Fairly new treatment for Plantar Fasciitis

[Guest guest]

Hi all

hope the mods allow this - it's not strictly thyroid, but i gather some people

with thyroid issues have plantar fasciitis, so thought i'd make people aware of

this, the wife of someone I work with has had this treatment, so it is available

on NHS.

chris

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http://thefootblog.wordpress.com/2006/11/29/autologous-blood-injection-in-the-tr\

eatment-of-plantar-fasciitis/

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. 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milliliters of blood was withdrawn from the dorsal vein of the hand and mixed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 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 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. 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.