Many people with plantar fasciitis don’t realise that there are two subtypes of plantar fasciitis. The first sub-type is the acute inflammatory stage that normally lasts 4-8 weeks after the onset of the symptoms, and after that, the second stage is one of chronic degeneration, where the fibres of the plantar fascia deteriorate and the blood supply becomes inadequate for tissue healing. So, to answer the question above, most people with chronic degenerative need treatments that stimulate tissue repair not anti-inflammatory treatments like icing stretching or steroid injections which all work better in the acute stage and not so well for chronic degenerative disease.
If you are reading this blog chances are it is highly likely that you have already tried the usual remedies of rest, stretching, and icing and they haven’t worked for you because you are now in the chronic degenerative phase, and you are probably looking for a treatment that is likely to get rid of your heel pain once and for all. In this case, the following blog is for you, it is an overview of commonly available treatments, saving the best treatment till last.
If you are short of time here is a plain English summary, steroid injections have pros and cons and come with some drawbacks, PRP is much better than steroids but is expensive, sometimes painful and often restrictive, leaving a focused shockwave – Not to be confused with a radial shockwave which is a less effective form). Focused shockwave isn’t the new kid on the block, far from it it was first used at the Atlanta Olympics way back n 1996. However, nearly 30 years later it is now becoming the most established treatment for stubborn recalcitrant plantar fasciitis. It has some overlap with PRP, additionally, it can trigger the reabsorption of calcification (the process that causes heel spurs). Furthermore, it is non-invasive, with little to no discomfort delivered at an affordable price point with no downtime.
Steroid Injections
Steroid injections work best in the acute inflammatory stages and less well in the chronic degenerative stage.
Steroid injections for plantar fasciitis have been performed since the 1950s but do they work? it would seem that about one-third of patients see a decent reduction in pain levels, as much as 80%, for 6-8 weeks but after the initial 12 weeks, however, the benefit of the masking effect soon wears off.
A 2019 review of just under 3000 participants who had received steroid injections for heel concluded that the results after the first 12 weeks of the corticosteroid injection are no more effective than placebo injections of salt water or local anaesthetic for reducing pain or improving function.
Steroid injections are considered safe, but they do have a number of downsides. They can cause a steroid flair, where pain can increase for several days or even up to a week after the injection, the pain from steroid flairs can be quite intense, and steroid injections can occasionally cause the plantar fascia to rupture especially if exercise is resumed too quickly.
Rupture can occur because the strength of the plantar fascia can reduce by 35% within the first two weeks of injection due to the negative effect steroid has on collagen. The other problem with steroid injections around the heel, is fat pad atrophy or in plain English shrinkage of the protective pad of fat tissue that cushions the heel. Fat pad atrophy is largely irreversible, injecting fat back into the fat pad has been attempted by some following liposuction, with mostly disappointing long-term results.
Furthermore, Steroid injections can cause an increase in blood sugar for about a week and in some people can very rarely trigger psychiatric conditions such as mania or delusions. Having said all of that, serious complications from steroid injections are very rare indeed, especially if given via ultrasound imaging, and they do have a big positive in that, every now and again, patients can see dramatic improvements, where they literally wake up the next day after a steroid injection pain-free.
Platelet-rich plasma injections (PRP)
PRP stands for Platelet-Rich Plasma, a treatment method used in regenerative medicine. PRP involves extracting a small amount of blood from a patient and then processing it to separate the different components of the blood. The platelet-rich fraction of the blood is then isolated and injected into and around the plantar fascia. Platelets are known to contain growth factors and other proteins that play a critical role in wound healing and tissue repair. By delivering a concentrated dose of these beneficial components directly to the site of the problem, PRP therapy can stimulate and accelerate the natural healing process. This treatment method is commonly used to treat other musculoskeletal injuries, osteoarthritis, and plantar fasciitis.
There is mounting evidence to suggest that PRP may be superior to steroid injections as a treatment option.
Platelets contain a variety of growth factors and cytokines that are thought to promote healing of the plantar fascia. Steroid injections, on the other hand, involve the injection of a synthetic corticosteroid into the affected area to reduce inflammation.
Many studies have compared the effectiveness of PRP and steroid injections for treating MSK conditions, including plantar fasciitis. A systematic review and meta-analysis published in the Journal of Orthopaedic Surgery and Research in 2019 analysed 14 randomized controlled trials that compared PRP to steroid injections for plantar fasciitis. The review found that PRP was significantly more effective than steroid injections in improving both pain and functional outcomes in patients with plantar fasciitis (Chu et al., 2019).
There are several possible reasons why PRP may be more effective than steroid injections for MSK conditions. First, PRP contains a variety of growth factors and cytokines that are thought to promote tissue healing, whereas steroids primarily reduce inflammation. Second, steroids can have negative side effects, including softening of tissue and increased risk of rupture, whereas PRP is derived from the patient’s own blood and typically has no adverse effects. Finally, steroids may provide only temporary relief, whereas PRP is known to have longer-lasting effects.
The evidence strongly suggests that PRP is a superior treatment option for MSK conditions, including plantar fasciitis, when compared to steroid injections.
Are there any downsides to PRP?
It is generally an expensive treatment with prices ranging between £1000–£2000, or more or when multiple treatments are required. PRP also has a reputation for being painful, this is because it is tricking the body into believing it has just sustained an acute injury. PRP is often painful even when the local anaesthetic is given, however, there are some exceptions -a subject of a future blog.
Finally, PRP is not associated with reabsorption of calcification (the process that causes heel spurs) whereas Focused shockwave can cause many similar effects to PRP and on top of that can even trigger the breakdown of calcifications. Practical downsides also include downtime and can be a little restrictive, many clinicians immobilise the foot for several days with a surgical boot to keep the PRP in place, making driving and normal day-to-day life hard. Finally, it is very hard for the average person in the street to compare different PRP providers because there is a bewildering array of PRP manufacturers and protocols out there. The academic community struggle to compare PRP studies for much the same reasons. A lack of academic comparability is one of the main reasons why PRP hasn’t really become universally adopted.
Focused shockwave
In recent years, shockwave therapy has emerged as an effective, non-invasive alternative treatment method for various stubborn musculoskeletal conditions such as plantar fasciitis.
Focused Shockwave Treatment utilises extracorporeal shockwaves generated by a medical device. These shockwaves are high-energy acoustic waves that can be focused on the plantar fascia through a process called electromagnetic shock generation. Energy is selectively directed towards the plantar fascia and unlike radial shockwave that a very limited depth of penetration, focused shockwave can penetrate to a depth of 12 cm, or right down to the heel bone and plantar fascia.
When the shockwaves pass through the skin and underlying tissues, they create mechanical stress and pressure within the affected area. This mechanical stimulation triggers the body’s natural healing response, leading to various beneficial effects such as:
- Increased Blood Flow: Shockwaves promote the formation of new blood vessels, a process known as angiogenesis. Enhanced blood flow ensures improved oxygen and nutrient supply to the plantar fascia, facilitating tissue regeneration and healing.
- Pain Reduction: Shockwave treatment can effectively reduce pain by interrupting the pain signals sent by nerve fibres. Additionally, it stimulates the release of natural pain-reducing substances (endorphins) and reduces local inflammation.
- Tissue Regeneration: The mechanical forces exerted by shockwaves on injured tissues help stimulate cellular activities related to tissue regeneration. This is particularly advantageous for chronic degenerative such as plantar fasciitis, where the healing process has stalled. Much like PRP, focused shockwave, causes a cascade of healing events that cause the body to divert more resources to the treated area lasting approximately three months from a single treatment.
- Dissolution of Calcifications: Focused Shockwave Treatment has been found effective in breaking down calcifications within tissues. The great thing about focused shockwave treatment is that it is regenerative, and it is also effective for heel pain caused by chronic compression of surrounding nerves. Furthermore, the success of Focused shockwave does not rely on the patient performing time-consuming exercises or stretching, which often go hand in hand with most other forms of plantar fasciitis treatment. Additionally, Focused shockwave has a lot of overlap with PRP plus it facilitates the breakdown and reabsorption of heel spurs. The vast majority of patients with chronic heel pain only require one treatment session.
Furthermore, focused shockwave treatment has been shown to be extremely effective with 72.2% of recalcitrant cases over 14 months duration only requiring one treatment and 22.9% requiring two treatments and only 5 % requiring three treatments.
Are there any negatives to having focused Shockwave treatment?
Focused shockwave treatment on the whole is generally a comfortable treatment to receive, however, from time to time during the treatment, some discomfort can be felt for a few seconds that most describe a 4/10, sometimes after treatment, there can be temporary bruising and swelling or localised redness lasting a day or so.
In a 2017 study that evaluated nine published shockwave studies including focused and radial ( the more painful form of shockwave), the nine studies included just under 1000 people, the study found “ no serious adverse events” following treatment, other than temporary mild pain and occasional bruising. Focused shockwave treatment is generally not suitable for those with blood clotting disorders, or those taking ‘ blood thinners’.
In our view focused shockwave treatment is the clear treatment of choice for those suffering from chronic stubborn heel pain.