PRP vs SteroidInjection for Heel Pain

Lawrence M. Oloff, DPM, FACFASTeam Podiatrist, San Francisco Giants

San Francisco, California

Thomas Chang, DPMClinical Professor / Part ChairmanDepartment of Podiatric Surgery

Samuel Merritt School of Podiatric MedicineRedwood Orthopaedic Surgery Associates

Santa Rosa, California

Faculty

Dr. Oloff disclosed no relevant financial relationships with any commercial interests.

Dr. Chang has disclosed relationships with Stryker Orthopedics, Paragon 28, Synthes/BME, and Bioventus

Faculty Disclosures

1) Describe what PRP is and how it is prepared2) Explain how PRP works3) Demonstrate PRP technique for heel pain4) Analyze which plantar fasciitis cases might benefit

from PRP

Learning Objectives

Plantar Fasciitis

PHASE I– Footwear

‒ Nonsteroidal anti-inflammatory drugs (NSAIDs)

‒ Taping/orthotics/cups

‒ Night splint

‒ Physical therapy (PT)

‒ Activity modification

‒ Determine etiology

Plantar Fasciitis

PHASE I‒ Footwear

‒ NSAIDs

‒ Taping/orthotics/cups

‒ Night splint

‒ PT

‒ Activity modification

‒ Determine etiology

PHASE II, III, IV‒ Steroid injection

‒ Prednisone

‒ Immobilization

‒ Nontraditional

Plantar Fascia SurgerySurgical Success (60%-80%)

• Bordelon RL. Clin Orthop Relat Res.1983;177:49-53.

• Daly PJ, et al. Foot Ankle. 1992;13(4):188-195.• Furey JG. J Bone Joint Surg Am.

1975;57(5):672-673. • Kinley S, et al. J Foot Ankle Surg.

1993;32(6):595-603.• Lutter LD. Am J Sports Med. 1986;14(6):481-

485.• Mann RA, et al. Foot Ankle. 1981;1(4):190-224.

Heel Pain

Etiology• Plantar fasciitis• Fascial tear• Fracture spur• Compartment syndrome• Calcaneal stress injury• Nerve entrapment• Stenosing tenosynovitis FHL• Fat pad syndromes• Bursitis• RadiculopathyFHL = flexor hallucis longus

Plantar Fascia SurgerySurgery

• No improvement• Simple• Not a finesse procedure• Functional considerations

Plantar Fascia SurgeryComplications

• Progressive loss of arch support function as fascia released medial to lateral

• Even partial fasciotomy decreases support function

• Risks may be greater in unstable feet

Thordarson DB, et al. Foot Ankle Int. 1997;18(1):16-20. Kitaoka HB, et al. Foot Ankle Int. 1997;18(1):8-15.

New Technologies

• “Regenerative medicine”• “Orthobiologic”• “Biologic therapy”

New Technologies?

NEW TECHNOLOGIES?

NEW TECHNOLOGIES?

PRP: WHAT’S ALL THE FUSS?

Platelet Rich Plasma:Science or Myth?

Growth Factors In Tendon And Ligament Healing

• Platelet-rich plasma (PRP) is defined as autologous blood with a concentration of platelets above baseline values

Fitzpatrick J, et al. Orthop J Sports Med. 2017;5(1): 2325967116675272 [published online January 3, 2017]. Accessed September 27, 2017.

Growth Factors Process

• Sample autologous blood• Centrifugation process• PRP contains noncellular components

(plasma)• Administered with/without an activating

agent• Combining with CaCl and/or thrombin

initiates platelet activation, clot formation, and growth factor release

Wang HL, et al. Eur J Dent. 2007;1(4):192-194.

Growth Factors Process

• Two-phase centrifugation process (plasmapheresis)

• Liquid and solid components of blood separated

• First phase: "Soft spin" (1200-1500 RPM) plasma and platelets are separated from red blood cells (RBC) and white blood cells (WBC)

• Second phase: "Hard spin" (4000-7000RPM) to further concentrate the platelet-rich and platelet-poor plasma components

Knezevic NN, et al. Med Clin North Am. 2016;100(1):199-217.

Growth Factor - Preparations

• More than 40 commercial systems• Volume autologous blood• Centrifuge rate/time• Delivery method• Leukocyte concentration• Final growth factor concentration

Growth Factors Debate

• Debate exists as to the optimal quantity of platelets and growth factors required for muscle and tendon healing

�VOLUME AUTOLOGOUS BLOOD�CENTIFUGE RATE/TIME�DELIVERY METHOD�LEUKOCYTE CONCENTRATION�FINAL GROWTH FACTOR

CONCENTRATION

System Volume of Blood

FinalVolume(mL)

Final PlateletConcentration

AutologousConditionedPlasma(Arthrex)

9 3-5 2-3x

Cascade(MTF) 9 or 18 2 or 4 N/A

GPS III(Biomet) 27 or 54 3 or 6 4-8x

SmartPReP(Harvest Technologies)

20 or 60 3 or 7 4.4-7.6x

Brand names are included in this table for participant clarification purposes only. No product promotion should be inferred.Hall MP, et al. J Am Acad Orthop Surg. 2009;17(10):602-608.

GROWTH FACTOR SOURCE FUNCTION

Platelet-derivedgrowth factor Platelets Stimulates cell replication,

angiogenesis, mitogen for fibroblasts

Vascular endothelialgrowth factor Platelets Angiogenesis

Transforming growth factor-B1 Platelets Key regulator in balance between fibrosis and myocyte regeneration

Fibroblast growth factor Platelets Stimulates proliferation of myeloblasts, angiogenesis

Epidermal growth factor PlateletsProliferation of mesenchymal and epithelial cells, potentiation of other growth factors

Hepatocyte growth factor Platelets Angiogenesis, mitogen for endothelial cells, antifibrotic

Insulin-like growth factor-1 PlateletsStimulates myoblasts and fibroblasts, mediates growth and repair of skeletal muscle

Hall MP, et al. J Am Acad Orthop Surg. 2009;17(10):602-608.

Growth Factors: Tendon and Ligament HealingIGF-1, PDGF-BB, bFGF

• Promote tendon healing• Promote tendon cell proliferation• Synergistic effect between growth factors• Facilitate tendon engineering

Costa MA, et al. Tissue Eng. 2006;7(12):1937-1943.

Rationale: Debridement & Growth Factors

• Chronic wound environment altered

• High type III/type I collagen ratio

• Cells produce abnormal collagen

• Long-term exposure to growth factors causes cells to produce faulty collagen

Plantar FasciitisRationale: Growth Factor Injections• Compared single PRP vs single-use guided 40 mg

methylprednisolone injection

• Phase 2 study, 40 patients randomized

• Control group (8 male/12 female) average 5.4 months conservative care and experiment group (9 male/11 female) 5.7 months

• 3cc PRP, cam walker 2 weeks. No NSAIDs for 2 weeks, and eccentric stretching

• America Orthopaedic Foot and Ankle Society scoring

• Cortisone group 52 points pre to 81 points post at 3 months, but dropped to 74 points at 6 months

• PRP group 37 points pre to 95 points post with no drop

Monto RR. Presented at: 12th EFORT Congress; June 1-4, 2011; Copenhagen, Denmark. Paper #652.

Plantar FasciitisRationale: Growth Factor Injections

• Shetty VD, et al. Foot Ankle Surg. 2014;20(1):10-13.

• Kim E, et al. PM R. 2014;6(2):152-158.

• Martinelli N, et al. Int Orthop. 2013;37(5):839-842.

• Ragab EM, et al. Arch Orthop Trauma Surg. 2012;132(8):1065-1070.

• Wilson JJ, et al. Foot Ankle Spec. 2014;7(1):61-67.

Plantar FasciitisRationale: Growth Factor Injections• Ragab and Othman looked at 25 patients who received

PRP for chronic plantar fasciitis

• In their prospective study, they had a mean follow-up of 10.3 months, with patients’ pain decreasing from an average of 9.1 to 1.6 on the visual analog scale (VAS) post-PRP injection

• They reported that 88 percent of patients were completely satisfied

Ragab EM, et al. Arch Orthop Trauma Surg. 2012;132(8):1065-1070.

Plantar FasciitisRationale: Growth Factor Injections

• The results showed a baseline VAS measurement for the PRP group of 7.3 ± 1.8 initially, which decreased to 3.6 ± 2.6 at six months postinjection

• Results in the steroid group were 6.9 ± 1.7 initially, which decreased to 2.4 ± 3.0 at six months postinjection

• The tender threshold results (higher number is a better result) initially for the PRP group was 3.1 ± 1.2, which increased to 6.5 ± 2.9 at six months postinjection

• For the steroid group, the initial measurement was 3.7 ± 2.0, which increased to 8.6 ± 3.1 at six months postinjection

• Although all patients found both injections painful, there were no complications in either group

• The conclusion from this article was, “Intralesional autologous blood injection is efficacious in lowering pain and tenderness in chronic plantar fasciitis, but corticosteroid is more superior in terms of speed and probably extent of improvement.”

Lee TG, et al. Foot Ankle Int. 2007;28(9):984-990.

Plantar FasciitisRationale: Growth Factor Injections• Barrett and Erredge investigated the use of PRP for plantar fasciitis in nine

patients

• The authors used ultrasound of the fascia before and after treatment, with the patients’ pain scale scores determining treatment efficacy

• They found that six of the nine patients achieved complete resolution of symptoms after two months; one patient required a second injection to achieve complete resolution

• The authors noted that 77.9 percent of their patients had no symptoms after one year of treatment

• They also concluded that ultrasound measurements of the thickness of the plantar fascia postinjection showed reduced thickness

Barrett S, et al. Podiatry Today. 2004;17(11):37-42.

Plantar FasciitisRationale: Growth Factor Injections• Aksahin and colleagues compared 30 patients treated

with PRP with 30 patients treated with corticosteroid injection

• Over a six-month period, they found both groups of patients to have significant improvement in symptoms,but there were no statistical differences between the groups

• The authors felt PRP to be safer than corticosteroid injection with the same effectiveness

Aksahin ED, et al. Arch Orthop Trauma Surg. 2012;132(6):781-785.

Growth Factor Injections May Be Useful for Plantar Fasciitis

• Primary treatment???• Recalcitrant cases• Risky surgical candidates• Prior surgery/injury• Patient preference• Fasciosis

Growth Factor Injections May Be Useful for Plantar Fasciitis

• Primary treatment???• Recalcitrant cases• Risky surgical candidates• Prior surgery/injury• Patient preference• Fasciosis

Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections May Be Useful For Plantar Fasciitis

• Primary treatment???• Recalcitrant cases• Risky surgical candidates• Prior surgery/injury• Patient preference• Fasciosis

Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections May Be Useful For Plantar Fasciitis

• Primary treatment???

• Recalcitrant cases

• Risky surgical candidates

• Prior surgery/injury

• Patient preference

• Fasciosis

Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections for Plantar Fasciitis: Is it for You?

• Primary treatment???

• Recalcitrant cases

• Risky surgical candidates

• Prior surgery/injury

• Patient preference

• Fasciosis

Growth Factor Injections for Plantar Fasciitis: Is it for You?

• Primary treatment???• Recalcitrant cases• Risky surgical candidates• Prior surgery/injury• Patient preference• Fasciosis

QUESTIONS

• Do growth factors enhance healing?

• Which factors work the best?

• How is it best administered?

• Does concentration make a difference?

• Is once enough?

In Conclusion: Growth Factor Injections May Be Useful for Plantar Fasciitis

• Primary treatment???• Recalcitrant cases• Risky surgical candidates• Prior surgery/injury• Patient preference• Fasciosis

SteroidInjection for Heel Pain

Thomas J. Chang, DPM

“Itis” vs “Osis”

• Tendonitis/Fasciitis– ACUTE reaction to an overused or stressed tendon

– Inflammatory cells are present

– Treated by rest and anti-inflammatory agents

• Tendonosis/Fasciosis– CHRONIC pain in the major tendons caused by overuse

– Characterized by collagen degeneration and hypovascularity

– No inflammatory cells

Plantar Fasciitis

• Mechanical Treatment

• Inflammation Treatment

Thomas A. Brosky II DPM & Jeremy Thomas PGYIDeKalb Medical Center 43

Confirming DiagnosisNormal measurement

3.22 mm

Thomas A. Brosky II DPM & Jeremy Thomas PGYIDeKalb Medical Center 44

Confirming DiagnosisAbnormal fascia> 7 mm

Uden H, et al. J Multidiscip Healthc. 2011;4:155-164.

RecommendationsUltrasound Guidance Helpful

Deep Injections “better”

Gurcay E, et al. J Foot Ankle Surg. 2017;56(4):783-787.

Pai VS. J Foot Ankle Surg. 1996;35(1):39-40

Advanced Treatment Options for Plantar Fasciitis

• EPAT - Extracorporeal Pulse Activation Treatment

• PRP – Platelet Rich Plasma

• RF – Radio Frequency Debridement

• Ultrasonic debridement

Goal – Degenerative process Regenerative process

PRP – Platelet Rich Plasma

PRP

• Uses the body’s own products to stimulate healing

• Injecting “fertilizer”

• 20 cc blood 4 cc PRP

• Platelet concentration 6% 24%

• Noncovered service

Mark Scioli, MD

PRP - Contraindications

• Cancer or metastatic disease

• An active infection

• A low platelet count

• Pregnancy or breastfeeding

Jain K, et al. Foot (Edinb). 2015;25(4):235-237.

Monto RR. Foot Ankle Int. 2014;35(4):313-318.

Acosta-Olivo C, et al. J Am Podiatr Med Assoc. 2016 Oct 11 [Epub ahead of print].

David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Comparison: Cortisone and PRP

David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Cochrane Review

David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Steroid Superior…

Wilson JJ, et al. Clin J Sport Med. 2013;23(2):131.

Buccilli TA Jr, et al. J Foot Ankle Surg. 2005;44(6):466-468.

Final Thoughts

• Structural preservation

• No burned bridges

• Clinical success