Comparing Injection treatments for Plantar Fasciitis, Plantar Fasciopathy and Plantar Fasciitis tears

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

Comparing Injection treatments for Plantar fasciitis, Plantar fasciopathy, and Plantar fasciitis tears

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

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

Moving on to injections for Plantar fasciitis

For many people, these 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 to 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 published in The Journal of Foot and Ankle Surgery (1) and it comes from medical university researchers in Turkey.

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

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

Research highlights:

The Results:

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 towards a more permanent solution to your foot pain.

Later in this article, we will discuss both Prolotherapy, injections of simple dextrose, and 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

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

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.

Dry Needling better than cortisone

A March 2019 study in The Journal of Foot and Ankle Surgery (2) 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:

The patients were divided into 2 groups

Patients were assessed in the third week and sixth month.

Dry needling in a needle with no medication.

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. . . “(3They also concluded that PRP injections would be more effective 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.(4)

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(5) the UK researchers noted: PRP injections are associated with improved pain and function scores at three-month follow-up when compared with corticosteroid injections.

Cortisone no better than placebo for restoring function?

This is an August 2019 study from medical university researchers in Australia published in the journal BioMed Central musculoskeletal disorders.(6) Here are the learning points of this study:

Hyaluronic Acid and Cortisone just about the same

A January 2020 study in the Journal of Pain Research (7) 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 (8) 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. The 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 benefit.

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.

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

Some patients 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.

In this image, ultrasound shows Nerve Release injection Therapy. In the before image, you can clearly see the entrapped nerve. In the after image the median nerve is released providing nerve pain relief to the patient

In this image, ultrasound shows Nerve Release Injection Therapy. In the before image, you can clearly see the entrapped nerve. After, the median nerve is released, providing nerve pain relief to the patient.

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


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 the 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. I like to use Platelet Rich Plasma or 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 the 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 (9) 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:

RESULTS:

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, (10) 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:

Plantar Fasciopathy Research – Why are we still thinking PRP is a “one-shot wonder?”

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 the more permanent relief the 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.(11)

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.(12) Enough so that some researchers want cortisone under ultrasound guidance restored as the primary treatment for plantar fasciitis,(13despite 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 Steroid, its effect does not wear off with time. At 12 months, PRP is significantly more effective than Steroid, making it better and more durable than cortisone injection.”(14)

Further research in the Singapore medical journal 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.(15)

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 the 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 (16) on the evaluation of the efficacy of dextrose Prolotherapy in the treatment of chronic resistant plantar fasciitis through comparison with a control group.

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.”(17)

An October 2019 study in the American Journal of Physical Medicine & Rehabilitation (18) also evaluated the effectiveness of dextrose Prolotherapy in the treatment of chronic resistant plantar fasciitis through comparison with a control group.

Results:

Conclusion:

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, or 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.

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.

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 (19) 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.

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

The relationship between plantar calcaneal spur (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.

Heel spur formation. Weakness in the plantar fascia (called plantar fasciitis) causes inflammation to occur at the calcaneal attachment, causing a heel spur.

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(20) 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:

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:

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.

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 not a 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, 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. (21)

Plantar fascia tears

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

Summary:

If you have questions about plantar fasciitis, get help and information from our Caring Medical staff

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This article was updated January 19, 2021

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