Platelet-Rich Plasma Applications in Foot and Ankle: Comparison
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Platelet-rich plasma can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. The platelet-rich plasma (PRP) therapy technique is still relatively new, yet it has already seen widespread application in the orthopedic field. Positive effects of PRP on various musculoskeletal conditions. PRP can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. 

 

  • platelet-rich plasma
  • foot and ankle
  • Achilles tendon
  • plantar fasciitis
  • review

1. Effectiveness of PRP for Bone Nonunion

Platelet-rich plasma (PRP) influence on bone healing has been extensively studied in vitro and in vivo [1][2][3][4][5][6][7]. The hypothesis is that platelets and their growth factors will boost osteopontin, osteoprotegerin, osteoblast, osteoclast-like cells, and the differentiation of myoblasts and osteoblastic cells [5][6][7][8][9]. PRP’s effectiveness at bone healing is still debated. Many studies indicate promise, while others show little difference between PRP and control or standard products.
In a study conducted by Gandi et al. [10], nine patients with nonunion after surgery for foot and ankle fractures were treated with PRP. All patients underwent the initial surgery within 20 days of the fracture and were diagnosed with nonunion within four to ten months after surgery. PRP combined with autograft was applied to the nonunion in the second revision surgery. The results showed that all nonunions healed after revision, and the mean healing time was 60 days. The authors also compared the growth factor concentrations in the hematoma at the fracture site in patients with nonunion and union and found that the concentrations of PDGF and TGF-β in nonunion hematoma were significantly lower than those in fresh fractures. 
In a prospective clinical study by Bibbo, 62 patients with high-risk factors for nonunion for elective foot and ankle surgery were followed for six months after receiving PRP [11]. The patients underwent surgery on different parts of the foot and ankle. Some of the patients received PRP therapy and autologous bone graft as required. The efficacy of PRP was evaluated by radiography every two weeks after surgery, and 94% of patients achieved bone union on average 41 days after surgery. The mean bone healing time of patients treated with PRP alone was 40 days, while that of patients treated with combination therapy was 45 days [11]. The authors believe that PRP is important for treating patients at high risk of nonunion. 
Coetzee and colleagues compared the effect of the PRP treatment with or without ankle replacement on the rate of syndesmosis fusion [12]. After the distal tibia and talus osteotomy, PRP was applied to the lower tibiofibular joint, the talus osteotomy’s surface, and the joint prosthesis’s surface. PRP and autograft were used in the lower tibiofibular joint. Radiographs were reviewed regularly after surgery. If the bone fusion is suspicious, they gave a CT review. The results showed that, compared with the 112 patients in the control group who did not receive the PRP treatment, the improvement rates of the lower tibiofibular fusion at 8 weeks and 12 weeks after surgery were 61.4% and 73.6%, respectively. Compared with the control group, the fusion improvement rates in the combined PRP and autograft group were 76% and 93.9%, respectively. PRP also significantly reduced the incidence of poor union or nonunion at the fusion site six months after surgery. 

2. Effectiveness of PRP Use in Ankle Sprains

Although there is currently limited evidence supporting the use of PRP in treating acute ankle sprains, it is becoming increasingly apparent that this treatment can improve the return to activity and reduce the severity of the injury. A small study on a group of elite athletes revealed that they had a quicker recovery and less pain after using PRP. In this study, the athletes who received ultrasound-guided PRP injections had a quicker recovery than those who received the same rehabilitation program without any treatment. They also performed better when returning to sports [13]. In a similar study, rugby players who suffered from syndesmotic injuries were more likely to recover faster after a PRP injection than those who had undergone the same rehabilitation program [14]. There is currently insufficient evidence supporting platelet-rich plasma (PRP) in treating ankle sprains. Rowden et al. conducted a double-blinded study to compare the effectiveness of the ultrasound-guided treatment of acute ankle sprain with local anesthetic versus standard saline injection [15]. They found that there was no statistical difference between the groups when it came to the VAS pain score and the Lower Extremity Functional Scale (LEFS). More research is needed to determine if this treatment can improve recovery and prevent further injury.

3. PRP Use in Achilles Tendon Pathology

3.1. Effectiveness of PRP Injections in Nonoperative Management of Achilles Tendinopathy

The effectiveness of PRP at treating Achilles tendinopathy has been studied. Various treatment options are available, such as dry needling and shock wave therapy. Previous studies have shown that using PRP can stimulate the differentiation of tissue stem cells (TSCs) into tenocytes. However, it cannot reverse the differentiation of these cells into non-tendinous tissues [16]. A study conducted on using ultrasound-guided tenotomy followed by the injection of PRP to treat chronic tendinopathy revealed that this procedure is very safe and effective [17]. In 2019, a randomized controlled trial revealed that the use of PRP significantly reduced pain and increased the function of the patients [18]. Erroi et al. performed a study on 45 individuals with insertional AT. They examined the effectiveness of shock wave therapy and PRP injections. Although both treatment options improved measured outcomes, there were no significant differences between the groups [19].
A second study analyzed the effectiveness of PRP and dry needling at treating AT. It involved 46 participants. At six months, no significant difference was found between the two treatment methods [20]. The results of the studies suggest that the use of PRP in treating AT is either inferior or inadequate compared with other conservative procedures. The literature supporting the use of this treatment modality has been more consistent. Zhu Junshan et al. [21] and Zou Guoyou et al. [22] treated 15 and 11 patients with Achilles tendinitis with local PRP injections, respectively. Painful local injections of PRP were performed in the treatment of 15 and 11 patients with chronic Achilles tendinitis, and the patients were followed up for 18 months after the treatment. After 18 months of follow-up, magnetic resonance imaging (MRI) showed a significant improvement in the soft tissue inflammation around the Achilles tendinitis. The patients regained their normal gait and daily activities.
Filardo et al. [23] studied 27 patients (men and women) with chronic Achilles tendinitis. The average follow-up time was 54.1 months (30 months), and the results showed that the Victorian Institute of Sport Assessment (VISA-A), Visual Analogue Scalar Score (EQ-VAS), and Tegner motor level scores were significantly improved, and PRP injections for chronic Achilles tendinitis had a stable medium-term outcome. In a randomized, double-blind prospective study by Boesen et al., 60 men with chronic mid-Achilles tendinitis were treated with PRP, and the results showed that centrifugal training, combined with high-dose steroid or local anesthetic injections and PRP injections, were effective at reducing pain, improving motion levels, and reducing tendon thickness; however, drugs were more effective than PRP at improving chronic mid-Achilles tendinitis in the short term [24].
The study by Liu et al. compared the effectiveness of PRP injection patients and assessed the VISA-A score for 12 weeks, 24 weeks, and one year. It did not find a difference between the two groups. The PRP cohort showed an improvement in efficacy after six weeks, and the tendon thickness and pain scores of those treated with the treatment were significantly increased [25].
Hanisch et al. conducted a further study to compare the effectiveness of the two types of PRP injection at treating chronic AT. They analyzed the data of 84 patients who had previously failed conservative therapy. They found that using LR-PRP or LP-PRP did not result in significant differences [26].
Zhang et al. recently reviewed combined data from four randomized controlled trials in a systematic review and meta-analysis. In the included studies, there were no statistically significant differences between the PRP and saline groups in the Victoria Exercise Assessment of Achilles tendon (VISA-A) ratings, ultrasound measurements of tendon thickness, or ultrasound color Doppler activity [24][27][28][29][30].
In 2021, another study conducted by Kearny and colleagues revealed that using PRP injections was not as effective as using a dry needle for treating AT. The study revealed that using a single intra-tendinous injection of PRP did not reduce the symptoms of AT in the participants at six months [31]. Although the findings of this study do not support the use of PRP for treating AT, the authors have raised questions about the study’s methodology and participant choice. Clinically, the evidence supporting the use of PRP in treating AT does not support a conservative option. The lack of research on non-insertional and insertional AT also prevents further conclusions from being made regarding this issue [32][33].

3.2. Effectiveness of PRP Injections in Surgical Augmentation in the AT

Various surgical procedures can be performed to treat AT. These include using a minimally invasive technique to debride the tendon and a percutaneous needle tenotomy procedure.
The study by Therman et al. analyzed the effects of debridement on 36 patients with midportion AT. They were randomized to the conventional technique or intraoperative PRP in combination with the procedure. It was found that the added PRP did not improve the outcomes compared with the debridement alone [34].
The study, which was conducted by Kirschner et al., analyzed the effectiveness of the two surgical procedures at treating chronic Achilles tendinosis. They were divided into two groups: the first was treated with the conventional technique, and the second was treated with PRP. After six weeks, the researchers found that the patients treated with PNT had lower pain scores than those treated with PRP [35]. However, the study’s results did not support using PRP as an augmentation to the tenotomy procedure.
Although there has been a positive result in the intraoperative use of PRP in Achilles tendinopathy, the present result is insufficient to claim its safe efficacy, but more research should be conducted on the topic.

4. Efficacy of PRP Injections in Achilles Tendon Rupture

The Achilles tendon rupture presents a new set of problems for the orthopedic surgeon compared to chronic tendinopathy. Treatment options include non-surgical, minimally invasive, and open surgery. The in vitro benefits of PRP make it a compelling treatment option for tendon and wound healing, in addition to surgical and non-surgical treatments. The use of whole blood and PRP for treating ruptured tendons has been associated with mixed clinical results. This is because the various application modalities and the biological composition of PRP can affect the results [28][36][37][38][39][40][41][42][43].
Gosens et al. randomized 20 patients with acute Achilles tendon ruptures into PRP treatment or control groups for surgical and non-surgical treatment groups [42]. The Achilles Tendon Rupture Score (ATRS), VISA-A, Foot and Ankle Outcome Score (FAOS), and Functional Ultrasound Elastography (FUSE) were used to monitor patients during weeks 1, 3, 6, 12, and 24. The PRP group showed significant improvements in ATRS, VISA-A, and FAOS scores, and the FUSE scans showed larger and stronger tendons.
In order to analyze the effectiveness of PRP at treating acute ATR, Keene et al. conducted a randomized, placebo-controlled trial. The study involved 230 participants. The researchers noted that using PRP in treating acute ATR was not associated with significantly improving the patient’s quality of life or functional outcomes [41]. The studies’ results suggest that using PRP to treat acute ATR does not improve clinical outcomes [41]. This therapy could help strengthen the healing process following an operation on the tendon.
A meta-analysis by Fitzpatrick et al. [44] analyzed the various studies that examined the effectiveness of PRP at treating tendinopathies. They found varying levels of blood-derived products used to treat these conditions. These included autologous whole blood, autologous conditioned serum, and leukocyte-poor PRP. Various preparation methods are utilized to produce PRP products [45]. The main factor that sets them apart from peripheral blood is their concentration. The methods used to produce PRP products contain different proportions of white blood cells and erythrocytes. This factor affects the therapeutic properties of the product and its biological composition [45][46][47].
De Carli et al. compared the effects of PRP injections in 30 individuals who had their Achilles tendon rupture surgically repaired [48]. At six months post-operative, the signal enhancement was lower in the PRP group than in the control group, indicating better tendon remodeling but no clinical changes.
The groups had no clinical differences between the functional tests or VAS, FAOS, or VISA-A scores. Regarding elasticity and functional outcomes, Schepull et al. found that PRP did not affect acute Achilles tendon healing. However, their findings are difficult to interpret due to significant patient variation.
A single-blind study was conducted on 30 individuals who had undergone a surgical procedure to repair an injured tendon. Schepull et al. [40] found that there was no biomechanical benefit from using 10 mL of PRP in treating the ruptured tendons. Instead, they applied a concentrate containing high levels of PRP to the site of the injury [40]. The researchers found no evidence of a biomechanical advantage from using 10 mL of PRP to treat the ruptured tendons. They also found that the concentration of PRP in the concentrate was 17 times higher than that of the patient’s peripheral blood [45][49][50][51].
A study by Alviti et al. [39] revealed that using the LR-PRP matrix over the site of the ruptured tendon significantly improved the ankle’s function. The study also reported that the patients who were treated with PRP augmentation had a significant improvement in their ankle motion efficiency.
A systematic review of the eight studies was conducted to analyze the data. These studies were conducted on 543 patients with a diagnosis of acute ATR. The authors identified five studies that analyzed the various types of PRP used in treating acute ATR. Only one study yielded significant positive results, revealing that the patients could recover a normal range of motion within four weeks following the injection. The results of the studies revealed that the use of PRP in treating acute ATR did not improve strength or functional outcomes. The authors concluded that the current evidence does not support the use of this therapy in this condition [52].
In 2016, a study conducted by Zou et al. revealed that using PRP as an adjunct to surgery for treating acute ATR could be beneficial. They divided the participants into two groups: the control group and the PRP group. At the three-month mark, the researchers noted that the PRP group exhibited better isokinetic muscle strength and improved Leppilah scores. The study’s results revealed that using PRP in treating acute ATR improved the ankle range of motion after two years [53]. Although this initial proof of its effectiveness is encouraging, further studies are needed to determine if it can help improve the healing process following an operation on the tendon.
Keene et al. also conducted a randomized controlled trial [41] to use 4 mL of LR-PRP in treating patients with acutely ruptured tendons. They found that this method prevented the infiltration of local anesthetics into the affected area. Despite the positive results of the laboratory studies, the authors concluded that the use of PRP did not appear to have a detectable effect on the healing of the injured tendons [41][46].
The results of the other studies contradicted those of Sanchez et al. [17], which sparked the controversy about using erythrocytes and leukocytes as crucial ingredients in the treatment of injured tendons, which were published by Arriaza et al. [18]. Most studies on white blood cells indicated that they could exert pro-inflammatory and catabolic effects on tenocytes [9][10][46][54][55].
The results of the clinical trials on the use of PRP in tendinopathies were mixed. Some trials indicated that LR-PRP injections resulted in better results than those given to patients with corticoid or saline [18][43][56][57]. On the other hand, some studies on whole blood and PRP did not show any beneficial effects [18][28][38][41][42][58][59][60][61].
The varying factors that affect the results of the clinical trials are also partly responsible for the mixed results. For instance, the number of injections, the type of tendon involved, and the patient’s age were all analyzed [62].
Recent studies on the development of stromal fibroblasts and human supraspinatus tendons from patients with ruptured ligaments revealed that these cells exhibited complex inflammation signatures [63][64]. These findings suggest that using PRP to treat these conditions could be a potential therapeutic option.
However, the lack of improvement in the functional and clinical outcomes of LR-PRP compared to the placebo or saline in patients with tendinopathies or ruptured tendons has raised doubts about its potential use in these conditions [65][66].
LR-PRP could also be beneficial for the healing of tendinopathies as it can stimulate the production of pro-inflammatory cytokines and catabolic substances on stromal cells [38][41][58][63][64][66]. This finding suggests that the effects of leukocytes on these cells could be partially derived from their pro-inflammatory and catabolic effects [47][66][67][68]. In addition, activating pro-inflammatory cytokines by injected leukocytes could potentially contribute to developing a non-resolving inflammation [58][62].
Studies on the development of osteoarthritis stem cells, stromal fibroblasts, and tendon stem cells from patients with tendinopathies revealed that the supernatant of LR-PRP could stimulate the production of pro-inflammatory cytokines. Compared to the supernatant of LP-PRP [47][62][69], the release of pro-inflammatory cytokines by the cultured cells was higher. This finding suggests that the use of this drug could be beneficial for the healing of these conditions [43].
In addition, Lipoxin A4, from platelets produced by arachidonic acid, has been shown to suppress the inflammatory processes in the tissues of people with tendinopathies and ruptured ligaments [65].
The lack of consistency in the results of the studies regarding the effectiveness of the PRP treatment process and the various preparation methods used for it has hindered the field’s advancement [20][24][28][31][32]. These elements can lead to misleading conclusions and prevent the public from being informed about its therapeutic potential.

5. Efficacy of PRP in Cartilage and Osteochondral Lesions of the Talus

Due to advances in the imaging technology, osteochondral lesions of the talus (OLT) are being increasingly recognized as a source of ankle discomfort. The conservative treatment is usually successful for small lesions, but surgical treatment is required for more extensive lesions or lesions that do not respond to the conservative treatment. Surgical procedures can be classified as either reparative or reconstructive.
PRP effectively treats osteochondral lesions (OLTs) and cartilage fractures in the talus. In a preclinical animal model, the treatment of OLTs with PRP resulted in improved histological scores and increased cartilage-like hyaline formation [51]. Clinical studies have shown that using PRP as an adjunct to the microfracture of OLT results in better outcomes than surgical repair [70][71].
In a randomized prospective trial study, Gurney et al. compared a total of 35 patients; patients in the control group (n = 16) received the microfracture surgery alone, whereas patients in the PRP group (n = 19) additionally received PRP therapy [71]. The authors found that after a mean follow-up of 16.2 months (range: 12 to 24 months), both groups showed significant improvements in clinical outcomes based on AOFAS scores, foot and ankle ability measures (FAAM), and VAS, although the PRP group outperformed the microfracture-only group. Patients with lesions larger than 20 mm in diameter were excluded from this investigation. The authors concluded that even if the addition of PRP to arthroscopic microfracture surgery for treating osteochondral lesions of the talus had shown better functional score status in the medium term, further research was required to evaluate the long-term.
In previous trials, most individuals with OCD lesions less than 15 mm in diameter were effectively treated with arthroscopic microfractures [72][73].
Mei-Dan et al. studied clinical and functional outcomes after three intra-articular PRP or HA injections [74]. At 28 weeks, the authors found that the PRP treatment greatly improved pain and function compared to HA. The data on PRP for osteochondral lesions of the talus are encouraging, but further studies are needed to evaluate the preparation, procedures, safety, and long-term outcomes before conclusions can be drawn.
A review conducted by Smyth et al. revealed that PRP could increase the number of chondrocytes and stem cells, the deposition of proteoglycans, and collagen formation. It also inhibited the effects of local catabolic cytokines; the researchers noted that using PRP during autologous osteochondral graft therapy significantly improved the graft integration and decreased the degree of cartilage degeneration [75].
There are still many questions to be resolved before the use of PRP can be considered an effective treatment for OLTs. For instance, the optimal combination of the PRP components should be studied. Those who were treated with allograft and PRP had similar results when it came to managing calcaneal fractures. They also exhibited better radiographic parameters and scores than those treated with the autograft alone [76]. The recommendations regarding using biologics to treat OLT can help clinicians make informed decisions regarding this difficult condition.

6. Efficacy of PRP Injections in Bone Healing

Bone regeneration with platelet-rich plasma (PRP) is designed to stimulate a healing response at fracture and fusion sites around the foot and ankle using platelet-derived products. In several preclinical studies, PRP has been shown to improve osteogenesis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94][95][96][97][98][99][100][101][102][103][104][105][106][107][108][109][110][111][112][113][114][115][116][117][118]. However, the translation of preclinical findings to in vivo bone repair has shown mixed results. Wei et al. conducted one of the few current studies on PRP and bone healing in the foot and ankle literature [76]. In a surgically-controlled, displaced intra-articular heel fracture, the authors examined the use of autografts against allografts with and without PRP. The AOFAS scores and imaging characteristics of the PRP and autograft groups were comparable at the long-term follow-up. Both were superior to the allograft group alone. Despite the high healing rate of heel fractures in the past, surgical treatment poses a significant risk of wound complications. 
Bibbo et al. investigated autologous platelet concentrate (APC) in elective surgery patients undergoing high-risk foot and ankle surgery [11]. Diabetic patients with neuropathy, immune, or nutritional compromise, a history of bone nonunion or delayed healing, prior surgery at the anticipated surgical site, or a history of open treatment after high-energy trauma were considered high-risk. Sixty-two high-risk patients were monitored with biweekly radiographs over six months to determine if they had radiographic healing. Patients who received APC alone had 40 days until healing, while those who received APC and autograft had 45 days until healing. The authors conclude that APC is a useful adjunct for high-risk patients those undergoing elective foot and ankle surgery to promote bone healing. The potential benefits of PRP in bone healing are intriguing, but further research is needed before any definitive conclusions can be drawn regarding using PRP in human bone regeneration.

7. Efficacy of PRP in Total Ankle Arthroplasty

Currently, numerous papers discuss the use of PRP in joint disorders, but few studies discuss the application of PRP in total ankle arthroplasty (TAR), and the topic is still debatable.
Barrow et al. [119] studied 20 patients with TAR who received PRP-assisted bone grafts for joint fusion. PRP was sprayed on the bone and prosthetic surfaces, mixed with the graft, and filled into the joint. This study showed 85% fusion within two months, 95% fusion within three months, and 100% fusion within six months, compared to the previous average of 62–82%. In a similar study, Coetzee et al. investigated the efficacy of platelet-rich plasma (PRP) in facilitating syndesmosis union after total ankle arthroplasty [12]. The retrospective analysis compared the outcomes of 66 patients who had PRP augmentation to those of 114 patients who did not. Eight weeks into the study, 61% of the control group had fused, and by the end of the study, 86% had fused. The fusion rate in the PRP group was 76% at eight weeks and 97% at six months. Patients with a cigarette use history showed a slightly increased fusion rate after PRP treatment. The authors conclude that carefully considering the patient history and risk factors is required before using PRP for fusion in ankle arthroplasty. More research is needed before further conclusions are drawn.

8. Efficacy of PRP in Ankle Osteoarthritis

Compared to hip or knee osteoarthritis, ankle osteoarthritis is quite rare [120][121]. In patients with knee OA, intra-articular PRP injections have enhanced clinical and functional outcomes [122][123][124][125][126]. A few articles on the use of PRP in ankle OA have been published. Repetto et al. studied 20 patients with symptomatic OA [124]. After a mean follow-up of 17.7 months, the authors found significant improvements in pain, function, and patient satisfaction.
In two studies, the effects of a combination of platelet-rich plasma and hyaluronic acid on the pain and function of patients with osteoarthritis were compared by Mei-dan et al. [74]. The study was conducted on 30 individuals with osteochondral lesions of the ankle. After 28 weeks, the patients were evaluated using the VAS, AHFS, and AOAFAS scores. After 28 weeks, the researchers noted that the patients who received the combination of PRP and hyaluronic acid experienced significantly better function and less pain.
Fukawa et al. studied 20 ankle OA patients who received three PRP injections every two weeks [125]. Up to 24 weeks after treatment, the authors found a significant improvement in pain and function. The greatest pain reduction occurred at week 12, after which the pain began to return to baseline levels but improved considerably.
In the study by Angthong et al. [127], they noted the clinical improvement in the VAS score after 16 months. They did not see changes in the joint after five months of follow-up. The researchers performed ultrasound-guided or scoped procedures on the subjects.
In vitro studies on chondrocytes revealed that the PRP increased their proliferation rate and stimulated matrix production. It also maintained the marker expression [116].
The analgesic effect of the PRP could be used as a potential drug for treating osteoarthritis. It could also enhance the secretion of hyaluronic acid. A recent study revealed that using PRP for treating osteoarthritis could be safely and effectively conducted with just a single injection [117].
Given the lack of available studies on the effectiveness of PRP at ankle OA, no definitive conclusions can be drawn. Limited data suggest a short- to medium-term benefit, but this must be compared with other injectable substances (corticosteroids, HA) in a long-term randomized controlled trial.

9. Efficacy of PRP Injections in Ankle Fractures

For over seven years, Wei et al. investigated all displaced type II heel fractures in their department [76]. A total of 276 fractures were randomly assigned to one of three treatment groups: autograft alone, allograft alone, or allograft with the addition of PRP. After one year, all fractures had completely healed, although there were no significant differences between the groups. At two and three years after the surgery, autografts alone and PRP-enhanced allografts were much less problematic than allografts alone and had much better radiographic outcomes (as measured by the Bohler angle, Gissane angle, and heel body dimensions). Clinical outcome assessments showed no differences between the groups in the degree of residual discomfort, walking ability, range of motion below the talus, or ankle-to-hindfoot alignment [76].
There is currently no evidence supporting the use of PRP in treating ankle fractures. However, limited data suggest that it cannot benefit ankle fracture recovery. It is important to conduct studies on the topic.

10. Efficacy of PRP Injections in Plantar Fasciitis

Plantar fasciitis has been the subject of many recent studies attempting to determine the function of PRP in its treatment [128][129]. Plantar fasciitis is the most common cause of heel discomfort in adults. The main cause is repeated microtrauma of the plantar fascia originating from the heel bone, leading to inflammation and degeneration. Some treatment possibilities include orthotics, splints, stretching exercises, physical therapy, extracorporeal shock wave therapy (ESWT), medications, injectables, and surgical release. Non-surgical treatments still fail in 10–15% of patients, resulting in persistent plantar fasciitis. Corticosteroids, autologous blood injections, and ESWT have all been tried with mixed results and risks, such as plantar fascia rupture after corticosteroid injection [130]. PRP is fascinating as a non-invasive method to improve plantar fascia recovery.
Martinell et al. treated 14 patients with chronic plantar fasciitis with PRP injections at three different puncture sites [131]. In total, 9 of the 12 patients showed significant improvement and reduced pain levels. They concluded that PRP is safe and effective at treating this disease. However, this study was limited by the lack of control treatment groups, such as the plantar stretching group. Similarly, Rabag et al. treated 25 patients with persistent plantar fasciitis with PRP injections and reported little or no functional limitation and significantly less discomfort in 23 of the 25 patients [132]. After the PRP injection, ultrasonography showed a significant increase in fascial thickness and signal intensity.
Aksahin et al. compared the PRP treatment with corticosteroids for persistent plantar fasciitis [133]. Thirty patients were injected with methylprednisolone and proparacaine, while the remaining 30 received PRP after the proparacaine injection. Pain ratings decreased sharply from 6.2 to 3.4 and 7.33 to 3.93 in the steroid and PRP groups. PRP appears to be a safer option when considering the risks of the corticosteroid treatment, such as sudden rupture, and the Carafino et al. study [134].
In patients with persistent plantar fasciitis, Kumar Jain et al. compared a single PRP injection with a corticosteroid injection [135][136]. They found that PRP and corticosteroids significantly improved VAS scores, modified Roles and Maudsley scores, the Foot and Ankle Outcome Instrument Core Scale, and the AOFAS Ankle-Hindfoot Scale, although there was no significant difference between the two groups.
According to Acosta-Olivo et al.’s statement, PRP showed the same effect as corticosteroids [137]. Aksahin et al. found significant improvement in VAS, modified Roles, and Maudsley scores with PRP and corticosteroid injections, but there was no significant difference between the two groups. Recent trials comparing PRP with corticosteroid injections and extended follow-up periods have found that PRP may have a more durable benefit than corticosteroids [138][139]. Monto found that PRP injections improved AOFAS scores after three months and that these effects lasted 24 months [139].
These findings contrast with those of corticosteroids, which improved AOFAS scores in the first three months but decreased to baseline at 24 months. Jain et al., in their investigation of correction functions and Maudsley scores, VAS scores, and AOFAS scores, observed similar effects [140]. PRP and corticosteroids scored the same at 3 and 6 months; however, PRP was much better at 12 months.
Singh et al. [141] combined the results of these and other studies in a systematic evaluation and meta-analysis. The authors concluded that PRP exceeded corticosteroids in VAS and AOFAS scores at three months but showed no difference in pain or function at 1, 6, or 12 months of the follow-up [141].
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. Further well-designed, prospective randomized controlled studies are needed to standardize the PRP injection in plantar fasciitis.

 

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