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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 26-30

Role of platelet-rich plasma versus corticosteroid injection in the treatment of plantar fasciitis: A comparative study


1 Department of Orthopaedics, UCMS and GTB Hospital, Delhi, India
2 Department of Orthopaedicss, SNMC, Agra, Uttar Pradesh, India

Date of Submission05-Sep-2019
Date of Decision06-Sep-2019
Date of Acceptance09-Sep-2019
Date of Web Publication21-Oct-2019

Correspondence Address:
Dr. Saurabh Kumar
Department of Orthopaedics, UCMS and GTB Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_9_19

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  Abstract 


Introduction: Platelet-rich plasma (PRP) is promoted nowadays as an ideal autologous biological blood-derived product. It enhances wound healing, bone healing, tendon healing and is currently being widely used. Aims and Objectives: A prospective cohort study was conducted to assess the efficacy of autologous PRP injection and to compare it with corticosteroid injection in the treatment of plantar fasciitis (PF). Materials and Methods: Fifty patients were included in the study and divided into two groups. Group I (25 patients) received PRP injection and Group II (25 patients) were given steroid injection. Patients were clinically assessed at different intervals. Functional outcome was evaluated on the basis of the visual analog scale (VAS) and foot and ankle ability measure (FAAM) scores. Plantar fascia thickness was assessed pre- and post-injection by ultrasound. Results: PRP and corticosteroid injection groups at the initial visit had VAS score of 8.86 and 8.60, respectively, which was reduced to 1.52 and 3.10 at the end of 6 months. The PRP and corticosteroid injection groups at the initial visit had FAAM score of 29.2 and 30.8, respectively, which increased to 84.2 and 68.3 at the end of 6 months. After injection, the PRP group had a significant reduction (34.80%) in the thickness of plantar fascia as compared to corticosteroid group (29.54%). Conclusion: Treatment of PF with PRP extract reduces pain and significantly increases function, exceeding the effect of steroid on long-term follow-up.

Keywords: Foot ankle ability measure score, plantar fasciitis, platelet-rich plasma, visual analog scale


How to cite this article:
Verma D, Kumar S, Dhammi IK, Kumar R, Kapoor R, Mittal A. Role of platelet-rich plasma versus corticosteroid injection in the treatment of plantar fasciitis: A comparative study. J Orthop Dis Traumatol 2019;2:26-30

How to cite this URL:
Verma D, Kumar S, Dhammi IK, Kumar R, Kapoor R, Mittal A. Role of platelet-rich plasma versus corticosteroid injection in the treatment of plantar fasciitis: A comparative study. J Orthop Dis Traumatol [serial online] 2019 [cited 2019 Dec 15];2:26-30. Available from: http://www.jodt.org/text.asp?2019/2/2/26/269586




  Introduction Top


Plantar fasciitis (PF) accounts for 15% of all foot disorders. More than 10% of the population is affected by it over their lifetime.[1],[2],[3] Although etiology of PF remains ill-understood, there are evidence to suggest that it is probably initiated by repeated microtrauma. Pathological changes are degenerative in nature (although partially reversible) and histologically changes, such as collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and matrix calcification are seen.[4],[5],[6],[7]

The most common presenting symptom of PF is a sharp pain of insidious onset with maximal tenderness at the anterior medial border of the calcaneus.[8] The pain is generally worst on the first few steps in the morning and with initial steps after prolonged sitting or inactivity, and on examination, there is mild-to-severe tenderness on medial calcaneal tubercle and sometimes, on the lateral aspect of the heel. Numerous methods have been advocated for treating PF, including rest, nonsteroidal anti-inflammatory drugs (NSAID),[9] night splints, foot orthosis,[10] stretching protocols,[11] and extracorporeal shock wave therapy.[12] The use of corticosteroids has been linked to rupture of plantar fascia, especially after repeated local injections.[13] Various types of surgical procedures have also been recommended for refractory cases.[14],[15] Platelet-rich plasma (PRP) is an ideal autologous biological blood-derived product, which can be exogenously applied to various tissues where it releases high concentrations of platelet-derived growth factors that enhance wound-healing, bone-healing, and also tendon healing. In addition, PRP possesses antimicrobial properties that may contribute to the prevention of infections. When platelets become activated, growth factors are released and initiate the body's natural healing response. The PRP injection might induce healing at the attachment of fascia at the os calcis.[16] The purpose of this study was to assess the role and efficacy of autologous PRP injection in the treatment of PF and compare it with corticosteroid injection.


  Materials and Methods Top


The study was conducted in the Department of Orthopedics, at a tertiary care hospital in India from 2014 to 2016. The diagnosis of PF is made with a reasonable level of certainty on the basis of history, clinical, and radiological assessment.

Inclusion criteria

  • Patients between the age group of 18–60 years presenting with complaints of plantar heel pain, worse with rising in the morning and/or after periods of sitting or lying presenting for 4 weeks or more
  • Patients with maximal tenderness at the attachment of the plantar fascia on the medial tubercle of the calcaneus
  • Willingness to participate in an investigational technique and follow-up with the written consent
  • Willingness to forgo any other concomitant conservative treatment modality; NSAIDS and orthotic devices during the study.


Exclusion criteria

  • Previous surgery for heel pain
  • Patient with neuropathic symptoms (radiculopathy, tarsal tunnel syndrome, tarsi sinus syndrome)
  • Patient with complex regional pain syndrome or with metastatic cancer
  • Achilles tendon pathology
  • Systemic diseases such as inflammatory or degenerative polyarthritis, diabetes mellitus, local or systemic infection, peripheral vascular diseases, metabolic disease, such as gout, clotting disorder, and anticoagulation therapy
  • Pregnant or breastfeeding female patients
  • Dysfunction of the knee, ankle, or foot
  • Work-related or compensable injury
  • Previous treatment: Corticosteroid injection in the past 6 months or NSAIDs treatment within the past 7 days.


Study design

Prospective interventional study

Method

After taking clearance from the ethical committee, patients were selected according to inclusion and exclusion criteria. Informed written consent was obtained from every patient who agreed to follow instructions and recommendations given by the clinician. Patient biography, detailed history, and clinical examination were done along with the ultrasonographic evaluation of plantar fascia thickness of both feet. All the fresh cases were initially treated with contrast bath, foot-stretching exercise, and silicon heel pad for 4 weeks. The patients, who were not improved with initial treatment, were explained about the autologous PRP injection and steroid injection.

Patients were randomly allocated into two groups

  • Group I: These patients were treated with single injection of 3 mL autologous PRP injection locally
  • Group II: These patients were treated with a single injection of 3 cc, i.e., 80 mg methylprednisolone acetate locally.


Platelet-rich plasma preparation method

A volume of 20 mL of a patient's own venous blood was withdrawn from antecubital vein under aseptic conditions and was collected in presterilized centrifuge vials. These centrifuge vials were preloaded with anticoagulant acid citrate dextrose. This blood was then centrifuged at 3200 rpm for 15 min. The blood is then separated into platelet-poor plasma (PPP) and PRP. The PPP is extracted and discarded. The resulting platelets concentrate contains approximately 6–8 times the concentration of platelets compared to baseline whole blood. The PRP samples were sent to the pathology laboratory at different intervals to know the concentration of platelets. The average platelet concentration in our sample was found to be 6.4 (standard deviation ± 1.2) times the baseline level.

Injection technique

The procedure was done on an outpatient basis and under complete aseptic conditions. Sites of maximum tenderness were pre-marked with a sterile marker. Patients of Group I received a 3 cc PRP injection into the origin of the plantar fascia at the site of maximum tenderness. 2 cc of 2% Lidocaine was infiltrated before injection. A peppering technique, i.e., spreading in clockwise manner was used to achieve a more extensive zone of delivery, with a single skin portal and four to five passes through the fascia itself. Lidocaine sensitivity was done before starting the procedure. Patients are rested for 15 min and then, they are allowed to walk.

Group II patients received 2 mL of Depo-Medrol (80 mg methylprednisolone) locally. About 2 mL of 2% lidocaine was infiltrated before this as in Group I. The patients were monitored for 20 min for adverse reactions and then sent home with instructions to limit their use of the feet for approximately 48 h and use opioid for pain. After 48 h, patients were given a standardized stretching protocol to follow for 2 weeks. A formal strengthening program is initiated after this stretching. At 4 weeks after the procedure, patients were allowed to proceed with normal sporting or recreational activities as tolerated. Any types of foot orthoses were not advised.

Follow-up

Follow-up of patients was done at 2, 4, 8, 12, and after 24 weeks. We used visual analog scale (VAS) and foot and ankle ability measure (FAAM) score for the assessment of pain and functional outcome. Ultrasonographic evaluation of thickness of plantar fascia was done pretreatment and 6 months posttreatment.


  Results Top


The study comprised a total of 54 patients of PF, of which 4 were lost during follow-up period. Thus, we had 50 patients for final assessment.

Statistical analysis was performed using the Statistical Package for the Social Sciences (16.0 version, IBM Crop., Armonk, New York, USA) software. The comparison of means between two groups tested was made using unpaired Student's t-test. For repeated measure, paired t-test was also used. The value of P < 0.05 is considered as statistically significant.

Of 50 patients, 25 were included in Group I (PRP group) and 25 were included in Group II (steroid group). The mean age of the patients was 41.94 ± 10.424 years in PRP group with a minimum age of 23 and maximum age of 60 years and for Group II, it is 40.64 ± 9. 26 with minimum age of 20 years and maximum age of 60 years which was comparable (P = 0.400). There were 22 males and 28 females with a total of 50 patients. Patients in PRP group, 10 were males and 15 were females. Patients in the steroid group, 12 were males and 13 were females.

Visual analog scale

When we calculated the difference between mean VAS score in the pretreatment period, i.e., baseline and mean VAS scores at different intervals in postinjection period, it was found that in PRP group, difference was maximum at 24 weeks and in the steroid group, it was at 12 weeks. This shows that the maximum effect of PRP on VAS was at 24 weeks, whereas in steroid group, it was at 12 weeks.

For within-group comparison in the PRP group, the results were statistically significant (P ≤ 0.05). The mean VAS score decreased from baseline continuously at 4 weeks, 8, 12, and up to 24 weeks. The VAS score was found to be statistically significant in comparison with baseline at all durations.

We have seen that within-group comparison for the steroid group, the results were also statistically significant. The mean VAS score decreased from baseline continuously at 4, 8, and up to 12. However, at the end of 24 weeks, there was increase in VAS score when compared to score at 12 weeks and found to be significant.

When both treatment methods were compared, it was observed that VAS score is significantly lower at 4, 8, and 12 weeks in steroid group as compared to PRP group. However at 24 weeks, VAS score was significantly lower in the PRP group as compared to steroid group.

Foot ankle ability measure score

When we calculated the difference between mean FAAM score in the pretreatment period, i.e., baseline and mean FAAM scores at different intervals in the postinjection period, it was found that in PRP group, difference was maximum at 24 weeks and in the steroid group, it was at 12 weeks. This shows that maximum effect of PRP on FAAM score was at 24 weeks, whereas in steroid group, it was at 12 weeks. For within-group comparison in PRP group, the results are statistically significant (P ≤ 0.05). The mean FAAM score increased from baseline continuously at 4, 8, 12, and up to 24 weeks. FAAM score is statistically significant in comparison with baseline at all durations.

Within-group comparison for the steroid group, the results are statistically significant. The mean FAAM score increased from baseline continuously at 4, 8, and up to 12 weeks. However, at the end of 24 weeks, there is fall in FAAM score when compared to score at 12 weeks.

When both treatment methods were compared, it was observed that FAAM score is significantly higher at 4, 8, and 12 weeks in the steroid group as compared to PRP group. However, at 24 weeks, FAAM score is significantly higher in PRP group as compared to the steroid group.

PRP and corticosteroid injection groups at the initial visit had VAS score of 8.86 and 8.60, respectively, which was reduced to 1.52 and 3.10 at the end of 6 months. The PRP and corticosteroid injection groups at the initial visit had FAAM score of 29.2 and 30.8, respectively, which increased to 84.2 and 68.3 at the end of 6 months. After injection, the PRP group had a significant reduction (34.80%) in the thickness of plantar fascia as compared to corticosteroid group (29.54%).


  Discussion Top


Chronic heel pain is a difficult condition to treat. It is well known that pain does not subside quickly, but can persist for several months and results in significant disability. PRP injection has emerged as a treatment alternative for many musculoskeletal conditions. The method of PRP preparation is based on studies conducted by Mazzocca, et al.[17] who concluded that platelet high spin method results in a higher number of growth factors and platelets in the sample, and hence, we adopted this method. The technique of PRP injection (peppering) was based on the studies by Scioli,[18] and Peerbooms et al.[19] found this method to be very effective.

Smith, et al.[20] have concluded that the FAAM score is the most extensively validated foot and ankle outcome instrument available. The score is sensitive to overall health status and comorbidities. That is why we took FAAM scoring as one of our tools for evaluating the functional outcome of the foot in postinjection period.

Direct imaging of the plantar fascia is possible with magnetic resonance imaging (MRI) and ultrasound.[21] These methods have revealed that plantar fascia is thicker in patients with PF than in those without PF.[22] Therefore, the changes in plantar fascia thickness after interventions in patients with PF are measurable with imaging techniques. The advantages of ultrasonography as compared with MRI are that it is noninvasive, it is radiation-free, it is a cost-effective approach, i.e., also well tolerated by patients and it is appropriate for serial follow-up.[23]

Gould et al.[24] concluded that VAS is widely used due to its simplicity and adaptability to a broad range of populations and settings. The VAS is more sensitive to small changes, especially when looking at change within individuals. The VAS takes <1 min to complete, no training is required other than the ability to use a ruler to measure the distance to determine a score.

For within-group comparison in PRP group, the results are statistically significant (P ≤ 0.05). The mean VAS score decreased from baseline continuously at 4, 8, 12, and up to 24 weeks. The VAS score is statistically significant in comparison with the baseline at all durations. We have seen that within-group comparison for the steroid group, the results are also statistically significant. The mean VAS score decreased from baseline continuously at 4, 8, and up to 12 weeks. However at the end of 24 weeks, there is rise in VAS score when compared to score at 12 weeks. Thus, as in both the groups, there has been a significant reduction in VAS score from the baseline over the course of study, and hence, both the treatment methods are effective ways for the treatment of PF. However when both treatment methods are compared it is observed that the decline in VAS score was at much faster rate in steroid group as compared to PRP group in the initial period of the study, i.e., at 4, 8, and 12 weeks. However in steroid group, mean VAS at 24 weeks is higher than the mean VAS score at 12 weeks, whereas in the PRP group, VAS score continues to decline up to 24 weeks. Still the mean VAS score at 24 weeks is significantly less than the baseline score in both the groups.

In the PRP group, there is a steady decline in the VAS score at 4, 8, 12, and 24 weeks. However, the rate of decline of VAS score is much less than the steroid group, i.e., why, VAS score at 4, 8, and 12 weeks in PRP group was significantly higher than the steroid group. At 24 weeks, mean VAS score in PRP group was significantly less than the steroid group.

Earlier Lee et al. conducted prospective randomized controlled study of 64 patients for a period of 6 months by comparing PRP with corticosteroid injection. The authors found that there was a significant reduction in VAS for both the groups over a time. At 6 weeks and 3 months, the corticosteroid group had significantly lower VAS than the PRP group, but the difference was not significant at 6 months. However in this study, we found a significant reduction in VAS score at 4 weeks, 8 weeks, and 3 months with corticosteroid group, whereas at 6 months, there was significant reduction in VAS in the PRP group compared to corticosteroid group.

A study performed by Aksahin et al.[25] compared the effects of corticosteroid injections and PRP injections to treat PF. Their study consisted of 60 patients who did not respond to conservative treatment for at least 3 months before either injection. The patients were placed into two groups, in which 30 patients were treated with corticosteroid injection and 30 patients were treated with a PRP injection. They found no significant difference in pain or patient satisfaction, thus demonstrating that PRP injections are as effective as corticosteroid injections.

In a study conducted by Tiwari andBhargava[26] the cortisone group had a pretreatment mean VAS score of 8.5, which initially improved to 1.1 at 12 weeks posttreatment to at 26 weeks, and then continuous increased to near baseline levels of 8.4 at 52 weeks. In contrast, the PRP group started with an average pretreatment 8.6 score decreased to 3.4 at 12 weeks, remained declining to 1.2 at 26 weeks, and 0.3 at 52 weeks.

Similarly, within group, results of FAAM scoring are statistically significant. For within-group comparison in PRP group, the results are statistically significant (P ≤ 0.05). The mean FAAM score increased from base-line continuously at 4, 8, 12, and up to 24 weeks. The FAAM score is statistically significant in comparison with baseline at all durations. For within-group comparison, the similar results were observed as in VAS score.

In the current study, the reduction of plantar fascia thickness measured by ultrasonography in both groups is statistically significant posttreatment after 24 weeks. Although, the reduction in the thickness was more in PRP (34.80%) group than steroid group (29.54%), it did not reach significant value.

Of 50 patients, only one patient had pretreatment plantar fascia thickness <4 mm. Almost all patients showed reduction in plantar fascia thickness after injection except 2 cases, 1 case in steroid group, and 1 in PRP group, which did not show any change in the thickness.

All the patients responded to the treatment except 2 cases in steroid group, which did not have any improvement in VAS or FAAM score or in their symptoms and was treated with some other modality. On the contrary, in the PRP group, all the patients responded to the treatment. Heel fat pad atrophy and plantar fascia rupture are two of the most feared complications associated with corticosteroid injections, as they can lead to intractable long-term complications. Fortunately, no complications were seen in any patients. Other studies for PF have had conflicting results regarding various issues surrounding PRP, such as preparation technique of PRP, amount to be injected, injection technique, the number of sessions, and the interval between them required for best therapeutic effect. However, much more work needs to be done to determine the best protocols and patient selection for the use of PRP.

This study outlines that both injecting steroid and PRP are effective and safe modalities in the treatment of PF. The data suggest that steroid injection is better in short-term period, but in long-term follow-up, PRP therapy is better than steroid (P< 0.05).


  Conclusion Top


Chronic heel pain is a difficult condition to treat and takes a long time to resolve. This study has shown that local corticosteroid injection is effective for immediate pain relief. The PRP injection is better for long-term pain relief in plantar fascitis with no side effects. The study has also established the efficacy of our method of extracting PRP from peripheral blood by high spin technique. Further studies are needed to see the effects of combined corticosteroid and PRP injection for chronic heel pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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