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Although it has been around for over 15 years and has been used with some success in treating difficult-to-heal wounds, platelet-rich plasma (PRP) has come into the literature recently for the treatment of many musculoskeletal conditions including tennis elbow, patellar and Achilles tendonitis. In addition, the successful use of PRP in the treatment of the injuries of many sports figures has been widely publicized. Some physicians that treat these problems are beginning to offer these treatments to their patients, sometimes as a last resort before surgery, sometimes, unfortunately, as an initial treatment. Most insurances have not yet begun to cover this treatment, citing its experimental nature. It can be very expensive to pay for out-of-pocket ($500-1000 or more).
Platelet-rich plasma is a preparation created from blood. The blood is taken from a vein and spun by a centrifuge. This separates the blood into blood cells, serum, and platelet-rich plasma. Platelet-rich plasma, as suggested by the name, contains a lot of platelets. These small fragments of cells when activated release a soup of proteins called growth factors that start the clotting and healing cascade after an injury. The preparation is then injected into the irritated area. Are they the right proteins to help a painful heel heal? Nobody knows.
According to Orthopedics Today, a widely distributed periodical for orthopedic surgeons, a study looking at the effect of PRP on plantar fasciitis was recently presented by Dr Raymond Monto at 12th EFORT Congress in Copenhagen in June 2011. In it, he found that the 40 patients that he studied did significantly better with the PRP injection than the cortisone injection. Dr. Monto is also a speaker for Exactech, a company that markets devices for the production of PRP.
Plantar fasciitis is a sometimes excruciatingly painful and frustrating irritation of the heel. It is the most common cause of heel pain and seems to be the result of chronic scarring of the plantar fascia, an important ligament that connects the heel to the toes and supports the arch. Plantar fasciitis commonly resolves on its own. More than eighty percent of people with plantar fasciitis get better within 6-12 months, sometimes without any treatment. Unfortunately, a portion of them do not. They can be a very unhappy group.
Over the last two decades, many treatments have come in and out of fashion for plantar fasciitis. In the early nineties, night splints, plastic splints that you strap on at night, were the solution. Subsequently, further scrutiny showed the results to be inconsistent and usually fairly marginal. In the early 2000s, Orthotripsy, the application of a high strength shock wave machine to the heel, promised to be the answer. Many orthopedists and podiatrists bought these machines. The manufacturer of one, the Ossatron, has since settled a class action suit over misrepresenting the results of this treatment. Coblation, the use of a probe to burn small holes into the plantar fascia, came out about the same time. Although I have heard little to state that it isn’t effective, the only paper on it over the ensuing years studied 14 patients. It was overall positive, but the evidence is still not sufficient to recommend it to my patients. No published literature is available from a center inside the US. Botulinum toxin, a chemical that paralyzes muscle for months where it is injected, best known for cosmetic treatments of the face, has been suggested beginning in 2005, but the studies to date involve less than thirty patients.
According to a systematic review of blood products including PRP by Van Vos et al in the British Medical Bulletin (2010):
“All studies showed that injections of autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact on improving pain and/or function over time. However, only three studies using autologous whole blood had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. At present, there is strong evidence that the use of injections with autologous whole blood should not be recommended. There were no high-quality studies found on PRP treatment.”
Many PRP systems come with the FDA required warning, “The platelet rich plasma prepared by this device has not been evaluated for any clinical indications.” In other words, the evidence to recommend PRP for anything is just not there yet.
While PRP is a promising treatment and evidence may eventually justify its cost, it should not be used as anything short of a last resort prior to surgery. Considerable out of pocket expense should be anticipated. It is my opinion that it should not be used outside of clinical trials until further evidence demonstrates clearly its effectiveness.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
Posted in New Treatments, Plantar fasciitis
Tags: feet, foot, foot pain, heel pain, heel spur, Plantar fasciitis, plasma, platelet, platelet rich plasma, PRP, tendon
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