|Year : 2020 | Volume
| Issue : 1 | Page : 186-190
Platelet rich plasma injection versus extracorporeal shock-wave therapy in treatment of plantar fasciitis
Samar G Soliman1, Alaa A Labeeb1, Eman A Abd Allah1, Tarek F Abd-Ella2, El Zahraa A. Abd-El Hady Hammad1
1 Department of Physical Medicine, Rheumatology and Rehabilitation, Menoufia University, Menoufia, Egypt
2 Department of Diagnostic Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||22-Sep-2018|
|Date of Decision||28-Oct-2018|
|Date of Acceptance||30-Oct-2018|
|Date of Web Publication||25-Mar-2020|
El Zahraa A. Abd-El Hady Hammad
Tala, Menoufia 32611
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the efficacy of local platelet-rich plasma (PRP) injection compared with extracorporeal shock-wave therapy (ESWT) for treatment of plantar fasciitis.
Plantar fasciitis is an important cause of heel pain. ESWT and PRP have emerged as new management options, alternative for surgery.
Patients and methods
This comparative study included 60 patients, comprising 48 female and 12 male patients with plantar fasciitis diagnosed clinically and by ultrasound. The patients were divided into two groups: 30 patients received single local PRP injection and 30 patients received three sessions of ESWT weekly. All patients were assessed using pain visual analog scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale, and plantar fascia thickness by ultrasound before treatment and at 1 and 3 months after treatment.
VAS, AOFAS ankle-hind foot score, and plantar fascia thickness improved significantly in both groups. The AOFAS ankle-hind foot scale shows more improvement in the ESWT group at 1 month after treatment (P = 0.009). Significant improvement in plantar fascia thickness was seen clearly in PRP group at 1 and 3 months after treatment (P < 0.001). VAS and AOFAS ankle-hind foot scale score in patients with calcaneal spur show more improvement in ESWT group at 1 month after treatment (P = 0.019 and P = 0.009, respectively).
Local PRP injection and ESWT improve pain and function in patients with plantar fasciitis. ESWT showed early improvement if plantar fasciitis is associated with calcaneal spur.
Keywords: extracorporeal shock-wave therapy, plantar fasciitis, platelet-rich plasma
|How to cite this article:|
Soliman SG, Labeeb AA, Abd Allah EA, Abd-Ella TF, Abd-El Hady Hammad EA. Platelet rich plasma injection versus extracorporeal shock-wave therapy in treatment of plantar fasciitis. Menoufia Med J 2020;33:186-90
|How to cite this URL:|
Soliman SG, Labeeb AA, Abd Allah EA, Abd-Ella TF, Abd-El Hady Hammad EA. Platelet rich plasma injection versus extracorporeal shock-wave therapy in treatment of plantar fasciitis. Menoufia Med J [serial online] 2020 [cited 2020 Jun 6];33:186-90. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/186/281296
| Introduction|| |
Plantar fasciitis is the commonest cause of heel pain. Plantar fasciitis is believed to be a result of over-stress and repetitive microtrauma to plantar fascia.
The diagnosis of plantar fasciitis was easily made on clinical basis. Imaging is recommended in chronic refractory cases for confirmation of the diagnosis. Conservative treatment of plantar fasciitis include NSAIDs, weight reduction, ice packs, shoe inserts, and calf muscles stretching exercises. It is effective in nearly 90–95% of patients. Steroid injections and surgical treatment were for resistant cases. Extracorporeal shock-wave therapy (ESWT) has emerged as an effective modality after failure of conservative measures. Platelet-rich plasma (PRP) is blood plasma enriched with a concentrated source of autologous platelets that affect soft tissue healing by growth factors such as transforming growth factor-β1, platelet-derived growth factor, and insulin-like growth factor. PRP has been reported to give promising results for treatment of chronic tendon disorders. The present study aimed to determine the efficacy of local PRP injection compared with ESWT in treatment of chronic plantar fasciitis and patients with symptomatic calcaneal spur.
| Patients and Methods|| |
In this comparative prospective study, 60 patients with idiopathic chronic plantar fasciitis were recruited from Orthopedic and Physical Medicine, Rheumatology and Rehabilitation outpatient clinics, Menoufia University Hospital, during the period between October 2016 and June 2017. All patients gave ethically informed consent after a full explanation of the study according to the ethical committee of Faculty of Medicine, Menoufia University.
Patients were included in this study according to the following criteria:
Plantar fasciitis was diagnosed clinically by inferior heel pain and point of maximal tenderness over the medial calcaneal tubercle plus sonographic features, increased thickness of the plantar fascia more than 4 mm at baseline, reduced echogenicity, and/or loss of definition of border of the fascia distal to the antero-inferior border of the calcaneus. All patients were unresponsive to conservative treatment for at least 3 months to be considered chronic plantar fasciitis.
Patients were excluded from study if they had received a previous corticosteroid injection for plantar fasciitis during the last 6 months before study; had a prior operative treatment of the foot; had any structural abnormalities of the foot, for example, flat foot; current pregnancy or breast feeding; generalized polyarthritis; sero-negative arthropathy; rheumatoid arthritis; tumors of the foot or ankle; coagulation disorders; presence of neurologic impairments (peripheral neuropathy); lower extremity nerve entrapment; or lumbar disc prolapse.
After enrollment, randomization was done using a simple randomization method (odd for PRP and even for shock-wave therapy) to divide the patients into two equal groups (30 patients each): group I received local PRP injection and group II received shock-wave therapy.
All patients were subjected to the following:
- Demographic data recording (age and sex), history taking, clinical examination, and laboratory investigations
- Radiological examination: plain radiography of pelvis (antero-posterior view) to exclude seronegative arthropathy, plain radiography of foot (lateral view) to detect calcaneal spur or pre-existing foot lesions, and ultrasound examination of plantar fascia for thickness and echogenicity were done
- Nerve conduction study of posterior tibial nerve to exclude tarsal tunnel syndrome.
Patients were evaluated before either PRP injection or ESWT sessions, at 1 month, and at 3 months after PRP injection or the third ESWT, using pain visual analog scale (VAS) scale, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale, and thickness of plantar fascia by ultrasound.
Ultrasound examination was performed using Philips HDI 5000 device (Philips, HDI 5000 device, Newark, New Jersey 07112, United States (967 mi)), with 7.5–14 MH linear probe, by a radiologist who was blinded to the treatment methods. The patients laid prone with dorsi-flexed ankle to 90°.
Extracorporeal shock-wave therapy sessions
The patients in the ESWT group received three sessions of ESWT once per week, and 2000 beats were applied. The applicator was placed perpendicular to the insertion of the plantar fascia at the most tender point. A gel was used to maintain contact with the skin. All patients were advised to perform active stretching of the plantar fascia at home. No local anesthesia was applied. The ESWT was performed with Pagani shock-wave medical device (Pagani, Campania, Italy) a piezo-electric system.
Preparation and injection of platelet-rich plasma
Overall, 10 ml of blood was obtained by a venous puncture and collected in sterile tubes containing an anticoagulant (sterile sodium citrated tubes). Thereafter, blood was centrifuged, with the first spin at 1800 rotations/min for 15 min. Plasma was separated and centrifuged, with the second spin at 3500 rotations/min for 10 min. Then the supernatant containing platelet-poor plasma was discarded. PRP left in the bottom of each tube was mixed with the platelet pellet. The patients were placed in a prone position with a neutral ankle. Skin of heel was disinfected. After injecting 0.5 ml of local anesthesia, 3 ml of PRP was injected through a medial approach in the most tender area. Patients were advised to wear comfortable shoes, reduce weight bearing for 3 days, and avoid using NSAIDs throughout the 3-month follow-up period as they produce anti-platelet and anti-coagulant effects, which may decrease the effectiveness of PRP. They can use acetaminophen or ice packs to control pain.
Data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package of the social science (version 20; SPSS Inc., Chicago, Illinois, USA), where the following statistics were applied.
- Descriptive statistics: in which quantitative data were presented in the form of mean, SD, and range, and qualitative data were presented in the form of numbers and percentages
- Analytical statistics: the used tests of significance included the following: χ2 test, Student's t test, Mann–Whitney test (nonparametric test), and Wilcoxon's signed rank test (nonparametric test).
P value of more than 0.05 was nonsignificant, P value of less than 0.05 was significant, and P value less than 0.001 was considered statistically highly significant.
| Results|| |
This study included 60 patients with plantar fasciitis, comprising 48 (80%) females and 12 (20%) males. The mean age was 39.5 ± 9.24 years, ranging from 25 to 59 years, and the duration of symptoms ranging from 4 to 18 months.
There was a significant statistically difference regarding AOFAS ankle-hind foot scale score at 1 month after treatment, as it was higher in group II (shockwave group) than group I (PRP group). This means that shockwave therapy gives more rapid relieving effect and improves function than PRP [Table 1]. There was a highly statistically significant difference among studied groups regarding plantar fascia thickness at 3 months after treatment, as it was lower in group I (PRP group) than group II (shockwave group). Regarding plantar fascia echogenicity at 1 month after treatment, it became better in group I (PRP group), in which 73.3% had normal echogenicity, than group II (shockwave group), in which 40% had normal echogenicity, with P value less than 0.001 [Table 2]. There was a statistically significant difference between studied groups in patients with calcaneal spur regarding VAS and AOFAS at 1 month after treatment, as they became better in group II (shockwave group) than group I (PRP group) [Table 3], [Figure 1].
|Table 1: Comparison among the studied groups regarding visual analog scale and American Orthopedic Foot and Ankle Society score before and after treatment|
Click here to view
|Table 2: Comparison among the studied groups regarding ultrasound findings before and after treatment|
Click here to view
|Table 3: Comparison of visual analog scale, American Orthopedic Foot and Ankle Society score, and plantar fascia thickness in spur-positive patient among studied groups|
Click here to view
|Figure 1: Sonographic changes in group I (PRP group). (a) Before injection, plantar fascia thickness was 6.3 mm and fascia is hypoechoic. (b) After 1 month, thickness was 4.6 mm, and echogenicity became better. (c) After 3 months, plantar fascia thickness decreased to be 4.3 mm. PRP, platelet-rich plasma.|
Click here to view
| Discussion|| |
In this study, there was a highly significant improvement regarding VAS and AOFAS ankle-hind foot scale at 1 and 3 months after PRP injection than before PRP injection in group I (PRP group). This comes in agreement with Acosta-Olivo et al. and Wei-Yi et al., who also reported improvement in pain and functional status starting after 4–6 weeks and further improvement seen up to 3 months in patients injected with local PRP. In contrast, Chew et al. found that PRP group demonstrated significant VAS improvements only 1 month after injection, which was not changed when evaluated 3 months after injection. This difference may be owing to the difference in technique of preparation and injection of PRP. In this study, there was a highly significant improvement regarding VAS at 1 and 3 months after shock wave therapy than before treatment in group II (shockwave group). This comes in agreement with Lai et al. and Lee et al.. In this study, we found a highly significant improvement of AOFAS ankle-hind foot scale at 1 and 3 months after treatment from before treatment in group II (shockwave group). This comes in agreement with Androsoni et al..
In this study, we found a nonsignificant difference regarding VAS between the two studied groups before, 1, and 3 months after treatment. This result was similar to the results obtained by Chew et al..
We found a highly significant decrease in plantar fascia thickness in group I (PRP group) at 1- and 3-month follow-up than before injection, with improvement in echogenicity; 100% were hypo-echoic before injection and became 100% normo-echoic at 3 month after treatment. This is in agreement with the study by Vahdatpour et al..
In this study, we found a highly significant improvement of plantar fascia thickness at 1 and 3 months after treatment than before treatment in group II (shockwave group). Saber et al. supported this finding after 3 months of ESWT treatment. In contrast to our results, Lai et al. reported increase in the mean thickness of the plantar fascia in shock-wave group at 1 month; however, at 3-month follow-up, it decreased gradually than it was at the first month but was still more than the baseline.
In agreement with the study by Chew et al., we found a highly significant difference at 3 month regarding plantar fascia thickness between the two studied groups, where group I (PRP group) showed decreased plantar fascia thickness than group II (shockwave group).
In this study, we found a significant improvement regarding VAS and AOFAS scale in patient with calcaneal spur at 1 month after treatment in group II more than group I. In agreement with us, a case report by Manickam et al. concluded that ESWT is effective in the treatment of calcaneal spur and improves patients' functional activities.
The current study had some limitations such as a lack of a control group, small sample size, unblinded design, and short duration of follow-up. This study results need to be confirmed by further studies with a larger sample of patients, longer follow-up duration, and ultrasound for diagnosis, during follow-up and for guidance of either PRP injection or application of shockwave therapy. Prevention and treatment of risk factors decrease the occurrence of plantar fasciitis and improve treatment outcome.
| Conclusion|| |
PRP injection and shockwave therapy can be used safely and effectively for treatment of chronic plantar fasciitis, helping the patients to avoid surgery. Shockwave therapy improves function and pain earlier and more effective in patient with heel spur than PRP injection. ESWT improves pain earlier than PRP.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sorrentino F, Iovane A, Vetro A, Vaccari A, Mantia R, Midiri M. Role of high-resolution ultrasound in guiding treatment of idiopathic plantar fasciitis with minimally invasive techniques. Radiol Med 2008; 113
Monto RR. Platelet-rich plasma and plantar fasciitis. Sports Med Arthrosc Rev 2013; 21
McNally EG, Shetty S. Plantar fascia: imaging diagnosis and guided treatment. Semin Musculoskelet Radiol 2010; 14
Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al
. The diagnosis and treatment of heel pain: a clinical practice guideline-revision. 2010. J Foot Ankle Surg 2010; 49
Dastgir N. Extracorporeal shock wave therapy for treatment of plantar fasciitis. J Pak Med Assoc 2014; 64
Schmitz C, Császár NB, Milz S, Schieker M, Maffulli N, Rompe JD, et al
. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull 2015; 116
Borrione P, Gianfrancesco A, Pereira M, Pigozzi F. Platelet-rich plasma in muscle healing. Am J Phys Med Rehabil 2010; 89
Sabir N, Demirlenk S, Yagci N, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med 2005; 24
Greve JM, Grecco MV, Santos-Silva PR. Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis. Clinics 2009; 64
Co AY. Plantar fasciosis treatment with platelet rich plasma. Podiatry Inst J 2012; 33
Aksahin E, Dogruyol D, Yuksel HY, Hapa O, Dogan O, Celebi L, et al
. The comparison of the effect of corticosteroids and platelet-rich plasma for treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012; 132
Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med 2008; 1
Acosta-Olivo C, Elizondo-Rodriguez J, Lopez-Cavazos R, Vilchez-Cavazos F, Simental-Mendia M, Mendoza-Lemus O. Plantar fasciitis – a comparison of treatment with intralesional steroids versus platelet-rich plasma: a randomized, blinded study. J Am Podiatr Med Assoc 2017; 107
Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, et al
. Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96
Chew KT, Leong D, Lin CY, Lim KK, Tan B. Comparison of autologous conditioned plasma injection, extracorporeal shockwave therapy and conventional treatment for plantar fasciitis: a randomized trial. PM R 2013; 5
Lai TW, Ma HL, Lee MS, Chen PM, Ku MC. Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: a randomized controlled trial. J Musculoskelet Neuronal Interact 2018; 18
Lee SJ, Kang JH, Kim JY, Kim JH, Yoon SR, Jung KI. Dose-related effect of extracorporeal shock wave therapy for plantar fasciitis. Ann Rehabil Med 2013; 37
Androsoni R, Netto AA, Macedo RR, Fasolin RP, Boni G, Moreira RF. Treatment of chronic plantar fasciitis with extra corporeal shock wave therapy: ultrasonographic morphological aspect and functional evaluation. Rev Brasil Ortop 2013; 48
Vahdatpour B, Kianimehr L, Ahrar MH. Autologous platelet-rich plasma compared with whole blood for the treatment of chronic plantar fasciitis; a comparative clinical trial. Adv Biomed Res 2016; 5
Saber S, Diab H, Nassar W, Razaak HA. Ultrasound guided local steroid injection versus extracorporeal shockwave therapy in the treatment of plantar fasciitis. Alex J Med 2012; 48
Manickam R, Laubscher D, Elbaz MA. Efficacy of extracorporeal shock wave therapy in the treatment of a patient with a calcaneal spur: a case report. Int J Physiother Res 2016; 4
[Table 1], [Table 2], [Table 3]