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Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

When we see patients who have continued problems with plantar fasciitis, we usually see patients who:

• Are runners or athletes who have been struggling with and trying to manage their plantar fasciitis for months, maybe years.
• Have already tried numerous variations of self-help and physio work including:
  • Rolling a ball with the sole of their foot
  • Rolling a bottle of frozen water with the sole of their foot
  • Varying foot, Achilles, and calf stretches
  • Various braces and taping
  • Various splints and shoe inserts
  • Boots
  • Changing shoes
  • Massages
  • Stopped running
  • Limited walking
  • Lots of anti-inflammatory medications

In April 2023, doctors writing in the Journal of foot and ankle research (36), described the real life day-to-day experiences of 15 people with long-term plantar fasciopathy. Let’s see what these 15 people have in common with you:

Researchers interviewed the 15 patients and found that “three core themes (main concerns) and ten sub-themes (similar concerns under the main heading – see below).

• The first theme was ‘Struggling to stay active’ with sub-themes ‘Struggling with pain and how to adjust it’, ‘ Finding alternative activities’ and ‘Longing for the experience of walking’.
• The second main theme was ‘Emotional challenges’ with the sub-themes ‘Feelings of frustration and self-blame’ and ‘Worries of weight gain and related consequences’.
• The third main theme was ‘Relations to others’ with the sub-themes ‘Participation in family and social life’, ‘ Visible in new ways’, ‘ Striving to avoid sick leave’ and ‘Bothering others’.

Conclusions: “Participants revealed how their heel pain led to inactivity and emotional and social challenges. Pain when walking and fear of aggravating it dominated the participants’ lives. They emphasized the importance of finding alternative ways to stay active and avoiding sick leave.” Sound like you?

If you are reading this article it is likely that you have tried many of these treatments/therapies and that you are looking for something else to help because you continue on with this problem.

Discussion points of this article:

• Moving on to injections for Plantar fasciitis.
• Comparing the therapeutic effects of extracorporeal shock wave therapy, platelet-rich plasma injection, local corticosteroid injection, and Prolotherapy for the treatment of chronic plantar fasciitis.
• Treatments with short-term or little relief value vs treatments with long-term relief value.
• Kinesio taping and extracorporeal shockwave therapy.

Cortisone

• Corticosteroid Injections, Extracorporeal Shock Wave Therapy, and Radiofrequency nerve ablation.
• Dry Needling is better than cortisone.
• Plantar Fasciopathy Research – Why is Cortisone still an option?
• Is Cortisone no better than a placebo for restoring function?
• Hyaluronic Acid and Cortisone results and outcomes are just about the same.
• Endoscopic fasciotomy and cortisone.
• A confusing diagnosis and a condition made worse by cortisone.
• Non-surgical Nerve Release & Regeneration Injection Therapy and Joint Stabilizing Treatments.

Platelet-rich Plasma Therapy

• Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis over Cortisone.
• “Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.”
• “Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long-lasting beneficial effect.”
• The atrophy of the arch or spring ligament is a problem of plantar fasciitis.

Prolotherapy

• Prolotherapy or extracorporeal shock wave therapy?
• One injection of cortisone and one injection of Prolotherapy.
• The relationship between plantar calcaneal spur (Heel Spurs) and Plantar fasciitis.
• Is the presence of the heel spur confusing the treatment options?

Comparing the therapeutic effects of extracorporeal shock wave therapy, platelet-rich plasma injection, local corticosteroid injection, and Prolotherapy for the treatment of chronic plantar fasciitis

Treatments for Plantar fasciitis

For many people, the various types of plantar fasciitis injection treatments can be very helpful and even make the plantar fasciitis go away entirely or for the most part. Unfortunately, for the patients we see, these treatments did not work. The patients we see came to our clinics because they had become “difficult to treat plantar fasciitis patients,” and were being suggested a possible surgery or other treatments. We do see patients who have had a cortisone injection, it may have worked for them for some time, but the plantar fasciitis returned.

We want to begin this article by going right into a study that will help us understand injection treatments for plantar fasciitis: the September 2018 article published in The Journal of Foot and Ankle Surgery (1) comes from medical university researchers in Turkey.

There is so much in this article we can share that will help you understand your treatment options. So let’s get to it.

Research highlights:

• The researchers performed a randomized controlled prospective clinical study of 4 groups.
  • The first group received extracorporeal shock wave therapy, (electric pulse therapy)
  • the second group received Prolotherapy, (simple dextrose injections)
  • the third group received Platelet-Rich Plasma injections, (injections of the patient’s blood platelets)
  • and the fourth group received a local corticosteroid injection.
• The study included 158 consecutive patients with a diagnosis of chronic plantar fasciitis with asymptomatic heel spur.
• The clinical outcomes were assessed using the visual analog scale (a pain scoring scale of 0-10) and Revised Foot Function Index (A questionnaire about foot disability and discomfort).

The Results:

• The corticosteroid injection was more effective in the first 3 months but then its effectiveness all but disappeared
• Extracorporeal shock wave therapy was an effective treatment method in the first 6 months in regard to pain.
• The effect of Prolotherapy and Platelet-Rich Plasma was seen within 3 to 12 months; however, at the 36-month follow-up point, no differences were found among the 4 treatments.

This study hits on many points that can help explain why cortisone and extracorporeal shock wave therapy are not long-term treatment options for chronic plantar fasciitis and how PRP and Prolotherapy treatments provide longer relief. This study also gives us the ability to point out helpful treatment guidelines for you toward a more permanent solution to your foot pain.

Later in this article, we will discuss Prolotherapy, injections of simple dextrose, Platelet Rich Plasma therapy, injections of concentrated blood platelets, and healing factors from your own blood and how we use these treatments in combination.

First, we would like to present research on all the options that you may have tried.

Treatments with short-term or little relief value vs treatments with long-term relief value

It is easy to understand why patients with chronic plantar fasciitis are frustrated. They are often given treatments that provide short-term relief but hurt their chances of long-term relief and the ability to return to activity.

• The first line of treatment is usually to recommend cutting back on the activity that is causing the pain.
• Foot stretching.
• Massaging the foot with a tennis ball and application of ice are commonly recommended.
• Inject steroids (see above) into the foot or prescribe anti-inflammatory medications in order to relieve the pain associated with the weakened plantar fascia.
• Shock wave therapy is often suggested.
• Often taping, orthotics, and night splints are used as well.

Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain relief benefits, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration. For example, cortisone will eventually weaken the fascia. If they are not strengthened, a painful heel spur will result.

Kinesio taping and extracorporeal shockwave therapy

A January 2021 (2) study published in the International Journal of Clinical Practice compared the effectiveness of low-dye Kinesio-taping, to sham (or placebo)-taping, with Extracorporeal shockwave therapy or alone Extracorporeal shockwave therapy in treating Plantar Fasciitis.

The low-dye Kinesio-taping is a way to apply the tape so that weight pressure is taken off the plantar fascia. The taping method also provides medial ankle arch support.

How did the researchers compare these methods?

First, they divided 45 patients with Plantar Fasciitis into three groups.

• In the first group: 15 patients received five sessions of Extracorporeal shockwave therapy with the low-dye Kinesio-taping
• In the second group: 15 patients received five sessions of Extracorporeal shockwave therapy plus the placebo or Sham-taping
• In the third group: 15 patients received five sessions of Extracorporeal shockwave therapy only.

Four weeks later all the patients were assessed. The cumulative data then revealed: “Although (the) low-dye Kinesio-taping (method) in addition to Extracorporeal shockwave therapy was more effective on foot function improvement than additive sham-taping and Extracorporeal shockwave therapy alone, it did not provide a significant benefit on pain and heel tenderness because of Plantar Fasciitis.”

So the results of this study did not suggest added benefits.

Corticosteroid Injections, Extracorporeal Shock Wave Therapy, and Radiofrequency nerve ablation

Let’s quickly point out that corticosteroid injection, extracorporeal shock wave therapy, and nerve ablation (burning the nerves to deaden pain) are not first-line treatments for chronic plantar heel pain and related plantar fasciitis. However, they are treatments offered to patients who have failed to gain any relief from those conservative care treatments mentioned above.

A January 2021 paper published in the medical journal Foot & Ankle International (3) looked at the effectiveness of corticosteroid injection, extracorporeal shock wave therapy, and radiofrequency thermal lesioning (ablation) in patients who did not respond to previous treatments.

Looking back at the results of treatments achieved in 217 previously treated patients, the researchers pulled the charts of:

• 73 patients who had a corticosteroid injection
• 75 patients who had extracorporeal shock wave therapy treatments
• and 69 patients who had radiofrequency thermal lesioning

All the patients had the previous treatments at least six months prior.

The researchers reported: “Pain intensity decreased significantly in all patients. However, it decreased significantly more in the corticosteroid injection and radiofrequency thermal lesioning groups than in the extracorporeal shock wave therapy group. Age, sex, body mass index, calcaneal spur presence, and symptom duration were similar among the 3 groups. No complications were noted. . . ” The takeaway was that the cortisone and radiofrequency nerve ablation provided the best relief. Among this group of treatments. But how does further research compare?

A January 2023 (4) comparison study of plantar fasciitis treatments in 40 patients found significant improvements in terms of pain, functional status, and daily life activities following the administration of either extracorporeal shockwave therapy or low-level laser therapy. Furthermore, low-level laser therapy was found to be significantly more effective in alleviating pain than extracorporeal shockwave therapy in the treatment of plantar fasciitis.

A May 2023 paper in The Journal of foot and ankle surgery (37) compare the effectiveness of prolotherapy with phonophoresis (an ultrasound wave device)  and steroid injection in patients with plantar fasciitis.

• One hundred forty-six patients with plantar fasciitis were randomly divided into prolotherapy, phonophoresis, and injection groups.
• Statistically significant improvements were found in all (pain, function, thickness) parameters at 1 and 3 months after treatment in all groups.
• A standard general health survey of patients at the third month after treatment in the prolotherapy group was significantly better at the first and third months compared to the other groups.
• This study results suggest that prolotherapy, phonophoresis, and steroid injection are beneficial as safe treatment modalities in the early period of PF treatment.

Dry Needling better than cortisone

A March 2019 study in The Journal of Foot and Ankle Surgery (5) suggested that dry needling would be as effective as the use of corticosteroid injections for treating Plantar fasciitis. The additional benefit would be avoiding the potential adverse effects of corticosteroids. To prove the point, the researchers of this study took patients diagnosed with Plantar fasciitis and prescribed them a 3-week nonoperative treatment regimen.

First two weeks of the program:

• First, the patients in the study were prescribed oral and topical anti-inflammatory drugs and gastrocnemius (calf) stretching exercises.
• After two weeks of anti-inflammatories and stretching, the patients who did not have pain relief and required further treatment were now moved onto the comparison study between cortisone and dry needling,

The patients were divided into 2 groups

• Group 1 underwent dry needling, and
• group 2 underwent corticosteroid injection.

Patients were assessed in the third week and sixth month.

• In terms of foot function index scores, dry needling caused a significant decrease in the third week and also in the sixth month.
• However, although corticosteroid use led to a significant decrease in the third week, it lost efficacy in the sixth month.
• In conclusion, dry needling seems to be a reliable procedure for treating plantar fasciitis, with better outcomes than corticosteroid injection.

Dry needling is a needle with no medication.

A January 2022 paper in the journal Physiotherapy theory and practice also tested the effects of dry needling, this time, in combination with stretching exercises.

Summary:

• In this parallel blinded randomized controlled trial, a total of thirty-seven patients with plantar fasciitis (forty feet) were enrolled randomly into either the control group (stretching exercise) or the experimental group (stretching exercise plus dry needling).
• All interventions lasted six weeks and both groups were followed for two weeks.
• Primary outcomes were first-step pain, pain, and activity daily function and secondary outcomes were plantar fascia thickness, and echogenicity (ultrasound examination revealing normal or abnormal structure ).

Results:

• In both groups, first-step pain, pain, and daily activity were improved compared to baseline measurements. There were considerable differences between the two groups and the experimental group (needling and exercise) experienced more improvements in primary outcomes compared to the control (exercise only) group. For secondary outcomes, plantar fascia thickness at insertion significantly decreased, and the echogenicity in the two regions significantly increased in the experimental group compared to the control group. (A more normal structure).

Conclusion: “These results suggest that the combination of dry needling and stretching exercises can be an effective conservative treatment for plantar fasciitis subjects.”

A January 2023 paper in the Archives of orthopaedic and trauma surgery (6) reviewed surgical treatment options for plantar fasciitis and their effectiveness, In this review, 17 studies involving 865 patients were included. Surgical options considered were open and endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy, and dry needling. All interventions resulted in improvement in VAS and AOFAS scores. No major complications were seen from any treatment modality.

An October 2022 paper in the Journal of sport rehabilitation (7) reviewed data from three studies examining the effectiveness of dry cupping for the treatment of plantar fasciitis. Two studies compared dry cupping to therapeutic exercises and stretching, and one study used electrical stimulation. The researchers found moderate evidence to support the use of dry cupping to improve pain and function in patients with plantar fasciitis.

Plantar Fasciopathy Research – Why is Cortisone still an option?

As in the study above, researchers are constantly trying to prove the effectiveness of one treatment over another to answer the simple question: What treatments work best for Plantar fasciitis and chronic plantar fasciopathy (disease of the plantar fascia)?

Researchers at the University of Northern Iowa wrote in the Journal of Sports Rehabilitation:

“For active individuals, plantar fasciitis is one of the most clinically diagnosed causes of heel pain. When conservative treatment fails, one of the next most commonly used treatments includes corticosteroid injections. Although plantar fasciitis has been identified as a degenerative condition, rather than inflammatory, corticosteroid injection is still commonly prescribed. . . ” (8) They also concluded that PRP injections would be more effective as a choice of treatment.

Doctors writing in the medical journal Rheumatology compared the effectiveness of a number of treatments. This included Platelet Rich Plasma Therapy, shock-wave therapy, and corticosteroid injection.

The researchers discovered a trend that favored the PRP treatment. They noted that Platelet Rich Plasma Therapy, followed by shock-wave therapy, was best in providing relief from pain at 3 months over cortisone. Shock-wave therapy and PRP had similar probabilities of providing pain relief at 6 months. (9)

Doctors in the United Kingdom published comparative research for platelet-rich plasma versus corticosteroid injections in treating plantar fasciopathy. Writing in the journal International Orthopaedics, (10) the UK researchers noted: PRP injections are associated with improved pain and function scores at a three-month follow-up when compared with corticosteroid injections.

Is Cortisone no better than a placebo for restoring function?

This is an August 2019 study from medical university researchers in Australia published in the journal BioMed Central Musculoskeletal Disorders. (11) Here are the learning points of this study:

• Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment.
• For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection and foot orthoses.
• There were no significant findings in the medium term.
• In the longer term, corticosteroid injection was less effective than dry needling and Platelet-Rich Plasma injection.
• Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short and medium terms.
• For improving function, corticosteroid injection was more effective than physical therapy in the short term.
• Corticosteroid injection is not more effective than a placebo injection for reducing pain or improving function. 

Hyaluronic Acid and Cortisone results and outcomes are just about the same

A January 2020 study in the Journal of Pain Research (12) suggests both cortisone and Hyaluronic Acid were effective modalities for plantar fasciitis and can improve pain and function with no superiority in 24th-week follow-ups, although cortisone seems to have a faster trend of improvement in the short term.

Endoscopic fasciotomy and cortisone

A January 2020 study in the journal Knee Surgery, Sports Traumatology, Arthroscopy (13) comes from Denmark. In this research, doctors examined the benefit of cortisone and physical therapy vs Endoscopic fasciotomy. The researchers of this study point out that 10-15% of plantar fasciitis patients may require surgery if they had failed cortisone and other conservative care treatments over a 6 month period. Endoscopic fasciotomy is a minimally invasive technique that cuts away at the ligaments at the heel attachment of the fascia to release tension. The researchers found that after failed cortisone/physical therapy treatments, Endoscopic fasciotomy could provide benefits.

We would like to point out that you have to go through 6 months of failed treatments before you would likely be considered for this surgery.

A confusing diagnosis and a condition made worse by cortisone

Many people have excellent success with cortisone. Sometimes it is an initial success and sometimes it is a long-term success. It is also very likely that if you have made it this far into this article cortisone injections did not provide the degree of treatment and symptom relief that you and your healthcare professionals desired for you. When cortisone fails, many times it failed because it was not the right treatment for the right diagnosis.

Here is a sample story emailed to us:

I have been experiencing foot pain for the past two years. Initially, my doctors thought I had plantar fasciitis, but, since none of the conservative care treatments and remedies were working for me, and in fact, because my pain was getting worse, I sought further opinions. I saw an orthopedic specialist and a physical therapist. I have flat feet so I was fitted for custom orthotics but this made the pain worse. One night the pain in my foot was so bad I made an “emergency” visit with another foot specialist to see if I could get any answers. This doctor diagnosed me with Tarsal Tunnel Syndrome and suggested I needed better orthotics, more cortisone injections, and I needed to start wearing a foot splint.

The doctor then proceeded to give me a cortisone injection. My foot swelled up even more and I think the cortisone is now a source of my pain. My pain is now very severe and I cannot walk or stand without enormous discomfort. I walk very little now and only with the aid of a walker.

What are we to make of a case like this?

The story above unfortunately is not a unique tale. It may in fact be a story that describes your current situation. Like the story above, we will often see patients who have been diagnosed with plantar fasciitis only to be later diagnosed with Tarsal Tunnel Syndrome because the proven treatment for plantar fasciitis has failed. Then we may see a patient whose upgrade diagnosis to Tarsal Tunnel Syndrome is now again thought to be a problem of plantar fasciitis when proven nerve entrapment remedies for Tarsal Tunnel Syndrome failed.

What do these patients really have? Tarsal Tunnel Syndrome? The Plantar Fasciitis? Both? Neither?

Many readers of this article will know firsthand of the confusion of diagnosis between Tarsal Tunnel Syndrome and plantar fasciitis and worse, the medical history of a lot of failed treatments.

Metatarsal ligament weakness is manifested by pain at the ball of the feet which often radiates into the toes. This is called metatarsalgia. Chronic metatarsal ligament weakness and arch weakness are known as plantar fasciitis. Fasciitis can cause numbness in the foot and toes in the same areas of pain. Pain and numbness in the foot can also be caused by ligament and tendon laxity in the knee. The lateral collateral ligament can refer to pain and numbness down the lateral side of the leg and foot and the medial collateral ligament down the medial side.

• It’s important to note that the pain experienced in the ankle with Tarsal Tunnel Syndrome is often referred pain and may be due to injured or weakened ligaments at the ball of the foot. The problems with a diagnosis are the problem of the sprain or weakening of the metatarsal, lateral collateral, and medial collateral ligaments, ligaments which are causing the pain and are rarely examined by a family physician or an orthopedic surgeon.
• You may get a nerve release surgery that was not necessary and will not help.

We have a much more extensive article on Tarsal Tunnel Syndrome – please see The Non-surgical approach to treating Tarsal Tunnel Syndrome.

A May 2022 paper in the journal Foot and ankle international (14) explored a comparison between Autologous blood injection (ABI)  combined with dry needling vs dry needling alone in treating chronic plantar fasciitis.

In this double-blinded study of 90 patients, with an average age of about 50 years old, 67% female, with symptoms of plantar fasciitis that had failed to improve with a minimum of 3 months of rehabilitation. Patients were divided into two groups autologous blood injection or an identical dry-needle fenestration-procedure without coadministration of autologous blood.

All participants received identically structured rehabilitation and were followed up at 2, 6, 12, and 26 weeks. There were no significant between-group differences seen at any time point studied. There were a number of statistically significant within-group improvements for local foot pain and function in both groups comparing baseline/follow-up data. Overall, levels of pain improved by 25% by 6 weeks and by 50% at 6 months. There were improvements in some generalized function markers. Activity rates did not change, demonstrating that improvements in pain did not necessarily influence physical activity.

A January 2022 study (15) in the journal Physiotherapy theory and practice revealed the results of a parallel blinded randomized controlled trial. In this study, thirty-seven subjects with plantar fasciitis (forty feet) were enrolled randomly into either the control group (stretching exercise) or the experimental group (stretching exercise plus dry needling). All treatments lasted six weeks and both groups were followed for two weeks. Results suggest that the combination of dry needling and stretching exercises can be an effective conservative treatment for plantar fasciitis subjects.

Non-surgical Nerve Release & Regeneration Injection Therapy and Joint Stabilizing Treatments

Some patients benefit from NRRIT, a nerve hydrodissection technique that releases peripheral nerve entrapments. It is a quick, straightforward process, often with instant results for the patient. First, the practitioner uses ultrasound to identify the nerves being entrapped. Next, a natural solution is injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures. This treatment would be used in conjunction with Prolotherapy and PRP injections.

The beneficial effect of Prolotherapy injection and Platelet-Rich Plasma was seen within 3 to 12 months

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Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis over Cortisone

Typical protocol treatment for the problem of plantar fasciitis and plantar fasciopathy would be a possible cortisone injection, foot stretching exercises, and rubbing it with an ice pack or cup among other self-help remedies. These treatments can provide temporary relief but they treat the symptoms and do not assist in the repair of the foot integrity and structural instability. We have seen where cortisone injections can lead to tissue rupture or plantar fasciitis tears.

From a regenerative treatment approach that will help repair and rebuild tissue, we like to use Prolotherapy and Platelet Rich Plasma Therapy. We like to use Platelet Rich Plasma (PRP) because there are studies (as documented in this article)  showing that PRP is superior to cortisone injections long-term. In some studies, it is suggested that within the first 6 months of treatment, cortisone and PRP will provide a similar benefit, but as research indicates, PRP provides better results and the PRP does not threaten the structural integrity of the tissue.

The treatment:

We use ultrasound-guided injection so we get to the right areas. We also use a numbing agent to make sure the patient is comfortable. When we begin treatment we inject along the plantar fascia. We investigate for tendinopathies that may be going down to the insertion of the heel. In some patients, when they step down on the heel they may have more issues than plantar fasciitis. We want to make sure that we address these issues as well. For some patients there may be nerve entrapment, for this, we offer Nerve Release & Regeneration Injection Therapy in addition to Prolotherapy and/or PRP (As explained above).

“Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.”

An October 2019 study in the American Journal of Sports Medicine (16) comes from University researchers in the Netherlands. Here the researchers published their observations that: “When nonoperative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporary pain reduction but no healing. Platelet-Rich Plasma (PRP) has proven to be a safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries.”

Here is what the researchers did:

• Patients with chronic plantar fasciitis were allocated to have steroid injections or PRP.
• The primary outcome measure was the Foot Function Index (FFI) Pain score.
• Secondary outcome measures involved function, as scored by the Foot Function Index Activity, Foot Function Index Disability, and American Orthopaedic Foot & Ankle Society, and quality of life, as scored with the short version of the World Health Organization Quality of Life
• All outcomes were measured at baseline and at 4, 12, and 26 weeks and 1 year after the procedure.

RESULTS:

• Of the 115 patients, 63 were allocated to the PRP group, of which 46 (73%) completed the study, and 52 were allocated to the control group (corticosteroid injection), of which 36 (69%) completed the study.
• In the control corticosteroid injection group, Foot Function Index Pain scores decreased quickly and then remained stable during follow-up.
• In the PRP group, Foot Function Index Pain reduction was more modest but reached a lower point after 12 months than in the control group.
• After adjusting for baseline differences, the PRP group showed significantly lower pain scores at the 1-year follow-up than the control group
• Of the 46 patients in the PRP group, 39 (84.4%) improved at least 25%, while only 20 (55.6%) of the 36 in the control group showed such improvement.
• The PRP group showed significantly lower FFI Disability scores than the control group (mean difference, 12.0; 95% CI, 2.3-21.6).

CONCLUSION: “Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.”

“Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long-lasting beneficial effect.”

In November 2019, (17) doctors writing in the Malaysian Orthopaedic Journal wrote:

“Many studies show that steroid injection provides pain relief in the short term but not long-lasting. Recent reports show autologous Platelet-Rich Plasma (PRP) injection promotes healing, resulting in better pain relief in the short as well as long term.” To assess this point, 60 patients were randomized in a double-blind study. Here are the findings:

• Patients with the clinical diagnosis of chronic plantar fasciitis (heel pain of more than six weeks) after failed conservative treatment and plantar fascia thickness of more than 4mm were included in the study.
• In this prospective double-blind study, 60 patients who fulfilled the criteria were divided randomly into two groups.
  • Patients in Group A received PRP injections and those in Group B received steroid injections.
  • Patients were assessed with the VAS visual analog scale  (Pain assessment and scoring system) and American Orthopedic Foot and Ankle Society (AOFAS) functional score.
  • The assessment was done before injection, at six weeks, three months, and six months follow-up after injection.
  • Plantar fascia thickness was assessed before the intervention and six months after treatment using sonography.
• Result: VAS pain assessment in Group A (PRP) decreased from 7.14 before injection to 1.41 after injection and in Group B (Cortisone) decreased from 7.21 before injection to 1.93 after injection, at the final follow-up.
• Result: Mean AOFAS function score in Group A (PRP) improved from 54 to 90.03 and in Group B (Cortisone) from 55.63 to 74.67 at the six months follow-up.
• The improvements observed in VAS and AOFAS were statistically significant. At the end of the six months follow-up, plantar fascia thickness had reduced in both groups (5.78mm to 3.35mm in Group A (PRP) and 5.6 to 3.75 in Group B (Cortisone)) and the difference was statistically significant.
• Conclusion: Local injection of Platelet-Rich Plasma is an effective treatment option for chronic plantar fasciitis when compared to steroid injection with a long-lasting beneficial effect.

PRP versus Partial Plantar Fasciotomy surgery and steroid injection

A November 2022 paper in the Journal of clinical medicine (18) wrote: “Platelet-Rich Plasma injection has become a desirable alternative to Partial Plantar Fasciotomy surgery and steroid injection for patients with chronic plantar fasciitis due to its potential for shorter recovery times, reduced complications, and similar activity scores. In this paper, the researchers compared PRP treatment to Partial Plantar Fasciotomy surgery in 16 patients with chronic plantar fasciitis. “Patients treated with PRP injection reported a significant increase in their activity scores, shorter recovery time, and lower complication rates compared to Partial Plantar Fasciotomy surgery. Moreover, with respect to existing literature, PRP may be as efficient as steroid injection with lower complication rates, including response to physical therapy. Therefore, PRP treatment may be a viable option before surgery as an earlier line treatment for chronic plantar fasciitis.”

Plantar Fasciopathy Research – Why are we still thinking PRP is a “one-shot wonder?” One shot of PRP usually does not compare well with one shot of cortisone. However, sometimes it does.

Most times studies on PRP effectiveness even the favorable ones – rely on a single dose treatment and a hope for a “one-shot” wonder. For many suffering from chronic plantar fasciitis, one-shot wonders typically do not provide more permanent relief than a patient is looking for. But as this study points out, the potential for PRP is great – when administered by an experienced provider.

As in the above study, doctors writing in British Medical Bulletin evaluated the evidence for Platelet-Rich Plasma injection as a treatment for chronic plantar fasciopathy. What they found was PRP for treating chronic plantar fasciopathy shows promising results and appears safe. However, the number of studies available is limited to give definite positive results and they would like to see more studies performed. (19)

That study was from 2014. The data from this study was cited in a 2020 research update published in the Journal of Orthopaedic Surgery and Research. (20) In this paper the doctors wrote: “Platelet-Rich Plasma (PRP) had been demonstrated to be useful in achieving helpful effects for plantar fasciopathy. The purpose of this study was to compare the pain and functional outcomes between PRP and corticosteroid or placebo for plantar fasciopathy through meta-analysis and provide the best evidence.”

The search for the best evidence

In this paper, the doctor reviewed previously published research to include articles regarding comparative research about the outcomes of PRP therapy and corticosteroid or placebo injection. The conclusion of this research? The doctors wrote: “No superiority of PRP had been found in well-designed double-blind studies, whereas it is implied that the outcomes of PRP are better than placebo based on available evidence.” In other words, the research does not match the clinical experience.

In other research, doctors say they can’t tell if PRP works because there is no standardized treatment technique and that based on “one-shot wonders” it doesn’t appear to be effective over other treatments. (21) Enough so that some researchers want cortisone under ultrasound guidance restored as the primary treatment for plantar fasciitis, (22) despite conflicting research as reported above and here:

Recent research contradicts that sentiment of restoring cortisone as a primary treatment for plantar fasciopathy. Doctors in the UK say “PRP is as effective as steroid injection at achieving symptom relief at 3 and 6 months after injection, for the treatment of plantar fasciitis, but unlike steroids, its effect does not wear off with time. At 12 months, PRP is significantly more effective than steroids, making it better and more durable than cortisone injection.” (23)

Further research in the Singapore Medical Journal (24) suggests it is evident that the effects of corticosteroid injections are usually short-term, lasting 4-12 weeks in duration. Complications and side effects such as plantar fascia rupture are uncommon, but physicians need to weigh the treatment benefits against such risks.

Another study says one shot of PRP can be very helpful

Here we have an October 2020 study published in the Indian Journal of Orthopaedics (25). Here are the learning points:

• PRP does not have side effects as compared to steroid injections.
• PRP injections have shown promising results in various studies.
• This study assessed the efficacy of a single local injection of PRP in chronic unilateral plantar fasciitis.

Here the doctors examined thirty people with unilateral (one foot) plantar fasciitis patients with symptom duration of 6 months or more were included in the study. Results: “The short-term results of single-dose PRP injections shows clinical and statistically significant improvements in VAS (0-10 pain score) for heel pain, functional outcome scores, and plantar fascia thickness. . .  This study concludes that local PRP injection is a viable management option for chronic plantar fasciitis.”

Summary research study on PRP

A February 2022 study in The Journal of Foot and Ankle Surgery  (26) wrote: “There is evidence to support the use of PRP compared to corticosteroid or placebo, especially at longer terms such as at 3, 6, and 12 months.” The researchers base this on a review of the most recent literature that found pain scores reduced. They also note: “While PRP and corticosteroid can both decrease inflammation, PRP has biological regenerative properties such as augmenting cellular migration, enhancing cellular proliferation, and promoting angiogenesis [formation of new blood vessels].

Prolotherapy plantar fasciitis treatment and Prolotherapy or PRP for plantar fasciitis?

Prolotherapy, like PRP, repairs plantar fasciitis by strengthening the fascia and providing support to the arch of the foot. Prolotherapy is a treatment that regenerates and strengthens weakened structures, such as the weakened plantar fascia ligament.

When a patient comes in with plantar fasciitis, an evaluation is made as to what type of treatments will likely benefit the patient most. Often times we will look for the simplest treatment. In many cases, simple dextrose Prolotherapy will do the trick. Sometimes a stronger proliferant solution like PRP is required.

Research:

In April 2020, researchers at the University of Health Sciences in Turkey published these findings in the American Journal of Physical Medicine and Rehabilitation (27) on the evaluation of the efficacy of dextrose Prolotherapy in the treatment of chronic resistant plantar fasciitis through comparison with a control group.

• In this double-blind, randomized, controlled study, the patients were divided into two groups.
  • The Prolotherapy group (30 people) was administered 5 ml of 30% dextrose, 4 ml of saline, and 1 ml of 2% lidocaine mixture (15% dextrose solution), and the control group was given 9 ml of saline and 1 ml of 2% lidocaine mixture twice at a 3-week interval.
  • During the 15-week follow-up period, pain intensity was measured using the visual analog scale during activity and at rest. The foot function index was used to measure pain and disability. The plantar fascia thickness was measured by ultrasonography. The measurements were undertaken before treatment and at post-treatment weeks 7 and 15.
• RESULTS: Improvements in visual analog scale during activity, at rest, foot function index (all subgroups), and plantar fascia thickness measured at the 7th and 15th weeks were significantly higher in the Prolotherapy group compared with the control group. Dextrose Prolotherapy has efficacy for up to 15 weeks and can be used as an alternative method in the treatment of chronic resistant Plantar fasciitis.

Korean doctors writing in PM & R: The Journal of Injury, Function, and Rehabilitation compared Prolotherapy to PRP in the treatment of chronic recalcitrant plantar fasciitis. Led by the Korea National Sports University, the researchers found all patients in both the Prolotherapy group and the PRP group showed significant improvements. They concluded: “Each treatment seems to be effective for chronic recalcitrant plantar fasciitis, expanding the treatment options for patients in whom conservative care has failed. PRP treatment also may lead to better initial improvement in function compared with dextrose Prolotherapy treatment.”(28)

Prolotherapy treatments need to focus on the spring ligament which is also called the plantar calcaneonavicular ligament. This is one of the most important ligaments in the arch that supports the arch. But whether someone has a high arch, normal arch, flat arch, or pes planus, if they have pain and tenderness to palpation, typically they’ll respond great to Prolotherapy because Prolotherapy stimulates the repair of the injured areas. It causes the proliferation of injured soft tissue so they repair.7416

The atrophy of the arch or spring ligament is a problem of plantar fasciitis

A December 2021 study in the medical journal Foot (29) comes to us from Morinomiya University of Medical Sciences in Japan. Here the doctors made a connection between atrophy of the spring ligament and thickening of the plantar fascia.

“Although patients with plantar fasciitis show spring ligament laxity, the thickness of the spring ligament in patients with plantar fasciitis remains unclear. This study aimed to (understand) the morphological characteristics of the spring ligament in patients with plantar fasciitis based on an ultrasound imaging system.

Thirty feet of 30 patients (painful group) diagnosed with plantar fasciitis at our hospital and thirty feet of 30 healthy volunteers (healthy group) without plantar pain were investigated.

The thicknesses of both the spring ligament and plantar fascia were assessed via ultrasound and a statistical comparison of the spring ligament and plantar fascia thickness between the painful and healthy groups was assessed.

The spring ligament thickness in the painful group was significantly lower than that in the healthy group. The thickness of the plantar fascia in the painful group was significantly greater than that in the healthy group. In addition . . .the thicker the plantar fascia in the subjects, the thinner was the spring ligament.

In this study, the ultimate suggestion was that insoles at an early stage could prevent the onset of plantar fasciitis. We suggest the early intervention of Prolotherapy.

Prolotherapy or extracorporeal shock wave therapy?

In this study, (30) researchers explored treating chronic plantar fasciitis patients with Prolotherapy or extracorporeal shock wave therapy.

Study learning points:

• In recent years, Prolotherapy is increasingly being used in the field of musculoskeletal medicine.
• The purpose of this study was to compare the effectiveness of ultrasound-guided dextrose Prolotherapy with radial extracorporeal shock wave therapy (ESWT) in the treatment of chronic plantar fasciitis.
• This randomized controlled trial was conducted on 59 patients with chronic plantar fasciitis. Patients were randomly assigned into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided interfacial 2 cc dextrose 20% injection (30 patients).
• The following outcome measures were assessed before and then six weeks and 12 weeks after the treatments:
  • pain intensity by visual analog scale (VAS),
  • daily life and exercise activities by Foot and Ankle Ability Measure (FAAM),
  • and the plantar fascia thickness by ultrasonographic imaging.
• The visual analog scale (VAS) and Foot and Ankle Ability Measure (FAAM) scales showed significant improvements in pain and function in both study groups 6 weeks and 12 weeks after the treatments.
• A significant reduction was noted in plantar fascia thickness at these intervals. The inter-group comparison revealed that except for the Foot and Ankle Ability Measure (FAAM)-sport subscale which favored ESWT, the interaction effects of group and time were not significant for other outcome measures.
• Dextrose Prolotherapy has comparable efficacy to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with PF. No serious adverse effects were observed in either group.

A February 2022 study in The Journal of Foot and Ankle Surgery (31) also compared the effectiveness of extracorporeal shockwave therapy (ESWT) versus dextrose Prolotherapy on pain and foot functions in patients with chronic plantar fasciitis

• A total of 29 patients in whom conservative care failed were enrolled in the study after the clinical and ultrasonographic assessment.
• The patients were randomly assigned to receive ESWT (15 patients) or dextrose Prolotherapy (14 patients).
• ESWT group received 1 treatment
• The dextrose Prolotherapy group underwent an injection of 5 ml of 15% dextrose solution with 2% lidocaine. (Our note: One injection of dextrose is one injection of dextrose we do not consider it a Prolotherapy treatment).

Results of three ESWT sessions versus three single injections of dextrose:

• ESWT and dextrose Prolotherapy were repeated 3 times by 2 weeks apart.
• Symptoms such as morning pain, and foot function improved significantly in both treatment groups at 6 weeks and 12 weeks compared to baseline.
• In (this) study dextrose Prolotherapy and ESWT had similar effectiveness in patients with chronic plantar fasciitis who have not responded to conservative care. The results showed ESWT and dextrose Prolotherapy were not superior to each other.

One injection of cortisone and one injection of Prolotherapy

Plantar fasciitis is more of a misnomer since “itis” means inflammation, and most patients who have been diagnosed with plantar fasciitis actually have a weakened, degenerated plantar fascia. The true inflamed tissue is hot to the touch, red, and swollen. Thus, the anti-inflammatory treatments do not promote repair and healing of the fascia because most cases of this type of foot pain are not truly inflammatory.

A study from 2021 published in the journal Foot and Ankle Specialist (32) compared one injection of cortisone and one injection of dextrose.

We would like to point out that a single injection of dextrose should not be considered a Prolotherapy treatment. It should be considered a single shot of dextrose. A single Prolotherapy treatment would be considered a “peppering of the area,” with the needle to address the ligaments and tendon attachments as described above.

Let’s however see how one injection of dextrose did against one injection of 40 mg methylprednisolone.

• A total of 44 patients suffering from chronic plantar fasciitis who visited a physical medicine and rehabilitation clinic were enrolled in the study.
• Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose.
• Both interventions significantly improved pain and function at 2 and 12 weeks post-injection.
• Conclusion: Both methods are effective. Compared with dextrose Prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks post-injection.

One injection of dextrose was just as good as one injection of cortisone by 12 weeks.

The relationship between plantar calcaneal spurs (Heel Spurs) and Plantar fasciitis

Plantar fasciitis is one of the most common causes of heel pain. Plantar fasciitis involves pain and inflammation of the plantar fascia, a flat band of tough tissue supporting the arch of the foot that runs from the heel to the base of the toes. It looks sort of like a series of fat rubber bands, but the plantar fascia is made of collagen which is rigid and non-stretchy. Plantar fasciitis is common in middle-aged people but also occurs in younger people who are on their feet a lot. When the plantar fascia is strained, it becomes weak, swollen, and irritated.

Repeated microscopic tears of the plantar fascia cause pain that is most notable in the morning after getting out of bed. Putting weight on the injured area after periods of rest (such as sleep) will cause stress on the area and a more sudden, aching pain.  Once the foot loosens up, the pain generally decreases. The pain may return, however, after long periods of standing, or after another period of rest. Plantar fasciitis may also be called “heel spurs,” but this is not always accurate because bony growths on the heel may or may not be involved.

In the medical journal Foot and Ankle Injury, (33) doctors in the United Kingdom point out the confusion foot specialists face when understanding the relationship between a heel spur and plantar fasciitis. Here is what they write:

• Plantar fasciitis is a common diagnosis in patients presenting with heel pain.
• The presence of co-existing calcaneal spurs has often been reported but confusion exists as to whether it is a casual or significant association. (In other words, does plantar fasciitis cause heel spurs?)

So how did this research team come up with the answer? By comparing soft tissue ligament instability. Does weakness in the soft tissue cause bone spur formation? Our website is filled with research that it does, of course, do so.

This is what the researchers did:

• They looked at lateral heel radiographs of nineteen patients with a diagnosis of plantar fasciitis and nineteen comparison subjects with a lateral ankle ligament sprain matched for age and sex and were reviewed independently by two observers.
• There was a significantly higher prevalence of heel spurs in the plantar fasciitis cases than in the comparison group (89% versus 32%.)

Studies like these give fantastic examples of the problems of joint instability and the body’s way of dealing with it at the point of the problem.

• Both the lateral ankle ligament sprain and the plantar fasciitis would cause pain and instability in the heel region.
• However, the way to stabilize the heel when plantar fasciitis was the problem was to grow a heel spur, albeit a painful one in 89% of the patients. When the ankle was the problem, the body grew a heel spur 32% of the time. In the other two-thirds of incidence, the body figured out a different way of dealing with the chronic ankle sprain and instability– chronic inflammation.

Note: Heel spurs are due to weakened ligamentous support of the plantar fascia. Prolotherapy to strengthen the plantar fascia will eliminate chronic heel pain. There is generally no need for heel spurs to be surgically removed after the supportive ligaments and plantar fascia have been repaired.

Then again, some people with heel spurs have heel pain, and some people with heel spurs have no heel pain. Is the presence of the heel spur confusing the treatment options?

Doctors at the University of Auckland and the Department of Orthopedic Surgery, Wellington Hospital in New Zealand published a comprehensive opinion on how to treat heel spurs. This paper was published in the Journal of Anatomy. (34)

• At the top the researchers noted that they had examined, (as we have here) patients with plantar calcaneal (heel) spurs who had significant pain episodes. The doctors also examined patients (as we have here) who have heel spurs that cause no pain at all. Also, heel spurs are present in 45–85% of patients with a diagnosis of plantar fasciitis. (Again, heel spurs are common, many do not cause pain).

Plantar fascia tears

In this video, Danielle R. Steilen-Matias, MMS, PA-C, discusses typical treatments for Plantar Fascia tears.

Summary:

• Plantar Fascia tears are different than Plantar Fasciitis. Fasciitis means inflammation from degeneration. The tear is a tear. If the fascia is completely torn off the bone, surgery will be needed to correct it. If the fascia is not completely torn off the bone then we can expect that would be able to help the condition with Prolotherapy.
• Many patients with tears have had boot therapy, medications, rest, and massage. In our clinic, we treat this differently because we are trying to get the tear to heal more aggressively. Here we would use Prolotherapy and when needed PRP and injections. These injections are performed under ultrasound guidance.
• In some patients, we would recommend a walking boot following the treatment to assist the accelerated healing. This is, of course, different than if you boot it on your own. We have seen many patients over the years who had the walking boot and while the boot provided stress and discomfort relief, it does not allow the fascia to heal the way the patients had hoped for. In our experience, booting is optimal when tissue is regenerating through treatments. Heel spurs are due to weakened ligamentous support of the plantar fascia. Prolotherapy to strengthen the plantar fascia will eliminate chronic heel pain. There is generally no need for heel spurs to be surgically removed after the supportive ligaments and plantar fascia have been repaired.

Summary and contact us. Can we help you?

Most recently a March 2022 review study (35) found “dextrose prolotherapy is an effective treatment of chronic plantar fasciitis to reduce pain, improve foot functional score and decrease plantar fascia thickness at short-term follow-up.” The paper also tells us that further studies in larger populations are needed to identify the optimal treatment regimen including dextrose concentration, volume, injection site, injection technique, and the number of injections required. The long-term effects of these treatments also require further examination.

We have almost three decades of experience in the use of Prolotherapy and case histories of nearly thirty years. Prolotherapy can be an effective treatment for Plantar Fasciitis.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your Plantar Fasciitis, Plantar Fasciopathy, and Plantar Fasciitis tears problems.  If you would like to get more information specific to your challenges of peroneal tendon injury and ankle instability, please email us: Get help and information from our Caring Medical staff

 

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This article was updated February 1, 2023

 

 

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