The plantar fascia is a band of connective tissue that connects the heel bone to the toes and acts like a biomechanical shock absorber supporting the arch of the foot. There are a number of intrinsic and extrinsic factors which can cause injuries in the plantar fascia such as anatomical and biomechanical variations of the foot posture (Pronated foot, supinated foot, flat foot), abnormal walking pattern, lower limb-length discrepancy, muscular factors such as lack of flexibility in the calf muscle (too tight Achilles tendon with limited ankle dorsal flexion), obesity and overuse1. These injuries develop into a condition known as “Plantar fasciitis” and if long-standing can be referred to as “plantar fasciosis”2. Causes of plantar fasciitis are multifactorial in the majority of the cases.
Plantar fasciitis is a condition in which there is repetitive and excessive loading tension causing micro-tearing, inflammation, and painful sharp/stabbing sensation in the plantar aspect of the heel. The condition is often characterized by pain, stiffness with weight bearing, especially with the first steps after waking up, and the pain decreases with sustained standing and walking activities due to constant stretching of the fascia.
Plantar fasciitis is the most common cause of heel pain. In fact, it has a remarkable impact on global population. In an article by Riddle & Schappert, report that approximately 10% of the total population will develop a plantar fasciitis episode at some point of their life3and it was found by Radwan et al, that ultrasonography is an effective tool in diagnosing plantar fasciitis. Plantar fasciitis is most common in individuals between the ages of 40 and 70 years with a higher incidence in women. However, anyone may be predisposed to develop plantar fasciitis4.
More recent histopathologic research by Lemont et al reported no inflammation found but the degeneration of the plantar fascia fibres, normally associated with more chronic plantar fasciitis conditions also known as plantar fasciosis2. This brought a new horizon in the plantar fasciitis treatment options. Corticosteroids years the years has been most common treatment used for this condition, due to the immediate pain relief and normalization of plantar fascia thickness; however, there are some limitations and side effects to this therapy such as heel pad atrophy and rupture of the plantar fascia5.
It is agreed that most of the cases diagnosed as “plantar fasciitis” is a result of micro-tearing and chronic degeneration of the plantar fascia fibres; therefore, current literature advise the use of regenerative treatments to treat this condition. Ming-Yen Hsiao et al performed a systematic review in 2015 comparing the effectiveness of autologous blood-derived products (regenerative treatment) vs corticosteroids injections vs shock-wave therapy and found regenerative treatments to be the preferred treatment in providing relief from pain. They found that this treatment, specifically PRP, improves treatment efficacy remarkably6.
It is important to mention at this point that with regenerative treatment, which has been found very effective to treat the lesions of the plantar fascia, we are not treating the root-cause of the condition itself, therefore if we don’t pay attention to the original cause of the plantar fasciitis, there will be high probabilities of recurrence despite the high effectiveness of the regenerative treatment. Therefore, it is essential to compensate the abnormal posture of the foot (flat foot, pronated foot, cavus foot) with proper shoes/orthotics, to treat the muscular disbalance, overweight or whichever the plantar fasciitis etiology is; before or at the same time as undergoing the injection therapy.
What to Expect Before the Injection
As mentioned before we have to find the main cause of the plantar fasciitis and treat that cause, then we can proceed to the main regenerative treatment. For that, we use the patient’s own blood which we need to withdraw the day before or the same day of the procedure, depending on the specific technique used, then we will process the blood in order to make the final injective treatment. Normally the full treatment is based on 3 – 4 injections over 2 weeks (one injection every 3 days approximately)
What to Expect During the Injection
The injection is performed in the plantar/internal aspect of the heel. As every other injection, this implies some discomfort but most of the patients tolerate this injection without major issues. If the patient is very scared of needles or has a low tolerance for the pain we have plenty of options and resources to make the treatment more tolerable. The time it takes to inject the treatment is very short (seconds) since we locate the exact anatomical area we want to inject using ultrasonography and then use ultrasound to guide the needle to inject at that very point.
What to Expect After the Injection
The patient leaves the clinic walking only ten minutes after the injection is finished. There will be slight discomfort at the sight of the injection during the day but normally patient goes back to normal within 24 hours.
The cells injected or involved in the regenerative treatment will be working for approximately 10-12 weeks repairing the affected tissue, creating a progressive relief of pain and tightness symptoms over this period of time.