EFFICACY OF AUTOLOGOUS PLATELET RICH PLASMA INJECTION IN PLANTAR FASCIITIS AND LATERAL EPICONDYLITIS
Vivek .K1 ,Vijaynarasimman Reddy. V3
1,2Department of Orthopaedics, SreeBalaji Medical College & Hospital, Chromepet, Chennai
We consider that platelet rich plasma injection for lateral epicondylitis and plantar fasciitis has served as an effective tool in management of these conditions.The aim is to study the efficacy of autologous platelet rich plasma injection in lateral epicondylitis and the efficacy of autologous platelet rich plasma injection in plantar fasciitis.
Keywords:platelet rich plasma, epicondylitis, plantar fasciitis, chemotaxis, visual analogue score, spondylo arthritis
Platelet rich plasma (PRP) injections are widely studied for treating various musculoskeletal disorders due to its increased healing properties . The contains growth factors such as Platelet-Derived Growth Factor, Insulin- Like Growth Factor, Transforming Growth Factor, Epidermal Growth Factor (EGF), Vascular Endothelial Growth Factor (VEGF), Fibroblast growth factor. Interaction of this growth with differentiation factors, and the adhesive protein factors such as fibronectin and vitronectin are responsible for the healing response promoting the regenerative process of chemotaxis, self proliferation, tissues debries, angiogenesis, extra cellular matrix formation, osteoid production and collagen synthesis, which enhance the healing rate in chronic tendinopathies
This methodology of treating chronic tendinopathies has general importance as this form a connecting approach between conservative management as well as surgical management3.The incidence of lateral epicondylitis is 4 -7 per 1000 per year in general population, and 35 -54 years age group are commonly involved4. Lateral epicondylitis occurs due to overuse of the wrist extensors or supinator muscle with may be incriminating. In lateral epicondylitis the muscle involved is Extensor carpi radialisbrevis .Various methods have been advocated for the treatment of lateral epicondylitis rest, physiotherapy, activity modiﬁcation, bracing, nonsteroidal anti-inﬂammatory drugs, and injections6. Surgery is also an option for patients who have persistent symptoms despite continued efforts at conservative treatment.
The common cause of heel pain is plantar fasciitis which affect 10% of the general population.
The age group of 40 -70 years most commonly occurs. It tends to occur more often in women, middle aged, military recruits, athletes and the obese persons. The inflammation is due to repeated trauma from overuse or injury. The degeneration occurs at origin of the plantar fascia at the medial tuberosity of the calcaneum.Various methods have been advocated for treating this condition like rest, non-steroidal anti inflammatory drugs, night splints, keeping appropriate wedge on shoe, soft heel pad, plantar stretching exercises, ultrasound massage to heel, extracorporeal shock wave therapy (ESWT), local corticosteroid injections, and operative treatments .Platelet rich plasma helps in healing both lateral epicondylitis and plantar fasciitis following which recurrence rate was found to be low.
MATERIALS AND METHODS
The present sample size of 80 patients were analysed prospectively by injecting platelet rich plasma for conditions such as lateral epicondylitis and plantar fasciitis. The study was conducted in sreebalaji medical college and hospital from march 2017 to march 2018with a follow up period of 3 months duration.
1. Plantar fasciitis diagnosed patients.
2. Lateral epicondylitis diagnosed patient.
3. Patients should have minimum three months duration of symptoms.
4. Patients should undergo conservative treatment for a minimum period of three months.
5. Pain scores more than seven at the time of injection.
6. Local steroid injection in the last 2 months.
7. Both male and female 8. Age group above 20 years.
Lateral epicondylitis and plantar fasciitis of less than three months duration.
1. Pain scores less than seven.
2. Patients without any trial of conservative treatment.
3. Recent local steroid injection.
4. Patients suffering from other causes like rheumatoid arthritis, Sero negative spondyloarthritis .
5. Infection or ulcer at the injection site 6. Patients less than 20 years
Informed consent was obtained from all the patients after explaining the disease condition and treatment with platelet rich plasma injection in their local language. All the patients were informed about the study. All the patients agreed for the procedure and to participate in the study.
All the patients and their nearest relative had signed in the consent form.
Pain in the lateral aspect of the elbow joint is the first clinical diagnosis of lateral epicondylitis.
Which is aggravated on wrist dorsiflexion. On examination of the patient localized tenderness is elicited over the lateral epicondyle.
Patient with heel pain are diagnosed to have plantar fasciitis which worsens in the early morning.
On examination localized tenderness is elicited over the plantar fascia insertion in the medial aspect of the calcaneum.
Visual Analogue Scale (VAS):
Nopain worstPossible Pain
The patient indicates intensity of pain on a 10cm line marked from “No Pain” at one end to
“Worst Possible Pain” it could be at the other end.
Numeric Rating Scale (NRS):
0 1 2 3 4 5 6 7 8 9 10
The patient rates pain on a scale from zero (“0”) to ten (“10”)
On the basis of numerical pain score, intensity of pain is classified into mild, moderate and severe.
1. Score - zero to three was taken as mild, 2. Score - four to six as moderate and 3. Score - seven to ten as severe pain.
Method of preparation of platelet rich plasma:
Initially a venous puncture is done and specific volume of autologous blood is collected from the patient (10ml of venous blood sample) into a tube containing an anticoagulant (sterile sodium citrated tubes) (figure 1).
Figure1: Test tube containing an anticoagulant (sodium citrated tube)
This is followed by two centrifugation steps (figure 2)
At 1800 rotations/minute (rpm) for 15 mins centrifugation takes place separating plasma from packed red blood cells. The top layer consists of plasma and bottom layer consists of red blood cell (Figure 3).
Figure2: Centrifuge machine.
The plasma is shifted to a sterile tube following which the packed cell layer is discarded.The second centrifugation takes place at 3500 rpm for 10 min which yields concentrated platelet layer after extraction of platelet poor plasma(Figure 4)
Figure 4 Injection technique:
Patient in supine position and palpate most tenderness point and marked using skin marker. The area was pre pared and draped for injection. Initially, a local block of lignocaine is infiltrated subcutaneously. Under proper aseptic precaution a 21 -g needle is used to inject, 1ml platelet rich plasma is injected over the maximum tenderness while the remaining platelet rich plasma is injected into the surrounding tissue. (figure 1 and 2).
Post Procedure Protocol:
Following injection, the patient is ask to lie supine for 15 minutes without moving the arm and foot. Instructions regarding the limited use of arm and foot for approximately 24 hours and use of pain reliever is given to the patient while sending them home. The use of non-steroidal medication is prohibited. Standardized stretching protocol for a two weeks follow up is given to the patient. A formal strengthening exercise program is also initiated after the stretching exercises. After the period of 4 weeks the patient are allowed to proceed with normal sporting or daily day activities as before. A visual analog pain score (0 - no pain;
Platelet Poor Plasma
Platelet rich Plasma
Figure 1: Injecting platelet rich plasma in lateral epicondylitis patient.
Figure 2: Injecting platelet rich plasma in plantar fasciitis patient.
10 - worst pain possible) used as outcome measures. The patients were examined at 1 st month, 2nd month, and 3rd month after the index procedure.
Patients were followed up for 3 months. Follow ups was done at 1st, 2nd and 3rd month.
Patients were assessed subjectively using the visual analogue score.
SPS software system was used to do statistical analysis by comparing the results.
Patients were analysed for pain relief subjectively at 1st 2nd and 3rd month post injection therapy and there pain is tabulated using visual analogue score (VAS) (pain score).
AGE 20 - 29 30 - 39 40 - 49 50 -59 TOTAL
PLANTAR FASCIITIS 2 (5%)
SEX MALES FEMALES TOTAL
PLANTAR FASCIITIS 15
Table 1: Comparison of VAS with age groups in lateral epicondylitis:
Age Group Total
20-29 30-39 40-49 50-59
Excellent 7 (100%)
7 (70%) 2 (25%)
Good 0 5
3 (30%) 6 (75%)
Fair 0 0 0 0 0
Chi sq 9.524 P value 0.023*
* significant (p<0.05).
Table 2: Comparison of VAS score with age in Plantar Fascitis:
VAS Score Age Group Total
20-29 30-39 40-49 50-59
Excellent 2 (100%)
Good 0 0 9
Fair 0 0 0 0 0
(100%) 8 (100%)
Chi sq 11.613 P value 0.009*
MEAN PAIN SCORE:
Pain score was assessed at the time of injection. The mean pain score of all the patients was 8.5
%. The mean pain score at 1,2,3 months was 4.825%, 3.3125%, and 1.935% respectively.
When individually analyzed mean pain score for lateral epicondylitis at 0, 1,2,3 months was 8.55%, 4.725%, 3.25%, 1.9 % respectively. Similarly mean pain score for plantar fasciitis at 0,1,2,3 months was 8.45%,4.925%,3.375%,1.925% respectively.
Table 3: Mean pain score:
Mean pain score at the time of
Mean pain score at 1stmonth
score at 2ndmonth
score at 3rdmonth Lateral
epicondylitis (40) 8.55% 4.725% 3.25% 1.9%
Plantar fasciitis (40)
8.45% 4.925% 3.375% 1.925%
Total (80) 8.5% 4.825% 3.3125% 1.935%
The mean difference between in VAS scoring system at the time of presentation was 8.5%, and there was gradual and significant improvement in VAS scoring system of both lateral epicondylitis and plantar fasciitis. Which showed as 4.825% at 1stmonth, 3.3125% at 2ndmonth, and 1.935% at 3rdmonth respectively.
The growing trend in using platelet rich plasma injection for condition like plantar fasciitis and lateral epicondylitis had significantly improved in last decade. The steep rise in use of platelet rich plasma is because of good functional outcome of this modality.We have taken up this study to evaluate the efficacy of platelet rich plasma in lateral epicondylitis and plantar fasciitis. We selected a sample size of 80 patients who were suffering from lateral epicondylitisand plantar fasciitis. The number of patients were divided into 40(100%) for plantar fasciitis and 40(100%) for Lateral epicondylitis. Out of which the sex distribution which was attributed to lateral epicondylitis was 22 males (55%) and 18 females (45%) and plantar fasciitis was 15 males (37.5%) and 25 females (62.5%).
Comparison of VAS score at each age group for lateral epicondylitis had a significant difference in their functional outcome at the end of mean follow up period of 3 months. The p value was 0.023. Which was found to be significant.Similarly comparison of VAS score at each group for plantar fasciitis had a significant difference at the end of mean follow up period of 3 months. The P value was 0.009. Which was found to be significant.
The comparison of these groups for lateral epicondylitis and plantar fasciitis at different age groups had shown significant difference in their outcome a t the end of 3 months. Therefore usage of platelet rich plasma injection for lateral epicondylitis and plantar fasciitis has show significant outcome due to its healing properties.
The significant difference in P value in different age groups had shown a proportionate improvement due to platelet rich plasma injection in varying age groups. Hence this type of management decreases the progressiveness for surgical management of lateral epicondylitis and plantar fasciitis.
Funding: No funding sources
Ethical approval: The study was approved by the Institutional Ethics Committee CONFLICT OF INTEREST
The authors declare no conflict of interest.
The encouragement and support from Bharath University, Chennai is gratefully acknowledged.
For provided the laboratory facilities to carry out the research work.
 Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The American journal of sports medicine. 2006 Nov;34(11):1774-8.
 Mishra A, Collado H, Fredericson M. Platelet-rich plasma compared with corticosteroid injection for chronic lateral elbow tendinosis. PM&R. 2009 Apr 1;1(4):366-70.
 Geaney LE, Arciero RA, DeBerardino TM, Mazzocca AD. The effects of platelet-rich plasma on tendon and ligament: basic science and clinical application. Operative Techniques in Sports Medicine. 2011 Sep 1;19(3):160-4.
 Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow: incidence, recurrence, and effectiveness of prevention strategies. The American Journal of Sports Medicine. 1979 Jul;7(4):234 -8.
 Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, Tytherleigh-strong G, Rushton N.
Lateral epicondylitis : a review of pathology and management Bone Joint J. 2013;
95B (9):1158 -1164
 Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T.
Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. The American journal of sports medicine. 2013 Mar;41(3):625 -35.
 Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. American family physician. 2007 Sep 15;76(6).
 Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. American family physician. 2001 Feb;63(3):467-74.
 Monto RR. Platelet-rich plasma and plantar fasciitis. Sports medicine and arthroscopy review. 2013 Dec 1;21(4):220-4.
 Pfeffer G, Bacchetti P, Deland J, Lewis AI, Anderson R, Davis W, Alvarez R, Brodsky J, Cooper P, Frey C, Herhck R. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot & Ankle International. 1999 Apr;20(4):214-21.
 Crawford F, Thomson CE. Interventions for treating plantar heel pain. Cochrane Database of Systematic Reviews. 2003(3).
 Andia I, Rubio-Azpeitia E, Maffulli N. Potential Links Between Tendon Pathology and Platelet Rich Plasma Biology. InPlatelet Rich Plasma in Musculoskeletal Practice 2016 (pp. 223 -240).
 Knighton DR, Ciresi KF, Fiegel VD, Austin LL, Butler EL. Classification and treatment of chronic nonhealing wounds. Successful treatment with autologous platelet - derived wound healing factors (PDWHF). Annals of surgery. 1986 Sep;204(3):322.
 Montero EC, Santos MF, Fernández RS. Platelet-rich plasma: applications in dermatology. ActasDermo - Sifiliográficas (English Edition). 2015 Mar 1;106(2):104-11.
 Ferrari M, Zia S, Valbonesi M, Henriquet F, Venere G, Spagnolo S, Grasso MA, Panzani I. A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery. The International journal of artificial organs. 1987 Jan;10(1):47-50.
 Anitua E. Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. International journal of Oral and maxillofacial Implants. 1999 Jul 1;14(4):529 -35.
 Garg AK. The use of platelet-rich plasma to enhance the success of bone grafts around dental implants. Dental implantology update. 2000 Mar;11(3):17.
 Navarrete Álvaro ML, Ortiz N, Rodriguez L, Boemo R, Fuentes JF, Mateo A, Ortiz P.
Pilot study on the efficiency of the biostimulation with autologous plasma rich in platelet growth factors in otorhinolaryngology: otologic surgery (tympanoplasty type I). ISRN surgery. 2011 Jun 20;2011.
 Petrungaro PS. Using platelet-rich plasma to accelerate soft tissue maturation in esthetic periodontal surgery. Compendium of continuing education in dentistry (Jamesburg, NJ:
1995). 2001 Sep;22(9):729 -32.
 Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Ferretti A. Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes. The American journal of sports medicine. 2013 Apr;41(4):795-803.
 Giordano S, Romeo M, Lankinen P. Platelet‐ rich plasma for androgenetic alopecia: Does it work? Evidence from meta analysis. Journal of cosmetic dermatology. 2017 Sep;16(3):374-81.
 Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The American journal of sports medicine 2006 Nov;34(11): 1774-8
 Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, Albisinni U,  Rimondi E, Baldini N, Giunti A. Enhanced tibial osteotomy healing with use of bone
grafts supplemented with platelet gel or platelet g el and bone marrow stromal cells. JBJS.
2007 Nov 1;89(11):2413-20.
 Samuel G, Menon J, Thimmaiah S, Behera G. Role of isolated percutaneous autologous platelet concentrate in delayed union of long bones. European Journal of Orthopaedic Surgery & Traumatology. 2018 Jul 1;28(5): 25.985-90 .
 Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and application in sports medicine. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2009 Oct 1; 17 (10):602-8.