PRP and Prolotherapy for Plantar fasciitis | Plantar Fasciopathy

Failed Back Surgery

Ross Hauser, MD

In this article, Ross Hauser MD explains treatment options for plantar fasciitis.

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.

Comprehensive Prolotherapy injections (the use of dextrose Prolotherapy, Stem Cell Therapy, and Platelet Rich Plasma Therapy) to the plantar fascia and its attachments stimulate regeneration and repair of the tissue. They do this by inducing a mild, temporary inflammation that triggers the production of new fibrous tissue. Once the soft tissue of the foot has been triggered to repair, it creates stronger tissue to support the foot, and the weight of the entire body.

Plantar fasciitis | Plantar Fasciopathy

What causes 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.

Traditional recommendations and the patient frustration

However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain relief benefit, 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.

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

In the medical journal Foot and Ankle Injury, 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 formation. This 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. 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. The other two-thirds of incidence, the body figured out a different way of dealing with the chronic ankle sprain and instability – chronic inflammation. Which leads us to our next discussion on cortisone.

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.

Plantar Fasciopathy Research – Why is Cortisone still an option?

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. . . “They 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, were 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.2

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, the UK researchers noted: PRP injections are associated with improved pain and function scores at three month follow-up when compared with corticosteroid injections.7

Plantar Fasciopathy Research – Why are we 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 a definitely positive results and they would like to see more studies performed.3

In other research, doctors say they cant tell if PRP works because there is no standardized treatment and that based on “one-shot wonders” it doesn’t appear to be effective over other treatments.4 Enough so that some researchers want cortisone under ultrasound guidance restored as the primary treatment for plantar fasciitis,5 despite conflicting research as reported above 1, and here:

New 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.”6

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.

Now that the evidence for PRP over cortisone has been presented, let’s go back and discuss the problem of plantar fasciitis.

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.

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. Lead by the Korea National Sport 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 a better initial improvement in function compared with dextrose Prolotherapy treatment.”8

Prolotherapy treatments need to focus on the the spring ligament which is also called the plantarcalcaneonavicular 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.

Follow up and exercise recommendations

When you receive treatment to your foot, there will be some soreness, so looser fitting footwear is encouraged on treatment days. You will however be able to walk out of the office as well as be encouraged to walk and move your feet during the Prolotherapy treatment period. No prolonged downtime is required, rather you can engage in activities such as cycling, running in a pool, and using the elliptical. Your Prolotherapist will provide you with guidelines for activities, and give you exercises to strengthen your feet.

If you are a runner, our Prolotherapists, being avid runners as well, will guide the runner through a rehabilitation program that includes getting the runner back to running as quickly as possible. Running on soft surfaces such as soft tracks can accelerate the process, as well as wearing proper running shoes. They will also provide the runner with foot strengthening exercises that will help prevent development of a recurrence in the future.

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

1 Karls SL, Snyder KR, Neibert PJ. Effectiveness of Corticosteroid Injections in the Treatment of Plantar Fasciitis. J Sport Rehabil. 2016 May;25(2):202-7. doi: 10.1123/jsr.2014-0234. [Pubmed] [Google Scholar]

2. Hsiao MY, Hung CY, Chang KV, Chien KL, Tu YK, Wang TG. Comparative effectiveness of autologous blood-derived products, shock-wave therapy and corticosteroids for treatment of plantar fasciitis: a network meta-analysis. Rheumatology (Oxford). 2015 Apr 6. [Pubmed] [Google Scholar]

3. Franceschi F, Papalia R, Franceschetti E, et al. Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull. 2014 Sep 19. pii: ldu025.  [Pubmed] [Google Scholar]

4. Sandrey MA. Autologous growth factor injections in chronic tendinopathy. J Athl Train. 2014 May-Jun;49(3):428-30. doi: 10.4085/1062-6050-49.3.06. Epub 2014 May 19 [Pubmed] [Google Scholar]

5. Kirkland P1, Beeson P. Use of primary corticosteroid injection in the management of plantar fasciopathy: is it time to challenge existing practice? J Am Podiatr Med Assoc. 2013 Sep-Oct;103(5):418-29. [Pubmed] [Google Scholar]

6. Jain K, Murphy PN, Clough TM. Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study. Foot (Edinb). 2015 Aug 22. pii: S0958-2592(15)00083-8. [Pubmed] [Google Scholar]

7 Singh P, Madanipour S, Bhamra JS, Gill I. A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy. Int Orthop. 2017 Jun;41(6):1169-1181. [Pubmed] [Google Scholar]

8 Kim E, Lee JH. Autologous platelet-rich plasma versus dextrose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis. PM&R. 2014 Feb 28;6(2):152-8. [Pubmed] [Google Scholar]

9 Ang TWA. The effectiveness of corticosteroid injection in the treatment of plantar fasciitis. Singapore Medical Journal. 2015;56(8):423-432. [Pubmed] [Google Scholar]

10 Johal KS, Milner SA. Plantar fasciitis and the calcaneal spur: Fact or fiction?. Foot and Ankle Surgery. 2012 Mar 31;18(1):39-41. [Pubmed] [Google Scholar]

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