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

Effect of corticosteroids over plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis

OBJECTIVES

Corticosteroid injections have been typically used for the management of plantar fasciitis with apparently good clinical outcomes; however, there is no information of the effect of corticosteroids on the thickness of the plantar fascia which is typically altered in this pathology. We aimed determine whether treatment with corticosteroid injections induces plantar fascia thickness changes in plantar fasciitis.

METHODS

MEDLINE, Embase, Web of Science, and Scopus databases were searched for randomized controlled trials (RCT) reporting the use of corticosteroid injection to treat plantar fasciitis to July 2022. Studies must have reported plantar fascia thickness measurement. The risk of bias in all studies was assessed with the Cochrane Risk of Bias 2.0 tool. Meta-analysis was conducted using a random-effects model and the generic inverse variance method.

RESULTS

Data from 17 RCT (including 1109 subjects) were collected. The follow-up period ranged from one to six months. Most studies measured the thickness of the plantar fascia at the insertion into the calcaneus using ultrasound. Pooled analysis revealed that corticosteroid injections had no significant effect on plantar fascia thickness (weighted mean differences [WMD], 0.06 mm [95% CI: -0.17, 0.29]; p = 0.61) or pain relief (WMD, 0.12 cm [95% CI: -0.36, 0.61]; p = 0.62) above active controls.

CONCLUSION

Corticosteroid injections do not perform better than other common interventions in terms of a decrease of plantar fascia thickness and pain relief for plantar fasciitis.

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.

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.

Autologous Whole-Blood Versus Corticosteroid Local Injection in Treatment of Plantar Fasciitis: A Randomized Single Blind Placebo-Controlled Study

BACKGROUND

Autologous whole-blood intralesional injection has attracted interest as a possible means of treatment for chronic plantar fasciitis. We contrasted its effectiveness with that of corticosteroids, which have a longer history of success in treating tendinopathies such as plantar fasciitis. In order to monitor the disease's progress naturally, we also compared them with a placebo.

METHODS

Sixty clinically diagnosed patients were taken up for intralesional injection of autologous whole blood (AWB), corticosteroid, and normal saline as placebo mixed with 2 mL of lignocaine after dividing them into three groups. Two doses were given and followed up in the third, sixth, and 12th weeks. The evaluation was done according to the visual analog scale (VAS) and the number of tablets of paracetamol (PCM) 500 mg consumed for the following period.

RESULTS

When compared to the placebo group in the third, sixth, and 12th weeks, the corticosteroid group exhibited a significant improvement with a p<0.001 in the VAS score, whereas the autologous whole blood group showed no meaningful difference. When compared to the placebo group at the sixth and 12th weeks, the AWB group's VAS score showed a statistically significant difference with a p>0.001. At each follow-up, the placebo group consumed more analgesics than the corticosteroid group, with a p<0.001. Only in the third week of follow-up did AWB demonstrate a statistically significant difference in PCM consumption as compared to the corticosteroid group.

CONCLUSION

Statistically significant improvement was seen in both the AWB group and corticosteroid group as compared to the placebo group. The corticosteroid group achieved earlier and superior relief of pain while AWB had a longer lasting effect. Therefore, study results indicate almost similar results in short-term studies.

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.

Effect of platelet-rich plasma versus steroid injection in plantar fasciitis: a randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common orthopaedic problem, with heel pain worsening the quality of life. Although steroid injection is often used if the conservative treatment fails, Platelet-Rich Plasma (PRP) injection is gaining popularity due to its safety and long-lasting effect. However, the effect of PRP versus steroid injection in PF has not been studied yet in Nepal. Therefore, this study aimed to assess the effect of PRP compared with steroid injection in the treatment of PF.

METHODS

This study was a single-center, hospital-based, open-label, parallel-group randomized clinical trial to compare the effect of PRP injection with steroid injection in plantar fasciitis between August 2020 and March 2022. A total of 90 randomly selected participants aged 18 to 60 years suffering from plantar fasciitis with failed conservative treatment were intervened. The American Orthopaedic Foot and Ankle Society (AOFAS) and the Visual Analog Scale (VAS) scoring system were used to evaluate functional mobility and pain before and after the intervention for three and six months, respectively. Statistical analyses were performed using a Student's two-sample t-test. P-value < 0.05 was considered statistically significant.

RESULTS

The PRP injection showed a better outcome than the steroid injection in six months follow-up. The mean (± SD) VAS score was significantly decreased in the PRP group (1.97 + 1.13) than in the steroid group (2.71 ± 0.94) with the group difference of -0.73 (95% CI: -1.18 to -0.28) at six months. Similarly, there was a significant increase in the AOFAS scores in the PRP group (86.04 ± 7.45) compared to the steroid group (81.23 ± 9.60) at six months of follow-up with a group difference of 4.80 (95% CI: 1.15 to 8.45). There was also a significant reduction of plantar fascia thickness in the PRP group compared to that of the steroid group (3.53 ± 0.81 versus 4.58 ± 1.02) at six months of follow-up with the group difference of -1.04 (95% CI: -1.44 to -0.65).

CONCLUSION

The PRP injection showed better outcomes than steroid injection in plantar fasciitis treatment over the course of six months. Further research with a larger population and longer follow-up than six months is needed to generalize the findings and their long-term efficacy.

TRIAL REGISTRATION

NCT04985396. First registered on 02 August 2021. ( https://clinicaltrials.gov/ct2/show/NCT04985396 ).

An assessment of plantar fascia with ultrasound findings in patients with plantar fasciitis: a systematic review

INTRODUCTION

Plantar fasciitis (PFS) is described by an intense pain over medial tubercle of calcaneus, increased with the first step after waking up, after rest and during weightbearing activity. It is the most common cause of plantar heel pain in adults with the prevalence estimated 10% of the general population. Ultrasound imaging is commonly being used to measure the PF thickness, evaluate the efficacy of different treatments and a guide therapeutic technique in patients with PFS. The objective of this study was to systematically review the studies that were previously published to evaluate the role of ultrasound in the assessment of PF in patients with PFS.

METHODS

A systematic search was carried out over the last 5 years from 2017 to 2022 on basis the following electronic databases: Science Direct, Scopus, Web of Science, Springer and PubMed. The keywords that used in the searching were: ultrasound, sonography, ultrasonography, plantar fasciitis, imaging of plantar fascia, physiotherapy of plantar fasciitis, interventional treatment of plantar fasciitis, randomized controlled trial of plantar fasciitis and interventional ultrasound. The review focused on the assessment of PF in patients with PFS underwent different interventions using B-mode, shear wave elastography (SWE) and color Doppler ultrasound.

RESULTS

During the search process, 1661 were recorded using the proper keywords from 2017 to 2022 in which 666 original articles were found after removing the review and duplicated articles. Of these, thirty articles met the inclusion criteria and included in this review. The articles have assessed the PF in patients with PFS under different conditions using different ultrasound modes. Twenty-six articles evaluated the effectiveness of different treatment on PF in patients with PFS using different ultrasound modes. In 8 of 26 articles, the ultrasound was used as both an assessment tool of PF and guide therapeutic technique in patients with PFS. In 18 articles, the ultrasound was used as only assessment tool to identify the PF thickness and its observation changes in patients with PFS. Four articles compared the PF thickness and its intrafascial changes between patients with PFS and healthy subjects.

CONCLUSION

The ultrasound can be a reliable tool in assessment the effect of different interventions on PF by evaluating its thickness, echogenicity and stiffness changes in patients with PFS. There were different methods and treatments were used among the studies.

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.

A Prospective Study Comparing the Efficacy of Local Injection of Platelet-Rich Plasma (PRP) vs Methylprednisolone in Plantar Fasciitis

Introduction

Plantar fasciitis is a common musculoskeletal problem in Orthopaedic practice. Heel pain caused due to plantar fasciitis, if persistent, can cause distress to the patient, so the correct intervention at the right time is needed. Plantar fasciitis is also common in the rural population.

Objectives

To compare the efficacy of local injection of platelet-rich plasma (PRP) and corticosteroid (CS) (methylprednisolone) in patients with chronic plantar fasciitis, and to evaluate the safety, side effect and complications of two different modalities of treatment.

Materials and methods

The study period was between August 2018 and September 2020. After obtaining proper written consent, 110 patients, who were above the age of 18 years and suffering from plantar fasciitis for more than three months, were included in the study. The patient characteristics including gender, age, weight, history of heel pain, duration of symptoms and types of prior treatment were noted. All the 110 patients were subjected to four parameter assessments before administration of the PRP/CS injections. Out of the 110 patients, 55 patients received PRP injection and 55 received CS - 2 ml (40 mg) methylprednisolone with 2 ml of sterile water injections. Post administration of injections, the patients' clinical, radiological, subjective and functional outcomes were assessed at the first, third and sixth month by using the Visual Analog Scale (VAS), Foot and Ankle Outcome Instrument Core Scale (FAI), Roles and Maudsley Scores (RMS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and ultrasonogram of plantar fascia thickness.

Discussion

In this study, 110 patients were screened and evaluated. Out of these 110 patients, five patients who received PRP and five who received CS were lost for follow-up. Out of the 110 patients, 59 were females and 41 were males. The majority of the patients were in the BMI range of 18.5 to 24.9, with a mean BMI of 23.6. Comparing the results in both the groups reflected an improvement in the group of patients who received PRP injections. Two patients had post-operative complications (superficial infection) in the PRP injection group, while 10 patients had post-procedure complications (five patients developed superficial infections, three patients developed skin depigmentation, and two patients had atrophy of fat pad) in the corticosteroid injections (CSI) group. Infections subsided in all the patients as observed during subsequent follow-up.

Conclusion

This study shows that PRP administration is a good method of managing patients suffering from chronic plantar fasciitis, presenting with some discomfort following activity, with more than three months of symptoms and with a VAS score of more than 6 and plantar fascia thickness of 5 mm and failed conservative management. This is evidenced by a comparison of AOFAS, FAI score and thickness of plantar fascia using an ultrasonogram before and after the procedure. This study reflects better treatment outcomes with PRP injection compared to local steroid infiltration. This is the largest series of cases studied compared to other previously available studies in the literature. PRP injections may thus be used as a superior alternative to the already available treatments for chronic heel pain.

Platelet Rich Plasma Injection for Soft Tissue Musculoskeletal Pain

Introduction

Treating soft tissue injuries can be a challenge for physicians as it can be overlooked which can lead to more problems. In recent studies, the use of Platelet Rich Plasma (PRP) has been gaining popularity for soft tissue injuries because of its benefits and minimal side effects. This study aims to evaluate the effect of PRP injection on various musculoskeletal soft tissues inflammation.

Material and Methods

This is a retrospective study of patients with soft tissue injury who underwent PRP therapy between 2015 and 2018 at an orthopaedic and traumatology hospital. The study collected demographic data including the type of soft tissue injury and Visual Analog Scale (VAS) before and after the PRP injection. Those data were statistically analysed to identify the significance of PRP.

Results

Seventy-six patients were included, predominantly female, middle aged (40-69 years old) and class one obesity. Most of the complaints (61.8%) were in the lower extremity region. Pain improvements measured with mean VAS score were observed in both acute (3.06±1.28 to 0.8±0.65) and chronic (4±1.75 to 0.97±0.62) cases. There was a significant decrease of VAS score before and after the PRP injection (p < 0.000).

Conclusion

PRP injection is able to alleviate both acute and chronic pain in soft tissue injuries without additional analgesic.

Effects and mechanism of platelet-rich plasma on military drill injury: a review

Military drill injury is a significant part of military medical research. The increase of training intensity and changes in training methods lead to differences in injury types. The ideal therapeutic modality should allow rapid healing at a reasonable cost and minimize impact on patients' life. Platelet -rich plasma (PRP), a platelet concentrate, is rich in a variety of growth factors and widely used clinically as a minimally invasive treatment. It plays an important role in injury repair and rehabilitation. In this article, we review the therapeutic role of PRP in military drill injury and its possible underlying mechanisms, with a focus on plantar fasciitis, stress fractures and other common injuries, in order to provide basic support for military reserve.