|Year : 2021 | Volume
| Issue : 1 | Page : 41-46
Role of platelet-rich plasma in painful early osteoarthritis knee and plantar Fasciitis: A prospective study
Karuna Shankar Dinkar1, Rajat Kapoor1, Vikas Kumar Mishra2, Chandra Prakash Pal1, Mohit Sharma3, Rohit Yadav1
1 Department of Orthopaedics, S. N. Medical College, Agra, Uttar Pradesh, India
2 Department of Orthopaedics, Autonomous State Medical College, Bahraich, India
3 Department of Orthopaedics, Saraswati Medical College, Unnao, Uttar Pradesh, India
|Date of Submission||10-May-2020|
|Date of Acceptance||11-Apr-2021|
|Date of Web Publication||16-Jun-2021|
Dr. Rohit Yadav
Department of Orthopaedics, S.N. Medical College, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Plantar fasciitis and early osteoarthritis knee are the most common painful orthopedic conditions treated by orthopedic practitioners. This study is to assess the role of platelet-rich plasma (PRP) injection in the treatment of plantar fasciitis and early osteoarthritis knee. Aims and Objectives: To access the role of platelet-rich plasma in plantar fasciitis and early osteoarthritis knee. Materials and Methods: A prospective interventional study was conducted at our center between January 2016 to March 2017. Patients included were complaining of pain in knee for 3 months, Grade 1 to Grade 2 osteoarthritis, presenting with complaints of plantar heel pain, tenderness at the attachment of the plantar fascia. The details of the clinical assessment filled and baseline WOMAC score for osteoarthritis knee and analog pain scale for plantar fasciitis was recorded. We explained the procedure to the patients and informed consent were taken. 4 ml of PRP was injected in either condition. Patients were followed up for 6 months at 1, 2, 3, 4, 5, and 6 months. Visual analog scale (VAS) for the assessment of pain in plantar fasciitis and WOMAC score for early osteoarthritis knee was recorded for all patients at the last visit and compared. Results: In 15 patients with osteoarthritis of knee, the mean score for preinjection baseline was 29.4 ± 5.80, which showed improvement by 27% from baseline during the 1st month with a mean of 21.4S7 ± 5.475 and during 6th month with a mean of 22.47 ± 9.516 but it never reverted to baseline pre injection value. In 30 patients with plantar fasciitis, the results are statistically significant (P ≤ 0.05), and all the patients responded to the treatment. VAS score is statistically significant in comparison with baseline at all duration. Conclusion: In our study, PRP is significantly effective in reducing pain in early osteoarthritis knee and plantar fasciitis.
Keywords: Osteoarthritis knee, plantar fasciitis, platelet-rich plasma
|How to cite this article:|
Dinkar KS, Kapoor R, Mishra VK, Pal CP, Sharma M, Yadav R. Role of platelet-rich plasma in painful early osteoarthritis knee and plantar Fasciitis: A prospective study. J Orthop Traumatol Rehabil 2021;13:41-6
|How to cite this URL:|
Dinkar KS, Kapoor R, Mishra VK, Pal CP, Sharma M, Yadav R. Role of platelet-rich plasma in painful early osteoarthritis knee and plantar Fasciitis: A prospective study. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 9];13:41-6. Available from: https://www.jotr.in/text.asp?2021/13/1/41/318407
| Introduction|| |
Plantar fasciitis and early osteoarthritis knee are the most common painful orthopedic conditions treated by orthopedic practitioners.
Plantar fasciitis accounts for 15% of all foot disorders with more than 10% of the population affected by it over their lifetime. It accounts for 7%–14% of sporting injuries and is especially prevalent in sports requiring a push-off motion. Plantar fasciitis is also popular as painful heel syndrome and occurs in both males and females with a higher predominance in young male athletes and middle-aged obese females. Although etiology of plantar fasciitis remains ill understood, there are evidence to suggest that it is probably initiated by repeated microtrauma. Plantar fasciitis is an inflammatory disorder probably initiated by repeated microtrauma.
Numerous methods have been advocated for treating plantar fasciitis, including rest, NSAIDs, night splints, foot orthosis, stretching protocols, and extracorporeal shock wave therapy and hot and cold fomentation. Steroid injections are a popular method of treating the condition, but only seem to be useful in the short term and only to a small degree. The use of corticosteroids has been linked to rupture of plantar fascia, especially after repeated local injections.,
Platelet-rich plasma is promoted as an ideal autologous biological blood-derived product, which can be exogenously applied to various tissues where it releases high concentrations of platelet-derived growth factors that enhance wound healing, bone healing, and tendon healing. In addition, platelet-rich plasma (PRP) possesses antimicrobial properties that may contribute to the prevention of infections.,, When platelets become activated, growth factors are released and initiate the body's natural healing response. Injection of these platelets in the attachment of the fascia to the os calcis might induce a healing response.
Osteoarthritis is a degenerative disorder of joint, leading to cartilage degeneration. It also has a strong hereditary basis. Osteoarthritis is clinically heterogeneous and poorly understood disease. The current trend of osteoarthritis has been shown to involve patients as early as 40 years of age; in this group, the treatment modalities are further limited.
Most commonly used treatment modalities are nonpharmacological, namely, quadriceps and hamstring strengthening exercises, short-wave diathermy, ultrasound therapy, transcutaneous electrical nerve stimulation, and interferential current therapy. The pharmacological treatment includes NSAIDs and COX-2 inhibitor group of drugs and oral cartilage constituents such as chondroitin and glucosamine (thought to make up for the apparent cartilage loss in affected joints).
One such modality of treatment would be to inject autologous platelet-rich plasma intra-articularly that delivers a large pool of growth factors implicated in tissue repair mechanism. Since PRP has healing properties at the molecular level, it is likely to repair the damaged cartilage and thus delay the need for arthroplasty in near future. In this study, our main aim and objective are to access the role of platelet-rich plasma in plantar fasciitis and early osteoarthritis knee.
| Materials and Methods|| |
This was a prospective interventional study conducted on patients attending the orthopedics outpatient department of SN Medical College, Agra, from January 2016 to March 2017. We included the patients who had osteoarthritis of the knee or plantar fasciitis (diagnosed on the basis of history, clinical and radiological assessment) and were not responding to conservative treatment. The patients were assessed on a number of variables in WOMAC scoring and visual analog scale (VAS) scoring before injection and then monthly for 6 months.
The sample size studied was 45 patients. The patients were selected after going through the inclusion and exclusion criteria mentioned as follows.
- Age: 20–70 years
- Complaining of pain in knee for 3 months
- Grade 1 to Grade 2 osteoarthritis knee as per Kellgren–Lawrence grading system
- Presenting with complaints of plantar heel pain, worse with rising in the morning and/or after periods of sitting or lying presenting for 4 weeks or more
- Examination reveals maximal tenderness at the attachment of the plantar fascia on the medial tubercle of the calcaneus.
- OA secondary to inflammatory arthritis
- Patient having chemical synovitis, e.g., gout and pseudogout
- Metabolic bone disease
- Coexisting lumbar radiculopathy
- Any intra-articular injection in the past
- History of thrombocytopenia and use of anticoagulant therapy. Active infection, tumor, and metastatic disease
- Uncontrolled diabetes mellitus, active peptic ulcer disease, or Cushing syndrome
- Morbid obesity body mass index >35.
A total of 15 patients with osteoarthritis knee and 30 patients with plantar fasciitis were selected on the basis of predefined inclusion and exclusion criteria after informed consent. The details of clinical assessment were filled and baseline WOMAC score was recorded for osteoarthritis knee and analog pain scale for plantar fasciitis. Informed consent was taken and the procedure was explained to the patient.
- 15–20 ml of blood was withdrawn from all patients under all aseptic precautions [Figure 1] and would be transferred in sterile acid citrate dextrose (ACD) vacutainer tubes and mixed well by gently moving the tubes upside down a few minutes [Figure 2]
- The blood was centrifuged at 3500 rpm for 9 min, which then got separated into layers of RBCs, buffy coat containing leukocytes, platelet-rich plasma just above it, and platelet-poor plasma from downward above [Figure 3]
- PRP was extracted from ACD vacutainer for injection [Figure 4]
- A fraction of the PRP sample along with the patient's unprocessed blood was analyzed for platelet count assessment and a small sample is sent for culture sensitivity.
- Injection technique for osteoarthritis knee [Figure 5]. The patients were made to lie down in the OT environment in the supine position with knee exposed. Under all aseptic precautions 4 ml of platelet-rich plasma injected by passing under the patella from the superolateral corner using a 23–24 G long needle and then made to flex and extend a few times. After 15 min of observation, the patients were discharged.
- Injection technique for plantar fasciitis [Figure 6]. The procedure was done on an outpatient basis and under complete aseptic conditions. Sites of maximum tenderness were premarked with a sterile marker. Patients received a 4 ml of PRP injection (consisting of their own PRP) into the origin of the plantar fascia and site of maximum tenderness. 2 ml of 2% lidocaine was infiltrated prior to injection. A peppering technique, i.e., spreading in a clockwise manner, was used to achieve a more expansive zone of delivery, with a single skin portal and 4–5 passes through the fascia.
|Figure 2: Sample collected and transferred to sterile acid citrate dextrose vial|
Click here to view
|Figure 4: Platelet-rich plasma separated and withdrawn into sterile syringe|
Click here to view
|Figure 5: Injecting platelet-rich plasma taking aseptic precaution in OA knee|
Click here to view
|Figure 6: Injecting platelet-rich plasma taking aseptic precaution in planter fasciitis|
Click here to view
| Observation and Results|| |
The mean age of patients was 52.33 ± 10.356 years. Age distribution was in the range of 40–72 years with maximum patients in the 45–60 years of age group. Sex distribution in the study was 6 males and 9 females in a group of 15 patients. On analysis of symptoms, it was noted that there was a significant change from baseline value preinjection during the 1st month of injection which is statistically significant (0.008) and then it continued the same pattern up to 3 months which is statistically significant (0.008) followed by deterioration at the 4th month which is also statistically significant (0.014) with again and improvement in the 5th month followed by a statistically significant (0.014) deterioration at 6 months [Table 1]. Trend of symptom score is shown in [Figure 7]. Normal or minimum value of this score is 8, so the lesser the score the patient would be having near normal value.
The total score showed an improvement in the 1st month from the baseline value (preinjection value) which was statistically significant. There was a further improvement in the 2nd and 3rd month followed by deterioration for the next 3 months but never reached the preinjection values [Table 2]. Trend is depicted in Line diagram below [Figure 8].
Plantar fasciitis group
The mean age of patients was 40.90 ± 9.362 years with a minimum age of 24 and a maximum age of 57 years [Table 3] and [Figure 9]. 11 (36.66%) patients were male and 19 (63.34%) were female. We followed every patient for a period of 6 months after giving the injection and used VAS score to evaluate the effect of PRP in plantar fasciitis. When we calculated the difference between mean VAS score in pretreatment period, i.e., baseline and mean VAS scores at different intervals in postinjection period, it was found that in the PRP group, difference was maximum at 24 weeks. This shows that maximum effect of PRP on VAS was at 24 weeks. For within-group comparison in the PRP group, the results were statistically significant (P ≤ 0.05). The mean VAS score decreased from baseline continuously at 4 weeks, 8 weeks, 12 weeks, 16 weeks, and up to 24 weeks [Table 4]. VAS score was statistically significant in comparison with baseline at all durations [Figure 10].
|Table 4: Comparison of mean visual analog score from baseline to visual analog score at frequent intervals|
Click here to view
|Figure 10: Comparison of mean Visual analog scale score from baseline to visual analog scale score at frequent intervals (mean difference in visual analog scale score)|
Click here to view
However, direct comparison with our study is difficult because of less sample size, shorter duration of follow-up, single injection, and different methodology.
| Discussion|| |
Osteoarthritis refers to a heterogeneous group of joint disorders characterized by symptoms of pain and stiffness. It is characterized by progressive deterioration and loss of articular cartilage and by reactive bone changes at the margins of the joints and in the subchondral bone. Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints. It is characterized by joint pain and limited function of the joint. In a synovial joint, several structures can cause these clinical symptoms. Diagnosis of this disease is mainly clinical and is diagnosed through the American College of Rheumatology Criteria and is aided by radiological Kellgren–Lawrence grading of OA knee. The disease is characterized by two main features:
- Progressive damage of articular cartilage
- Bone remodeling or new bone formation (osteophytes and subchondral bone sclerosis).
Use of autologous blood products (rich in cellular and hormonal mediators) favor tissue healing in a variety of applications in one such therapy. The rationale is based on the activity of blood growth factors. The growth factors are a diverse group of polypeptides that have an important role in the regulation of growth and tissue development, determining the behavior of all cells, including chondrocytes. In the past decade, several crucial roles of growth factors have been identified in tissue repair. Blood-derived growth factors delivered form of autologous blood or platelet-rich plasma have been already studied for the potential of tissue healing and documented in the literature. Khoshbin et al. did a systematic review to evaluate the clinical efficacy of PRP versus a control injection for knee OA and found that as compared with HA injection, multiple sequential intra-articular PRP injections may have beneficial effects in the treatment of adult patients with mild to moderate knee OA at approximately 6 months.
The case series reporting the longest follow-up period was conducted by Filardo et al. (2012) on 91 patients who received three injections of PRP given at 3 weekly intervals (2nd and 3rd injections used frozen PRP). A decrease in pain and an increase in function scores were reported after 12 months when compared to baseline. Results at 24 months were still significantly improved over baseline, but had begun to approach baseline levels.
The case series by Wang-Saegusa et al. described the results of 261 patients injected three times with PRP at 2-week intervals. At 6-month follow-up, clinically significant improvements in WOMAC, quality of life (SF36), and functional scores were reported when compared to baseline values, with no adverse events described.
| Conclusion|| |
- The result of our study supports the effectiveness of PRP injection for relieving pain and improving knee function in OA knee
- Improvement in symptoms was noted by 1 month after PRP injection which continued to improve over next 2 months followed by some recurrence or worsening till 6 months but never reached the preinjection level
- Some improvements persisted till 6 months after PRP injection
- No local or systemic complications were reported with the PRP injection
- Our method of PRP preparation using an in-house centrifugation machine is a cost-effective method of PRP injection preparation in which no special equipment or help of blood bank is required.
Plantar fasciitis group
Plantar fasciitis is the most common cause of heel pain in our study, with the most common affected age group being young male adults and middle-aged females. The mean age of patients was 40 years. It is more common in females; out of total patients, 60% were female. Patients can be diagnosed on the basis of history and clinical and radiological examination.
The mean baseline VAS score was found to be significantly lowered at frequent intervals, i.e., 4 weeks, 8 weeks, 12 weeks, 16 weeks, and 24 weeks in postinjection period. Considering the long-term effectiveness of PRP, we recommend the use of PRP as the preferred treatment for PF.
Thus, it is concluded in the study that PRP is significantly effective in reducing pain in early osteoarthritis knee and plantar fasciitis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barrett SL, Robert OM. Plantar fasciitis and other causes of heel pain. Am Fam Physician 1999;59:2200-6.
Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kotter MW. Conservative treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc. 1998;88:375-80. doi: 10.7547/87507315-88-8-375. PMID: 9735623.
Urovitz EP, Urovitz AB, Urovitz EB. Endoscopic plantar fasciotomy in the treatment of chronic heel pain. Can J Surg 2008;51:281-3.
Tatli YZ, Kapasi S. The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Curr Rev Musculoskelet Med 2009;2:3-9.
Barrett SL, Day SV, Brown MG. Endoscopic plantar fasciotomy: Preliminary study with cadaveric specimens. J Foot Surg 1991;30:170-2.
Mehta V. Platelet-rich plasma: A review of the science and possible clinical applications. Orthopedics 2010;33:111.
Morizaki Y, Zhao C, An KN, Amadio PC. The effects of platelet-rich plasma on bone marrow stromal cell transplants for tendon healing in vitro
. J Hand Surg Am 2010;35:1833-41.
Platelet-rich plasma therapy. Harnessing the healing power of these blood cells is intriguing, but research is lacking. Harv Health Lett 2009;34:6-7.
Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg 2010;18:406-16.
Altman RD, Hochberg M, Murphy WA Jr., Wolfe F, Lequesne M. Atlas of individual radiographic features in osteoarthritis. Osteoarthritis Cartilage 1995;3 Suppl A: 3-70.
Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, et al.
The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: A systematic review with quantitative synthesis. Arthroscopy 2013;29:2037-48.
Filardo G, Kon E, Di Martino A, Di Matteo B, Merli ML, Cenacchi A, et al
. Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: Study design and preliminary results of a randomized controlled trial. BMC Musculoskelet Disord 2012;13:229.
Wang-Saegusa A, Cugat R, Ares O, Seijas R, Cuscó X, Garcia-Balletbó M. Infiltration of plasma rich in growth factors for osteoarthritis of the knee short-term effects on function and quality of life. Arch Orthop Trauma Surg 2011;131:311-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4]