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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 70-74

To evaluate the role of intralesional injection of platelet-rich plasma versus corticosteroid (triamcinolone) in plantar fasciitis


Department of Orthopaedics, MGM Medical College and My Hospital, Indore, Madhya Pradesh, India

Date of Submission20-Feb-2021
Date of Acceptance10-Nov-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Pawan Baghel
Department of Orthopaedics, MGM Medical College and My Hospital, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_9_21

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  Abstract 


Introduction: Plantar fasciitis is an aseptic inflammation of the plantar fascia and also the most common cause of plantar heel pain.Approximately more than 10% of the population is affected by it over their lifetime. Aims and Objectives: The aim of this study is to evaluate the role of platelet-rich plasma (PRP) versus corticosteroid (triamcinolone) therapy in plantar fasciitis and to study the complications associated with both the procedures and their management. Materials and Methods: The study included 36 patients of plantar fasciitis (fulfilling the inclusion criteria) who presented to the OPD/Casualty of Department of Orthopaedics and Traumatology, M.G.M. Medical College and M.Y. Hospital, Indore, between September 2018 and August 2020. The study was a prospective and interventional type. Results: The mean Roles and Maudsley Subjective Pain score (RMSPS) score at pretreatment was 3.72 ± 0.46 for PRP and 3.72 ± 0.46 for steroids; at 1 month, it was 1.61 ± 0.78 for PRP and 1.44 ± 0.70 for steroids; and at 6 months, it was 1.22 ± 0.55 for PRP and 1.94 ± 0.73 for steroids. The mean Visual Analog Scale (VAS) score at pretreatment was 7.72 ± 0.96 for PRP and 7.78 ± 1.0 for steroids; at 1 month, it was 2.89 ± 1.68 for PRP and 2.50 ± 1.47 for steroids; and at 6 months, it was 1.28 ± 1.49 for PRP and 2.61 ± 1.69 for steroids. PRP injections have shown effectiveness in providing pain relief, improving function in plantar fasciitis patients. As a result, VAS and RMSPS score was significantly reduced (P = 0.015) at 6 months as compared to preprocedure and thus proved the effectiveness of the PRP therapy. It also shows that PRP is a better method in reducing pain in plantar fasciitis compared to steroid injection. Conclusion: Our study demonstrates PRP injection to be an effective and well-tolerated alternative to corticosteroid injection in the management of chronic plantar fasciitis with an added advantage of almost no side effects due to its biological nature and better patient compliance.

Keywords: Plantar fasciitis, platelet-rich plasma therapy, RMSPS score


How to cite this article:
Solanki M, Kelkar R, Baghel P. To evaluate the role of intralesional injection of platelet-rich plasma versus corticosteroid (triamcinolone) in plantar fasciitis. J Orthop Traumatol Rehabil 2022;14:70-4

How to cite this URL:
Solanki M, Kelkar R, Baghel P. To evaluate the role of intralesional injection of platelet-rich plasma versus corticosteroid (triamcinolone) in plantar fasciitis. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 27];14:70-4. Available from: https://www.jotr.in/text.asp?2022/14/1/70/347377




  Introduction Top


Plantar fasciitis is an aseptic inflammation of the plantar fascia and also the most common cause of plantar heel pain.[1] Many times it is thought as an inflammatory process but mostly plantar fasciitis is a disorder of degenerative changes in the fascia, and may be more accurately termed as plantar fasciosis.[2] It accounts for almost 15% of all foot disorders. Approximately more than 10% of the population is affected by it over their lifetime.[3] Although precise etiology of plantar fasciitis remains ill understood, there is evidence to suggest that it is probably initiated by recurrent microtrauma and also the pathological changes are degenerative in nature[4] (although partially reversible) and histologically changes, such as collagen necrosis, angiofibroblastic hyperplasia, and matrix calcification, are seen. Most commonly, patients come with a complaint of insidious onset sharp pain with maximal tenderness at the anterior medial border of the calcaneus, which is generally worst on the first few steps in the morning and with initial steps after prolonged sitting or inactivity,[5] and on examination, there is mild-to-severe tenderness on the medial aspect of the heel. Many methods are already tried for treating plantar fasciitis, including rest, night splints, nonsteroidal anti-inflammatory drugs (NSAIDs), foot orthosis, stretching exercises, and extracorporeal shock wave therapy,[6] local injection of corticosteroids, and platelet-rich plasma (PRP). Various types of surgical procedures have also been recommended for refractory cases.[7] The primary aim of our study was to evaluate the role of PRP versus corticosteroid (triamcinolone) therapy in plantar fasciitis, and the secondary aim was to study the associated complications and their management.


  Materials and Methods Top


The study included 36 patients of plantar fasciitis who presented to the OPD/Casualty of Department of Orthopaedics and Traumatology, M.G.M. Medical College and M.Y. Hospital, Indore, between September 2018 and August 2020. The study was prospective and interventional type. Preinjection, patients were selected on an odd–even basis and were assessed according to a RMSPS and Visual Analog Scale (VAS) score. Post-PRP or steroid injection details were recorded till the period of 6 months at regular follow-up. They were evaluated by RMSPS score and VAS score. Those who fulfilled the following inclusion criteria were included in the study:

  • Age of the patient more than 18
  • Patients with plantar fasciitis who had undergone at least 4 weeks of conservative treatment.


Exclusion criteria

  • Age of the patient <18 years
  • Infections
  • Tumor of lower extremity
  • Hemorrhagic disorders
  • On anticoagulant therapy
  • Pregnancy
  • Uncontrolled diabetes
  • Bilateral plantar fasciitis
  • Refusal of inclusion by patient.


The selected patients who satisfied the above inclusion criteria were then registered, and all history and clinical details were recorded in the history sheet as per the pro forma. Risks and benefits were thoroughly reviewed with the patient, and informed written consent was obtained.

Mechanism of action

  1. PRP [Figure 1]
  2. Steroids [Figure 2].
Figure 1: Mechanism of action of PRP

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Figure 2: Mechanism of action of steroid Injection

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Procedure

Procedure was done on an outpatient basis and under complete aseptic conditions. The site of maximum tenderness was premarked with a sterile marker. Patients of Group I received 1 mL of PRP injection [Figure 3] into the origin of the plantar fascia at the site of maximum tenderness by peppering technique (using a 20-gauge needle), i.e., spreading in a clockwise manner was used to achieve a more extensive zone of delivery, with a single skin portal and four to five passes through the fascia itself. Group II patients received 1 mL of steroid (40 mg triamcinolone) by the same techniques. Patients were rested for 15 min and then they were allowed to walk.
Figure 3: Steps of PRP preperation

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Postinjection protocol

  • A patient was advised rest for 15 min and ice fomentation
  • Postprocedure oral antibiotic was given for 3 days
  • Patients were advised to avoid hot tubs for the first 24–48 h to reduce infection risk
  • Tramadol or opiates were given to avoid postprocedure soreness
  • NSAIDs may impair the inflammatory phase of healing, so it was avoided.


Functional results

  1. RMSPS score
  2. VAS score.


Follow-up protocol

The patients were evaluated through RMSPS score and VAS score preprocedural, 3rd day, 15th day, 1 month, 3 month, and 6 months.

Statistical analysis

Statistical analysis was performed using the SPSS Statistics for Windows, version 12.0 (SPSS Inc., Chicago, Ill., USA) for Windows, and statistical significance was set at P < 0.05. Descriptive statistics were generated for all the study variables, including the mean average for continuous variables and relative frequencies for categorical variables.


  Results Top


PRP injections have shown effectiveness in providing pain relief, improving function in plantar fasciitis patients. As a result, VAS [Table 1] and RMSPS [Table 2] score was significantly reduced (P = 0.015) at 6 months as compared to preprocedure and thus proved the effectiveness of the PRP therapy. It also shows that PRP is a better method in reducing pain in plantar fasciitis compared to steroid injection.
Table 1: Comparison of mean RMSPS score between different time intervals

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Table 2: Comparison of mean Visual Analog Scale score between different time intervals

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  Discussion Top


Plantar fasciitis is an aseptic inflammation of the plantar fascia, with a high prevalence mostly affecting middle age groups. Since there is no definitive treatment options available, also the conservative management has poor compliance and surgical intervention was not warranted.[8] Although steroid injections are considered one of the treatment modalities, unfortunately, it has short-term results and is associated with complications.[9]

Intralesional injection is the preferred method to administer PRP/steroid into the lesion, and the peppering technique (multiple penetrations without withdrawing the needle allow dispersal of PRP or corticosteroid to a larger area) is adequate for administration of PRP or steroid.[10] Intralesional injection is a very simple procedure, takes only around 40–45 min including the preparation time of PRP, financially very low cost, requires less surgical skill, and hence can be done on an outpatient basis.

PRP increases the amount of growth promoter to the injured area, and as it is obtained from patient's own blood, so it comes with a natural benefit of almost no side effects, whereas triamcinolone is a synthetic glucocorticoid which is readily available and inexpensive has its own side effects.

The effect of PRP/steroid in plantar fasciitis was indirectly assessed by improvement in pain, mobility, and daily activity through VAS and RMSPS scores. Several case reports and comparative studies have reported that with the use of PRP injections, there are improvements in signs and symptoms by pain scores.

In our study, we found that although both the groups showed improvement initially, patients who received PRP injections were found to have significantly improved pain scores at 6 months compared to the steroid group which effects wear off with time. RMSPS score suggested that symptoms improved at the end of 1 month [Table 1] in both the corticosteroid and PRP groups. However, the corticosteroid group had a preintervention average RMSPS score of 3.72 ± 0.46, which initially improved to 1.44 ± 0.70 at 1 month, but again rose to levels of 1.94 ± 0.73 at 6 months. In contrast, the PRP group started with an average preinjection RMSPS score of 3.72 ± 0.46, and had a final score of 1.22 ± 0.55 at 6 months.

  • In our study, 15 (42%) patients were in the age group of 41–50 years. The mean age found was 40.2 years and it is comparable to those cited in other studies, like Paresh V. Patil et al. (2017) reported a mean age of 41.36 years, and Aziza S. Omar et al. (2016)[11] from Egypt reported a mean age of 37.5 years in their study
  • In our study, 14 males and 22 females were affected, the ratio being 1:1.6. A similar preponderance of females was seen in other studies like Patil et al.[12] and O'Malley et al. which may be related to greater wear and tear, differences in mechanical alignment, anatomic differences, and genetic and hormonal issues.
  • In our study, we found the left side to be involved more than the right side, the ratio being 1.6:1 in both the PRP and steroid groups, showing a higher incidence of left-sided involvement in our study. Patil et al.[12] have reported a left-to-right ratio of 1.7:1 in the PRP group and 1.14:1 in the steroid group. There was no specific identifiable cause of this predisposition in our study which may be due to small sample size.
  • In our study, 14 (43%) patients were homemakers, 6 (17%) were laborers, and 4 (11%) were students. Homemakers being involved in daily heavy physical workload are thus more prone to develop heel pain. A similar preponderance of females was seen in other studies like Patil et al.[12] and O'Malley et al.[6] shows 64% female with high daily physical activity.
  • In our study, the mean VAS score decreases from pretreatment 7.72 for PRP and 7.78 for steroids to 1.28 for PRP and 2.61 for steroids at 6 months and it is comparable to those cited in other studies, like Nicolo Martinelli et al. (2012),[13] and VAS for pain was significantly decreased from 7.1 ± 1.1 before treatment to 1.9 ± 1.5 at the last follow-up (P < 0.01) in the PRP group, like Martin J. O'Malley et al. (2013).[6] Thirty injections were given in 23 patients, with one patient lost to follow-up. The mean VAS score improved from 7 to 4.
  • In our study, those patients treated with PRP the mean RMSPS score decreases from pre-treatment value of 3.72 to 1.22 and for the patients treated with steroid from pre-treatment value of 3.72 to 1.94 at 6 months and it is comparable to those cited in other studies, like Nicolo Martinelli et al. (2012),[6] Roles and Maudsley score, at 12 months of follow-up, results were rated as excellent in nine (64.3%), good in two (14.3%), acceptable in two (14.3%), and poor in one (7.1%) patient in the PRP group.
  • We encountered two cases of postinjection fever; in our study, both were from the steroid group. The patient was given antipyretics and antibiotics for the same and was settled.



  Conclusion Top


Our study demonstrates PRP injection to be an effective and well-tolerated alternative to corticosteroid injection in the management of chronic plantar fasciitis with an added advantage of almost no side effects due to its biological nature and better patient compliance. Furthermore, PRP has added analgesic and antimicrobial properties.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schwartz EN, Su J. Plantar fasciitis: A concise review. Perm J 2014;18:e105-7.  Back to cited text no. 1
    
2.
Lemont H, Ammirati K, Usen N. Plantar fasciitis: A degenerative process (Fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93:234-7.  Back to cited text no. 2
    
3.
Buchanan BK, Kushner D. Plantar fasciitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.https://www.ncbi.nlm.nih.gov/books/NBK431073/ [Last updated on 2020 Jun 07].  Back to cited text no. 3
    
4.
Cutts S, Obi N, Pasapula C, Chan W. Plantar fasciitis. Ann R Coll Surg Engl 2012;94:539-42.  Back to cited text no. 4
    
5.
Lim AT, How CH, Tan B. Management of plantar fasciitis in the outpatient setting. Singapore Med J 2016;57:168-70.  Back to cited text no. 5
    
6.
O'Malley MJ, Vosseller JT, Gu Y. Successful use of platelet-rich plasma for chronic plantar fasciitis. HSS J 2013;9:129-33.  Back to cited text no. 6
    
7.
Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, et al. Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017;96:e8475.  Back to cited text no. 7
    
8.
Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: How successful is surgical intervention? Foot Ankle Int 1999;20:803-7.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Deghedy A, Hamid M, Helal A, El-Sherif S, Latief H. Platelet-rich plasma in treatment of plantar fasciitis: Randomized double-blinded placebo controlled study. Journal of Applied Clinical Pathology. 2019;2:1. [doi: 10.24983/scitemed.jacp.2019.00097].  Back to cited text no. 10
    
11.
Omar AS, Ibrahim A, Ahmed M, Said A, Mahmoud S. Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: Randomized clinical trial. The Egyptian Rheumatologist. 2012;34:43-9. 10.1016/j.ejr.2011.12.001.  Back to cited text no. 11
    
12.
Patil PV, Chanchpara G, Gunaki RB, Gaonkar K, Gaonkar N, Solanki M, et al. Platelet rich plasma for plantar fasciitis: Is it a hype. Int J Orthop Sci 2017;3:226-30. DOI: 10.22271/ortho.2017.v3.i2d.33.  Back to cited text no. 12
    
13.
Martinelli N, Marinozzi A, Carnì S, Trovato U, Bianchi A, Denaro V. Platelet-rich plasma injections for chronic plantar fasciitis. Int Orthop 2013;37:839-42.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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