PRP vs Cortisone for Plantar Fasciitis

Platelet-Rich Plasma Is More Effective Than Cortisone for Chronic Plantar Fasciitis Raymond Rocco Monto, MD

Nantucket Cottage Hospital

AAOS Annual Meeting, San Francisco, 2012

Financial Disclosures

Exactech Inc (Gainesville, FLA) Consultant

PRP for Plantar Fasciitis 

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Distractive forces of Achilles tendon and plantar fascia (windlass mechanism) Compression loads Heel cord contracture Nerve irritation

PRP and Plantar Fasciitis 

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Pathophysiology similar to tennis elbow and Achilles tendonitis Degenerative micro-tears Chaotic vascularity & local tissue hypoxia Apoptosis / autophagic cell death Decreased collagen production & slower matrix turnover

PRP for Plantar Fasciitis 

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traditional treatments effective in 70-89% of cases rest, icing, stretching, shoe mods, orthotics, PT, NSAIDs, steroids, night splinting tertiary treatments in severe cases are less predictable ESWT, Topaz bipolar, cryosurgery, open or endoscopic surgical release

PRP for Plantar Fasciitis 

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PRP is a native bioactive component of whole blood Normal whole blood contains 200,000 platelets/mcl PRP concentrate contains 2,000,000 platelets/mcl

Level 1 evidence has supported use in lateral epicondylitis and tendonitis

How does PRP work? 

Platelets normally function in the clotting cascade (with calcium + thrombin)

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PRP releases growth factors (cytokines) and active proteins via alpha granules

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Platelets release serotonin and adenosine via dense granules

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Histamine levels rise to increase membrane permeability

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Cytokines rise linearly with PRP concentration (>1100 proteins)

PRP for Plantar Fasciitis     

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Prospective Block Randomized Longitudinal cohort study 40 patients (20 in each arm) All patients with MRI evidence of plantar fasciitis All failed minimum 4 months conservative treatment 

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(NSAIDS, heel lifts, HEP, night splints, PT, oral steroids)

No prior injections in either group Single cortisone ultrasound-guided injection vs.

Single PRP ultrasound-guided injection One year follow-up at 3 month intervals (No rescue)

PRP for Plantar Fasciitis

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MRI findings of partial tears and edema seen at the calcaneal origin in all patients

PRP for Plantar Fasciitis

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Radiographic findings of spurs and calcifications 28/40 patients

PRP for Plantar Fasciitis

June 2007

August 2009

PRP for Plantar Fasciitis 

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Local anesthesia (6cc 0.5% Rhopivicaine) Ultrasound guided needle placement (GE logiq book) Group I: 3 cc un-activated PRP injected un-buffered into injury zone (collagen trigger) Group II: 40 mg DepoMedrol Discharged in CAM walker x 2 weeks WBAT Resume eccentric HEP No NSAIDS x 4 weeks

PRP and Plantar Fasciitis 

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Accelerate Platelet Concentrating System (Exactech, Inc) 27 cc venous blood draw mixed with 3 cc ACD-A Centrifuge 2400 rpm x 12 minutes (zero brake) 3cc PRP harvest

PRP for Plantar Fasciitis 

Cortisone group: Average age 59 (range 24-74)  Duration symptoms 5.4 months (4-24)  Pre-treatment AOFAS score 52 (24-60)  3 mos Post-treatment AOFAS score 81 (56-90)  6 mos Post-treatment AOFAS score 74 (54-87)  12 mos Post-treatemnt AOFAS score 58 (45-77)  No patients lost to follow-up 

PRP for Plantar Fasciitis 

PRP group: Average age 51 (range 21-67)  Duration of symptoms 5.7 months (4-26)  Pre-treatment AOFAS score 37 (30-56)  3 mos Post-treatment AOFAS score 95 (88-100)  6 mos Post-treatment AOFAS score 94 (87-100)  12 mos Post-treatment AOFAS score 94 (86-100)  No patients lost to follow-up 

PRP for Plantar Fasciitis 100 90 80 70 60 50 40 30 20 10 0

AOFAS score

PRP Cortisone

CI 95%

0

3

6

Months after injection

12

P=0.001

PRP for Plantar Fasciitis ď Ž

PRP is significantly more effective than cortisone in the short and long term management of severe chronic plantar fasciitis refractory to standard nonoperative management (CI 95% P=0.001)

PRP for Plantar Fasciitis 

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PRP promotes modulation of angiogenesis, collagen turnover, anti-inflammatory effects, tissue healing Harness inflammation- do not eliminate it Consider PRP when traditional treatment fails

Thank You