PRP vs Steroid Injection for Heel Pain

PRP vs Steroid Injection for Heel Pain

Faculty Lawrence M. Oloff, DPM, FACFAS Team Podiatrist, San Francisco Giants San Francisco, California Thomas Chang, DPM Clinical Professor / Part Chairman Department of Podiatric Surgery Samuel Merritt School of Podiatric Medicine Redwood Orthopaedic Surgery Associates Santa Rosa, California

Faculty Disclosures Dr. Oloff disclosed no relevant financial relationships with any commercial interests. Dr. Chang has disclosed relationships with Stryker Orthopedics, Paragon 28, Synthes/BME, and Bioventus

Learning Objectives 1) Describe what PRP is and how it is prepared 2) Explain how PRP works 3) Demonstrate PRP technique for heel pain 4) Analyze which plantar fasciitis cases might benefit from PRP

Plantar Fasciitis PHASE I Footwear Nonsteroidal anti-inflammatory drugs (NSAIDs) Taping/orthotics/cups Night splint Physical therapy (PT) Activity modification Determine etiology

Plantar Fasciitis PHASE I Footwear NSAIDs Taping/orthotics/cups Night splint PT Activity modification Determine etiology PHASE II, III, IV Steroid injection Prednisone Immobilization Nontraditional

Plantar Fascia Surgery Surgical Success (60%-80%) Bordelon RL. Clin Orthop Relat Res. 1983;177:49-53. Daly PJ, et al. Foot Ankle. 1992;13(4):188-195. Furey JG. J Bone Joint Surg Am. 1975;57(5):672-673. Kinley S, et al. J Foot Ankle Surg. 1993;32(6):595-603. Lutter LD. Am J Sports Med. 1986;14(6):481-485. Mann RA, et al. Foot Ankle. 1981;1(4):190-224.

Heel Pain Etiology Plantar fasciitis Fascial tear Fracture spur Compartment syndrome Calcaneal stress injury Nerve entrapment Stenosing tenosynovitis FHL Fat pad syndromes Bursitis Radiculopathy FHL = flexor hallucis longus

Plantar Fascia Surgery Surgery No improvement Simple Not a finesse procedure Functional considerations

Plantar Fascia Surgery Complications Progressive loss of arch support function as fascia released medial to lateral Even partial fasciotomy decreases support function Risks may be greater in unstable feet Thordarson DB, et al. Foot Ankle Int. 1997;18(1):16-20. Kitaoka HB, et al. Foot Ankle Int. 1997;18(1):8-15.

New Technologies Regenerative medicine Orthobiologic Biologic therapy

New Technologies?

NEW TECHNOLOGIES?

NEW TECHNOLOGIES?

PRP: WHAT S ALL THE FUSS?

Platelet Rich Plasma: Science or Myth?

Growth Factors In Tendon And Ligament Healing Platelet-rich plasma (PRP) is defined as autologous blood with a concentration of platelets above baseline values Fitzpatrick J, et al. Orthop J Sports Med. 2017;5(1): 2325967116675272 [published online January 3, 2017]. Accessed September 27, 2017.

Growth Factors Process Sample autologous blood Centrifugation process PRP contains noncellular components (plasma) Administered with/without an activating agent Combining with CaCl and/or thrombin initiates platelet activation, clot formation, and growth factor release Wang HL, et al. Eur J Dent. 2007;1(4):192-194.

Growth Factors Process Two-phase centrifugation process (plasmapheresis) Liquid and solid components of blood separated First phase: "Soft spin" (1200-1500 RPM) plasma and platelets are separated from red blood cells (RBC) and white blood cells (WBC) Second phase: "Hard spin" (4000-7000 RPM) to further concentrate the plateletrich and platelet-poor plasma components Knezevic NN, et al. Med Clin North Am. 2016;100(1):199-217.

Growth Factor - Preparations More than 40 commercial systems Volume autologous blood Centrifuge rate/time Delivery method Leukocyte concentration Final growth factor concentration

Growth Factors Debate Debate exists as to the optimal quantity of platelets and growth factors required for muscle and tendon healing

System Volume of Blood Final Volume (ml) Final Platelet Concentration Autologous Conditioned Plasma (Arthrex) Cascade (MTF) GPS III (Biomet) 9 3-5 2-3x VOLUME AUTOLOGOUS BLOOD CENTIFUGE RATE/TIME DELIVERY 9 or 18 METHOD 2 or 4 N/A LEUKOCYTE CONCENTRATION FINAL GROWTH FACTOR 27 or 54 3 or 6 4-8x CONCENTRATION SmartPReP (Harvest Technologies) 20 or 60 3 or 7 4.4-7.6x Brand names are included in this table for participant clarification purposes only. No product promotion should be inferred. Hall MP, et al. J Am Acad Orthop Surg. 2009;17(10):602-608.

GROWTH FACTOR SOURCE FUNCTION Platelet-derived growth factor Vascular endothelial growth factor Platelets Platelets Stimulates cell replication, angiogenesis, mitogen for fibroblasts Angiogenesis Transforming growth factor-b1 Platelets Key regulator in balance between fibrosis and myocyte regeneration Fibroblast growth factor Platelets Stimulates proliferation of myeloblasts, angiogenesis Epidermal growth factor Platelets Proliferation of mesenchymal and epithelial cells, potentiation of other growth factors Hepatocyte growth factor Platelets Angiogenesis, mitogen for endothelial cells, antifibrotic Insulin-like growth factor-1 Platelets Stimulates myoblasts and fibroblasts, mediates growth and repair of skeletal muscle Hall MP, et al. J Am Acad Orthop Surg. 2009;17(10):602-608.

Growth Factors: Tendon and Ligament Healing IGF-1, PDGF-BB, bfgf Promote tendon healing Promote tendon cell proliferation Synergistic effect between growth factors Facilitate tendon engineering Costa MA, et al. Tissue Eng. 2006;7(12):1937-1943.

Rationale: Debridement & Growth Factors Chronic wound environment altered High type III/type I collagen ratio Cells produce abnormal collagen Long-term exposure to growth factors causes cells to produce faulty collagen

Plantar Fasciitis Rationale: Growth Factor Injections Compared single PRP vs single-use guided 40 mg methylprednisolone injection Phase 2 study, 40 patients randomized Control group (8 male/12 female) average 5.4 months conservative care and experiment group (9 male/11 female) 5.7 months 3cc PRP, cam walker 2 weeks. No NSAIDs for 2 weeks, and eccentric stretching America Orthopaedic Foot and Ankle Society scoring Cortisone group 52 points pre to 81 points post at 3 months, but dropped to 74 points at 6 months PRP group 37 points pre to 95 points post with no drop Monto RR. Presented at: 12th EFORT Congress; June 1-4, 2011; Copenhagen, Denmark. Paper #652.

Plantar Fasciitis Rationale: Growth Factor Injections Shetty VD, et al. Foot Ankle Surg. 2014;20(1):10-13. Kim E, et al. PM R. 2014;6(2):152-158. Martinelli N, et al. Int Orthop. 2013;37(5):839-842. Ragab EM, et al. Arch Orthop Trauma Surg. 2012;132(8):1065-1070. Wilson JJ, et al. Foot Ankle Spec. 2014;7(1):61-67.

Plantar Fasciitis Rationale: Growth Factor Injections Ragab and Othman looked at 25 patients who received PRP for chronic plantar fasciitis In their prospective study, they had a mean follow-up of 10.3 months, with patients pain decreasing from an average of 9.1 to 1.6 on the visual analog scale (VAS) post-prp injection They reported that 88 percent of patients were completely satisfied Ragab EM, et al. Arch Orthop Trauma Surg. 2012;132(8):1065-1070.

Plantar Fasciitis Rationale: Growth Factor Injections The results showed a baseline VAS measurement for the PRP group of 7.3 ± 1.8 initially, which decreased to 3.6 ± 2.6 at six months postinjection Results in the steroid group were 6.9 ± 1.7 initially, which decreased to 2.4 ± 3.0 at six months postinjection The tender threshold results (higher number is a better result) initially for the PRP group was 3.1 ± 1.2, which increased to 6.5 ± 2.9 at six months postinjection For the steroid group, the initial measurement was 3.7 ± 2.0, which increased to 8.6 ± 3.1 at six months postinjection Although all patients found both injections painful, there were no complications in either group The conclusion from this article was, Intralesional autologous blood injection is efficacious in lowering pain and tenderness in chronic plantar fasciitis, but corticosteroid is more superior in terms of speed and probably extent of Lee TG, et al. Foot Ankle Int. 2007;28(9):984-990. improvement.

Plantar Fasciitis Rationale: Growth Factor Injections Barrett and Erredge investigated the use of PRP for plantar fasciitis in nine patients The authors used ultrasound of the fascia before and after treatment, with the patients pain scale scores determining treatment efficacy They found that six of the nine patients achieved complete resolution of symptoms after two months; one patient required a second injection to achieve complete resolution The authors noted that 77.9 percent of their patients had no symptoms after one year of treatment They also concluded that ultrasound measurements of the thickness of the plantar fascia postinjection showed reduced thickness Barrett S, et al. Podiatry Today. 2004;17(11):37-42.

Plantar Fasciitis Rationale: Growth Factor Injections Aksahin and colleagues compared 30 patients treated with PRP with 30 patients treated with corticosteroid injection Over a six-month period, they found both groups of patients to have significant improvement in symptoms, but there were no statistical differences between the groups The authors felt PRP to be safer than corticosteroid injection with the same effectiveness Aksahin ED, et al. Arch Orthop Trauma Surg. 2012;132(6):781-785.

Growth Factor Injections May Be Useful for Plantar Fasciitis Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis

Growth Factor Injections May Be Useful for Plantar Fasciitis Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections May Be Useful For Plantar Fasciitis Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections May Be Useful For Plantar Fasciitis Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis Lemont HL, et al. Podiatr Med Assoc. 2003;93(3):234-237.

Growth Factor Injections for Plantar Fasciitis: Is it for You? Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis

Growth Factor Injections for Plantar Fasciitis: Is it for You? Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis

QUESTIONS Do growth factors enhance healing? Which factors work the best? How is it best administered? Does concentration make a difference? Is once enough?

In Conclusion: Growth Factor Injections May Be Useful for Plantar Fasciitis Primary treatment??? Recalcitrant cases Risky surgical candidates Prior surgery/injury Patient preference Fasciosis

Steroid Injection for Heel Pain Thomas J. Chang, DPM

Itis vs Osis Tendonitis/Fasciitis ACUTE reaction to an overused or stressed tendon Inflammatory cells are present Treated by rest and anti-inflammatory agents Tendonosis/Fasciosis CHRONIC pain in the major tendons caused by overuse Characterized by collagen degeneration and hypovascularity No inflammatory cells

Plantar Fasciitis Mechanical Treatment Inflammation Treatment

Confirming Diagnosis Normal measurement 3.22 mm Thomas A. Brosky II DPM & Jeremy Thomas PGYI DeKalb Medical Center 43

Confirming Diagnosis Abnormal fascia > 7 mm Thomas A. Brosky II DPM & Jeremy Thomas PGYI DeKalb Medical Center 44

Uden H, et al. J Multidiscip Healthc. 2011;4:155-164.

Recommendations Ultrasound Guidance Helpful Deep Injections better Gurcay E, et al. J Foot Ankle Surg. 2017;56(4):783-787.

Pai VS. J Foot Ankle Surg. 1996;35(1):39-40

Advanced Treatment Options for Plantar Fasciitis EPAT - Extracorporeal Pulse Activation Treatment PRP Platelet Rich Plasma RF Radio Frequency Debridement Ultrasonic debridement Goal Degenerative process Regenerative process

PRP Platelet Rich Plasma

PRP Uses the body s own products to stimulate healing Injecting fertilizer 20 cc blood 4 cc PRP Platelet concentration 6% 24% Noncovered service

Mark Scioli, MD

PRP - Contraindications Cancer or metastatic disease An active infection A low platelet count Pregnancy or breastfeeding

Jain K, et al. Foot (Edinb). 2015;25(4):235-237.

Monto RR. Foot Ankle Int. 2014;35(4):313-318.

Acosta-Olivo C, et al. J Am Podiatr Med Assoc. 2016 Oct 11 [Epub ahead of print].

David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Comparison: Cortisone and PRP David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Cochrane Review David JA, et al. Cochrane Database Sys Rev. 2017;6:CD009348.

Wilson JJ, et al. Clin J Sport Med. 2013;23(2):131. Steroid Superior

Buccilli TA Jr, et al. J Foot Ankle Surg. 2005;44(6):466-468.

Final Thoughts Structural preservation No burned bridges Clinical success