Created: Monday, November 12, 2007

Autologous blood injections for the treatment of plantar fasciiti 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.  Edwards and Calcandruccio reported on 28 patients who underwent autologous blood injections for the treatment of lateral epicondylitis or tennis elbow. 2 milliliters of blood was withdrawn from the dorsal vein of the hand and mixed with 1 mL of 2% lidocaine or 1 mL of 0.5% bupivacaine.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. 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. 

All patients had thickened fascial hypertrophy on ultrasound examination confirming plantar fasciosis.20 ccís of the patientís blood was withdrawn and using the Smart Prepģ System (Harvest Technologies), 3 ccís of APC+ was obtained for injection.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 ccís 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 Edwards study.

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.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 andneedle dissectionof the fascia.  However, these techniques including autologous blood injection appear to be viable techniques and a good alternative to corticosteroid injection therapy.