The role of autologous blood injections in the

treatment for patients with chronic plantar

fasciitis – A case series and longer-term
follow-up
Patrick C. Wheeler 1,2,3
1
Department for Sport & Exercise Medicine, University Hospitals of Leicester NHS Trust, UK, 2School for Sport,
Exercise, & Health Sciences, Loughborough University, UK, 3National Centre for Sport & Exercise Medicine –
East Midlands (NCSEM-EM), UK

Objective: To identify outcomes for patients following autologous blood injections for chronic plantar fasciitis
symptoms.
Methods: Prospective case series performed by a single clinician in a National Health Service Sports
Medicine Department. Patients with recalcitrant symptoms had a single autologous blood injection
performed along with a structured rehabilitation programme. Patients were followed up clinically as part of
routine care, and those who had previously been discharged, after care was finished, were contacted for
a current assessment of symptoms and function.
Results: Sixty-two patients were identified and follow-up data was available for all patients, with a median
follow-up of 631 days and with follow-up of at least 1 year for nearly three-quarters of patients. There was
an average reduction in pain as assessed by visual analogue score (VAS) of 84%, with 55% of patients
reporting themselves as ‘pain-free’ (VAS = 0), and 68% as ‘virtually pain-free’ (VAS 0–1). There were no
serious side-effects reported.
Discussion: Autologous blood injections appear to be an appropriate option in the management of
patients with chronic plantar fasciitis, although evidence from randomised control trials is still needed
to prove causality. There remain a small proportion of patients who do not seem to benefit sufficiently
from this procedure and who require alternative treatment options. Further work is required to identify
any factors that may be associated with either good or poor response to better tailor individual
treatments.
Keywords: Plantar fascia, Autologous blood, Injection, Outcome

Introduction treatments are very similar. Indeed the plantar fascia,

The plantar fascia is a band of connective tissue on the
plantar aspect of the foot, which attaches to the calca-
neus proximally and the metatarsal heads distally and
acts to support the arch of the foot. Plantar fasciitis is
an abnormal thickening of the attachment of the
plantar fascia which is typically either at, or adjacent
to, its attachment to the calcaneus.
Rather than an inflammatory condition, the pathol-
ogy of plantar fasciitis is degenerative in nature and is
assumed to be due to either a delay in healing or a
failed healing response.1 Whilst not strictly a tendino-
pathy, plantar fasciitis is very similar to an insertional
tendinopathy, or enthesopathy, and the effective
Correspondence to: Patrick C. Wheeler, Department of Sport & Exercise
Medicine, University Hospitals of Leicester NHS Trust, Leicester General
Hospital, Gwendolen Road, Leicester, LE5 4PW, UK.
Email: patrick.wheeler@uhl-tr.nhs.uk
arising from the under-surface of the calcaneus, can
be seen as the functional end-point of the Achilles
tendon, which attaches to the posterior margin of the
calcaneus. There are some superficial fibres directly
connecting the Achilles tendon to the plantar fascia
which decrease as the foot ages, although they persist
into adult life.2 Furthermore, increasing tension in
the calf muscle and Achilles tendon increases the
strain through the plantar fascia, which could be one
of the contributing factors to the development of
plantar fasciitis.3
Plantar fasciitis is a common condition causing
plantar aspect foot pain, typically affecting people in
their fourth and fifth decades, affecting sedentary as
well as active populations.1,4,5 Although most patients
with plantar fasciitis will improve within 12 months,
approximately 10% will go on to develop persisting

© W. S. Maney & Son Ltd and the British Institute of Musculoskeletal Medicine 2015
DOI 10.1179/1753615415Y.0000000004 International Musculoskeletal Medicine 2015 VOL. 37 NO. 2 47
Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis
symptoms.6 Whilst the causation remains unclear,
mechanical overload and micro-trauma are thought
to play a key role.7 Identified risk factors for the devel-
opment of plantar fasciitis include obesity, regular
prolonged periods of standing, and possibly excessive
foot pronation.4,8–10
Symptoms of plantar fasciitis include localised heel
pain on weight-bearing, most typically worst first
thing in the morning or after periods of prolonged
sitting.4 Examination findings include localised heel
pain, most commonly over the medial attachment of
the plantar fascia into the calcaneus, with tight calf
musculature and pes planus being common associated
findings.1 Ultrasound assessment of the plantar fascia
can demonstrate local thickening, greater than the
normal sagittal diameter upper limit of 5.3 mm:11
however imaging can sometimes be normal in patients
with plantar fasciitis.1
A wide variety of conservative therapies are used to
treat patients with plantar fasciitis.5 Low risk conser-
vative therapies include rest, stretches, tension night
splints, taping, and orthotics.6,12–17 Corticosteroid
and local anaesthetic injections are often used with a
variety of differing techniques and success reported
in the literature, but with some papers reporting a
plantar fascia rupture rate of up to 10%.18–21
Surgery has been performed for plantar fasciitis
resistant to conservative treatments, with a wide
range of differing surgical techniques being reported,
and success reported of 75–90% of cases although
this is defined differently in different papers.22–29
One recent case series from a single hospital reviewed
the longer-term results following surgery for plantar
fasciitis, and found that there were good results follow-
ing surgery in the short, medium, and longer term for
patients with symptoms previously resistant to a range
of conservative measures.30
An alternative to surgical intervention may be the
use of autologous blood injections (ABIs). These are
injections of a small quantity of whole blood (typically
3–4 mls) into the area of damage which are thought to
promote a healing response, and which are most com-
monly performed under image guidance to ensure that
the injection is targeted in the correct location. This
blood is normally obtained by simple venepuncture
at the time of the procedure and is injected without
any direct manipulation of it, unlike platelet-rich
plasma injections where a larger volume of blood is
taken by venepuncture and the centrifuged to obtain
a small fraction of the whole blood contents. ABIs
are undertaken for a range of different tendinopathies
with a varying evidence-base and may be an effective
treatment when symptoms have been resistant to a
range of conservative therapies, and may be a less-
invasive alternative to surgery. The evidence so far
for the use of autologous blood injections in cases of
48 International Musculoskeletal Medicine 2015 VOL.
recalcitrant plantar fasciitis is very limited. The
National Institute for Health & Clinical Excellence
(NICE) has issued updated guidance on the use of
autologous blood injections for plantar fasciitis31
and for other tendinopathy conditions.32 The first
paragraph of the summary reads as follows:
• Autologous blood injection for plantar fasciitis
(January 2013) – ‘The evidence on autologous blood
injection for plantar fasciitis raises no major safety
concerns. The evidence on efficacy is inadequate in
quantity and quality. Therefore, this procedure
should only be used with special arrangements for
clinical governance, consent and audit or research.’31
The evidence considered by NICE includes a study
from 2007 which randomised patients with plantar fas-
ciitis symptoms of more than 6 weeks duration to
either receive a corticosteroid injection or an injection
with autologous blood, and found a better early
response to corticosteroid injections than ABI,
although at 6 months there was no significant differ-
ence between the two groups.33 More recently an
investigator and participant-blinded RCT comparing
corticosteroid injections versus a placebo injection
for 82 patients with plantar fasciitis for more than 8
weeks, found no significant improvement to pain
score from the corticosteroid injection after 4 weeks
compared to the placebo injection.34
The author has published an initial pilot study to
investigate the use of ABI in patients with chronic
plantar fasciitis in a National Health Service (NHS)
Sports Medicine clinic, with patients with an average
duration of symptoms pre-ABI of nearly 4 years, and
the results showed an average reduction in the visual
analogue score (VAS) of pain of nearly 85%, with
71% of patients with more than 2-month follow-up
self-reporting as pain-free.35 This current article
extends the original pilot study and now contains
nearly double the number of subjects, with more
robust outcome measures, and three times the
average follow-up duration.
Methods
The patients were all treated by the study author in an
NHS Sport & Exercise Medicine clinic in a secondary
care hospital in Leicester, UK. All patients received a
single autologous blood injection for their plantar
fascia pain. Following the ABI procedure the patients
undergo routine follow-up in clinic settings, with
outcome recorded at each visit. Patients who had
already been discharged from routine clinical follow-
up were contacted by the author to ascertain longer-
term outcomes.
Procedure
The technical procedure is performed as follows. The
patient lies supine on a couch with the leg extended.
The site of maximal pain is indicated by the patient
37 NO. 2
 Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis
and marked. The area around the injection is cleaned
using skin preparation and the injection is performed
under a sterile no-touch technique. Ultrasound confir-
mation using sterile gel is performed to locate the area
of maximal thickening. A total of 1–2 ml of 1 or 2%
lidocaine is injected to the skin layers of the sole of
the foot, distal to the site of pain. Under direct ultra-
sound guidance a 21-gauge needle is introduced in
line with the plantar fascia through the subcutaneous
planes to the plantar fascia attachment to the calca-
neus, where the site of damage is localised, and a dry
needling technique is performed under direct ultra-
sound observation. During this time, venepuncture is
performed by a nurse assistant, 4–5 ml of blood is
obtained and passed to the person performing the
ABI procedure. A total of 3–4 ml of this whole
blood is then injected using a peppering technique to
the area of damage evident of the ultrasound
machine, all performed under real-time direct ultra-
sound visualisation.
Figure 1 demonstrates the standard view obtained at
the time of the procedure.
After the procedure is completed the needle is with-
drawn and a small adhesive plaster applied. The
patient can walk on this straightaway but is instructed
to limit activity especially for the first 48–72 hours
post-procedure. The patient is advised to avoid non-
steroidal anti-inflammatories for a minimum of 72
hours post-procedure, but can use simple analgesia
or ice if required for pain.
The patient is given a standardised home exercise
programme to undertake, and informed as to progres-
sing this. In addition to plantar fascia stretches, this
Figure 1 Image of ultrasound-guided autologous blood injection.
International Musculoskeletal Medicine
rehabilitation regime includes stretches for the gastro-
cnemius and soleus components of the calf muscle
complex, for the flexor hallucis longus, and the ham-
string muscle groups. In addition to this the patient
progresses onto calf muscle strengthening, balance/
proprioception, and intrinsic foot muscle strengthen-
ing exercises as well.
The patient is then routinely followed-up at 2–3
weeks to ensure compliance with the rehabilitation
plan, and then at 6 weeks post-procedure for the first
of the outcome measures to be recorded. After this
the patient is typically seen at 3 and 6 months post-
ABI, although the dates of all of these appointments
are booked according to patient and appointment
availability. Outcome measures used include pain
score, satisfaction score, and specific Patient-Rated
Outcome Measures (PROMs) including the revised
Foot Function Index (FFI-r) questionnaire.
Data collection
Data is recorded routinely at patient follow-up
appointments and inputted into a spreadsheet for
procedure outcome maintained by the author. In
addition in September 2014 all patients who had pre-
viously undergone autologous blood injections and
who did not have follow-up data recorded in the pre-
vious 6 weeks were posted a letter to their home
address with a structured outcome questionnaire
within it. Patients were asked to complete and
return this form to the author. Patients who did not
respond were sent a further reminder letter 6 weeks
later, and attempts were made to contact by telephone
those that did not respond, on two occasions over the
2015 VOL. 37 NO. 2 49
Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis

next month. Patients who did not respond were
excluded from that data source and the most recent
clinic follow-up data were used as the latest
outcome data.
Statistical analysis
Data were taken from the collection tools and inputted
into a bespoke spreadsheet (MS Excel for Mac 2011,
v14.4.7), and calculations occurred within this
software.
Results
A total of 62 patients were identified from procedure
diaries. There was an average age at the time of the
autologous blood injection of 52.5 years, with a
range of 25.6–80.4 years. Twenty-nine (47%) of the
patients were male, and 33 (53%) were female.
Patients had been suffering with plantar fascia symp-
toms at the time of the ABI for an average of 50
months, with a range of 4–360 months. The median
number of months was 33.
Prior to the ABI procedure, all patients had tried
analgesia, physiotherapy, and podiatry; in addition
79% of patients had also tried a tension night splint
prior to the ABI procedure. Two patients (3.2%) had
previously undergone surgery prior to ABI and still
had residual symptoms. Patients had received an
average of 1.9 corticosteroid injections (range 0–7)
during their entire treatment journey prior to autolo-
gous blood injection, with an average reported
benefit of only 1.9 weeks following their last injection
(range 0–12).
All 62 patients had some follow-up data available;
the median duration of follow-up was 631 days (1.7
years), the mean was 600 days (1.6 years). Follow-up
data of at least 1 year was available for 46 patients
Table 1 Maximum duration of follow-up
Duration of follow-up available n %
More than 2 years 21
1–2 years 25
6 months–1 year 12
3–6 months only 3 5
Less than 3 months only 1 2
62
(74%) and of 2 years for 21 patients (34%). The
longest follow-up was 1211 days (3.3 years) post-ABI
procedure.
The following table displays the length of time of
maximal follow-up in various time categories
(Table 1).
The practice of autologous blood injections was
compared against the NICE recommendations and
audit criteria and found to be fully compliant for all
recommendations. No patients suffered a serious
adverse event following the ABI procedure.
The patient with the shortest length of follow-up
was also the youngest patient, and had the shortest
length of previous symptoms. This was an elite
athlete whom the author treated, but who unfortu-
nately did not respond adequately to the ABI pro-
cedure and subsequently required surgical treatment.
In terms of general outcome measures, 85% of
patients reported benefit to them from the ABI pro-
cedure. Overall 55% of patients were pain-free follow-
ing the procedure, 68% were ‘virtually pain-free’
(recording a pain score on a 0–10 VAS for pain at 0
or 1); however a total of three patients (4.9%) did
not improve sufficiently following the ABI procedure
and underwent surgery for recalcitrant symptoms.
Overall there was a pain score reported on a 0–10
VAS of 8.1 before the ABI procedure, and a mean
score post-ABI at follow-up of 1.3; this represents a
mean reduction in pain score of 84%. Using the
change in VAS from baseline recorded at differing
time points, the effect size of the changes seen was cal-
culated, which give an overall average effect size across
all time points of 2.93, indicating a very large effect
size. The following table (Table 2) and graph (Fig. 2)
display the trend for pain score across different time
points of follow-up. The different numbers of results
at different time points reflect the natural variation
in follow-up post-procedure.
The proportion of patients who were reporting as
‘pain-free’ (VAS = 0), ‘virtually pain-free’ (VAS 0–1),
34 or ‘no pain or low pain’ (VAS of 1–2) at different
40
time points was also calculated. This information is
19
displayed in Fig. 3.
Two multiple-choice outcome questions were also
asked identifying symptom resolution and return to

Table 2 VAS pain score at different time points

Length of time post-ABI Number of results VAS mean (SD) Min Max Median Effect size (compared to baseline)

At baseline 62 8.1 (1.4) 4 10 8

2 weeks (7–21 days) 37 4.6 (2.4) 0 8 5 1.78
6 weeks (28–56 days) 47 2.9 (2.2) 0 8 3 2.82
3 months (70–120 days) 45 2.0 (2.0) 0 7 2 3.53
6 months (140–220 days) 39 1.6 (2.2) 0 9 0.5 3.53
12 months (300–400 days) 22 2.4 (2.9) 0 10 1.5 2.5
18 months (450–700 days) 16 2.2 (3.4) 0 10 1 2.27
>2 years (>700 days) 24 1.1 (2.3) 0 9 0 3.68

50 International Musculoskeletal Medicine 2015 VOL. 37 NO. 2

 Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis

Figure 2 Displaying average pain score against time.

Figure 3 Displaying the proportions of patients who were ‘pain-free’, ‘virtually pain-free’, or ‘no or low pain’ at different lengths
of time post-ABI.

the patients normal level of activities post-procedure, Patients were asked to self-rate their level of satisfac-
and Tables 3 and 4 detail the latest responses for the tion with the outcome of their procedure on a 5-part
patients in this case series. Likert satisfaction scale. The results of this were

Table 3 ‘How do you rate your symptoms recently,
compared to your symptoms before the procedure was
carried out?’ (Roles and Maudsley score)
I have no symptoms or minimal symptoms now 52%
I have some symptoms, but these are significantly 21%
improved from before the treatment
I have some symptoms, but these are somewhat better 10%
from before the treatment
My symptoms are no better or are worse than before the 17%
treatment
Table 4 ‘Have you returned to your “normal” level of activity
following the procedure that you had?’
Yes, I have been able to return to everything that I want 55%
to do
I have not returned to my previous level, but not primarily 7%
because of my foot symptoms
I have been able to return to most things, but with some 21%
limitations due to my foot symptoms
No, I have not been able to return to my previous level 17%
due to limitations from my foot symptoms

International Musculoskeletal Medicine 2015 VOL. 37 NO. 2 51

Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis
Table 5 Displaying the result to the self-rated satisfaction
question against average change in outcome measures
‘So far, how
satisfied are
you with the
outcome of the Mean Mean
treatments you Proportion of reduction in reduction in
have respondents VAS score FFI-r score
received?’ (%) (%)
Very satisfied 62 97
Satisfied 12 95
Neutral 12 80
Dissatisfied 10 64
Very 4.8 15
dissatisfied
compared to the mean reduction in pain (on a 0–10
pain VAS) and the total score for the FFI-r question-
naire to show the correlation between satisfaction
and outcome scores (Table 5).
Finally, patients were asked to rate whether they
would recommend the procedure to a friend or
family member with the same symptoms – akin to a
friends and family test. A total of 74% said that they
would ‘definitely recommend’ the procedure, and a
further 14% would ‘probably recommend’ it, com-
pared to 7% who would ‘maybe recommend’, and
5% who would ‘not recommend’ the autologous
blood injection procedure. Again, there were improved
outcome scores in those most likely to recommend the
procedure compared to other groups.
Using the change in VAS from baseline recorded at
differing time points, the effect size of the changes seen
was calculated, which give an overall average effect
size across all time points of 2.93, and the different cal-
culated values are displayed in Table.
Discussion
This case series demonstrates that a large proportion
of patients see an improvement in their symptoms fol-
lowing autologous blood injection. However this
information is from a case series and whilst an associ-
ation may be assumed, true causality cannot be
demonstrated from this study design, and other
forms of research such as a randomised controlled
trial will be required for this.
Overall there was a mean reduction in pain score of
84% and more than two-thirds of patients were either
pain-free or virtually pain-free. There does not seem to
be any specific fall-off of benefit over time as found in
this series, with good benefit reported at 12 months or
more following procedure for the majority of patients.
There was a slight anomaly in the data noted at the
12-month follow-up period with slightly worsened
reduction in VAS at this point compared to time
points before and after, however this difference did
not appear to be significant. This may have reflected
a data issue in individual results obtained at that
52 International Musculoskeletal Medicine 2015 VOL.
time point or variation within a general trend as
there seemed to be more benefit again after this time
point: however further work could be directed to
explore this as a possible issue.
Not all patients reported significant benefit follow-
ing the autologous blood injection procedure and the
figures in this series do show a broad range of
(%)
responses (as indicated by the standard deviation
96 figures included above) demonstrating considerable
65
46
variability in response. From this data, it is not clear
11 why certain patients differ in their responsiveness. It
−4 was noted from practitioner observations recorded in
the clinic letters of the patients in this series that com-
pliance with rehabilitation was a strong indicator of
success, in that those patients who were poorly able
to demonstrate rehabilitation exercises at follow-up
appointments achieved worse outcomes than those
who could. This suggests that on-going rehabilitation
remains a key component of successful treatments,
however other factors are almost certainly involved
as well. There remain many uncertainties as to what
other factors may be helpful in predicting in advance
either a good or poor response to treatments, and
further work should be directed at this to better
direct more individualised treatment options in the
future.
The choice of outcome measures also bears some
consideration, and in this case series a wide range of
outcome measures were used including a VAS pain
score, several validated PROMs, and a range of
other outcome measures. The headline figures
suggested that 38% of patients still felt limited to
some extent by their foot symptoms, which is a
greater proportion than the change in VAS would
suggest. The best way of recording outcomes is not
clear, and it may be that a combination of pain, func-
tion, and subjective outcome measures allow a global
assessment of patient experiences and prove an ideal
way of recording outcomes, although that is more
involved than a simple pain score.
In summary this case series, which investigates
longer-term outcomes from a large case series,
appears to suggest that a large number of patients
benefit significantly from the autologous blood injec-
tion procedure: however causality cannot be proven
from this series so further research is required to satis-
factorily answer this question. Furthermore, questions
remain about the most appropriate outcome measures
to be used and why some patients appear to respond
better than others.
Acknowledgements
The author would like to offer his thanks to the two
nurse practitioners in the Sports Medicine
Department who have assisted in performing this pro-
cedure, and to his admin team who has been
37 NO. 2
 Wheeler The role of autologous blood injections in the treatment for patients with chronic plantar fasciitis
extensively involved in chasing patients to respond to
the letters seeking information about symptoms for
this case series study.
Disclaimer statements
Contributors The author himself prepared the paper,
analysed the results, and wrote the manuscript.
Funding None.
Conflicts of interest None.
Ethics approval Ethics approval was not needed for
this study as it reflected a service evaluation and was
registered locally with the hospital as such.
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