I wanted to see how effective a new technique—platelet-rich plasma (PRP)—would be with patients who have chronic plantar fasciitis. These patients had symptoms for a long time and traditional treatment modalities weren’t working for them,” explained Raymond Rocco Monto, MD, who presented his paper, “PRP Is More Effective than Cortisone for Chronic Severe Plantar Fasciitis” during the 2012 AAOS Annual Meeting. “To examine the worst-case scenarios, I specifically wanted patients whose symptoms weren’t responding to conservative treatment.”

According to Dr. Monto, chronic plantar fasciitis is a common, yet occasionally difficult, condition to treat successfully. Improved outcomes using PRP as a treatment in a study of patients with severe, chronic, Achilles tendinitis led him to consider using PRP with his plantar fasciitis patients.

Dr. Monto identified 40 patients (17 men, 23 women) whose severe chronic plantar fasciitis had failed to respond to traditional nonsurgical treatments (rest, physical therapy, silicone heel lifts, CAM (controlled ankle motion) walker bracing, cast immobilization, night splinting, and nonsteroidal medication) and block randomized them into two study groups.

Control group participants (8 men, 12 women) were an average of 59 years old (range: 24 to 74 years) and had previously had, on average, 5.4 months (range: 4 to 24 months) of standard nonsurgical management. Prior to treatment, control group patients had an average American Orthopaedic Foot & Ankle Society (AOFAS) score of 52 (range: 24 to 60).

Patients in the experimental group (9 men, 11 women) were an average of 51 years old (range: 21 to 67 years) and had had 5.7 months (range: 4 to 26 months) of standard nonsurgical management, with an average pretreatment AOFAS score of 37 (range: 30 to 56).

The control group received a single ultrasound-guided injection of 40 mg methylprednisolone at the injury site. Patients in the experimental group received a single ultrasound-guided injection (3 mL) of unbuffered autologous PRP at the injury site.

All patients were fitted with an inflatable walking Aircast fracture boot, worn for 2 weeks. They were started on eccentric home exercises and allowed to return to normal activities as tolerated and without support. Patients were given a home eccentric exercise and stretching program and were not permitted to use nonsteroidal medications during the first 2 weeks after treatment.

Encouraging results
At 3-month follow-up, AOFAS scores had improved for all patients. The mean score for patients in the control group was 81 (range: 60 to 90), while for patients in the experimental group it was 95 (range: 84 to 90).

However, the average score for patients in the control group fell to 74 (range: 56 to 85) at the 6-month follow-up and to 58 (range: 45 to 77) at 12 months. In contrast, the average score for patients in the experimental PRP group remained high, at 94 (range: 87 to 100) at both 6 months and 12 months (Fig. 1).

Despite the long-term success of PRP in this study, Dr. Monto notes that the fundamental treatment paradigm of rest, ice, eccentric exercise, activity modification, and selective immobilization is still successful in most patients with mild to moderate disease and should not be abandoned.

“I have been most impressed by the durability of the treatment,” said Dr. Monto. “I had expected the results to degrade over time. In the early results, the cortisone patients did very well, but after initial follow-up, their scores began to recede, and at 6 months the difference was significant. At 12 months, many of the patients who received cortisone had returned to their baseline, whereas the PRP-treated patients had retained most of their improvement. I continue to monitor the patients’ progress, with the goal of reporting 2-year follow-up.

“I consider these results encouraging, but of course this is an early clinical study,” explained Dr. Monto. “Eventually we want to generate good Level I or Level II research to determine in what cases PRP is effective and in what cases it is not and to optimize our delivery vectors.”

Disclosure information: Dr. Monto—Exactech, Inc.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Additional Resources
Platelet-Rich Rich Plasma is More Effective than Cortisone for Chronic Severe Plantar Fasciitis