Over the years we have seen many patients with Plantar Fasciitis that have been unresponsive to conventional treatments. These conventional treatments included physical therapy, cortisone, and anti-inflammatories. While not the best choice for doctor or patient, many of these people considered the surgical option as the ultimate choice because they “have to do something.” But will surgery be any more effective? We will cover this in research cited later in this article.
Is it the heel spur causing pain or is it plantar fasciitis?
When a patient comes into our office with plantar fasciitis and a bone or heel spur revealed on an x-ray or an MRI, the first thing they want to know is can we get rid of the bone spur? I usually have to do a little convincing that it is usually not the bone spur that is causing them their pain and that heel spur is not the issue we want to tackle at the start of the treatment. I explain to the patient that the issue is that you’re overdoing an activity which is irritating the place where the fascia (the soft tissue that connects the toes to the heel) meets the heel bone. When that irritation is constant and chronic, bone spurs form. We want to treat that problem.
Some people with heel spurs have pain, some people with heel spurs have no pain. Some people get plantar fasciitis
There was an interesting study published recently in the Journal of Anatomy. (1) It is a very detailed analysis of heel spurs. Listen to what these researchers said:
- Bone spurs can cause painful heels in some patients. However, many people with bone spurs in the heel have no painful symptoms that can be pinpointed to the bone spur. The pain is coming from somewhere else.
- Many things can cause the formation of heel spurs including tears in the plantar fascia and plantar fasciitis.
- Plantar fasciitis is hypothesized to be due to mechanical overload of the Plantar fascia resulting in microtears; the repeated trauma from heel strike does not allow the foot to heal itself and results in a chronic fascial inflammatory condition.
- Heel spurs are present in 45–85% of those with plantar fasciitis; they also share a number of risk factors such as obesity and advancing age, suggesting that the two may be linked.
- However there is little evidence of an active inflammatory response suggesting that this condition is more of a degenerative fasciosis rather than an inflammatory fasciitis.
In many people, plantar fasciitis is not an “itis,” or an inflammation problem, but an “osis,” a degenerative problem that anti-inflammatories will not help in the long run.
Plantar calcaneal spurs and plantar fascial thickening
This confusion is diagnosis was also the subject of a 2019 study (2) which suggested:
“Plantar calcaneal spurs and plantar fascial thickening frequently coexist in individuals with plantar heel pain.”
“Tenderness on palpation of the heel has limited value for clinical assessment.”
“Plantar heel pain is multifactorial and cannot be exclusively attributed to individual imaging findings.”
Simply, pain in the heel and imaging studies may not present an accurate picture of which is going on.
Knowing the thickness of the plantar fascia may not be helpful to successful treatment
As the first two studies suggest, a patient will come in, they have an MRI report that talks about plantar fascia thickening. That problem, they have been told, is THE problem. Anti-inflammatories will be recommended. A 2018 study says, not so. Plantar fascia thickening is NOT THE problem. At the Istanbul Training and Research Hospital in Turkey doctors reported the findings of their study (3):
- “Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis.”
Surgery? “Open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery.”
Surgeons in the United Kingdom wondered why “successful” partial plantar fascial release surgical techniques were not as successful as they would have thought. This is what they said in their research (4):
“Plantar fasciitis is thought to be a self-limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and surgery may be indicated. Partial plantar fascial release is reported to have a short-term success rate of up to 80%, but anecdotally this was not thought to represent our local experience.”
“A prolonged recovery period and generally poor outcomes leads the authors to suggest that open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery.”
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
We are also asked about Stem Cell Therapy. Sometimes this treatment may be used. This too is an injection into the heel, plantar fascia area this time with stem cells that have been drawn from the patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen and soft tissue such as fascia.
Often I am asked to compare these treatments to cortisone.
Often I am asked to compare these treatments to cortisone. Simply, we prefer the regenerative medicine techniques of PRP and stem cells vs. cortisone. We have over 20 years experience in seeing the clinical results.
A study in the Journal of Foot and Ankle Surgery helps explain: (5)
- Previous studies have shown the superiority of Platelet-rich plasma (PRP) over corticosteroids for chronic plantar fasciitis.
- The aim of this study was to compare the pain and functional outcomes of PRP with cortisone and placebo injections for the treatment of chronic plantar fasciitis.
- 90 patients:
- PRP (30 patients),
- Cortisone (30 patients),
- and placebo ( 30 patients).
- The patients were followed at regular intervals until 18 months postinjection
- Cortisone showing significantly better improvement than PRP in the short term, whereas longer-term PRP was significantly better than corticosteroids.
- In summary, both PRP and Cortisone are safe and effective treatment options for chronic plantar fasciitis, showing superior results to placebo treatment. The longer-term results and less reinjection and/or surgery rate of PRP makes it more attractive as an injection treatment option versus corticosteroids injection.
Three recent studies in The American journal of sports medicine. PRP better than cortisone
In a November 2019 (6) study, Orthopedic surgeons in the Netherlands found that when they treated patients with PRP and corticosteroid, “treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.”
Similar findings were published in December 2019 (7) from Orthopedic surgeons in China who wrote: “The use of PRP yields statistically and clinically better long-term functional improvement than that of corticosteroid in the treatment of plantar fasciitis.”
In November 2019, (8) doctors reporting on their study findings in the Malaysian orthopaedic journal wrote: “Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long lasting beneficial effect.”
The treatment of Plantar Fasciitis requires a physical examination and a look at how this problem is impacting you. If you were to come into my office we would assess and evaluate your situation and discuss the realistic healing options possible.
“There is no advantage of corticosteroid”
A 2020 study (9) compared PRP to to corticosteroid injections for pain control in cases of plantar fasciitis. The results of this study: “systematic review and meta-analysis suggest that PRP is superior to corticosteroid injections for pain control at 3 months and lasts up to 1 year. In the short term, there is no advantage of corticosteroid infiltration.”
“PRP may lead to a greater improvement in pain and functional outcome over corticosteroid injections.”
An April 2020 study,(10) this time in the Orthopaedic journal of sports medicine, examined nine randomized control studies which combined compared 239 patients with PRP with 240 patients with corticosteroid injections. At the follow-up time points, including one month to 1.5 months to three months to six months to 12 months, there were statistically significant differences in pain reduction scores in favor of PRP . At 1 and 3 months, there was no difference in pain scores However, at 6 and 12 months, there was a difference in pain scores in favor of PRP.”
Conclusion: In patients with chronic plantar fasciitis, the current clinical evidence suggests that PRP may lead to a greater improvement in pain and functional outcome over corticosteroid injections.
Do you have questions? Ask Dr. Darrow
A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025
Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.
1 Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. J Anat. 2017 Jun;230(6):743-751. doi: 10.1111/joa.12607. Epub 2017 Mar 29. PubMed PMID: 28369929; PubMed Central PMCID: PMC5442149.
2 Menz HB, Thomas MJ, Marshall M, Rathod-Mistry T, Hall A, Chesterton LS, Peat GM, Roddy E. Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain. Rheumatology (Oxford). 2019 Feb 1;58(2):237-245. doi: 10.1093/rheumatology/key266. PMID: 30204912; PMCID: PMC6519610.
3 Ermutlu C, Aksakal M, Gümüştaş A, Özkaya G, Kovalak E, Özkan Y. Thickness of plantar fascia is not predictive of functional outcome in plantar fasciitis treatment. Acta Orthop Traumatol Turc. 2018 Nov;52(6):442-446. doi: 10.1016/j.aott.2018.01.002. Epub 2018 Oct 9. PubMed PMID: 30314878; PubMed Central PMCID: PMC6318475.
4. MacInnes A, Roberts SC, Kimpton J, Pillai A. Long-term outcome of open plantar fascia release. Foot & ankle international. 2016 Jan;37(1):17-23.
5. Shetty SH, Dhond A, Arora M, Deore S. Platelet-Rich Plasma Has Better Long-Term Results Than Corticosteroids or Placebo for Chronic Plantar Fasciitis: Randomized Control Trial. The Journal of Foot and Ankle Surgery. 2019 Jan 1;58(1):42-6.
6. Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial. Am J Sports Med. 2019 Nov;47(13):3238-3246. doi: 10.1177/0363546519877181. Epub 2019 Oct 11. PubMed
7 Huang K, Giddins G, Wu LD. Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis. Am J Sports Med. 2019 Dec
8 Soraganvi P, Nagakiran KV, Raghavendra-Raju RP, Anilkumar D, Wooly S, Basti BD, Janakiraman P. Is Platelet-rich Plasma Injection more Effective than Steroid Injection in the Treatment of Chronic Plantar Fasciitis in Achieving Long-term Relief? [Google Scholar]
9 Hohmann E, Tetsworth K, Glatt V. Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis [published online ahead of print, 2020 Aug 21]. Am J Sports Med. 2020;363546520937293. doi:10.1177/0363546520937293
10 Hurley ET, Shimozono Y, Hannon CP, Smyth NA, Murawski CD, Kennedy JG. Platelet-Rich Plasma Versus Corticosteroids for Plantar Fasciitis: A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med. 2020;8(4):2325967120915704. Published 2020 Apr 27. doi:10.1177/2325967120915704