“To compare the relative effectiveness of intralesional steroid versus platelet-rich plasma injection among 80 patients in plantar fasciitis: A prospective study”

Ashish Kumar Arya; Kumar Chandan; Pankaj Kumarverma; Santosh Kumar

doi:10.4103/jotr.jotr_27_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 14 | Issue : 2 | Page : 121-125

“To compare the relative effectiveness of intralesional steroid versus platelet-rich plasma injection among 80 patients in plantar fasciitis: A prospective study”

Ashish Kumar Arya¹, Kumar Chandan¹, Pankaj Kumarverma², Santosh Kumar¹
¹ Department of Orthopaedics, IGIMS, Patna, Bihar, India
² Department of Orthopaedics, SKMCH, Muzaffarpur, Bihar, India

Date of Submission	10-Mar-2022
Date of Acceptance	30-Oct-2022
Date of Web Publication	30-Dec-2022

Correspondence Address:
Dr. Kumar Chandan
Department of Orthopaedics, IGIMS, Patna, Bihar
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jotr.jotr_27_22

Abstract

Objective: The objective of the study to compare the relative effectiveness of intralesional steroid versus platelet-rich plasma (PRP) injection among 80 patients in plantar fasciitis. Materials and Methods: A total number of 80 patients with plantar fasciitis were divided into two groups. Group A with 30 patients received intralesional PRP and Group B received intralesional methylprednisolone acetate injection. Pre- and post-intervention visual analogue scale (VAS), the Foot and Ankle Ability Measure (FAAM) score, and Plantar Fascia (PF) thickness for the assessment of pain relief in two groups were recorded at 6 months. Results: The mean VAS scores for heel pain measured after 6 months of treatment were 1.460 ± 0.6911 in PRP group and 3.024 ± 0.9572 in steroid group. The decrease in mean VAS score in both the groups was statistically significant when compared with pretreatment values (8.38 ± 0.6820 in PRP group and 8.44 ± 0.6021 in steroid group). The mean FAAM score measured after 6 months of treatment increased in both the groups (83.43 ± 5.661 in PRP group and 69.12 ± 5.795 in steroid group) when compared with pretreatment value (29.97 ± 5.997 in PRP group and 31.68 ± 6.297 in steroid group), and it was statistically significant. There was 35.90% reduction in mean PF thickness in PRP group and 28.67% reduction in steroid group as compared to baseline values after 6 months of injection. Conclusion: Intralesional injections of both the PRP and steroid are effective and safe modalities of treatment for plantar fasciitis. A steroid is better for short-term treatment of plantar fasciitis, but in long-term follow-up, PRP therapy is better than steroid. Both the treatment methods have caused a significant reduction in PF thickness.

Keywords: Plantar fasciitis, platelet-rich plasma, steroid

How to cite this article:
Arya AK, Chandan K, Kumarverma P, Kumar S. “To compare the relative effectiveness of intralesional steroid versus platelet-rich plasma injection among 80 patients in plantar fasciitis: A prospective study”. J Orthop Traumatol Rehabil 2022;14:121-5

How to cite this URL:
Arya AK, Chandan K, Kumarverma P, Kumar S. “To compare the relative effectiveness of intralesional steroid versus platelet-rich plasma injection among 80 patients in plantar fasciitis: A prospective study”. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:121-5. Available from: https://www.jotr.in/text.asp?2022/14/2/121/365826

Introduction

Plantar fasciitis is a common cause of heel pain. It occurs due to a degenerative process resulting in acute and chronic inflammation of plantar fascia (PF). It may also cause calcification at the origin of the PF and bony traction spur formation. Approximately 10% of the population experience plantar heel pain at some point during their lifetime.^[1]

The etiology of plantar fasciitis is somewhat controversial, but many factors that may precipitate the condition include poor foot mechanics due to pes planus or cavus foot type, obesity, inappropriate footwear, nerve entrapment, tight triceps surae, fat-pad atrophy, and repetitive microtrauma.^[2]

Patient with plantar fasciitis present with heel pain which is characterized by “first-step pain.” This pain occurs after a period of rest, such as in the morning when arising from bed. This acute pain usually subsides after the first couple of steps, either disappearing completely or remaining as a constant ache that worsens again after a period of rest.^[2],[3]

A diagnosis of planter fasciitis is clinical and done by taking a detailed history and physical examination. Although imaging studies are done to confirm the diagnosis or rule out other causes of heel pain. Plain radiographs can rule out bony lesions or stress fractures whereas ultrasound is another relatively inexpensive diagnostic tool that can rule out certain causes of heel pain such as plantar fibromatosis, foreign body, plantar xanthomas, and can aid in diagnosis by establishing plantar fascial thickness and the presence of fascial tears.^[4],[5] Other investigations that are not routinely done are technetium bone scintigraphy, electromyography, and magnetic resonance imaging. Depending on the overall clinical picture, blood tests such as a white cell count, human leukocyte antigen B27, antinuclear antibodies, and uric acid may also be performed in younger patients or patients who have bilateral heel pain.^[6]

The initial treatment of plantar fasciitis is conservative that includes rest, activity modification, and medication therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or corticosteroids. Other therapy includes stretching, orthotics and night splints, corticosteroid injections, platelet-rich plasma (PRP) injections, autologous blood injections, botulinum toxin injections, extracorporeal shock wave therapy, and radiation therapy. Surgical options include partial or complete PF release and gastrocnemius release if the patient has continued pain even after 6–12 months of nonsurgical management.^[4],[6]

We conducted a simple randomized prospective comparative study to compare the relative effectiveness of intralesional steroid versus PRP injection in plantar fasciitis.

Material and Methods

After obtaining written informed consent, a randomized prospective trial was conducted. Initially, 89 patients were included in this study but 9 patients were lost during follow-up period. Hence, finally, 80 patients of plantar fasciitis in the age group of 18–60 years were taken for intralesional steroid and PRP injection locally. Thirty patients in Group-A for PRP injection and 50 patients in Group-B for steroid injection were taken by simple random sampling. The study was conducted at Indira Gandhi Institute of Medical Science, Patna, Bihar, India, between 2020 and 2021.

Patients included were those with age group between 18 and 60 years presenting with complaints of plantar heel pain, worse with rising in morning and/or after periods of rest with maximal tenderness at the attachment of the PF on the medial tubercle of the calcaneus for 4 weeks or more and willingness to forgo any other concomitant conservative treatment modality; NSAIDS and orthotic devices during the study.

Patients excluded were those with inflammatory or degenerative polyarthritis, diabetes mellitus, local or systemic infection, peripheral vascular diseases, metabolic diseases such as gout, clotting disorder, anticoagulation therapy, neuropathic symptoms, complex regional pain syndrome, metastatic cancer, previous surgery, pregnancy or breastfeeding female patients and previous treatment with corticosteroid injection in the past 6 months or NSAIDs treatment within the past 7 day.

The patients were divided into two groups:

Group A: Intralesional 3 ml autologous PRP injection locally
Group B: Intralesional single injection of 2 cc, i.e., 80 mg methylprednisolone acetate locally.

After 48 h of treatment, patients were given a standardized stretching protocol to follow for 2 weeks.

Patient biography, detailed history, and clinical evaluation were done along with ultrasonic evaluation of PF thickness of both feet. The diagnosis was made on clinical and radiological ground. All the fresh cases were initially treated with contrast bath foot stretching exercise and silicone heel pad for 4 weeks.

Follow-up of patients after treatment was done at 4 weeks, 8 weeks, 12 weeks, and after 24 weeks. We used visual analog scale (VAS) and the Foot and Ankle Ability Measure (FAAM) for the assessment of pain relief and functional improvement in two groups. Ultrasonographic evaluation of the thickness of PF was done pretreatment and after 6 months of treatment in all the patients whereas thickness of more than 4 mm was considered abnormal.^[7],[8],[9]

Platelet-rich plasma preparation method

Twenty-seven milliliter of a patient's own venous blood was withdrawn from cubital vein under aseptic condition and collected in presterilized centrifuge vials preloaded with anticoagulant sodium citrate in a ratio of 1:9. This blood was then centrifuged at 3200 rpm for 15 min. The blood was then separated into platelet-poor plasma and PRP. The platelet-poor plasma was extracted and discarded. Three milliliter of PRP was harvested finally containing approximately 6–8 times the concentration of platelets compared to baseline whole blood.^[10]

Injection technique

The procedure was done on an outpatient basis and under complete aseptic condition. Lidocaine sensitivity was done before starting the procedure. Two cc of 2% lidocaine was infiltrated before injection. Patients of Group A received 3 cc of autologous PRP injection into the origin of the PF and directly into site of maximum tenderness at the heel through “peppering technique,” i.e., single skin entry, partially withdrawing the needle, redirecting, and making multiple penetrations to the fascia.

Group B patients received 2 ml of methylprednisolone acetate locally. The patients were monitored for 20 min for any adverse reactions.^[10]

Statistical analysis

The data were entered into Microsoft Excel and analyzed using statistical software SPSS (version 22). Released 2013. (IBM SPSS Statistics for window, version 22.0. Armonk, NY: IBM Corp.)
Categorical variables were analyzed using Chi-square test
Normally distributed variables were analyzed using the Student's t-test
Analysis of variance was used for demographic data
P < 0.05 was considered statistically significant.

Results

Of 80 patients, 30 were included in PRP group, i. e., Group A and 50 were included in the steroid group, i.e., Group B.

Within group comparison, in PRP group, the result was statistically significant (P < 0.001). The mean VAS score decreased from baseline continuously which was statistically significant. The difference in mean VAS score between pretreatment period, i.e., baseline and posttreatment period at 24 weeks was highest.

Within group comparison, in the steroid group, the result was statistically significant (P < 0.001). The mean VAS score decreased from baseline continuously up to12 weeks. However, at the end of 24 weeks, there was rise in mean VAS score when compared to mean VAS score at 12 weeks.

When both treatment methods compared, the mean VAS score was significantly lower at 4 weeks, 8 weeks, and 12 weeks in steroid group as compared to PRP group. However, at 24 weeks, mean VAS score was significantly lower in PRP group as compared to steroid group.

Within group comparison, in PRP group, the result was statistically significant (P < 0.001). The mean FAAM score increased from baseline continuously which was statistically significant. The difference in mean FAAM score between pretreatment period, i.e., baseline and mean FAAM scores at 24 weeks of posttreatment was highest.

Within group comparison, in steroid group, the result was statistically significant (P < 0.001). The mean FAAM score increased from baseline continuously up to 12 weeks. However, at the end of 24 weeks, there was decrease in mean FAAM score when compared to mean FAAM score at 12 weeks.

When both treatment methods compared, the mean FAAM score was significantly higher at 4 weeks, 8 weeks, and 12 weeks in steroid group as compared to PRP group. However, at 24 weeks, the mean FAAM score was significantly higher in PRP group as compared to steroid group.

There was significant decrease in mean PF thickness in both modalities of treatment at 24 weeks of posttreatment as compared to baseline values. There was 35.90% reduction in mean PF thickness in PRP group and 28.67% reduction in steroid group.

Discussion

Plantar fasciitis is one of the most common causes of heel pain in adults. However, the true etiology of plantar fasciitis is still unknown and many different etiological factors have been attributed. The etiology and treatment are still not fully understood. In general, plantar fasciitis is a self-limiting disease. Unfortunately, the time until resolution is often 6–18 months, which can lead to frustration for patients and physicians. The diagnosis of planter fasciitis is done by taking a detailed history and physical examination. Whereas imaging studies are done to confirm the diagnosis or rule out other causes of heel pain.^[6],[11]

There are many available treatment methods, but in chronic debilitating conditions conservative treatment may fail. Already various other injectable agents have been researched in the past including simple solutions such as hyperosmolar dextrose to complex orthobiologic agents such as bone morphogenic protein, but none achieved uniform success. PRP injection has emerged as a treatment alternative for many musculoskeletal conditions. Steroid injections are often effective in the short term although they have been shown to cause fat pad atrophy and very occasionally, they may precipitate rupture of the PF.^[6],[12]

Tatli and Kapasi in their study concluded that steroid therapy, when coupled with plantar stretching, can provide efficacious pain relief.^[13]

Ragab and Othman conducted a study on 25 patients with chronic plantar fasciitis and concluded that PRP is safe and useful treatment modality in the treatment of plantar fasciitis.^[11]

In our study, all patients were in the age group between 18 and 60 years. The mean patient age was 40.90 ± 9.632 years in PRP group and 37.82 ± 11.047 years in the steroid group. There was no statistical significance in the distribution of age categories (P = 0.4). In total, males comprised 37.5% and females comprised 62.5% of total 80 subjects. Of 30 patients in PRP group, 11 (36.6%) were male and 19 (63.3%) were female. Out of 50 patients in steroid group 19 (38%) were male and 31 (62%) were female.

We followed every subject for 6 months after giving injection and used VAS score, FAAM score, and PF thickness to evaluate the effect of both modalities of treatment.^[7],[8],[9]

Within group comparison in PRP group, the result was statistically significant (P < 0.001). The mean VAS score decreased continuously from baseline which was statistically significant. The difference in mean VAS score between pretreatment and 24 weeks of posttreatment was highest [Table 1] and [Table 2]. The mean FAAM score posttreatment increased continuously from baseline which was statistically significant (P < 0.001). The difference in mean FAAM score between pretreatment and 24 weeks of posttreatment was highest. This shows that the maximum effect of PRP on VAS score and FAAM score was at 24 weeks [Table 3]. The above results are comparable with the studies conducted by Martinelli et al.^[14]

Table 1: Baseline characteristics between platelet rich plasma and steroid group

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Table 2: Comparison of mean visual analog score between baseline and visual analog score at frequent intervals in platelet-rich plasma group

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Table 3: Comparison of mean visual analog score between baseline and visual analog score at frequent intervals in steroid group

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Within group comparison for steroid group, the result was statistically significant (P < 0.001). The mean VAS score at posttreatment decreased from baseline continuously but at the end of 24 weeks, there was rise in mean VAS score (3.024 ± 0.9572) when compared to mean VAS score at 12 weeks (1.188 + 0.5189). The difference in mean VAS score between pretreatment and 12 weeks of posttreatment was highest [Table 4]. The mean FAAM score posttreatment increased from baseline continuously but at the end of 24 weeks, there was decrease in mean FAAM score (69.12 ± 5.795) when compared to mean FAAM score at 12 weeks (81.08 ± 5.900). The difference in mean FAAM score between pretreatment and 12 weeks of posttreatment was highest. This shows that the maximum effect of steroid on VAS score and FAAM score was at 12 weeks [Table 5]. The above results are comparable with the studies conducted by Johannsen et al.^[15] and Schneider et al.^[16]

Table 4: Comparison of effect of treatment methods (platelet-rich plasma and steroid) on visual analog score

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Table 5: Comparison of mean Foot and Ankle Ability Measure Score from baseline and mean foot and ankle ability measure score at frequent intervals in platelet-rich plasma group

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When both treatment methods were compared with respect to pain and function, we observed that in PRP group, there was steady decline in mean VAS score till 24 weeks of posttreatment. In the steroid group, the decline in mean VAS score was much faster during the initial period of posttreatment up to 12 weeks after that there was rise in mean VAS score. The mean VAS score was significantly lower at 4 weeks, 8 weeks, and 12 weeks in steroid group as compared to PRP group but at 24 weeks mean VAS score was significantly lower in PRP group as compared to steroid group [Table 6]. Similarly, the mean FAAM score was significantly higher at 4 weeks, 8 weeks, and 12 weeks in steroid group as compared to PRP group but at 24 weeks mean FAAM score was significantly higher in PRP group as compared to steroid group [Table 7]. The results of our study are comparable with the studies conducted by Shetty SH et al.,^[17] Mahindra P et al.,^[18] Ling Y et al.,^[19] and Soraganvi P et al.^[20]

Table 6: Comparison of mean Foot and Ankle Ability Measure Score at baseline and mean Foot and Ankle Ability Measure Score at frequent intervals in steroid group

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Table 7: Comparison of effect of treatment methods (platelet-rich plasma and steroid) on foot and ankle ability measure score

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In the current study, reduction in PF thickness measured by ultrasonography after 24 weeks of treatment in both the groups was statistically significant (P < 0.001). Although the reduction in the thickness was more in PRP group (35.90%) than steroid group (28.67%), yet did not reach a significant value [Table 8].^[13],[21]

Table 8: Test of significance of plantar fascia thickness in platelet-rich plasma group and steroid group

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Hence, this study outlines that intralesional injection of both the PRP and steroid are effective and safe modalities of treatment for plantar fasciitis. In addition, with respect to pain and function steroid is better for short-term treatment but in long-term follow-up PRP therapy is better than steroid.

In our study, three cases in steroid group showed no improvement in symptoms and they were treated with some other modality. We found no serious complications (local or systemic) in our study with either steroid or PRP therapy. Limitation of this study is the variability of platelet concentration among different patients, short duration of study, and small sample size. However, future studies with a larger patient population and a longer follow-up may provide a better insight into the efficacy of both treatment modalities.

Conclusion

Our study is a randomized prospective comparative study which showed that intralesional injection of both the PRP and steroid are effective and safe modalities of treatment for plantar fasciitis. However, steroid is better for short-term treatment but in long-term follow-up PRP therapy is better than steroid.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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