Comparing Injection treatments for Plantar Fasciitis, Plantar Fasciopathy and Plantar Fasciitis tears
Ross Hauser, MD, aring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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:
- 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
- Changing shoes
- Stopped running
- Limited walking
- Lots of anti-inflammatory medications
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. It is a 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.
- 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 injection, (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 a symptomatic 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 corticosteroid injection was more effective in the first 3 months but then its effectiveness all but disappeared
- The 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 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 a patient 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.
- Massaging the foot with a tennis ball and application of ice are commonly recommended.
- Inject steroids (see above) into the foot or to 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 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.
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:
- 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 at 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 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. . . “(3) 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.(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:
- 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 placebo injection for reducing pain or improving function.
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.
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
In the video below David N. Woznica, MD, gives a brief introduction to Prolotherapy and Platelet rich Plasma treatments. The transcript summary of the video is below followed by published research summaries.
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 similar benefit, but as research indicates, PRP provides better results and the PRP does not threaten the structural integrity of the tissue.
I 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 a 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:
- Patients with chronic plantar fasciitis were allocated to have steroid injection or PRP.
- The primary outcome measure was the Foot Function Index (FFI) Pain score.
- Secondary outcome measures were 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.
- 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 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 an 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, (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:
- Patients with the clinical diagnosis of chronic plantar fasciitis (heel pain of more than six weeks) after failed conservative treatment and plantar fascia thickness 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 injection and those in Group B received steroid injection.
- Patients were assessed with VAS visual analog scale (Pain assessment and scoring system) and American Orthopedic Foot and Ankle Society (AOFAS) functional score.
- 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 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 six months’ follow-up.
- The improvements observed in VAS and AOFAS were statistically significant. At the end of 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 with steroid injection with long lasting beneficial effect.
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,(13) 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 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 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. 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.”(16)
An October 2019 study in the American journal of physical medicine & rehabilitation (17) also evaluated the effectiveness of dextrose Prolotherapy in the treatment of chronic resistant plantar fasciitis through comparison with a control group.
- This was a double-blind, randomized, controlled study, the patients were divided into two groups.
- Thirty (30) patients comprised teh Prolotherapy group. They were administered 5 cc 30% dextrose, 4 cc saline, 1cc 2% lidocaine mixture (15% dextrose solution) and the control group was given 9 cc saline and 1 cc 2% lidocaine mixture twice at a three-week interval.
- During the fifteen-week follow-up period, pain intensity was measured using the visual analog scale during activity (VAS-A) and at rest (VAS-R). The foot function index (FFI) 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.
- Improvements in Visual analog scale during activity, Visual analog scale during rest, and foot function index and plantar fascia thickness measured at the 7th and 15th weeks were significantly higher in the Prolotherapy group compared to the control group.
- “Dextrose prolotherapy has efficacy up to 15 weeks and can be used as an alternative method in the treatment of chronic resistant Plantar fasciitis.
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.
Now that the evidence for PRP and Prolotherapy over cortisone has been presented, let’s go back and discuss the problem of plantar fasciitis.
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.
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, (18) 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, were reviewed independently by two observers.
- There was a significantly higher prevalence of heel spurs in the plantar fasciitis cases than 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. 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 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. (19)
- 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 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.
- 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 would be able to help the condition with Prolotherapy.
- Many patients with tears have had the boot therapy, medications, rest, and massage. In our clinic we treat this differently as 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.
If you have questions about plantar fasciitis, get help and information from our Caring Medical staff
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