Information on Plantar fasciitis injections

Marc Darrow, MD, JD.

Over the years we have seen many patients with Plantar Fasciitis that had 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 explain that in many cases it is not usually 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.

plantar fasciitis

Some people with heel spurs have pain, some people with heel spurs have no pain. It may not be the bone spur causing the pain.

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.

The heel spur may not always be the primary source of pain

An October 2023 study (2) also noted: “Plantar fasciitis is the leading cause of heel pain, involving the inflammation or strain of the plantar fascia, resulting in a sharp or stabbing pain in the heel region. Although heel spurs can coexist with plantar fasciitis, they may not always be the primary source of pain.

And again noted in a February 2023 paper (3): “The presence and size of calcaneal spurs are associated with pain. However, it should be kept in mind that a high rate of spurs can also be found in painless feet, so spur is not the only factor that causes pain.”

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.”

However, a May 2024 retrospective analysis (5) of 45 patients suffering from plantar fasciitis with bone spurs suggested that patients underwent a four-step procedure, including plantar fascia release, calcaneal spur grinding, inflammatory tissue removal, and calcaneal burr decompression showed significant improvement in pain, function and bone spur size at 30 months follow up.

Plantar calcaneal spurs and plantar fascial thickening

This confusion is diagnosis was also the subject of a 2019 study (6) 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 (7):

  • “Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis.”

Corticosteroid Injections, Extracorporeal Shock Wave Therapy, and Radiofrequency Thermal Lesioning (Ablation)

A January 2021 study (8) compared the effectiveness of corticosteroid injection, extracorporeal shock wave therapy, and radiofrequency thermal lesioning (Ablation) treatments in chronic plantar heel pain that has been unresponsive to other conservative treatments.

The researchers “retrospectively analyzed the results of 217 patients treated with corticosteroid injection (73 patients), extracorporeal shock wave therapy (75 patients), and radiofrequency thermal lesioning (69 patients). The treatment efficacy and pain intensity, as measured using the visual analog scale, were recorded and compared at the 6-month follow-up.”

  • Pain intensity decreased significantly in all patients. However, it decreased significantly more in the corticosteroid injection and radiofrequency thermal lesioning groups than in the extracorporeal shock wave therapy group.

In May 2024, (9) researchers compared  extracorporeal shock waves versus corticosteroids injections on pain, thickness of plantar fascia and foot function in patients with plantar fasciitis. Sixteen studies involving 1121 patients, suggested at three months, extracorporeal shock waves were better than corticosteroids injections in reducing pain and thickness of the plantar fascia  and increasing foot function. At six months, extracorporeal shock waves are more effective in reducing pain and increasing foot function.

Dry Needling, cortisone and extracorporeal shock wave therapy

One study published in December 2021 (10) suggested that dry needling – the injection with nothing in it had better long-term pain relief (the dry needling technique is a therapeutic treatment as it causes an injury to the area and brings about an immune response).

A March 2024 study compared the effects of dry needling (DN) and extracorporeal shock wave therapy (ESWT) in the treatment of plantar fasciitis. The study included 55 patients with plantar fasciitis.

  • The patients were randomly divided into 2 groups.
    • The dry needling group applied 3 sessions of dry needling to the myofascial trigger points in the lower limb muscles.
    • The ESWT group applied 3 sessions of ESWT to the plantar fascia.
    • For clinical evaluation, the study used a visual analog scale (VAS 0 – 10 pain scale) (first step, rest, activity) and Foot Function Index (FFI) (pain, disability, activity).
    • Assessments were done baseline, post-treatment first week, and fourth week. Maximum pain-free standing time (Max PfST) and maximum pain-free walking distance (Max PfWD) were recorded at baseline and post-treatment fourth week.

The researchers found significant improvement in pain scores, Foot Function Index , Maximum pain-free standing time (Max PfST) and maximum pain-free walking distance (Max PfWD) in both groups.

VAS-activity (pain with activity) baseline-forth week change was significantly superior in the dry needling group compared to the ESWT group. FFI-disability baseline-fourth week change was significantly superior in the dry needling group compared to the ESWT group. This study showed that DN may be a good alternative treatment for patients with plantar fasciitis, with effects similar to or even superior to ESWT.

Platelet Rich Plasma (PRP) injections

PRP injections 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.

We are also asked about bone marrow derived stem cell injections. This too is an injection into the heel, plantar fascia area. This time with cells that have been drawn from the patient’s own bone marrow.

An April 2021, (11) makes the argument for biologic treatments such as PRP or cell injections: “Plantar fasciitis has been considered an acute inflammatory disorder. However, the local histologic findings represent a more chronic, degenerative state without inflammation. Patients may be stuck in a chronic state of cyclical inflammation leading to tissue degeneration, refractory symptoms, and disability. This idea process has influenced the treatment approach of some practitioners who have implemented the idea of regenerative medicine and use of biologic adjuvants in the treatment of plantar heel pain. Biologic therapies provide many different cellular components, growth factors, and proteins to restore normal tissue biology and are a useful adjunct in the treatment of recalcitrant plantar fasciitis.”

A January 2024 study (12) evaluated twenty-five plantar fasciitis patients who had failed conservative therapy for more than six months. In this group of patients, (48%) were between 21-30 years, nearly two-thirds (64%) were women. Sixteen patients had plantar fasciitis in both feet, while nine had it in one foot. Most female patients (75%) had bilateral plantar fasciitis.

Before PRP therapy, both the patients reported high self-reported pain scores for both heels. However, after PRP injections, the pain scores significantly decreased at three weeks, three months, and six months post-injection, indicating pain relief. The researchers concluded that: “The outcomes of a single dosage of PRP injections demonstrate clinically and statistically substantial improvements in functional outcome scores, plantar fascia thickness  . . . (and)  scores for heel pain. According to the results of this study, local PRP injection is an effective treatment for chronic plantar fasciitis.”

PRP and extracorporeal shockwave therapy beneficial for plantar fasciitis?

A study from February 2021 (13) found that PRP injections and extracorporeal shockwave therapy are both beneficial in pain amelioration in patients with chronic plantar fasciitis. The study authors also indicated that PRP injections were associated with better pain reduction results compared to extracorporeal shockwave therapy.

A February 2024 study (14) compared platelet-rich plasma (PRP) injections and extracorporeal shock wave therapy (ESWT). Six randomized controlled trials, comparing a total of 214 subjects in the PRP group and 218 subjects in the ESWT group, were analyzed. A significantly greater statistical improvement was seen in the PRP group in VAS pain (0 – 10 pain scoring) and plantar fascia thickness (PFT).

A study in the Journal of Foot and Ankle Surgery helps explain: (15)

  • 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 post-injection
  • 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.

Platelet-rich plasma (PRP) injection compared to corticosteroid injection

A study published in April 2020 (16) “summarizes all literature assessing the long term effects of platelet-rich plasma (PRP) injection compared to corticosteroid injection to relieve pain and improve function in Plantar Fasciitis patients.”

What this study found was ten prospective trials that examined the results in 543 participants. The PRP group had significantly better pain scores at 3 months and 6 months follow-up. PRP injections provide better pain relief, compared to corticosteroids, in patients with plantar fasciitis.

Study: Platelet-rich plasma has better mid-term clinical results than traditional steroid injection for plantar fasciitis.

Most recently, a study from July 2021 (17) suggested that Platelet-rich plasma has better mid-term clinical results than traditional steroid injection for plantar fasciitis. The study authors noted: “Recently, local platelet-rich plasma (PRP) injection has been gradually used in the treatment of plantar fasciitis. However, compared with traditional steroid injection, the clinical results of local PRP injection for plantar fasciitis patients remain controversial. Therefore, we performed a systematic review to focus on two questions as follows:

(1) is PRP more effective than steroid to relieve pain in plantar fasciitis patients?

(2) is PRP more effective than steroid to improve the foot and ankle function of plantar fasciitis patients?”

After reviewing twelve randomized controlled trials, involving 653 plantar fasciitis patients, the results showed that pain scores of the PRP group was significantly lower than that of the steroid group at 6-months, 1-year, and 1.5-year follow-up. Therefore “Compared to local steroid injection, local autologous PRP injection is more effective in relieving pain and improving the foot and ankle function at mid-term follow-up.”

In a November 2019 (18) 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 (19) 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, (20) 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.”

Seventy patients who failed three months of conservative plantar fasciitis care treatment were assessed for improvements following PRP or corticosteroid injections in a July 2023 study (21). Of the 70 patients, 35  received a platelet rich plasma injection of 3 ml and 35 patients received a local corticosteroid injection of 2 ml. The patients were then followed up with at 15 days, one month, three months and six months. After 1 month, 3 months and 6 months duration, the PRP injected study subjects showed significant relief in pain compared to corticosteroids.

“PRP may lead to a greater improvement in pain and functional outcome over corticosteroid injections.”

A 2020 study (22) 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.”

An April 2020 study,(23) 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.

Comparing Botox injections with PRP treatments

A study from March 2021 (24) compared corticosteroid and botulinum toxin A along with a third control group using a local anesthetic. The study found: “All patients showed better clinical outcomes compared with their initial evaluations, without differences between groups at the end of follow-up. . . Considering all the evaluated outcomes, no significant differences between treatment groups were observed. The pain relief and functional improvement obtained with the different treatments was maintained during the 6-month follow-up.”

This study was a single shot comparison, as stated in many of my articles we do not consider PRP treatments as a single shot treatment.

Doctors compared Platelet-rich plasma (PRP) and botulinum toxin type A injections for plantar fasciitis treatments in an October 2023 paper (25). In previous research, doctors found good outcomes in both treatments for patients suffering with plantar fasciitis treatment.

In this study, 59 patients were divided into a control group, single ultrasound-guided botulinum toxin type A injection group, or single ultrasound-guided PRP injection group.

Using patient reported outcomes surveys and questionnaires, the study researchers found better results at one month post injection in the  botulinum toxin type A. However,  the PRP injection group patients found better pain reduction and functional improvements in the long-term. Both the Platelet-rich plasma (PRP) and the botulinum toxin type A injections significantly reduced the average plantar fascia thickness at one month and three month examination.

Plantar fasciotomy with Platelet Rich Plasma

A December 2023 study (26) found that patients who had ultrasound guided percutaneous plantar fasciotomy with Platelet Rich Plasma faired better on self-reported surgical outcomes. In this study, doctors reviewed the post-surgery records of 30 patients and found the patients reported significant decrease in pain. However, the patients who were treated with PRP had a statistically significant decrease in pain level as compared to the patients who did not receive PRP treatments.

A February 2023 study (27) suggest the research above and “based on the current evidence, it is still being determined whether the modest benefits claimed for PRP for persistent plantar fasciitis are sufficient to justify its efficacy. Most of the research on the topic shows that PRP injection significantly improves plantar fasciitis.”

Prolotherapy injections

A November 2023 paper (28) the compared the use of dextrose prolotherapy for plantar fasciopathy versus normal saline and corticosteroid. “Low certainty evidence (insufficient data numbers or lack of controlled testing procedure) demonstrated that dextrose prolotherapy was superior to normal saline injections in reducing pain and improving function in the medium term, but moderate certainty evidence showed that dextrose prolotherapy was inferior to corticosteroid in reducing pain in the short term.”

A 2014 study (29) compared Prolotherapy to PRP for chronic recalcitrant plantar fasciitis. The researchers found all patients in both the Prolotherapy group and the PRP group showed significant improvements. They concluded: “PRP treatment also may lead to better initial improvement in function compared with dextrose Prolotherapy treatment.”

An August 2021 study (30) compared the effectiveness of ultrasound-guided dextrose Prolotherapy with radial extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis.

  • 59 patients were divided into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided interfacial 2 cc dextrose 20% injection (30 patients).
  • At six and 12 weeks after treatment, pain, disability and plantar fascia thickness were monitored.
  • Pain and disability patient reported outcomes showed significant improvements in pain and function in both study groups 6 weeks and 12 weeks after the treatments.
  • A significant reduction was also seen in plantar fascia thickness at these intervals.
  • Dextrose Prolotherapy is comparable to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with plantar fasciitis.

Kinesio taping and extracorporeal shockwave therapy

A January 2021 (31) study offered these observations on the use of Extracorporeal shockwave therapy (ESWT) and low-dye taping, which, the study suggests, is the most preferred method of banding treatments, provides an analgesic effect by correcting biomechanics.

The aim of this study was to compare the effectiveness of adjuvant (adding) low-dye kinesio-taping (KT), to sham-taping, with Extracorporeal shockwave therapy or alone Extracorporeal shockwave therapy in treating Plantar Fasciitis.

In this double-blind, sham-controlled study, 45 patients with Plantar Fasciitis were randomized into Group 3

  • Group 1: ESWT plus low-dye low-dye kinesio-taping : 15 patients.
  • Group 2: ESWT plus Sham-taping : 15 patients, and
  • Group 3: ESWT only : 15 patients.

The results were: “Although low-dye kinesio-taping in addition to ESWT was more effective on foot function improvement than additive sham-taping and ESWT alone, it did not provide a significant benefit on pain and heel tenderness because of Plantar Fasciitis.

Everything can be helped by weight loss

A February 2021 study (32) looked for the possible causes of chronic plantar fasciitis pain. The researchers of this study noted that “The lack of agreement on plantar fasciitis etiology makes treatment challenging and highlights the importance of understanding risk factors for preventive efforts.” What they recommended was that focus on body mass and weight and the load on the force-absorbing plantar surface structures may be a good starting point in the prevention and treatment of active individuals with plantar fasciitis.

This should be considered as more than passing advice from these researchers. Carrying extra weight, along with the obvious health risks it brings with it a suppressed immune system and a more challenging healing to an injury. This is highlighted by the findings of a February 2020 study (33) comparing PRP and cortisone treatments. In this research the cortisone injections provided more relief to obese patients than the PRP did. Let’ examine the study:

  • The researchers investigated the efficacy of local injection of platelet-rich plasma (PRP) compared with the conventional method of local corticosteroid injection in obese patients who were resistant to other nonsurgical treatments.
  • In this single-blind, randomized clinical trial, 32 obese patients with chronic plantar heel pain were randomly allocated to 2 groups of 16 participants each.
    • In 1 group, 40 mg of dimethylprednisolone was injected once into the painful heel, whereas the other group received 3 separate injections of PRP, with each injection administered 1 week apart.
  • The groups were compared at baseline and at 24 weeks after the injection, or course of injections, was administered.
  • Morning pain, and foot function index were not statistically significantly different between the groups at baseline; however, at 24 weeks after the treatment, final pain and morning pain scores were statistically significantly better in the corticosteroid group. In obese patients with plantar fasciitis, injection with corticosteroid was more effective than PRP at reducing pain and improving function.

One way to look at this study is to think that the PRP is not working as well as the cortisone because the immune system in the obese patient is compromised. The inability of the body to heal would be considered troubling for some.

A September 2020 study (34) found that “people with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion (range of motion) and lower BMI (body mass index), while they experience improved foot function (as well) if they have lower fear-avoidance beliefs and lower BMI.”

A January 2024 paper (35) assessed the effects of plantar fascia release and the use of foot orthoses on the medial longitudinal arch of the foot. This was a cadaver study. A cross-sectional study was designed (20 body-donors). Anthropometric measurements of the foot, foot posture index and the windlass test and force (toe extension when weight is applied) were measured in different conditions: unloaded, loaded position, with foot orthoses, after a 25% plantar fascia release and after a 50% release. The results indicate that the presence of foot orthoses leads to a significant increase in arch height compared to other conditions. Furthermore, when plantar fascia release is performed, the arch does not exhibit any signs of collapse.

More than just heel pain

An April 2023 study (36) demonstrated how heel pain went beyond the foot and impacted the persons’ whole body and mind. This is what the researchers wrote: “The suffering from persistent plantar fasciopathy does not seem to be limited to the foot alone. Participants in our study explained how they struggled on an individual level, but also how their pain affected their relationship with others and their surroundings. Aggravated pain while walking and the efforts to stay physically active predominated the participants’ lives. Furthermore, feelings of frustration, hopelessness, self-blame, dimished social interaction with others and worries of weight gain and its related consequences became daily experiences for participants with persistent plantar fasciopathy.”

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References:

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