EXPERT VIEW/REVIEW PAPER | https://doi.org/10.5005/jp-journals-10040-1143 |
Plantar Fasciitis: Orthobiologics
1,2Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
3Department for Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London, UK
Corresponding Author: Nicola Maffulli, Department for Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London, UK, Phone: +44 20 8567 7553, e-mail: n.maffulli@qmul.ac.uk
How to cite this article Tarulli FR, Aletto C, Maffulli N. Plantar Fasciitis: Orthobiologics. J Foot Ankle Surg (Asia Pacific) 2021;8(1):24–27.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Plantar fasciitis (PF) is characterized by plantar medial heel pain, usually present in the morning at the first few steps. Obese individuals, who stand for prolonged periods and who walk on hard surfaces, typically suffer from PF, the most common cause of plantar heel pain in adults. The diagnosis can be achieved through patient clinical history and clinical findings. Stretching exercises, activity modification, and use of several analgesics resolve symptoms in over 80% of patients, while biomechanical factors can be corrected by insoles or various kinds of orthotics or night splints. In the outnumbered group of patients who develop intractable PF, other available strategies are extracorporeal shock wave therapy and corticosteroid injections. Surgical management of PF consists of plantar fascia release, but efficacy is still debated. In recent years, biological treatments have been getting popularity in many orthopedic conditions.
Keywords: Biologics treatment, Bone marrow aspirate concentrate, Plantar heel pain.
BACKGROUND
Plantar fasciitis (PF) is usually solved with conservative treatment, but some cases are challenging to manage. New biological therapies have been suggested for multiple soft tissue problems and are gradually gaining the interest of scientific world in this condition as well.
PLATELET-RICH PLASMA
Platelet-rich plasma (PRP) is a device used for several chronic degenerative soft-tissue conditions, including PF. To prepare PRP, patient’s own blood is centrifuged to obtain an increased platelet concentration. Platelet alpha-granules contain growth factors and mediators [vascular endothelial growth factor (VEGF), transforming growth factor-beta 1 (TGF-β1), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), insulin-like growth factor 1 (IGF-1)], which are concentrated through a single- or double-centrifugation process. Supraphysiological amounts of these cytokines and growth factors are injected to injury site and promote the physiological healing process.1–10 Platelet-rich plasma is postulated to promote native tissue regeneration.11
Platelet-rich plasma injection efficacy in the management of chronic PF has been evaluated in several randomized controlled trials. Platelet-rich plasma is not associated with the complications of corticosteroid injections, such as, plantar fascia rupture or fat pad atrophy.12
Platelet-rich plasma injections were compared to corticosteroid injections by two recent meta-analyzes, they conclude that PRP injections were a valid alternative to corticosteroid injections with some studies demonstrating superiority of PRP.13–15
Ragab and Othman assessed 25 patients managed with a single injection of PRP. The average visual analog scale (VAS) pain decreased from 9.1 to 2.1 after 1 year postintervention.16
After 1 year, a marked improvement in terms of VAS after PRP injection (from 7.1 ± 1.1 to 1.9 ± 1.5) was reported in a prospective uncontrolled study by Martinelli et al.17 (Table 1).
Sami et al. evaluated the use of PRP injections under ultrasonography guidance to physiotherapy. They prospectively recruited patients suffering from chronic PF and divided them into two treatment groups (PRP group vs physiotherapy group). All patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score before and after treatment. The AOFAS score improved significantly in the PRP group. Ultrasonography was performed before and 4 weeks after treatment, fascial echogenicity was significantly changed in most of the patients after PRP injection, and fascial thickness was statistically decreased in the PRP group compared to the physiotherapy group.18
A comprehensive systematic review analyzed the use of PRP in the treatment of PF.19 Most the studies analyzed mentioned a significantly larger improvement in symptoms between the first visit and the last follow-up evaluation.
| References | Success definition | Success rate (%) |
|---|---|---|
| Kumar et al. (2013)20 | Patients’ satisfaction at the question “would have the procedure again” | 64 |
| Martinelli et al. (2013)17 | ReM excellent and good | 78.6 |
| Ragab and Othman (2012)16 | Satisfaction at patient’s questionnaire | 88 |
| Aksahin et al. (2012)21 | ReM excellent and good | 33.3 |
Platelet-rich plasma injections are an effective option to decrease pain and enhance function in chronic PF and may be safer and more efficient than corticosteroid injections.16
Corticosteroid vs Platelet-rich Plasma
Different studies analyzed the use of corticosteroids injections vs PRP in patients with PF using functional evaluation and pain scales.
Monto recruited 40 individuals with chronic unilateral PF who had failed traditional conservative treatment. They were randomized into two groups:14 Group I was managed with only ultrasound-guided injection of 40 mg DepoMedrol (methylprednisolone), and group II with one ultrasound-guided injection of autologous PRP.
Average AOFAS score before treatment was 52 in the cortisone group, improving to 81 at 3 months posttreatment and decreasing to 74 at 6 months, at 12 months it dropped to 58 and persisted to decay to a final score of 56 at 24 months. Conversely, average AOFAS score was 37 in the PRP group before treatment and raised to 95 at 3 months, remaining elevated at 94 at 6 and 12 months, and reaching a final score of 92 at 24 months.
In patients with severe chronic PF who have not obtained the wished result to traditional conservative management, PRP is able to provide successful benefits in the long-term, being more efficacious than corticosteroid injections, and appearing safer than surgical alternatives.22
In the controlled, randomized, blinded clinical study by Acosta-Olivo et al.,23 patients were randomized into two groups. Administration of dexamethasone 8 mg plus 2 mL of lidocaine was adopted in the steroid treatment group, while 3 mL of PRP activated with 0.45 mL of 10% calcium gluconate was used in the PRP treatment group. The VAS, Foot and Ankle Disability Index (FADI), and AOFAS scale were proposed to all patients at the beginning of the study, and at 2, 4, 8, 12, and 16 weeks posttreatment.
Platelet-rich plasma was a valid strategy when patients with PF failed to respond to nonoperative treatment. The PRP efficiency was comparable to that of steroids injections, without complications associated with steroid use. On the contrary, there are some disadvantages: PRP is more costly than steroids; the process to obtain PRP is time expensive for patients and physicians. In addition, PRP reduces inflammation and promotes the regeneration of damaged tissue, especially soft tissues, in particular muscles and tendons, thanks to its regenerative proprieties.
In conclusion, the use of PRP seems more efficacious than corticosteroid injections.
Prolotherapy
Prolotherapy is an injection-based treatment used in chronic musculoskeletal conditions, such as, PF. In this procedure, a natural irritant (such as, hyperosmolar dextrose) is injected into the soft tissues of the plantar fascia to cause the osmotic rupture of local cells and trigger a healing response. Prolotherapy injections can be effective in patients with chronic PF.24–26 The efficacy of a prolotherapy injection is superior to that of corticosteroids, as it allows tissue healing similar to PRP.27 Prolotherapy injections are simpler to prepare than PRP, noninvasive, and more cost-effective.28 This procedure is considered safe and efficacious, with only minor reported adverse effects mainly pain or discomfort at the site of injections.29 Uğurlar et al. compared the use of extracorporeal shock wave therapy (ESWT) to corticosteroids, PRP, and prolotherapy injections for the treatment of PF through a randomized controlled prospective clinical trial. The VAS and Revised Foot Function Index were used to evaluate the clinical outcomes. The corticosteroid injection reduced foot pain in the first 3 months, while ESWT had similar results in the first 6 months. The result of prolotherapy and PRP was seen during the follow-up period, while the corticosteroid injection lost its effectiveness. Nevertheless, at the 36-month follow-up point, no significant difference was noted in terms of VAS and Revised Foot Function Index score among the four treatments.30
Bone Marrow Aspirate Concentrate
One promising new non-surgical treatment is bone marrow concentrate (BMC) or bone marrow aspirate concentrate (BMAC) therapy.31 Bone marrow aspirate concentrate is obtained by centrifugation of autologous bone marrow aspiration. Bone marrow aspirate concentrate is composed of a concentration of mesenchymal stem cells (MSCs), white blood cells, hematopoietic stem cells (HSCs), growth factors, and platelets.32 After centrifugation, the percentage of MSCs in BMAC varies from 0.001 to 0.01% of mononuclear cells. However, growth factors, including PDGF, transforming growth factor-beta (TGF-b), bone morphogenetic protein (BMP)-2, and BMP-7 with their anabolic and anti-inflammatory effects, can be found in BMAC.33
Recently, there has been much curiosity in the use of BMAC in orthopedic field. Much of the focus on the benefits of BMAC in musculoskeletal ailments is on the potential of MSCs to differentiate into various cells and tissues originated from mesenchymal cells.34,35 Inflammatory process, mechanical stress, degenerative changes, and disorganized healing are all mechanisms of tendon injury. Bone marrow aspirate concentrate promotes tenocyte proliferation to enhance the recovery and healing of injured tendons.
Many theories have been suggested to understand the cellular healing promoted by BMAC: Cells contained in BMAC modulate the healing process of pathological tendons controlling inflammation, recruiting other cells, such as, tenocytes and MSCs, to ensure regeneration and reduce fibrosis.36 Courneya et al. showed that IL-4 and IL-13 contained in BMAC stimulate the proliferation of human tenocytes. Vascular endothelial growth factors are also included in BMAC to aid healing.37
CONCLUSION
Conservative treatment is successful in most patients with PF. Physicians need to bear in mind that early diagnosis and management usually lead to a shorter treatment as well as increased chance of success with conservative measures.
Strengthening and stretching programs play a key role in the management of PF, and must be recommended in addition to biological treatments.
The current widespread use of corticosteroids must be discouraged because of the adverse reactions and the limitation of their prolonged use.
Biological treatments are becoming a viable management option because of their low risks for the patient, and their sustainability. In addition, less known types of injections are becoming more fashionable, such as, botulinum toxin-A injections, providing significant pain relief.38,39
In some cases, after 6 or more months of conservative treatment, it is necessary to try more invasive options. Surgical release of the plantar fascia is an available option when biological measures are not effective, but it is destined to a small proportion of patients. New techniques, such as, endoscopic plantar release, may play a role.
Usually, PF is a self-limiting condition, but time until resolution ranges from 6 to 18 months, leading to frustration for patients and physicians.
Patients’ regular activities can be compromised by chronic heel pain; physicians can prevent this condition using the right conservative measures.
Further randomized double-blinded controlled trials need to be undertaken, especially to demonstrate whether in most cases heel pain disappears because of treatment or because of its natural course.
REFERENCES
1. Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop 1965;39(39):178–186. DOI: 10.1097/00003086-196500390-00016.
2. Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003;85(5):872–877. DOI: 10.2106/00004623-200305000-00015.
3. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004;25(5):303–310. DOI: 10.1177/107110070402500505.
4. Levy JC, Mizel MS, Clifford PD, et al. Value of radiographs in the initial evaluation of nontraumatic adult heel pain. Foot Ankle Int 2006;27(6):427–430. DOI: 10.1177/107110070602700607.
5. Position statement: endoscopic and open heel surgery. American Orthopaedic Foot and Ankle Society. 2010.
6. Porter MD, Shadbolt B. Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med Off J Can Acad Sport Med 2005;15(3):119–124. DOI: 10.1097/01.jsm.0000164039.91787.dc.
7. Sammarco GJ, Helfrey RB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int 1996;17(9):520–526. DOI: 10.1177/107110079601700902.
8. Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999;20(12):803–807. DOI: 10.1177/107110079902001209.
9. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med 2008;1(3–4):165–174. DOI: 10.1007/s12178-008-9032-5.
10. Boswell SG, Cole BJ, Sundman EA, et al. Platelet-rich plasma: a milieu of bioactive factors. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2012;28(3):429–439. DOI: 10.1016/j.arthro.2011.10.018.
11. Lee KS, Wilson JJ, Rabago DP, et al. Musculoskeletal applications of platelet-rich plasma: fad or future? AJR Am J Roentgenol 2011;196(3):628–636. DOI: 10.2214/AJR.10.5975.
12. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 2008;16(6):338–346. DOI: 10.5435/00124635-200806000-00006.
13. Mahindra P, Yamin M, Selhi HS, et al. Chronic plantar fasciitis: Effect of platelet-rich plasma, corticosteroid, and placebo. Orthopedics 2016;39(2):e285–e289. DOI: 10.3928/01477447-20160222-01.
14. Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int 2014;35(4):313–318. DOI: 10.1177/1071100713519778.
15. Say F, Gürler D, İnkaya E, et al. Comparison of platelet-rich plasma and steroid injection in the treatment of plantar fasciitis. Acta Orthop Traumatol Turc 2014;48(6):667–672. DOI: 10.3944/AOTT.2014.13.0142.
16. Ragab EMS, Othman AMA. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg 2012;132(8):1065–1070. DOI: 10.1007/s00402-012-1505-8.
17. Martinelli N, Marinozzi A, Carnì S, et al. Platelet-rich plasma injections for chronic plantar fasciitis. Int Orthop 2013;37(5):839–842. DOI: 10.1007/s00264-012-1741-0.
18. Sami M, Nassr MH, Hamdy M, et al. Preliminary study reveals the efficiency of platelet rich plasma injection over physiotherapy for chronic plantar fasciitis treatment. Int J Clin Rheumatol 2019;14(3):120–126. Available at:https://www.openaccessjournals.com/abstract/preliminary-study-reveals-the-efficiency-of-platelet-rich-plasma-injection-over-physiotherapy-for-chronic-plantar-fascii-13022.html.
19. Franceschi F, Papalia R, Franceschetti E, et al. Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull 2014;112(1):83–95. DOI: 10.1093/bmb/ldu025.
20. Kumar V, Millar T, Murphy PN, et al. The treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot (Edinb) 2013;23(2–3):74–77. DOI: 10.1016/j.foot.2013.06.002 .Epub 2013 Jul 30. PMID: 23906977.
21. Akşahin E, Doğruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012;132(6):781–785. DOI: 10.1007/s00402-012-1488-5 .Epub 2012 Mar 8. PMID: 22399039.
22. Tabrizi A, Dindarian S, Mohammadi S. The effect of corticosteroid local injection versus platelet-rich plasma for the treatment of plantar fasciitis in obese patients: a single-blind, Randomized Clinical Trial. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg 2020;59(1):64–68. DOI: 10.1053/j.jfas.2019.07.004.
23. Acosta-Olivo C, Elizondo-Rodriguez J, Lopez-Cavazos R, et al. Plantar Fasciitis-A comparison of treatment with intralesional steroids versus platelet-rich plasma. A randomized, blinded study. J Am Podiatr Med Assoc 2017;107(6):490–496. DOI: 10.7547/15-125.
24. Ryan MB, Wong AD, Gillies JH, et al. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med 2009;43(4):303–306. DOI: 10.1136/bjsm.2008.050021.
25. Chen C-M, Chen J-S, Tsai W-C, et al. Effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis. Am J Phys Med Rehabil 2013;92(7):597–605. DOI: 10.1097/PHM.0b013e318278a831.
26. Ersen Ö, Koca K, Akpancar S, et al. A randomized-controlled trial of prolotherapy injections in the treatment of plantar fasciitis. Turk J Phys Med Rehabil 2018;64(1):59–65. DOI: 10.5606/tftrd.2018.944.
27. Seven M, Koca K, Akpancar S, et al. Prolotherapy injections in the treatment of overuse injuries. Balk Mil Med Rev 2016;19(3):1. DOI: 10.5455/bmmr.227853.
28. Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Prim Care 2010;37(1):65–80. DOI: 10.1016/j.pop.2009.09.013.
29. Dorman TA. Prolotherapy: a survey. J Orthop Med 1993;15(2):49–50. DOI: 10.1080/1355297X.1993.11719720.
30. Uğurlar M, Sönmez MM, Uğurlar ÖY, et al. Effectiveness of four different treatment modalities in the treatment of chronic plantar fasciitis during a 36-month follow-up period: a randomized controlled trial. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg 2018;57(5):913–918. DOI: 10.1053/j.jfas.2018.03.017.
31. Harford JS, Dekker TJ, Adams SB. Bone marrow aspirate concentrate for bone healing in foot and ankle surgery. Foot Ankle Clin 2016;21(4):839–845. DOI: 10.1016/j.fcl.2016.07.005.
32. Cavinatto L, Hinckel BB, Tomlinson RE, et al. The role of bone marrow aspirate concentrate for the treatment of focal chondral lesions of the knee: a systematic review and critical analysis of animal and clinical studies. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2019;35(6):1860–1877. DOI: 10.1016/j.arthro.2018.11.073.
33. Chahla J, Dean CS, Moatshe G, et al. Concentrated bone marrow aspirate for the treatment of chondral injuries and osteoarthritis of the knee: a systematic review of outcomes. Orthop J Sports Med 2016;4(1). DOI: 10.1177/23259671156254812325967115625481.
34. Dominici M, Le Blanc K, Mueller I, et al. Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy 2006;8(4):315–317. DOI: 10.1080/14653240600855905.
35. Pittenger MF, Mackay AM, Beck SC, et al. Multilineage potential of adult human mesenchymal stem cells. Science 1999;284(5411):143–147. DOI: 10.1126/science.284.5411.143.
36. Cottom JM, Plemmons BS. Bone marrow aspirate concentrate and its uses in the foot and ankle. Clin Podiatr Med Surg 2018;35(1):19–26. DOI: 10.1016/j.cpm.2017.08.006.
37. Courneya J-P, Luzina IG, Zeller CB, et al. Interleukins 4 and 13 modulate gene expression and promote proliferation of primary human tenocytes. Fibrogenesis Tissue Repair 2010;3(1):9. DOI: 10.1186/1755-1536-3-9.
38. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int 2017;38(1):1–7. DOI: 10.1177/1071100716666364.
39. Tsikopoulos K, Vasiliadis HS, Mavridis D. Injection therapies for plantar fasciopathy (‘plantar fasciitis’): a systematic review and network meta-analysis of 22 randomised controlled trials. Br J Sports Med 2016;50(22):1367–1375. DOI: 10.1136/bjsports-2015-095437.
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