Tag Archives: plantar fasciitis

Platelet Rich Plasma for Plantar Fasciitis – writing about something I know nothing about…

Platelet Rich Plasma for Plantar Fasciitis


I have to be honest and admit that the use of platelet rich plasma (PRP) for plantar fasciitis is something that I have had no more than a superficial interest in. I pretty much scanned the abstracts of the studies and systematic reviews as they are published of it in this thread and the one comparing it to other interventions on Podiatry Arena. I also note comments in social media on it from those whose views I respect. From my superficial understanding, it works, it does not work, it works, it does not work … a lot of the studies that compare it to other treatments do not do the “other” treatment very well (ie wrong dosing), which can easily bias the study to PRP being better. Some of the comments in social media from people who I consider real experts, especially in the context of tendinopathy are that it does not work, yet a lot of people claim it does. Yes, I know that the “plantar fasica” is not a “tendon” and it may or may not be appropriate to translate “tendinopathy” research to “plantar fasciitis” (not that this stops people doing so or not doing so if the research on it matches their pre-conceived biases!).

I do note that the most recent meta-analysis of PRP concludes that it is as effective as other interventions. I do note when I glance at most of the studies that do get included in the systematic reviews and meta-analyses that there does appear to be some methodological issue with almost all of them, so how much weight should be given to them?

Anyway, as you can see, I really do not know much about PRP for plantar fasciitis except for that superficial understanding of the evidence and listening to those whose views I normally respect. However, my interest in PRP picked up a week ago when at the AAPSM meeting in San Francisco in which there was a presentation on the topic.

I stand to be corrected and have not verified this by searching the literature, but he said two things in the presentation that I think I interpreted correctly that really got me interested:

1) Local anaesthetic deactivates the PRP. What this means is that if a lot of local was infiltrated in the area vs just a small superficial amount prior to the PRP injection then this may affect the clinical effectiveness of the PRP. Of more importance, if a lot of local was used in a study of PRP, then that would bias the study in the direction of the PRP not being effective. That study is unlikely to be excluded from a meta-analysis or systematic review if all the other methodological issues are sound (ie sample size, blinding etc).

2) The effectiveness of PRP in tendons (he did not mention this in the context of the plantar fascia) might depend on the leucocyte concentration in the PRP. I have not checked the literature on this, but I think he said the PRP works in tendons if the leucocyte concentration is high and does not work in tendons if the leucocyte concentration is low. If this is correct, then it is easy to see how a study could be biased against it working if the leukocyte concentration is low. Those low leucocyte concentration studies will be included the in the meta-analyses and biases them in the direction of PRP not being effective for tendons.

Again, I no expert (or even have a little knowledge) in this and I only superficially aware of the literature in this, but even I can see the issues here. The use of small vs high amounts of local before injecting the PRP and the effectiveness of high vs low concentration of leukocytes in the PRP are issues that need to be resolved and potentially could have huge impacts on the results of individual studies, systematic reviews and meta-analyses; and, more importantly, policy recommendations and clinical guidelines that grow out of that. I see this as a serious problem.

It may well be that if studies are repeated on the local anaesthetic dose and the leucocyte concentration that it does not affect the outcome and then will not bias the systematic reviews and meta-analyses. It is, however, an issue that should be resolved.

Does PRP work for plantar fasciitis? My conclusion is that we do not yet know.

Does this sound familiar? Its the same issues I wrote about on foot orthotic dosing … or am I just being biased or using the logical fallacy of ‘special pleading’?

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Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+

Plantar fasciitis loading programs – overhyped evidence

I have managed to get myself into a few spats in social media lately over the results of the Rathleff et al (2014) study on loading programs for plantar fasciitis mainly because I think the study is way overhyped and blindly and widely shared by too many devoid of critical thinking skills. I blogged about this study at the time on my other blog, so thought I would re-litigate the main issues here, so I can refer those in my social media spats to have a read of.

Firstly, I do clinically use the loading/strengthening program that is advocated in this study, have been using it and teaching it in my Clinical Biomechanics Boot Camps since before the study was published, so I like it and think it is important to do. I use it as it makes sense to do so. The approach I have long advocated for plantar fasciitis is to deal with that initial ‘hot’ phase (ice, NSAIDs; strapping); then reduce loads (activity modification; foot orthotics with the right design features (getting that right is important); stretching); then loading and strengthening; then return to full activity plan; if that does not go according to desired outcomes, then do things to facilitate healing (eg shockwave, injection therapy, etc). Above all, plantar fasciitis is a mechanical problem and needs mechanical solutions (initially reduce loads, then increase loads).

So what is the problem I have with the Rathlef et al study? The problem I have, is the hype and importance that is given to it. It is way over hyped. It still gets widely promoted in social media. The strength of evidence that the study gives to the use of a loading program is really low, if at all. It should not make it into a meta-analysis or any sort of consensus document because of that weakness (unless, of course, those writing the consensus document want to use it to confirm their preconceived biases).

The study randomized participants with plantar fasciitis into two groups. One group got the strengthening/loading program and the other a stretching program. Both groups got better, but at 3 months the loading program group did better. On the surface that looks like a good outcome for loading programs.

However, both groups were also given silicone heel pads which we know from the Pfeffer et al (1999) study that they work in plantar fasciitis. Both groups were probably going to get better because of that. It could easily have been that both the stretching and loading/strengthening actually delayed healing but they still got better because of the silicone heel pads. The claimed results that the loading group did better could easily be explained by the loading/strengthening not delaying healing as much as the stretching group. The study did not have a ‘no treatment’ group or control group. Now, in all honesty, I very much doubt that is what happened, but because it remains a possibility to explain the results, you can see why I think the results of the study are way over-hyped and given too much weight. This is also why the strength of the design of the study is so weak, as we do not know how a placebo or no treatment group would have gone (or preferably, a group just given the silicone inserts). If there was a third group that just had the silicone insert, then presumably this group would have improved (as the Pfeffer study showed), so how much better than that would have the stretching and strengthening/loading groups have been, if at all? We just do not know.

Another issue, and I on shaky grounds saying this, is look at the graph in the paper of the results. Look at the reduction in the Foot Function Index at say 3 months and at 6 months. How well do you think you would be doing in clinical practice if that was all you were getting in your patients? Like I said, I on shaky grounds saying this as this is the artificial environment of a clinical trial, but if you are not getting those levels of pain reduction at 1 month, then you probably need to take a serious look at your clinical practice as to why.

…nuff said. Critical thinking please. Next.

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Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+