By Al Kline DPM

 

Introduction 

Autologous blood injections for the treatment of plantar fasciitis is relatively new to the literature.  In podiatry, this is a relatively new and poorly studied treatment technique as an alternative to steroid injection therapy.  The idea and use of autologous blood injection stems from studies performed in 2004 using autologous blood injections for the treatment of refractory lateral epicondylitis.  Edwards and Calcandruccio reported on 28 patients who underwent autologous blood injections for the treatment of lateral epicondylitis or tennis elbow.  14 men and 14 women enrolled in the study.  Symptoms of epidondylitis had persisted for over 3 months in duration.  Conservative care was also instituted prior to the study including physical therapy, splinting, nonsteroidal anti-inflammatory drugs and local steroid injections.  2 milliliters of blood was withdrawn from the dorsal vein of the hand and mixed with 1 mL of 2% lidocaine or 1 mL of 0.5% bupivacaine.  This mixture was then reinjected just proximal to the lateral epicondyle of the elbow along the supracondylar ridge and then advanced into the undersurface of the extensor carpi radialis.  The patients were then splinted and told to not use any nonsteroidal anti-inflammatories.  During the first 3 weeks after injection, the patients were restricted from therapy or activity.   At 3 weeks, patients began interval wrist motion and stretching therapy.  By 6 weeks, they were released to full activity.  Using the Nirschl pain scale, patients were asked to rate their pain before and after injection.  If pain did not resolve within 6 weeks, an additional injection was offered.  Of the 28 patients enrolled in the study, 9 patients underwent additional injections.  Of those 9, 2 required a third injection.  Fourteen of the 28 patients had complete and total pain relief.  Of the patients who required additional injections, all had complete pain relief and resolution of symptoms following the injection therapy. 

It is thought that introducing autologous blood into an area of inflammation will initiate the inflammatory cascade and promote healing in an otherwise degenerative process such as tendonosis or fasciosis.  In 2004, Dr. Barrett discussed the misnomer of using the term plantar fasciitis.  He suggested that the condition is not an inflammatory entity and points out that researchers have been unable to find inflammatory cells microscopically in cases labeled fasciitis.  He suggested that the condition is rather a degenerative condition of the fascia.  He points to a landmark study performed by Lemont in 2003 and termed chronic conditions of heel pain as plantar fasciosis (see article Coblation Technique in the Treatment of Plantar Fasciosis ).  Barrett et al also reported on the use of injectable Autologous Platelet Concentrate (APC+) for the treatment of plantar fasciosis.  The hypothesis was to injecting APC+ into recalcitrant, symptomatic plantar fascia in an attempt to cause a reparative effect leading to a resolution of symptoms. He termed this technique plantar fasciorraphy.  His study included 9 patients who enrolled in the study.  The patients agreed to forego steroid injection treatment within 90 days of the study and not undergo any therapy, NSAID treatments or wear orthotics.  All patients had thickened fascial hypertrophy on ultrasound examination confirming plantar fasciosis.  20 cc’s of the patient’s blood was withdrawn and using the Smart Prep® System (Harvest Technologies), 3 cc’s of APC+ was obtained for injection.  A posterior tibial and sural nerve block was then performed and under ultrasound guidance using a 25 gauge needle, 3 cc’s of APC+ was then injected into the most hypoechoic areas of the plantar fascia.  The patients were then placed in a below the knee cast immobilization boot and advised to avoid weight bearing for 48 hours.  Patient could then resume ambulation over the following days.  Patients were monitored at varying intervals post injection phase.  Using ultrasound measurement, an overall reduction in the thickness of the fascia was demonstrated post injection.  Of the 9 patients enrolled, 6 patients reported complete relief of symptoms post injection.  At one year post study, 7 of the 9 patients had complete relief of symptoms (about 77.8%).  Barrett stated the results were comparable to the Edwards study. 

More recently, Mark Scioli at the Center for Orthopedic Surgery in Lubbock, Texas reported on the treatment of recalcitrant enthesopthy of the hip using Platelet Rich Plasma.  His report included 3 case studies of patients with chronic, severe greater trochanteric bursal pain.  Using the GPS or Gravitational Platelet Separation System (Biomet), 50 cc of whole blood was withdrawn yielding about 8-10 cc’s of platelet-rich plasma.  This was then injected with a 23 gauge needle down to trochanteric bone, gently withdrawn, and repositioned into the bursal tissue beneath the fascia lata.  Points of maximum tenderness were marked preinjection.  He reported that all 3 patients noted a dramatic relief with improved ability to get up and down, walk and roll over at night. 

In May 2006, Platelet-Rich plasma was also used in a study to treat chronic elbow tendonitis.  In a cohort study, Mishra and Pavelko studied 140 patients with elbow epicondylar pain and noted a 60% improvement using the visual analog pain scale.  This compared to only 16% in a control group.  By 6 months, the treatment group noted an 81% improvement and by 2 years there was a 93% reported improvement after injection treatments. 

 

The question then comes to mind:  How does APC+, autologous blood and other non-steroidal injectibles compare to traditional steroid injection therapy that has been used for years?  The most recent report in JAPMA in 2006 did just that.  In a prospective randomized study of plantar heel pain in 45 patients , 3 groups of 15 patients each were treated with 1mL of 2% prilocaine using the peppering technique, 1mL of 2% prilocaine combined with 2mL of autologous blood or 1mL of 2% prilocaine mixed with 40mg of methlprednisonolone acetate respectively.  One patient in the corticosteroid injection group discontinued the study after 3 months, so the data is based on 44 patients.  Results were analyzed using sample t-tests within groups and repeated-measures analysis of variance between groups.  At 6 month follow-up, clinical improvement was evaluated using a 10-cm visual analog scale and the rear foot score of the American Orthopaedic Foot and Ankle Society.   Kiter, et al found no statistically significant difference among the 3 groups tested.  This would suggest that injection results of corticosteroids will provide the same level of success as autologous blood or even traumatic peppering of the fascia with simple anesthetic and needle dissection of the fascia.  However, these techniques including autologous blood injection appear to be viable techniques and a good alternative to corticosteroid injection therapy. 

On-going Studies 

 

Recently, I have been email corresponding with  Robert Martin MD at the Naval Branch Health Clinic in Mayport, Florida.  He is presently studying the effects of autologous blood injections for the treatment of plantar fasciitis.  He started performing the injections  over 3 years ago and has treated over 200 patients with autologous blood injections for plantar fasciitis.  He has all but abandoned steroid injection therapy and reports up to 80% success rate with the injection technique.  He has used this technique on competitive marathon runners, semipro baseball players, waitresses, and elderly patients. One patient was a Navy Seal jumping out of helicopters in Iraq and the procedure helped him in a few days. He suggested that he would never consider giving a steroid injection and let someone jump out wearing 50 lbs of armor and weaponry because the risk of fascial rupture from steroid therapy was too great.   

 

Dr. Martin recently presented his results at the annual American Medical Society of Sports Medicine (AMSSM) meeting.  His report included sixteen patients with plantar fasciitis that were offered autologous blood injection after other conservative measures had been tried. The patients surveyed had plantar fascia pain duration ranging from 3 months to 5 years with average being 1.79 years.  Fifty-six percent had tried orthotics, 94% had tried physical therapy, 63% tried night splints and 50% had tried at least one steroid injection. All patients were instructed to stop NSAIDs for two weeks prior to injection.  A bolus of 1 ml of Lidocaine and 2 ml of blood was injected where the plantar fascia was most tender. Patients rated their pain (0-10) and Nirschl staging (0-7) at least 4 weeks after injection.  Prior to injection, 15 of 16 patients reported pain with light activities of daily living and exercise was not possible (Nirschl 6 or greater).  After autologous blood injection, the average pain severity scale decreased from 7.13 to 2.75.  The average Nirschl activity staging scale decreased from 6.19 to 2.88. Ten of sixteen patients (62%) were able to resume strenuous activity.  Seven of these ten (70%) that returned to strenuous activity could do so without pain. Three of the sixteen (19%) surveyed reported no response to blood injection.    Autologous blood injection for plantar fasciitis is a safe, simple and inexpensive office procedure that offers dramatic results in many patients that have failed other treatments.  Further large-scale prospective studies would help develop treatment protocols for this promising new treatment option. 

 

Conclusions 

Autologous blood injection appears to be a viable alternative to steroid injection therapy.  It appears to be safe and no reports of reflex sympathetic dystrophy, infection or other major complications have been reported thus far.  More recent studies have suggested that steroid treatment and fascial peppering with local anesthetic and fascial dissection may have similar results to autologous blood injection therapy.  Further study will likely be considered in the future.

 

 

 

References 

 

Edwards S, Calandruccio J: Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 28A (2):272-278, 2003. 

 

Barrett, S.L. , Erredge, S.E.  Growth Factors for Chronic Plantar Fasciitis?  Podiatry Today Vol.17-Issue 11- pages: 36-42 ,  November 2004  

 

Scioli, M.  Treatment of recalcitrant enthesopathy of the hip with Platelet rich Plasma- A report of Three Cases  COSNEWS, An Official Publication of The Clinical Orthopaedic Society, Spring 2006. 

 

Mishra, A, Pavelko, T  Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma.  The Am J of Sports Med  34:1774-1778, 2006. 

 

Kiter, et al  Comparison of Injection Modalities in the Treatment of Plantar Heel Pain  A Randomized Controlled Trial  JAPMA. 96, No.4, 2983-296, 2006

 

 

© Al Kline DPM, 2006