The Foot 23 (2013) 74–77

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The Foot
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The treatment of intractable plantar fasciitis with platelet-rich plasma

injection
Vishwajeet Kumar a,∗ , Tim Millar a , Philip N. Murphy b , Tim Clough a
a
Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, United Kingdom
b
Department of Psychology, Edge Hill University, St. Helens Road, Ormskirk, Lancashire L 39 4 Q P, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Background: Whilst most cases of plantar fasciitis can be settled with existing conservative treatment, a
Received 17 January 2013 few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety
Received in revised form 10 June 2013 of soft tissue problems.
Accepted 30 June 2013
Objective: Evaluate the effectiveness of platelet rich plasma (PRP) in chronic cases of plantar fasciitis.
Patients and methods: Patients with plantar fasciitis not responded to a minimum of 1 year standard
Keywords:
conservative management were offered PRP therapy. Injections were performed in theatre as a day case.
Resistant
Roles–Maudsley (RM) scores, Visual Analogue Scores (VAS), AOFAS scores and ‘would have injection
Plantar fasciitis
Platelet-rich plasma
again’ were collated pre-operatively, three and six months.
Results: Prospective data was collected of 50 heels (44 patients). At six month review, RM score improved
from mean 4 to 2 (p < 0.001), VAS improved from 7.7 to 4.2 (p < 0.001) and AOFAS improved from 60.6 to
81.9 (p < 0.001). 28 patients (64%) were very satisfied and would have the injection again.
No complications were reported.
Conclusion: In these chronic cases, PRP produce an efficacy rate, approaching 2 out of every 3. The pro-
cedure was safe with no reported complications. The authors feel PRP may have some role in treatment,
and merits further study with a prospective randomised trial.
Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.

1. Introduction biomechanical factors, night splints, activity modification and use

Plantar fasciitis (PF) is mainly a clinical diagnosis characterised
by medial heel pain, which is often worse with the first few steps
in the morning. It is commoner in the obese, in those standing for
prolonged periods at work, and in those whose jobs involve walking
on hard surfaces [1,2]. It remains the commonest cause of plantar
heel pain [3].
The diagnosis is mainly based on the patients’ history and clin-
ical findings. Further investigations are seldom required [4], but
may be necessary to rule out other underlying pathologies such as
nerve entrapment, stress fracture, tumour or infection and systemic
underlying conditions such as rheumatoid arthritis, and some sero-
negative spondyloarthropathies such as ankylosing spondylitis and
Reiter syndrome.
In over 80% of cases, symptoms can be resolved with simple non-
operative measures of eccentric stretching exercises to the Achilles
tendon and plantar fascia, cushioned insoles or orthotics to correct
∗ Corresponding author at: 26, Dobson Close, Wrightington, West Lancs WN6 9ES,
United Kingdom. Tel.: +44 7758639749.
E-mail address: drvjeet@yahoo.com (V. Kumar).
of simple analgesics [5].
In the minority of patients who develop intractable plantar fasci-
itis, other options available include cortico-steroid injections and
extracorporeal shock wave therapy [6]. Surgical release of the fas-
cia can also be considered, but results have been variable in efficacy
[7,8].
Biologic treatments such as platelet-rich plasma (PRP) have
started to gain popularity in recent years, for a wide variety of
orthopaedic conditions, though as yet there are few robust trials [9].
PRP is derived by centrifuging whole blood and has a platelet con-
centration higher than that of whole blood. These platelets produce
granules that release growth factors that initiate and promote nat-
ural tissue healing. Studies of its use in chronic lateral epicondylitis
of the elbow show some encouraging results [10–12]. Other stud-
ies have looked at its use in augmentation of operative repair of the
Achilles tendon [13], and use in the treatment of chronic patellar
tendinopathy [14].
The underlying condition that causes plantar fasciopathy is a
degenerative tissue condition that occurs near the site of the origin
of the plantar fascia at the medial tuberosity of the calcaneus.
There are very few reports in the orthopaedic literature on the
efficacy of PRP in the treatment of chronic plantar fasciitis. Barrett
and Erredge [15] only reported a study of 9 patients, documenting

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 V. Kumar et al. / The Foot 23 (2013) 74–77 75

a significant improvement in symptoms, which was maintained 3.2. Assessment measures

at one year’s follow up. Scioli [16] reported a study of 30 patients
with an apparent 93% efficacy. Table 1 summarises the scores obtained from the RM instru-
ment, the VAS for pain, and the AOFAS ankle and hindfoot score.
The RM instrument showed a lower score at both follow-up
points compared to pre-injection scores, indicating an improve-
2. Patients and methods
ment in the patients. The main effect across these three
measurement points was highly significant (2 [2,N = 46] = 55.635,
Patients presenting to the Wrightington Hospital with
p < 0.001). The pre-injection ratings were significantly higher than
intractable plantar fasciitis, which had not responded to cush-
ratings at both the 3 month follow up (T = 1, p < 0.001, two tailed)
ioned insoles, a full course of eccentric stretching exercises and
and the 6 month follow up (T = 0, p < 0.001, two-tailed).
at least one previous cortico-steroid injection, were offered PRP
VAS scores were lower at both follow-up points than the pre-
injection therapy. All patients had symptoms for at least 12
injection scores, showing less pain being reported by patients. The
months. In addition to pre-operative assessment, patients were
main effect across these three measurement points was highly sig-
reviewed in the Foot and Ankle clinic at three and six months
nificant (2 [2,N = 46] = 46.177, p < 0.001). The pre-injection ratings
following injection. Data was collected prospectively on the
were significantly higher than ratings at both the 3 month follow
cohort.
up (T = 3, p < 0.001, two tailed) and the 6 month follow up (T = 2,
All patients were assessed with the Roles–Maudsley (RM) Score,
p < 0.001, two-tailed).
the Visual Analogue Score for pain and the American Orthopaedic
The increase in AOFAS ratings across the three measurement
Foot and Ankle Society (AOFAS) Ankle and Hindfoot score. Patients
points showed an improvement in the condition of patients. As
were asked at the six month review whether they would have the
sphericity could not be assumed for the within-participants ANOVA
procedure again. Complications of the procedure were also docu-
(Mauchley’s W = .505, approximate 2 [2] = 29.349, p < 0.001), the
mented.
Greenhouse–Geisser F value was taken. This showed a highly sig-
Platelet-rich plasma was harvested with the use of GPSIII system
nificant main effect across the three measurement points (F (1.338,
(Biomet Biologics, Warsaw, IN). Twenty-seven millilitres (ml) of
58.876) = 36.982, p < 0.001, 2p = .457). The post hoc comparisons
blood was withdrawn from the patient and added to 3 ml of sodium
showed that the pre-injection ratings were significantly lower than
citrate (anticoagulant). This was placed in the centrifuge machine
ratings at both the 3 month follow up (p < 0.001, two tailed) and the
and spun for 15 min at 3200 revolutions per minute. The plasma
6 month follow up (p < 0.001, two-tailed), respectively.
portion of the centrifuged mixture was discarded. Since the antico-
Patients were asked at the six month stage whether or not
agulant introduced to the whole blood used to produce the platelet
they would have the procedure again. 28 patients (64%) were very
concentrate is acidic, the PRP portion harvested is buffered with
satisfied with the clinical improvement and would have the injec-
8.4% sodium bicarbonate, to increase the pH back to normal physio-
tion again. 3 patients had bilateral simultaneous injections, which
logical levels. From the initial 27 ml blood harvest, between 2.5 and
unfortunately did not seem to work, and this technique was there-
3.5 ml of buffered PRP was obtained. This was injected under aseptic
fore abandoned during the study period. 3 further patients who
technique in theatre, directly into the area of maximal tenderness
had bilateral injections, performed on separate occasions, reported
at the heel, via a peppering technique (single skin entry, partially
good results and would have the injection again.
withdrawing the needle, redirecting and making multiple pene-
Twenty-two patients (50%) were found to have complete or
trations to the fascia). Three patients who underwent a bilateral
almost complete resolution of symptoms (AOFAS 90 and above),
injection at the same sitting, the volume was divided between the
and a further 8 patients (18%) had an AOFAS score above 80. All
two heels. All patients were advised to continue with their eccen-
of these patients attributed their improvement to the PRP injec-
tric stretching programme and the cushioned insoles following the
tion. One patient was found to have tarsal tunnel syndrome, which
injection.
improved following surgical decompression.
As an analytic strategy, data from the RM and VAS were analysed
using the nonparametric Friedman test, followed by comparisons
in which pre-injection scores were tested against the 3 month and
4. Discussion
6 month scores, respectively, using the Wilcoxon signed ranks test
evaluated as two-tailed against a Bonferroni adjusted alpha level
Patients presenting to the Foot and Ankle clinic with intractable
(˛ ) of p ≤ 0.025. AOFAS data were treated as objective clinician
plantar fasciitis present a particular challenge. It can be a chronic
ratings, and were analysed using within-participants ANOVA, with
debilitating condition, and may not respond to traditional meth-
post hoc pairwise comparisons for the pre-injection scores versus
ods of treatment [17,18]. These newer biologic treatments aim to
the 3 month and 6 month scores, respectively. These comparisons
initiate and promote natural healing and allow for direct repair of
were evaluated as two-tailed against a Bonferroni adjusted alpha
the damaged tissue, without the attendant risks of surgery. Studies
level (˛ ) of p ≤ 0.025.
suggest the Biomet Biologics GPS III system gives a four to five fold
concentrate platelets over patients own blood [19]. Growth factors
and cytokines have essential roles in regulating the mechanisms
3. Results and pathways that govern wound healing and tissue formation.
As platelets contain granules and growth factors, predominantly
3.1. Demographics platelet derived growth factor (PDGF), transforming growth fac-
tor beta (TGFbeta), vascular endothelial growth factor (VEGF) and
Data was available on fifty heels (44 patients). Six of the patients epithelial growth factor (EGF), which promote and initiate a heal-
had bilateral injections – three of these were performed at the same ing response, it is hypothesised that by concentrating them, and
sitting, with the other three patients having the injections per- injecting them focally to the site of diseased tissue, it will initiate
formed on separate occasions. There were 15 male patients and 29 and stimulate a natural healing response.
female patients with a mean age of 51 years (range 25–79). The left This is one of the largest studies to date looking at the efficacy
side was injected in 18 patients, the right side in 20, and bilateral of treatment of PRP in plantar fasciopathy. Barrett and Erredge [15]
injection in 6 patients. reported only on 9 patients, suggesting positive results. Scioli [16]
76 V. Kumar et al. / The Foot 23 (2013) 74–77
Table 1
Summary of the assessment of scores.
Measure Pre-injection 3 months follow up
Mean or median Measure of spread Mean or median
Roles–Maudsley Median = 4 Inter-quartile range = 0.0 Median = 2
Visual Analogue Mean = 7.7 SD = 1.4 Mean = 4.6
Scale (VAS)
AOFAS Mean = 60.6 SD = 13.1 Mean = 78.8
has recently reported on 30 patients using the Harvest SmartPReP
system (Harvest Technologies, Plymouth, MA), reporting ‘benefit’
in all but 2 patients, but did not include what validated assess-
ment scores and outcome measures were actually used in the study.
Ragab and Othman [20] reported on 25 patients with an 88% satis-
faction rate. They used visual analogue scores, overall satisfaction,
and reduction in ultrasonographic plantar fascial thickness as out-
come measures. Our study reports on 50 patients. We found this
procedure to be well tolerated by patients. We did not utilise local
anaesthetic, and the injections were performed by injecting directly
into the area of maximal tenderness. Whilst we did not use ultra-
sound (USS) guidance for the injection, we accept arguably this may
allow for a more accurate placement of the PRP, and could be con-
sidered. This may be perceived as a shortcoming of the study, but a
RCT by Kane et al. [21] showed no advantage of USS guidance over
direct palpation guidance of the most tender area, when steroid
was injected for plantar fasciitis.
This was a safe procedure with no reported complications in
our patients on review. All patients who improved felt that this
was directly related to the PRP injection, although all patients were
also encouraged to continue with the gel heel cups and stretching
exercises. Improvement was noted within the first three months
from the injection. There was no further significant improvement
in symptoms between three and six months, but equally no deteri-
oration or relapse, with efficacy maintained for the full six months
of the study duration.
We found that the 3 patients who underwent bilateral PF injec-
tions at the same sitting did not improve. This may have been
related to the reduced volume of PRP that was injected into each
heel (only 1.5 ml to each heel). Subsequent bilateral injections have
been performed at separate intervals, and the full amount of PRP
(3 ml) has been injected into each heel, with success.
One patient was found to have tarsal tunnel syndrome and this
improved following surgical decompression. In intractable cases, it
is important to rule out other conditions which can mimic plantar
fasciitis, such as tarsal tunnel syndrome and stress fractures. Addi-
tional investigations may be warranted such as MRI scanning or
nerve conduction testing.
The authors recognise the failings in this study, particularly in
view of the fact it has no control arm. However the authors feel
these results show some promise for a new technique, which now
warrants further study and investigation with a randomised con-
trolled trial.
5. Conclusions
These results would indicate that PRP injection may have a role
to play in the management of chronic intractable plantar fasci-
itis, the authors finding the technique’s efficacy in such cases, to
approach 2 out of every 3. It seems a safe clinical procedure – indeed
we had no reported side effects. We await a larger data set, and will
follow these patients up in the long-term. We believe that these
initial encouraging results now warrant further investigation, in
particular with the use of a prospective randomised controlled trial
(RCT).
6 months follow up
Measure of spread Mean or median Measure of spread
Inter-quartile range = 2.0 Median = 2 Inter-quartile range = 1.0
SD = 3.0 Mean = 4.2 SD = 3.2
SD = 16.4 Mean = 81.9 SD = 16.6
Authors’ contribution
We confirm and declare that all the authors have made sub-
stantial contributions and were fully involved in the preparation of
manuscript and the final version of the article to be submitted.
Conflict of interest
There are no competing interests in the undertaking of this
research. Each author certifies that he or she has no commercial
associations that might pose a conflict of interest in connection
with the submitted article.
Acknowledgements
We would like to thank Dr. A.F. Helyar for her assistance with
the preparation of the manuscript. We declare that we have not
received any funding or grants for this research work.
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