekly injections of PRP. Mean VAS reduction was 27.67±13.13 points (p<.005). WORMS sc mean score was 32±18.5 points. No correlation between WORMSsc and VAS was found. A moderate correlation between WORMSsc score and preoperative VAS was found (r=.43; p<.005).

CONCLUSION

There is no correlation between the damage to the subchondral bone assessed by MR and pain relief at 12 weeks in patients treated with intraarticular platelet-rich plasma in patients with knee osteoarthritis. A greater damage to the subchondral bone could be associated with more pain.

Evidence-based orthobiologic practice: Current evidence review and future directions

The field of orthopedic and regenerative medicine is rapidly evolving with the increasing utilization of orthobiologic. These biologically derived therapies, including platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate, stromal vascular fraction (SVF), and autologous chondrocyte implantation, are gaining traction for their potential to enhance the body's natural healing processes. They offer a promising alternative to traditional surgical interventions for musculoskeletal injuries and degenerative conditions. Current evidence suggests significant benefits of orthobiologics in treating conditions like osteoarthritis, tendon injuries, and spinal disorders, yet inconsistencies in treatment protocols and outcomes persist. The global market for orthobiologics is projected to grow substantially, driven by advancements in biologic therapies such as adipose-derived stem cells and SVF, and the demand for minimally invasive treatments. Despite their promise, regulatory and ethical challenges, as well as the need for high-quality, standardized research, remain significant obstacles. Future directions in the field include advancements in delivery systems, personalized medicine approaches, and the exploration of novel sources like induced pluripotent stem cells, aiming for more targeted and effective treatments. Collaborative efforts are crucial to overcoming these challenges and ensuring the safe and effective application of orthobiologics in clinical practice.

Subchondral bone damage has no influence in 12-week clinical outcome in patients with knee osteoarthritis treated with intraarticular platelet-rich plasma: A retrospective study

OBJECTIVE

To determine if subchondral bone damage can influence the clinical results of intraarticular platelet-rich-plasma (PRP) treatment in knee osteoarthritic patients.

MATERIAL AND METHODS

A retrospective review of patients treated with intraarticular PRP injections for knee osteoarthritis who previously underwent a Magnetic Resonance (MR) of the knee was performed. Visual Analogic Score (VAS) was assesed for pain, whereas WORMS MR score was adapted to assess the damage to the subchondral bone (WORMSsc score).

RESULTS

Sixty-one patients were treated with 3 weekly injections of PRP. Mean VAS reduction was 27.67±13.13 points (P<.005). WORMS sc mean score was 32±18.5 points. NO correlation between WORMSsc and VAS was found. A moderate correlation between WORMSsc score and Preoperative VAS was found (r=.43; P<.005).

CONCLUSION

There is no correlation between the damage to the subchondral bone assesed by MR and pain relief at 12 weeks in patients treated with intraarticular platelet-rich plasma in patients with knee osteoarthritis. A greater damage to the subchondral bone could be associated with more pain.

Informed consent form for platelet rich plasma injections: evidence-based and legally guide for orthopaedic surgeons

Regarding medico-legal malpractice suits, lawyers and insurers focus on informed consent documentation. Unfortunately, there is no standard protocol for obtaining informed consent for platelet-rich plasma (PRP) injections. The objective of the present study was to create a pre-designed, evidence-based informed consent form specifically for PRP injections. The current evidence on the medico-legal implications of PRP injections was accessed, as well as informed consent in general and specifically informed consent in PRP injections. Additionally, we interviewed orthopaedic surgeons and patients who had undergone PRP injections in the past year using a semi-structured approach. A legally valid and evidence-based informed consent form for PRP injections ensures rights, encouraging open communication and transparency between the patient and surgeon. Moreover, if a lawsuit arose, informed consent would be a critical document in surgeons' defence and would withstand scrutiny from lawyers and the judiciary. An evidence-based informed consent form for PRP injections was elaborated and reviewed by a legal expert to ensure adherence to legal proprieties. The final form of the informed consent for PRP injection was administered for one year and validated at our institution.

Ultrasonic Fasciotomy for the Treatment of Chronic Plantar Fasciopathy: A Prospective Study

OBJECTIVE

To evaluate the long-term efficacy and safety of an ultrasonic fasciotomy for plantar fasciopathy.

DESIGN

Prospective observational study.

SETTING

Tertiary care academic medical center.

PARTICIPANTS

Patients with chronic plantar fasciopathy refractory to standard, conservative treatments were included in this study.

INTERVENTIONS

Patients underwent ultrasonic fasciotomy of the plantar fascia.

MAIN OUTCOME MEASURES

The primary outcome measures were change in visual analog scale at 12 and 52 weeks post-procedure compared with baseline as well as patients' self-reported satisfaction with the procedure.

RESULTS

Sixty-seven patients were included. There was a significant improvement in visual analog scale at all follow-up time points, with an average overall improvement of 5.87 ( P < 0.0001). 94% of patients reported satisfaction with the outcomes of their procedure at 12 and 52 weeks. No procedural complications were seen.

CONCLUSIONS

This study demonstrates that an ultrasonic fasciotomy is a safe and effective treatment option for chronic plantar fasciopathy, with continued symptom improvement and a high degree of patient satisfaction up to 52 weeks post-procedure.

CLINICAL RELEVANCE

These findings suggest that an ultrasonic fasciotomy should be considered for patients with chronic plantar fasciopathy refractory to conservative treatments.

Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore

Introduction

Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play.

Method

A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus.

Results

Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF.

Conclusion

The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Editorial Commentary: Platelet-Rich Plasma for Musculoskeletal Conditions Is Supported by a Large Number of Clinical Studies, Particularly for Knee Osteoarthritis

Platelet-rich plasma (PRP) represents a biological treatment for various musculoskeletal conditions. Over the past 20 years, publications regarding the treatment of orthopaedic conditions with PRP have shown a 4-fold increase. Several systematic reviews and meta-analyses have demonstrated that PRP is effective and often superior to other treatment modalities. However, the value of these studies is somehow limited as high risk of bias, study heterogeneity, and low levels of certainty compromise the validity of their conclusions. In this scenario, expert consensus studies can be useful and allow pooling of expert opinion in a scientific manner. Using the modified Delphi technology, it was determined that the definition of PRP, whether leukocyte rich or poor, is still not clear. In addition, it remains unclear whether PRP should be activated, how often it should be injected, what the ideal dose is and how to prepare PRP. Despite these uncertainties, the use PRP for various orthopaedic conditions, in particular for the treatment of knee osteoarthritis, is supported by a large number of clinical studies. However, its use remains an unsolved controversy, and the foundation of a biologics association is a step in the right direction to develop standards and foster research with regards to the safety, clinical efficacy, and clinical applications of orthobiologics. In summary, there is no strong consensus, but many individual statements result in a strong consensus rating.

Outcomes of Platelet-Rich Plasma Infiltration and Weightbearing Cast Immobilization in Distal Tibialis Anterior Tendinopathy: A Prospective Cohort Study

BACKGROUND

Distal tibialis anterior tendinopathy (DTAT) is a chronic condition that may lead to functional impairment and secondary forefoot deformities when left untreated. Current clinical practice is mainly guided by case reports and small retrospective case series; little consensus exists on which treatment protocol is most effective. This study aims to assess a conservative treatment for DTAT consisting of PRP infiltration and walking cast immobilization.

METHODS

This prospective study included 18 feet in 18 patients, recruited between September 2020 and September 2022 at a single institution. Ultrasonography was performed; leukocyte-poor PRP was infiltrated around the tibialis anterior tendon insertion. Walking cast immobilization was used for 3 weeks after infiltration, followed by eccentric exercises of the DTAT, and gastrocnemius-soleus muscle complex stretching. Clinical findings, visual analog scale (VAS), Foot Function Index (FFI), and American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores were recorded at inclusion, and 6 and 12 weeks after PRP infiltration. Minimal clinically important difference (MCID) limits were researched to assess clinical relevance of statistical outcomes. Means were determined for age, sex, and body mass index (BMI). One-way repeated measures ANOVA was performed over time for FFI, AOFAS, and VAS scores.

RESULTS

Mean age was 65 years with a mean BMI of 25. Tendon thickening and hypoechogenicity were the most commonly reported ultrasonographic findings. Significant improvement from baseline VAS (VASrest: 4.71 ± 2.7, VASactivity: 5.66 ± 2.5) to 12 weeks follow-up (VASrest: 2.14 ± 2.7, VASactivity: 3.34 ± 2.5) was found. Both AOFAS and FFITotal improved significantly from baseline (AOFAS: 66.9 ± 3.3, FFITotal: 32.9 ± 3.3) to 6-week follow-up (AOFAS6w: 79.4 ± 3.3, P = .019; FFITotal: 19.4 ± 3.3, P = .011). No statistically significant further improvement was found at 12 weeks compared to 6 weeks' follow-up. Two (11%) patients chose operative treatment because of persisting symptoms.

CONCLUSION

We found that PRP infiltration with walking cast immobilization as a first-line treatment was associated with general early symptom improvement.

LEVEL OF EVIDENCE

Level IV, case series.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

The use of platelet-rich plasma in pathologies of the foot and ankle: A comprehensive review of the recent literature

Platelet-rich plasma (PRP) is an autologous serum containing higher concentrations of platelets and growth factors above normal blood. The process of obtaining PRP involves the extraction of blood from the patient which is then centrifuged to obtain a concentrated suspension of platelets. PRP continues to evolve as a potential treatment modality with many applications in orthopaedic surgery. The therapeutic components of PRP possess numerous theoretical regenerative properties. The present manuscript outlines how PRP is prepared, noting the tremendous variability between preparation protocols. Given the growing body of evidence examining the use of PRP in pathologies of the foot and ankle, we assess its efficacy as it relates to our field. Specifically, we evaluate the literature in the past five years regarding the role of PRP in treating plantar fasciitis, Achilles tendinopathy, insertional Achilles tendinitis, Achilles tendon ruptures, osteochondral lesions of the talus, hallux rigidus, and ankle osteoarthritis.

Efficacy of Platelet-Rich Plasma Injection on Range of Motion, Pain, and Disability in Patients With Adhesive Capsulitis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of platelet-rich plasma (PRP) injection on range of motion, pain, and disability in patients with adhesive capsulitis (AC).

DATA SOURCES

The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases in February 2023.

STUDY SELECTION

Prospective studies comparing the outcomes of PRP with other intervention in patients with AC.

DATA EXTRACTION

The quality of included randomized trials was assessed using the revised Cochrane Risk of Bias (RoB 2.0) tool. The Risk of Bias in Non-Randomized Studies of Interventions tool was applied to assess the quality of nonrandomized trials. The mean difference (MD) or standardized mean difference (SMD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs).

DATA SYNTHESIS

Fourteen studies involving 1139 patients were included. Our meta-analysis revealed that PRP injection can significantly improve passive abduction (MD=3.91; 95% CI, 0.84-6.98), passive flexion (MD=3.90; 95% CI, 0.15-7.84), and disability (SMD=-0.50; 95% CI, -1.29 to -0.74) within 1 month after intervention. Moreover, PRP injection can significantly improve passive abduction (MD=17.19; 95% CI, 12.38-22.01), passive flexion (MD=17.74; 95% CI, 9.89-25.59), passive external rotation (MD=12.95; 95% CI, 10.04-15.87), pain (MD=-8.40; 95% CI, -16.73 to -0.06), and disability (SMD=-1.02; 95% CI, -1.29 to -0.74) 3 months after intervention. PRP injection can also significantly improve pain (MD=-18.98; 95% CI, -24.71 to -13.26), and disability (SMD=-2.01; 95% CI, -3.02 to -1.00) 6 months after intervention. In addition, no adverse effects of PRP injection were reported.

CONCLUSIONS

PRP injection may serve as an effective and safe treatment for patients with AC.

Efficacy of pharmacological and non-pharmacological therapies on pain intensity and disability for plantar fasciitis: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of pharmacological and non-pharmacological therapies on pain intensity and disability for plantar fasciitis.

DESIGN

Systematic review of randomised controlled trials (RCTs).

DATA SOURCES

AMED, MEDLINE, PEDro, Cochrane, SPORTDiscus, CINAHL, EMBASE and PsycINFO without language or date restrictions up to 3 February 2023.

ELIGIBILITY CRITERIA

RCTs that evaluated the efficacy of any pharmacological and non-pharmacological therapies compared with control (placebo, sham, waiting list or no intervention) on pain intensity and disability in people with plantar fasciitis. Two reviewers independently screened eligible trials, extracted data, assessed the methodological quality of included trials and assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. Mean differences (MDs) with 95% CIs were reported.

RESULTS

Seventeen different therapies investigated in 28 trials were included in the quantitative analysis. For non-pharmacological therapies, moderate certainty evidence showed short-term effects of customised orthoses on pain intensity when compared with control (MD of -12.0 points (95% CI -17.1 to -7.0) on a 0-100 scale). Low certainty evidence showed short-term effects of taping on pain intensity (-21.3 (95% CI -38.6 to -4.0)). Long-term effects and effects on disability are still uncertain. For pharmacological therapies, low to very low quality evidence from few trials with small samples was inconclusive and supports that high-quality trials are needed.

CONCLUSIONS

Moderate-quality and low-quality evidence demonstrates customised orthoses and taping, respectively, reduce pain intensity in the short term in patients with plantar fasciitis.

PROSPERO REGISTRATION NUMBER

CRD42021224416.

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.

Effectiveness of Hypertonic Dextrose Injection (Prolotherapy) in Plantar Fasciopathy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To systematically review the effectiveness of hypertonic dextrose prolotherapy (DPT) in plantar fasciopathy (PF) compared with other non-surgical treatments.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Allied and Complementary Medicine Database, Global Health, Ovid Nursing Database, Dimensions, and WHO ICTRP were searched from inception to April 30th, 2022.

STUDY SELECTION

Two independent reviewers selected randomized controlled trials (RCTs) that evaluated the effectiveness of DPT in PF compared with non-surgical treatments. Outcomes included pain intensity, foot and ankle function, and plantar fascia thickness.

DATA EXTRACTION

Two independent reviewers conducted data extraction. Risk of bias (RoB) assessment was conducted using the Cochrane Risk of Bias 2 (RoB 2) tool, and certainty of evidence was assessed with Grading of Recommendation Assessment, Development, and Evaluation (GRADE).

DATA SYNTHESIS

Eight RCTs (n=469) met the inclusion criteria. Pooled results favored the use of DPT versus normal saline (NS) injections in reducing pain (weighted mean difference [WMD] -41.72; 95% confidence interval [CI] -62.36 to -21.08; P<.01; low certainty evidence) and improving function [WMD -39.04; 95% CI -55.24 to -22.85; P<.01; low certainty evidence] in the medium term. Pooled results also showed corticosteroid (CS) injections was superior to DPT in reducing pain in the short term [standardized mean difference 0.77; 95% CI 0.40 to 1.14; P<.01; moderate certainty evidence]. Overall RoB varied from "some concerns" to "high". The overall certainty of evidence presented ranges from very low to moderate based on the assessment with the GRADE approach.

CONCLUSION

Low certainty evidence demonstrated that DPT was superior to NS injections in reducing pain and improving function in the medium term, but moderate certainty evidence showed that it was inferior to CS in reducing pain in the short term. Further high-quality RCTs with standard protocol, longer-term follow-up, and adequate sample size are needed to confirm its role in clinical practice.

Plantar Fasciitis: An Updated Review

Plantar fasciitis (PF) is a common musculoskeletal disease. Histologic findings of patients with PF showed mainly chronic degenerative processes rather than inflammation. In addition to mechanical factors, such as repetitive stress and reduced ankle dorsiflexion, PF is also linked to rheumatologic diseases and genetic factors. Ultrasound is becoming a standard imaging technique for assessing PF. Major sonographic findings included increased plantar fascia thickness and hypoechoic plantar fascia. In addition to traditional B-mode ultrasound, sonoelastography can also be utilized to diagnose PF. Ultrasound can also be used to guide therapeutic interventions. Over 80% of patients with PF improved under nonsurgical treatment. Treatment options for PF include physical therapy, modalities (laser, therapeutic ultrasound), extracorporeal shock wave therapy (ESWT), injections, transcatheter arterial embolization, and surgery. For injections, corticosteroid was mostly used in the past but has been replaced gradually by other techniques such as platelet-rich plasma or dextrose prolotherapy. There is also more and more evidence about ESWT in treating PF. Surgery serves as an option for recalcitrant PF cases, and endoscopic fasciotomy seemed to have good outcomes. Ultrasound plays an important role in diagnosing of PF and evaluating the treatment effect, and the use of sonoelastography in addition to traditional B-mode ultrasound may help in the early detection of PF and assessment of the treatment effect.

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.

Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia

Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.

Imaging-Guided Musculoskeletal Interventions in the Lower Limb

Imaging guidance is essential for musculoskeletal interventional procedures performed in the lower limb. A strong evidence supports the use of imaging guidance to improve safety, accuracy, and effectiveness of these interventions. Joints, tendons, bursae, and nerves can be effectively approached especially with ultrasound-guided injections. Here, we discuss evidence and technique of the most common image-guided musculoskeletal interventional procedures in the lower limb.

The Epidemiology of Platelet-Rich Plasma Injections From 2010 to 2020 in a Large US Commercial Insurance Claims Database: A Recent Update

INTRODUCTION

The popularity of platelet-rich plasma (PRP) injections for the treatment of orthopaedic conditions has grown markedly. We sought to better define the trends in the usage of orthopaedic PRP injections across an insured US population over the past decade.

METHODS

The PearlDiver M91Ortho commercial administrative claims database was queried for all patients receiving PRP injections for orthopaedic conditions from 2010 through the first quarter of 2020 (Q1.2020). Trends in PRP use, reimbursement charges, demographics, joints injected, and administering physicians were assessed over time and reported as year-over-year (YOY) changes.

RESULTS

Over the study period, 14,096 unique patients had 17,759 orthopaedic PRP injections. The number of PRP injections administered had a YOY increase of 7.1% (144 injections/year, 95% confidence interval [CI] = 89 to 199, Ptrend = 0.0009). A YOY increase of 895% was observed in total nonsurgical charges ($683,974/yr, 95% CI 441,504 to 926,444, Ptrend = 0.0009). The median age of PRP recipients increased (YOY change = +0.6 years, 95% CI 0.4 to 0.8, Ptrend = 0.0005). Injections to the elbow (YOY change = -0.8%, 95% CI -0.10% to [-0.06%], Ptrend = 0.005) and foot/ankle (YOY change = -1.0%, 95% CI -1.4% to [-0.06%], Ptrend = 0.002) decreased, whereas hip (YOY change = +0.4%, 95% CI 0.2% to 0.6%, Ptrend = 0.019), knee (YOY change = +0.9%, 95% CI 0.3% to 1.2%, Ptrend = 0.016), and spine (YOY change = +0.2%, 95% CI 0.0% to 0.4%, Ptrend = 0.033) injections increased. PRP injections given by sports medicine orthopaedic surgeons (YOY change = +0.8%, 95% CI 0.6% to 1.2%, Ptrend <0.0001) increased over time, whereas those by general orthopaedic surgeons decreased (YOY change = -0.9, 95% CI -1.2 to [-0.6%], Ptrend = 0.001).

CONCLUSION

PRP injections quadrupled in prevalence from 2010 to Q1.2020, with a projected increase in annual usage in this data set of 66% by 2030. As greater evidence-based indications for PRP use are identified, more specialists and insurance providers may consider expanding their involvement in this growing field.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Advances in the Clinical Application of Platelet-Rich Plasma in the Foot and Ankle: A Review

Autologous and recombinant biologic substances have been generated as a result of the research into the cellular features of the healing process. Orthobiologics are increasingly being used in sports medicine and musculoskeletal surgery. Nevertheless, clinical data are limited; consequently, further studies are required, particularly in foot and ankle pathologies. This review aims to provide evidence of the most recent literature results and ignite the interest of orthopedic specialists eager for an update about the most current discussion on platelet-rich plasma (PRP) clinical applications in the foot and ankle fields. Previous studies have shown that platelet-rich plasma can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. Despite the positive effects of PRP on various musculoskeletal conditions, more prospective studies are needed to confirm its effectiveness at treating ankle and foot pathologies. In addition to clinical trials, other factors, such as the quality of the research and the procedures involved, must be considered before they can be used in patients. More long-term evaluations are needed to support or oppose its application in treating foot and ankle disorders. We present the most extensive review of PRP's clinical applications in the foot and ankle field.

Platelet-rich plasma, a biomaterial, for the treatment of anterior talofibular ligament in lateral ankle sprain

Background: Because of the rising prevalence of anterior talofibular ligament (ATFL) damage, there is a considerable interest in developing innovative techniques to improve the biological healing response of ATFL. Platelet-rich plasma (PRP) includes several growth factors linked to a favorable healing response, however none of the studies involved both quality evaluation and clinical results to evaluate this treatment. Purpose: To determine the clinical results of PRP injections into the ATFL in lateral ankle sprain (LAS) patients, as well as the quality of the ATFL based on radiographic outcomes. Methods: Patients with clinically confirmed grade II LAS for the first time (n = 83) were examined. The clinical outcomes of three types of injection methods were evaluated: none, once within 48 h after the sprain, and once more 4 weeks later after first injection. PRP was injected into the tear site of the ATFL using ultrasound guidance, and all ankles were immobilized for 2 weeks. The American Orthopedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) were used to assess the results at 2, 6, 8, 24, and 48 weeks of follow-up. The signal/noise ratio (SNR) value of Magnetic Resonance Imaging (MRI)-based ATFL signal intensity can disclose ATFL quality. The ATFL SNR results were then assessed 8, 24 and 48 weeks following the first injection to compare ATFL quality. Results: The PRP injection groups outperformed the control group in terms of clinical outcomes, and the two injections group outperformed other groups in terms of pain reduction and functional outcome at 8 weeks. The clinical results of all groups were comparable at 6 and 12 months follow-up. ATFL SNR findings improved significantly across all groups over time. At the same follow-up time, the PRP injection groups outperformed the control group, and the best SNR result showed in the two injections group at the final follow-up. Conclusion: PRP injection helped relieve early symptoms of LAS, although all patients saw a similar development after 6 months. The two PRP injections group produced considerably better clinical results and quality of the ATFL in short-term follow-up.

Efficacy of Platelet-Rich Plasma in Soft Tissue Foot and Ankle Pathology

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The preparation methodology for platelet-rich plasma (PRP) may have important clinical implications with varying effectiveness with leukocyte, platelet, and growth factor concentrations.

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There is high-quality evidence to support the superiority of PRP over corticosteroids in the case of chronic plantar fasciitis.

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There is moderate-quality to high-quality evidence for PRP's ability to increase tendon thickness with no capacity to decrease pain, increase function, or augment percutaneous tenotomy in Achilles tendinopathy.

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There is insufficient evidence to support PRP injections in the definitive treatment of Achilles tendon rupture. However, PRP may contribute to postoperative recovery after tendon rupture repair, but this requires further research.

➢

The biochemical theory supporting the clinical use of PRP must be reinforced with high-level evidence research. Based on the current literature, PRP may serve as a viable treatment method in chronic plantar fasciitis. Further high-quality, comparative studies with longer clinical follow-up are required to support recommendations for use of PRP in the treatment of Achilles tendon pathology.

The Effects of Intra-Articular Platelet-Rich Plasma Injections in Rheumatoid Arthritis: A Narrative Review

Platelet-rich plasma injections have been a therapeutic option with exponential growth in several pathologies in the last decades, particularly musculoskeletal for their effect on improving pain and functionality. Rheumatoid arthritis is a chronic joint disease, which involves inflammation of the synovial membrane with cartilage and juxta-articular bone destruction. Conventional and biological disease-modifying anti-rheumatoid drugs are the cornerstone of the treatment of this disease. However, the use of intra-articular glucocorticoids is often necessary and the role of platelet-rich plasma injections in these patients remains uncertain.

A literature review was carried out through the PubMed database, Cochrane and Google Scholar for the search terms “rheumatoid arthritis” and “platelet-rich plasma”. Eleven studies have been included in this review: two of these are in vitro studies, five are animal studies, one case report, two case series and one randomized controlled trial. Most of the studies demonstrated a decrease in pain and inflammatory mediators and improvement of functional outcomes, with no severe adverse effects reported.

However, the quantity and quality of literature about the effects and safety of plasma-rich plasma injections in rheumatoid arthritis patients are still scarce. It is essential that well-designed randomized controlled trials are made on this topic to understand if platelet-rich plasma may be useful as a coadjuvant therapy in rheumatoid arthritis.

Platelet-Activating Biominerals Enhanced Injectable Hydrogels With Superior Bioactivity for Bone Regeneration

Refractory bone fracture, which is difficult to be treated, is a common clinical disease. Taking inspiration from the natural process of bone regeneration, we provide a biomimetic strategy to develop a new injectable biomaterial for repairing bone defects, which is mainly composed of platelets, fibrins, and biominerals. Biomineral nanoparticles (EACPNs) with an amorphous phase are prepared by an enzyme-catalyzed route and display a platelet-activating property. The composite hydrogel (EPH) of EACPNs, fibrins, and platelets is injectable, and has similar chemical properties to natural materials in bone regeneration. The dried EPH samples display a highly porous structure, which would be favorable for cell attachment and growth. The results from in vitro studies indicate that EPH has high biocompatibility and superior bioactivity in promoting the osteogenic differentiation of rat bone marrow stem cells (rBMSCs). Furthermore, the results from in vivo studies clearly indicate that EPH can induce the formation of new collagen and vessels in the defect area, thus leading to faster regeneration of bone defects at 2 weeks. Our study provides a strategy for designing new biomimetic materials, which may be favorable in the treatment of refractory bone fracture.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

American Medical Society for Sports Medicine Position Statement: Principles for the Responsible Use of Regenerative Medicine in Sports Medicine

ABSTRACT

Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.