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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 141-145

A comparative study between platelet-rich plasma, corticosteroid, and autologous whole blood injection in patient of plantar fasciitis


Department of Orthopedics, F.H. Medical College, Agra, Uttar Pradesh, India

Date of Submission26-Sep-2022
Date of Acceptance02-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Imran Sajid
Department of Orthopedics, F.H. Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_29_22

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  Abstract 

Introduction: Majority of the patient with heel pain are diagnosed with plantar fasciitis (PF). PF is the condition characterized by isolated inferior heel pain particularly with the first steps of the day or after sitting for hours and the reason is due to degeneration of the plantar fascia and perifascial structures. Regular walking on hard surfaces, wearing hard sole footwear, and obesity are the risk factors for this condition. Injecting steroids is the most popular method of treating the condition but has its own advantages and disadvantages. There have been cases reported of rupture of plantar fascia after giving corticosteroid injections, especially when it was given repeatedly. Platelet-rich plasma (PRP) is known to enhance the healing process of the body as it has platelet-derived growth factors that boost the healing of soft tissue, bone healing, and also tendon healing. Aims and Objective: The objective of our study was to know among the PRP injection, autologous whole blood steroid injection which is a superior mode of intervention in PF management. Materials and Methods: A sample size of 225 was taken and patients were divided into 3 groups, in which Group A was given PRP injection, Group B was given steroid injection, and Group C was given whole blood. The follow-up was done on 2 weeks, 4 weeks, and 12 weeks. Patients of age more than 18, those who were clinically diagnosed PF, and those who were not improving with 3 months of conservative management were included in the study. Patients with any ligament injury or with Buerger’s disease, pseudo-gout, and Haglund disease were excluded from the study. All patients were asked for their pain to quantify it according to visual analog scale (VAS) scale and the score was noted on pre-injection follow by on 2 weeks, 4 weeks, and 12 weeks. Results: The VAS score before infiltration was almost similar (P > 0.05) in Group A (7.8 ± 1.26), Group B (7.5 ± 1.05), and Group C (7.8 ± 0.87). The VAS score significantly decreased in Group B who were injected steroids in the initial 2 weeks when compared to that of Group A who were injected PRP and Group C who were injected whole blood. A significant decrease in VAS was seen in Group A at after 12 weeks when compared to Group B and Group C. Conclusion: Our study showed that autologous PRP therapy can lead to a sustained reduction in symptom complaints when compared to corticosteroid injections and autologous whole blood. PRP injection holds promise as a potential therapy to hasten the healing of chronic PF.

Keywords: Autologous PRP, corticosteroid, heel pain, plantar fasciitis


How to cite this article:
Ravikant U, Kumar A, Sajid I, Dubey S, Pal SK. A comparative study between platelet-rich plasma, corticosteroid, and autologous whole blood injection in patient of plantar fasciitis. J Bone Joint Dis 2022;37:141-5

How to cite this URL:
Ravikant U, Kumar A, Sajid I, Dubey S, Pal SK. A comparative study between platelet-rich plasma, corticosteroid, and autologous whole blood injection in patient of plantar fasciitis. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:141-5. Available from: http://www.jbjd.in/text.asp?2022/37/3/141/363851




  Introduction Top


Majority of the patient with heel pain are diagnosed with plantar fasciitis (PF). PF is a condition characterized by isolated inferior heel pain particularly with the first steps of the day or after sitting for hours and the reason is due to degeneration of the plantar fascia and perifascial structures.[1] Regular walking on hard surfaces, wearing hard sole footwear, and obesity are the risk factors for this condition.[2],[3],[4]

Though there are many theories regarding the pathology of PF, there is evidence to suggest that the initiation is probably due to repeated micro trauma. The inflammation is never acute and in chronic cases; in fact, there is a loss of inflammatory response and chronic scar formation.

With early diagnosis and timely application of traditional nonsurgical treatments such as activity modification, anti-inflammatory medications,[5] gastrocnemius and plantar fascia-specific stretching[6] and/or shoe inserts, the prognosis is favorable with approximately 80% of patients achieving symptom resolution within 1 year.[5],[7] With such a controversial etiology, there have been so many treatment options available with different actions yet none of them have shown an ideal efficacy and safety characteristics.

Injecting steroids is the most popular method of treating the condition but has its own advantages and disadvantages. There have been cases reported of rupture of plantar fascia after giving corticosteroid injection especially when it was given repeatedly.[8],[9]

Platelet-rich plasma (PRP) is known to enhance the healing process of the body as it has platelet-derived growth factors that boost the healing of soft tissue, bone healing, and also tendon healing. In addition, it helps in preventing bacterial infection due to its antimicrobial properties.[10],[11],[12] The growth factors on activation cause the initiation of the body's natural healing process. Injection of these platelets in the attachment of the fascia to the os calcis might induce a healing response.[13]


  Aim and Objective Top


The objective of our study was to know among PRP injection, autologous whole blood, and steroid injection that is a superior mode of intervention in PF management.


  Materials and Methods Top


A sample size of 225 was taken and patients were divided into three groups, in which Group A was given PRP injection, Group B was given steroid injection, and Group C was given whole blood. The follow-up was done on 2 weeks, 4 weeks, and 12 weeks. Patients of age more than 18, those who were clinically diagnosed PF, and those whowere not improving with 3 months of conservative management were included in the study. Patients with any ligament injury or with Buerger’s disease, pseudo-gout, and Haglund’s disease were excluded from the study. All patients were asked for their pain to quantify it according to visual analog scale (VAS) scale and the score was noted on pre-injection follow by on 2 weeks, 4 weeks, and 12 weeks. All injections were injected in under full aseptic conditions at the most tender point.

PRP preparation technique

PRP was prepared using the double spin centrifugation method of Augustus et al.[14] 20 mL of venous blood is drawn from the cubital vein. The blood is immediately transferred into six 2.7-mL vaccutainers prefilled with acid citrate dextrose. 2.7-mL acid citrate dextrose containing vaccutainers are readily available in the hospital. All the containers are filled till the markings on the vaccutainers. The vaccutainers are then placed in the slot available in the centrifugation machine in such a way that they are counter balanced. The initial centrifuge was done at 1500 rotations per minute for three minutes. This separates the blood into two layers. Red blood cells rich at the bottom and plasma along with the platelets are at the top [see [Figure 1]]. The top layer is then transferred to fresh vaccutainers using a long 18-G needle and syringe. The vaccutainers are now again centrifuged at 2500 rotations per minute for three minutes. This separates the column of plasma to platelet rich at the bottom and platelet poor at the top. Using a long 18 G, the top half column which is platelet poor is discarded. The PRP at the bottom is now collected from the vaccutainers and is now ready for use [see [Figure 2]].[15]
Figure 1: PRP sample after centrifugation

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Figure 2: PRP sample in 5-mL syringe

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Technique of infiltration

Most tender point was palpated and marked using a skin marker and area was prepared for injection. Under aseptic precaution using a 21 and 1 1/2 inch needle, 1-mL PRP is injected initially over the maximum tender point and needle is partially withdrawn and multiple punctures are made in the surrounding tissue (peppering technique) [Figure 3]. The remaining 1 mL of PRP was injected in surrounding tissue.[15]
Figure 3: Injecting PRP in area of maximum tenderness

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Steroid injection

There are a lot of options to a medical professional when it comes to choosing a steroid. We selected dexamethasone, as it was easily available and literature has shown that there is no significant changes when using dexamethasone and any other steroid for PF

Technique of infiltration

Most tender point was palpated and marked using a skin marker and area was prepared for injection. Under aseptic precaution using a 21 and 1 1/2 inch needle, 2 mL of dexamethasone (8 mg) as normal dosage when used for inflammation is 0.2–6 mg/day,is injected initially over the maximum tender point and needle is partially withdrawn and multiple punctures are made in the surrounding tissue (peppering technique)

Autologous whole blood

2 mL of venous blood was taken under sterile conditions and without doing any add on procedures was inserted as a modality of treatment in plantar fascia

Technique of infiltration

Most tender point was palpated and marked using a skin marker and area was prepared for injection. Under aseptic precaution using a 21 and 1 1/2 inch needle, 2 mL of autologous whole blood was injected initially over the maximum tender point and needle is partially withdrawn and multiple punctures are made in the surrounding tissue (peppering technique).


  Results Top


A total of 225 cases were taken for study, 75 per group out of which 9 were lost during follow-up. Therefore, follow-up of 216 cases was done for 3 months between January 2021 and January 2022. The majority of people in our study group fall under the age 40–50 with an average age of 43.72 in Group A, 44.88 in Group B, and 40.36 in Group C [Table 1].
Table 1: Age wise distribution of patients between three groups

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The comparison of the VAS score between the two groups is presented in [Table 2] and [Figure 4]. The VAS score before infiltration was almost similar (P > 0.05) in Group A (7.8 ± 1.26), Group B (7.5 ± 1.05), and Group C (7.8 ± 0.87). The VAS score significantly decreased in Group B who were injected steroids in initial 2 weeks when compared to that of Group A who were injected PRP and Group C who were injected whole blood, but a significant drop in VAS was seen in Group A at after 12 weeks when compared to that of Group B and Group C.
Table 2: Comparison of VAS score between three groups

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Figure 4: Graphical representation of VAS score at different intervals

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  Discussion Top


This study attempted to evaluate the effectiveness of autologous PRP injection in comparison to that of steroid and whole blood in patients diagnosed with PF after not improving with 3 months of conservative management. The majority of people in our study group fall under the age 40–50 with an average age of 43.72 in Group A, 44.88 in Group B, and 40.36 in Group C.

In our study, it was found that although both Groups A and B showed improvement at the end of 1 month and 3 month but not in group C, patients who received PRP injections were found to have significantly improved pain scores at 3 months compared with other two groups (P < .05). This study showed that at the end of the third month, pain score did not decrease after decreasing initially in group B and C, yet increased in group C [Figure 4]. At this point the score was not statistically significant with the baseline parameters in group C. It could be concluded that the duration of pain relief effectiveness is less than 3 months in patients who received corticosteroid injections and whole blood. Our result confirms the findings of Crawford et al., who reported a statistically significant reduction in pain at 1 month, but thereafter no differences could be detected. Hence, it is concluded that steroid injections can provide short-term relief. On the contrary, the pain score remained significantly low at 3 months and even at the end of 6 months in group A.

This is attributed to the fact that the PRP contains concentrated growth factors that initiate and accelerate the body’s healing mechanisms into growing new connective tissue. PRP contains several different growth factors (cytokines) that encourage the healing of bone and soft tissue. PRP serves as a growth factor agonist and has both mitogenic and chemotactic properties. These growth factors in combination with anti-inflammatory components initiate the healing cascade and help in reversal of the degenerative process. In other words, the durability of the efficacy of PRP is gradually improving and significantly longer compared to corticosteroid.

Also, the authors do not recommend routine use of corticosteroid in cases of Chronic PF owing to detrimental long-term effects. In the present study, there was a clear trend for increased NSAIDS doses in the control group when compared with the study group. This could be attributed to the weaning effect of corticosteroid injection

Our analysis shows that injecting PRP as a treatment modality in PF has longer and better results when compared to that of steroid injections. Its action is slower but is effective for longer period of time.

Despite PRP therapy becoming an increasingly popular treatment modality, authors recommend further research and development with a large sample size.


  Conclusion Top


The results of our present comparative clinical study of PRP therapy for the treatment of chronic Planter fasciitis showed that autologous PRP therapy can lead to a sustained reduction in symptom complaints when compared to corticosteroid injections and autologous whole blood. PRP injection holds promise as a potential therapy to hasten the healing of chronic PF.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Yi TI, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR Clinical characteristics of the causes of plantar heel pain. Ann Rehabil Med 2011;35:507-13.  Back to cited text no. 1
    
2.
Irving DB, Cook JL, Menz HB Factors associated with chronic plantar heel pain: A systematic review. J Sci Med Sport 2006;9:11-22; discussion 23-4.  Back to cited text no. 2
    
3.
Riddle DL, Pulisic M, Pidcoe P, Johnson RE Risk factors for plantar fasciitis: A matched case-control study. J Bone Joint Surg Am 2003;85:872-7.  Back to cited text no. 3
    
4.
Werner RA, Gell N, Hartigan A, Wiggerman N, Keyserling WM Risk factors for plantar fasciitis among assembly plant workers. Pm R 2010;2:110-6; quiz 1 p following 167.  Back to cited text no. 4
    
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Hyland MR, Webber-Gaffney A, Cohen L, Lichtman PT Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. J Orthop Sports Phys Ther 2006;36:364-71.  Back to cited text no. 6
    
7.
Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al; American College of Foot and Ankle Surgeons heel pain committee. The diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49:S1-19.  Back to cited text no. 7
    
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Baskin A, Ji A, Benk JL Complications of plantar fascia Rupture Associated with Corticosteroid injection. Foot Ankle 1996;19:91.  Back to cited text no. 8
    
9.
Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA Platelet-rich plasma: Current concepts and application in sports medicine. J Am Acad Orthop Surg 2009;17:602-8.  Back to cited text no. 9
    
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Mehta V Platelet-rich plasma: A review of the science and possible clinical applications. Orthopedics 2010;33:111.  Back to cited text no. 10
    
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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.  Back to cited text no. 11
    
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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. 12
    
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Lacci KM, Dardik A Platelet-rich plasma: Support for its use in wound healing. Yale J Biol Med 2010;83:1-9.  Back to cited text no. 13
    
14.
De Bie RA, Verhagen A, de Vet HC, Lenssen T, van der Wildenberg FA, Kootstra G, et al. Efficacy of 904 nm laser therapy in musculoskeletal disorders. Phys Ther Rev 1998;3:1-14.  Back to cited text no. 14
    
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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: 303-10.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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