Kowshik, J.,Murphy, P.N., and Clough, T.M. (2015). Platelet rich plasma versus corticosteroid injection for plantar fasciitis: a comparative study.The Foot,25, 235-237.
Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study.
Background
Plantar fasciitis is the commonest cause of heel pain (Riddle). Whilst most cases of plantar fasciitissettle with conservative treatment, a few intractable cases can be difficult to treat. The pathophysiology remains poorly understood, but appears similar to Achilles tendinopathy with microscopic degenerative injury and local disruption of the collagen matrix and microtears rather than a failed healing response (Astrom). A number of treatment options have been used without reproducible success (Toomey). Nonoperative approaches include rest, heel cups, stretching, orthotics, immobilization, nonsteroidal andsteroidal anti-inflammatory medication, and physio therapy (Toomey). Injection treatment could utilise Platelet-rich plasma (PRP) or Steroid. Surgical release of plantar fascia is rarely used and only reserved for severe and unremitting plantar fasciitis (Cheung).
PRP stimulates the natural healing process through growth factors contained in the platelets such as Platelet derived growth factor, Fibroblast growth factor, Insulin like growth factor etc. PRP applied to the wound area accelerates the physiological healing process, provides support for the connection of cells, reduces pain and has anti-inflammatory and anti-bacterial effects (Sanchez M).
In this study, autologous platelet-rich plasma (PRP), a concentrated bioactive blood component rich in cytokines and growth factors, was compared to traditional cortisone injection in the treatment of chronic cases of plantar fasciitis resistant to traditional nonoperative management. The aim of the study was to compare the efficacy of PRP to that of Steroid at 3, 6 and 12 months after injection.
Methods
Patients presenting to the Wrightington Hospital between 2013 and 2014 with intractable plantar fasciitis, which had not responded to cushioned insoles and a full course of eccentric stretching exercises were included in the study. In total 60 heels in 46 patients were recruited. The patients were included in one of the two arms based on surgeon’s preference. All patients were assessed with the Roles–Maudsley (RM) Score, the Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hind foot score. The scores were collected pre-treatment and at 3, 6 and 12 months post injection. Complicationsoftheprocedurewerealsodocumented.
Patients in the steroid arm underwent Triamcinolone (Kenalog) 40 mg and Levobupivacaine hydrochloride (Chirocaine) injection.
PRPwasharvestedwiththeuseofGPSIIIsystem (Biomet Biologics,Warsaw,IN).Twenty-sevenmillilitres(ml)of blood waswithdrawnfromthepatientand addedto3mlofsodium citrate (anticoagulant).Thiswasplacedinthecentrifugemachine and spunfor15minat3200revolutionsperminute.Theplasma portion ofthecentrifugedmixturewasdiscarded.Sincetheanticoagulant introducedtothewholebloodusedtoproducetheplatelet concentrate isacidic,thePRPportionharvestedisbufferedwith 8.4% sodiumbicarbonate,toincreasethe Ph backtonormalphysiological levels.Fromtheinitial27mlbloodharvest,between2.5and 3.5 mlofbufferedPRPwasobtained.
Steroid and PRP wereinjectedunderaseptic technique intheatre,directlyintotheareaofmaximaltenderness at theheel, via a pepperingtechnique(singleskinentry,partially withdrawing theneedle,redirectingandmakingmultiplepenetrations tothefascia).
Sixpatientswhounderwentbilateral PRP injection inthesamesitting,thevolumeof blood withdrawn and anticoagulant added were doubled resulting in 6 to 7 ml of PRP; this was equally divided between the heels.Allpatientswereadvisedtocontinue eccentric stretchingprogrammeandcushionedinsolesfollowingthe injection.
Statistical tests
The mean scores of the two groups were compared using student t test. A p value of 0.05 or less was considered to be statistically significant.
Results
The age range of patients in the study was31 to 79 years with mean age of 55.6 yrs. male to female ratio was 16:30. 14 patients underwent bilateral heel injection. 31 injections were performed on the right heel and 19on the left side. In the PRP arm Male to female ratio was 8:16 and 6 underwent bilateral injection. In the steroid arm Male to female ratio was 8:14 and 8 underwent bilateral injection.
The mean RM, VAS and AOFAS scores of the two groups were compared pre-injection and at 3, 6 and 12 months post injection.
Table1. Mean pre injection scores
Pre (Steroid) / Pre(PRP) / P valueRM / 3.6 / 3.7 / 0.32
VAS / 8.3 / 8.3 / 0.47
AOFAS / 56.7 / 58.6 / 0.32
Table2. Mean scores at 3 months post injection
3 M (Steroid) / 3 M (PRP) / P valueRM / 1.9 / 2.0 / 0.34
VAS / 2.8 / 3.5 / 0.22
AOFAS / 86.4 / 83.7 / 0.26
Table3. Mean scores 6 months post injection
6 M (Steroid) / 6 M (PRP) / P valueRM / 2.2 / 2.1 / 0.42
VAS / 3.3 / 3.7 / 0.28
AOFAS / 83.8 / 88.5 / 0.12
Table4. Mean scores 12 months post injection
12 M (Steroid) / 12 M (PRP) / P valueRM / 2.6 / 1.9 / 0.008
VAS / 5.1 / 3.3 / 0.02
AOFAS / 77.0 / 88.5 / 0.002
VAS score PRP v Steroid RM score PRP v Steroid
Table 1 gives the mean pre-injection RM, VAS and AOFAS scores of the two arms. It shows that the two groups are well matched and there is no statistically significant difference in the values.
At 3 months (Table2) all three scores have improved from the pretreatment level in both groups. The scores in the Steroid arm are better than in the PRP arm but this difference is not statistically significant. At 6 months (Table3) there is no statistically significant difference between the two groups and there is a trend that the PRP scores are becoming better than the Steroid scores.
At 12 months (Table4) all three scores in the PRP arm are significantly better than the steroid arm.
There was no complication in either group.
Discussion
This study was conducted to compare the efficacy of PRP and Steroid for plantar fasciitis at 3, 6 and 12 months post injection. The English language literature has 4 studies which have looked at this topic.
Shetty et al compared Steroid v PRP in 60 patients (30 in each arm) and found that result of PRP was significantly better than that of Steroid. The AOFAS, VAS and FADI were all significantly better in the PRP group at 3 months. There results were preliminary and there was no data available on results beyond the 3 months stage.
Say et al compared PRP and Steroid in 50 patients (25 in each arm) and found that VAS and AOFAS scores were significantly better at 6 weeks and 6 months in the PRP group. There was no data available beyond 6 months.
Aksahin et al compared PRP and Steroid in 60 patients (30 in each arm). At 3 weeks and 6 months post injection the VAS and RM scores in each group was better than the pretreatment scores but there was no statistically significant difference between groups. The authors concluded that both treatments were effective in treating plantar fasciitis and PRP is as effective as Steroid.
Rocco published the results of 40 patients randomized to receive PRP and Steroid for chronic plantar fasciitis. All patients received ultrasound guided PRP and Steroid injection. The outcome measure in all patients was AOFAS. The Steroid group showed initial improvement which tapered after 6 months. In the PRP group the benefit remained for 24 months. The limitation of this study is that only AOFAS score was used as the outcome measure. AOFAS may not be the best outcome measure to use in plantar fasciitis as there is no limitation of function in this pathology and pain specific outcome measures such as RM and VAS are much better for this disorder. Our study has shown that non ultrasound guided injection with PRP can give excellent pain relief which is long lasting. We however agree with the conclusion of Rocco that PRP is more effective and durable than cortisone injection for the treatment of chronic recalcitrant cases of plantar fasciitis.
The results of our study will help clinicians in counselling the patients about potential advantages of PRP over Steroid for treating plantar fasciitis.
Conclusion
Steroid is as effective as PRP at 3 and 6 months after injection but at 12 months PRP is significantly more effective than Steroid. So both the modalities achieve reliable symptom relief but the duration of relief is longer in PRP than Steroid.
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