Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Plantar Fasciitis

Abstract

Objective

This study aims to compare the efficacy of platelet-rich plasma and corticosteroids in treating plantar fasciitis, focusing on pain relief, foot function, and plantar fascia thickness to identify the optimal treatment approach.

Design

A comprehensive search of medical databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing an extensive keyword strategy. Inclusion criteria encompassed prospective randomized controlled trials involving adult patients with plantar fasciitis treated with local platelet-rich plasma or corticosteroid injections, specifically assessing outcomes such as the visual analog scale, American Orthopedic Foot and Ankle Society scores, and plantar fascia thickness.

Results

The meta-analysis included 24 randomized controlled trials with 1653 participants. Platelet-rich plasma injections yielded significantly better visual analog scale scores compared to corticosteroid injections at 3 mos (P = 0.03) and 6 mos (P < 0.001), with no significant differences at 1 mo (P = 0.12) and 12 mos (P = 0.08). American Orthopedic Foot and Ankle Society scores demonstrated that platelet-rich plasma was superior to corticosteroid at 3 (P = 0.05), 6 (P < 0.001), and 12 mos (P < 0.001), with no significant differences at 1 mo (P = 0.31). Regarding plantar fascia thickness, there were no significant differences between platelet-rich plasma and corticosteroid at 1–1.5 mos (P = 0.18), 3 mos (P = 0.64), and 6 mos (P = 0.05).

Conclusions

Platelet-rich plasma injections offer superior pain control compared to corticosteroids in the medium term (3–6 mos) but not in the short term or at 1 yr.

What Is Known

• The efficacy of platelet-rich plasma (PRP) and corticosteroid (CS) injections for treating plantar fasciitis has been a subject of ongoing debate.

What Is New

• This systematic review reveals that while PRP injections do not outperform CS in the short term or at 1-yr follow-up, they provide significantly better pain relief in the medium term (3–6 mos). These insights can help doctors make informed decisions when choosing between PRP and CS treatments for plantar fasciitis, especially for patients seeking longer-term pain management.

Plantar fasciitis (PF) is a common and debilitating degenerative condition of the plantar fascia, primarily caused by repetitive microtrauma and excessive tension on the plantar surface.¹ This repeated stress leads to microtears within the fascia, which precipitate fibroblastic proliferation and subsequent abnormal collagen deposition, ultimately culminating in tissue degeneration and structural changes. These microtears result in edema and degenerative alterations, which are key mechanisms responsible for the pain experienced by patients with plantar fasciitis. While traditionally associated with inflammatory processes, emerging evidence suggests that PF is predominantly a degenerative condition with minimal inflammation, characterized by vascular dysfunction and structural damage within the fascia.² PF is the most frequent cause of heel pain, with a global lifetime prevalence of 10%, and is more prevalent among females.³ The condition significantly impairs patients’ quality of life, as the resulting pain and mobility restrictions limit daily activities, potentially leading to decreased physical fitness, work absenteeism, and psychological stress.⁴

Typically, the first line of treatment for plantar fasciitis is nonsurgical, involving nonsteroidal anti-inflammatory drugs, orthotics, and physical therapy.¹ For patients who do not respond to these interventions, different types of injections are available. The current standard for local injection therapies includes corticosteroid (CS) injections, which provide short-term pain relief in approximately 70%–80% of patients. The effects generally last between 4 and 12 wks, with the greatest relief observed around 4 wks after injection. In most cases, a single injection is sufficient to achieve significant pain reduction. However, in refractory cases, up to three injections may be administered, although this increases the risk of complications. These complications may include plantar fascia rupture, infection, skin pigmentation changes, muscle damage, and fat pad atrophy. Although many patients experience partial improvement, the benefits tend to diminish over time, and full resolution of symptoms is not guaranteed.^5–8 In recent years, platelet-rich plasma (PRP) injections have gained prominence in the treatment of plantar fasciitis by leveraging the regenerative potential of platelets and leukocytes.⁹ PRP releases a concentrated array of growth factors, such as platelet-derived growth factor, transforming growth factor beta, and vascular endothelial growth factor (VEGF), all of which are pivotal in tissue repair and regeneration. These growth factors enhance cellular proliferation, stimulate collagen synthesis, and promote angiogenesis, which are critical for the restoration of damaged plantar fascia. Moreover, the leukocytes in PRP contribute to its antimicrobial properties, reducing the risk of infection and further supporting the healing process.^10,11 This multifaceted approach positions PRP as a promising therapeutic option, particularly for patients who have not responded adequately to conventional treatments.

The efficacy of PRP versus CS treatment for plantar fasciitis remains controversial, as various randomized controlled trials (RCTs) have yielded conflicting results. While some studies have found no significant difference in efficacy between PRP and CSs^12,13, others have reported superior outcomes with PRP.^14,15 Therefore, our study aims to compare the effectiveness of PRP and CSs in treating plantar fasciitis across the following three critical aspects: pain, foot function, and plantar fascia thickness—each of which represents a clinically relevant dimension of the condition. Pain is the primary and most debilitating symptom, directly affecting patients’ quality of life. Foot function is crucial as it determines patients’ ability to perform daily activities, which is often severely impaired in those with plantar fasciitis. Plantar fascia thickness serves as a measurable indicator of structural changes within the fascia, providing insights into the underlying pathophysiology and the treatment’s impact on tissue morphology. By thoroughly assessing these dimensions, we aim to provide robust insights into the most suitable treatment method for this widespread and impactful condition.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement¹⁶ (See Supplementary Checklist, http://links.lww.com/PHM/C671). The protocol was registered in PROSPERO (CRD42024496055).

Search Strategy

Two independent reviewers systematically conducted a comprehensive search for relevant studies in major electronic medical databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Web of Science, and Embase. This search encompassed all records available up to February 1, 2024. The search strategy employed a targeted set of keywords aligned with the PICOS framework: “Plantar Fasciitis,” “Platelet-Rich Plasma,” “PRP,” “Autologous Plasma,” “Corticosteroids,” “Steroids,” “Methylprednisolone,” “Betamethasone,” “Dexamethasone,” “pain relief,” “healing rate,” “functional improvement,” “symptom reduction,” “treatment outcomes,” “Randomized Controlled Trials,” “RCTs,” and “Clinical Trials.” This methodology was tailored to each database, with no specific filters applied.

Eligibility Criteria

The inclusion criteria for this study were as follows: (1) prospective RCTs; (2) Studies involving local injections of PRP and CSs; (3) reporting of at least one of the following outcomes: the visual analog scale (VAS) for pain assessment, the American Orthopedic Foot and Ankle Society (AOFAS) scores for functional evaluation, or the thickness of the plantar fascia. The thickness of the plantar fascia was measured using sonographic examination with a 5- to 12-MHz linear array transducer on heels, specifically in the longitudinal view from the anterior edge of the inferior calcaneal border; (4) Adult participants diagnosed with plantar fasciitis (aged 18 yrs or older); (5) studies in which injections were administered following at least 3 mos of unsuccessful conservative treatment.

The exclusion criteria for this study were as follows: (1) animal studies; (2) nonoriginal research articles, such as reviews or technical reports; (3) duplicate publications; (4) studies presented only as abstracts; and (5) studies involving patients with concomitant foot or ankle pathologies, such as rheumatoid arthritis, tarsal tunnel syndrome, or Achilles tendinopathy, which may contribute to pain beyond that caused by plantar fasciitis alone.

Data Extraction

Two independent researchers meticulously screened all the studies included in the meta-analysis, extracting data in accordance with the predefined inclusion and exclusion criteria. The demographic and clinical characteristics extracted for the meta-analysis included the first author, year of publication, country of origin, study design, sample size per study, gender distribution (male/female ratio), average age of participants, detailed descriptions of the interventions (specifically PRP and steroid treatments), injection guidance, defined outcome measures, and the duration of follow-up. In cases where trials featured more than two intervention groups, data were specifically extracted from the groups receiving PRP and steroid interventions only. All extracted data were systematically entered into a digital spreadsheet for analysis. Any discrepancies encountered during this process were resolved through discussion, with a consensus reached through the involvement of a third researcher when necessary.

Assessment of Methodological Quality

Two independent reviewers evaluated the methodological quality of the included studies using the Cochrane Risk of Bias Tool 2 (RoB 2).¹⁷ This tool is organized into the following five distinct domains of bias: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome, and bias in the selection of the reported result. This comprehensive approach ensures a thorough assessment of potential biases within each study.

Statistical Analysis

The statistical analysis of our meta-analysis was independently conducted using Stata 16.0 by two researchers. We calculated the weighted mean difference (WMD) between the PRP and steroid groups, reporting these differences along with 95% confidence intervals (95% CIs). This approach was applied to evaluate continuous variables. The I² statistic was used as an objective measure to assess heterogeneity across studies. When the I² value exceeded 50%, indicating significant heterogeneity, we employed a random-effects model. Conversely, a fixed-effects model was used in instances of low heterogeneity (I² ≤ 50%). Sensitivity analysis was conducted for I² statistics greater than 50%. Forest plots were generated to visually depict the comparative outcomes between PRP and steroid groups across all included studies. A P value of less than 0.05 was considered indicative of statistical significance.

RESULTS

Included Studies

Following the literature search, a total of 233 relevant publications were initially identified. After the removal of duplicates, 149 studies were screened based on their titles and abstracts. Of these, 125 records were excluded for being reviews, letters, or not pertinent to our research topic. Consequently, 24 RCTs,^{12–15,18–37} encompassing a collective total of 1,653 participants, met the selection criteria and were included in this meta-analysis. The process of study selection and inclusion is illustrated in the flow diagram presented in Figure 1 of the current study.

FIGURE 1.

PRISMA flowchart of the study search process.

Studies Characteristics

The 24 RCTs included in our meta-analysis are detailed in Supplementary Table 1, http://links.lww.com/PHM/C672. These studies were globally distributed, with 14 conducted in India, four in Egypt, and one each in the UK, Mexico, Iran, Turkey, Sri Lanka, and Nepal. The studies focused on patients with plantar fasciitis, treated in the experimental groups with local injections of autologous platelet-rich plasma (PRP) and in the control groups with local steroid injections. The PRP, derived from the patient’s own peripheral blood, was consistently produced following detailed methodologies outlined in each study, with administered volumes ranging from 2 ml to 5 ml. Notably, two studies utilized calcium gluconate as an activating agent for PRP. The steroid injections varied across studies: 16 used methylprednisolone, four used triamcinolone, and the remainder employed betamethasone, dexamethasone, or an unspecified steroid, often in combination with local anesthetics like prilocaine or lidocaine. These RCTs were published between 2013 and 2023.

Quality Assessment of Individual Trials

Figure 2 provides a summary of the methodological quality of all the studies included in our analysis. Among these, 23 studies demonstrated adequate random sequence generation. Allocation concealment was appropriately implemented in 16 of the included studies. Nine studies reported blinding of outcome assessors, ensuring an objective assessment of results. Furthermore, our evaluation did not reveal any other obvious sources of bias within the trials.

FIGURE 2.

Quality assessment of the 24 RCTs using the Cochrane ROB tool.

Meta-analysis of VAS

A total of 21 studies provided data on visual analog scale (VAS) scores following local injections, with 756 patients in the PRP group and 756 in the steroid group. The results of the pooled analyses are presented in Figures 3 and 4. These findings revealed that the VAS scores in the local PRP injection group were significantly lower compared to the local steroid injection group at the 3-mo (WMD = −0.61; 95% CI, −1.17 to −0.05; P = 0.03; I² = 96.07%) and 6-mo (WMD = −1.55; 95% CI, −2.23 to −0.87; P < 0.001; I² = 97.04%) follow-ups. However, no significant differences were observed in the VAS scores between the two groups at the 1-mo (WMD = 0.41; 95% CI, −0.10 to 0.93; P = 0.12; I² = 93.50%) and 1-yr (WMD = −1.11; 95% CI, −2.33 to 0.11; P = 0.08; I² = 53.18%) follow-ups.

FIGURE 3.

Forest plot compares the VAS scores between PRP and CS at 1 mo (A) and 3 mos (B).

FIGURE 4.

Forest plot compares the VAS scores between PRP and CS at 6 mos (A) and 12 mos (B).

Meta-analysis of AOFAS Scores

A total of 11 studies reported on the AOFAS scores following local injection treatment, encompassing 339 patients in the PRP group and 337 in the steroid group. The results of these pooled analyses are depicted in Figure 5. They indicated that the AOFAS scores in the local PRP injection group were significantly higher than those in the local steroid injection group at the 3-mo (WMD = 7.11; 95% CI, 0.15 to 14.06; P = 0.05; I² = 96.15%), 6-mo (WMD = 10.28; 95% CI, 5.42 to 15.14; P < 0.001; I² = 89.83%), and 1-yr (WMD = 8.33; 95% CI, 3.54 to 13.12; P < 0.001; I² = 00.00%) follow-ups. However, there were no significant differences in AOFAS scores between the two groups at the 1-mo follow-up (WMD = −2.84; 95% CI, −2.62 to 8.30; P = 0.31; I² = 78.99%).

FIGURE 5.

Forest plot compares the AOFAS scores between PRP and CS at 1 mo (A), 3 mos (B), 6 mos (C), and 12 mos (D).

Meta-analysis of Fascia Thickness

A total of seven studies reported on fascia thickness following local injection treatment, involving 202 patients in the PRP group and 201 in the steroid group. The results of these pooled analyses are presented in Figure 6. They demonstrated that there were no significant differences in fascia thickness between the local PRP injection group and the local steroid injection group at the 1–1.5 mo (WMD = 0.34; 95% CI, −0.16 to 0.84; P = 0.18; I² = 84.25%), 3-mo (WMD = −0.20; 95% CI, −1.05 to 0.65; P = 0.64; I² = 94.92%), and 6-mo (WMD = −0.51; 95% CI, −1.02 to 0.01; P = 0.05; I² = 92.87%) follow-ups.

FIGURE 6.

Forest plot compares the Plantar fascia thickness between PRP and CS at 1–1.5 mos (A), 3 mos (B), and 6 mos (C).

Sensitivity Analysis

A sensitivity analysis was conducted, involving the individual removal of each study, to assess the stability of the pooled results. This analysis confirmed that the pooled results for the VAS, AOFAS scores, and fascia thickness remained stable.

DISCUSSION

We identified 24 RCTs comparing PRP and CS injections for the treatment of plantar fasciitis. Our meta-analysis found that, compared to CS injections, local injections of PRP provided better relief from pain and improvement in foot and ankle function at 3 to 6 mos.

Pain significantly affects the quality of life of patients with plantar fasciitis, and the VAS score is widely used to assess pain. Our meta-analysis found no difference in pain relief between PRP and CS at 1 mo. However, at 3 and 6 mos, PRP provided better pain relief than CS, while no difference was observed between them at 12 mos. Corticosteroids, with their strong anti-inflammatory effects, can accelerate pain relief and inhibit fibroblast proliferation and matrix protein expression,³⁸ suggesting a reparative effect on the plantar fascia, which explains why CSs relieve pain in the early and middle stages of PF. PRP also contains many anti-inflammatory factors that can alleviate inflammation, hence the similar pain scores at 1 mo.³⁹ However, pain in plantar fasciitis patients, especially in chronic cases, is mainly due to degeneration of the plantar fascia.⁴⁰ PRP releases numerous growth factors, such as platelet-derived growth factors, to initiate the repair and reconstruction process,⁴¹ which takes time, leading to the better pain relief from PRP at 3 and 6 mos. However, at 12 mos, the VAS scores for PRP and CS treatments converged, with only three studies reporting these outcomes, each showing different results. One study found that both PRP and CS injections continued to reduce VAS scores at 12 mos, indicating sustained effectiveness with no significant differences between the treatments.²⁹ Another study demonstrated that PRP maintained its therapeutic effect at 12 mos, while the VAS scores in the CS group began to rebound, making PRP more effective at the 1-yr mark.¹⁹ The third study reported that although both PRP and CSs were effective in the first 6 mos, VAS scores increased in both groups at 12 mos, with no significant differences between the treatments.²⁴ The recurrence of symptoms observed at 12 mos is understandable; CSs, known for their potent anti-inflammatory effects, typically provide relief within the first 4–12 wks, a period considered “short-term.” After this period, the benefits of CSs diminish, likely because of reduced inflammation without addressing the underlying degenerative processes. Overuse of the foot following initial pain relief may exacerbate symptoms, as increased activity can worsen the underlying condition.⁴² Additionally, anatomical abnormalities inherent in plantar fasciitis, such as flat feet, high arches, and leg-length discrepancies, are not corrected by injections alone, contributing to the recurrence of pain. In contrast, PRP offers both anti-inflammatory properties and growth factors that promote tissue repair, explaining its superior performance over the medium term (3–6 mos). However, because PRP is typically administered as a single injection, the limited release of growth factors may not suffice to sustain long-term effects. The persistence of anatomical risk factors and overuse further contribute to the observed decline in efficacy at 12 mos. Therefore, more high-quality RCTs with standardized protocols and longer follow-up periods are needed to verify the long-term effects of PRP treatment for plantar fasciitis.

The AOFAS score, a widely used index for evaluating foot and ankle function, showed no difference between PRP and CSs at 1 mo. However, at 3, 6, and 12 mos, PRP demonstrated superior improvements in AOFAS scores compared to CSs, suggesting better mid- to long-term functional outcomes with PRP. This improvement likely reflects PRP’s role in enhancing tissue repair and restoring overall foot function, which is crucial for daily activities and quality of life. The discrepancy between AOFAS and VAS scores may be attributed to the fact that VAS primarily measures pain, while AOFAS provides a broader assessment of foot function, including pain, activity limitations, and alignment. PRP’s ability to enhance functional recovery beyond mere pain relief could explain its superior performance in AOFAS scores over time. However, it is important to note that only two studies reported 12-mo AOFAS scores, indicating that the evidence remains limited. This underscores the need for further high-quality RCTs with standardized protocols and longer follow-up periods to confirm these findings and establish the long-term functional benefits of PRP over CSs.

Plantar fasciitis results from inflammation and degeneration due to microtears in the plantar fascia. A plantar fascia thickness greater than 4 mm is considered abnormal.^43,44 Several RCTs have used plantar fascia thickness to evaluate the efficacy of PRP and CS treatments. Our meta-analysis revealed no significant difference in plantar fascia thickness between PRP and CS treatments at 1, 3, and 6 mos. However, both interventions were associated with a significant reduction in thickness over time. This reduction is clinically meaningful, likely reflecting a decrease in inflammation and a potential restoration of normal fascial architecture—key therapeutic objectives in managing plantar fasciitis. The ability of ultrasound to detect these subtle changes in thickness underscores its utility as an objective marker for treatment efficacy. Given its high sensitivity, noninvasive nature, and capacity for precise, repeatable measurements, ultrasound is an indispensable tool not only for the initial diagnosis of plantar fasciitis but also for the ongoing monitoring of treatment outcomes.⁴⁵ The increased thickness of the plantar fascia in patients with plantar fasciitis is primarily attributed to inflammation and degenerative changes within the fascia. Inflammation leads to fluid accumulation within the tissue, causing edema and contributing to the increase in thickness. Degenerative changes, including collagen fiber disorganization, fibrosis, and fibroblast proliferation, also contribute to the overall thickening of the fascia. On ultrasound imaging, inflammation is typically manifested as an increase in plantar fascia thickness, whereas degenerative changes are more likely to be reflected in alterations of echo intensity rather than in thickness alone.⁴⁶ Our study found no significant differences in thickness between PRP and CS treatments, indicating that both treatments have similar anti-inflammatory effects. However, the reparative advantages of PRP may not be fully captured by thickness measurements alone and might be better indicated by changes in echo intensity. Therefore, future research should consider incorporating echo intensity measurements into assessments to provide a more comprehensive evaluation of treatment efficacy and gain deeper insights into the tissue changes associated with plantar fasciitis.

Common adverse reactions following CS injections primarily include local infections and heel fat pad atrophy, with repeated injections potentially leading to plantar fascia rupture.⁴⁷ In contrast, the primary adverse effect associated with PRP injections is pain, which typically lasts from a few hours to 3 days and generally does not result in long-term complications. This pain is largely due to the inhibition of platelet aggregation and reduced growth factor release when PRP is mixed with anesthetics such as lidocaine.⁴⁸ Consequently, PRP is usually administered without anesthetics, leading to significant discomfort. Additionally, PRP-induced pain may be linked to proinflammatory substances released by leukocytes and residual red blood cells in the preparation.¹¹ In contrast, CSs are almost always combined with anesthetics like lidocaine to minimize immediate postinjection pain. The short-term pain associated with PRP injections can restrict patient mobility, potentially requiring assistance after treatment, which negatively impacts the overall patient experience and acceptance of PRP therapy. Therefore, further research is necessary to elucidate the mechanisms underlying PRP-induced pain and to develop strategies for its mitigation.

Future studies require more stringent RCTs to compare the long-term efficacy of PRP and steroid treatments for plantar fasciitis. Currently, there is no standardized protocol for PRP treatment of plantar fasciitis, and the preparation of PRP lacks uniform standards, leading to significant variability. Almost no trials report on the concentration of platelets, yet this concentration is crucial to PRP’s effectiveness. Some studies suggest that the number of growth factor receptors varies across different tissue types, implying that too low a concentration of platelets might not provide enough growth factors, affecting therapeutic outcomes.⁴⁹ Conversely, too high a concentration might lead to adverse effects, such as cell apoptosis, receptor desensitization, and downregulation of growth factor receptors, potentially inhibiting the therapeutic effect. Thus, the appropriate concentration of platelets for PRP treatment of plantar fasciitis requires further exploration. Additionally, while each injection is typically 2–3 ml, whether multiple injections are more effective than a single injection needs investigation. Steroids are limited to single injections due to the risk of plantar fascia rupture with multiple injections, whereas PRP, aside from causing temporary pain after injection, has not shown other side effects, suggesting that a multiple-injection regimen could be considered. However, whether multiple injections can enhance the effect and the optimal interval between injections still need further study. Two studies chose to activate PRP with calcium chloride¹⁵ or calcium gluconate²³ before injection, while others did not use an activator, indicating that the use of activators also requires more research.

Limitations

Our meta-analysis exhibits several limitations. The quality of some included studies is suboptimal, particularly in terms of blinding procedures, which introduces potential biases. Despite recommendations against its use due to its high ceiling effect, the AOFAS score was utilized. High I² values further underscore potential limitations of this study. Variability in PRP preparation protocols across different trials has led to inconsistencies in PRP quality and, consequently, therapeutic outcomes. Although control groups uniformly received CSs, variations in the types and brands of CSs used highlight the necessity for more comprehensive and rigorous RCTs to validate the efficacy of PRP injections in treating plantar fasciitis.

CONCLUSIONS

Our systematic review and meta-analysis demonstrate that PRP injections provide superior pain control compared to CSs at 3 to 6 mos, although this advantage is not observed in the short term or at 1 yr. PRP also resulted in better AOFAS scores at mid- to long-term follow-up, indicating improved foot and ankle function. While both PRP and CSs were associated with a reduction in plantar fascia thickness, no significant difference was observed between the two treatments. These findings highlight the need for further high-quality RCTs with standardized protocols and extended follow-up periods to fully elucidate the role of PRP, not only in pain control but also in functional recovery and structural improvement in patients with plantar fasciitis.