A novel technique that transplants a patient’s own fat into the sole of their foot could offer relief to those suffering from plantar fasciitis, according to a proof-of-concept study from University of Pittsburgh School of Medicine.
In a pilot study published in Plastic and Reconstructive Surgery and led by a wife-and-husband team, the fat injection procedure improved symptoms of plantar fasciitis in patients – also popularly known as “joggers heel”, “policeman’s heel”, and “heel-spur syndrome” – and laying the groundwork for a larger clinical trial.
“We developed this procedure to harness the regenerative properties of fat,” said Dr Jeffrey Gusenoff, professor of plastic surgery at the University of Pittsburgh. "In this proof-of-concept study, we showed that fat injections into the foot reduced heel pain, helped patients get back to doing sports and activities and boosted quality of life.”
Plantar fasciitis, or PF, is one of the most common causes of heel pain, affecting about 2m people in the United States. It’s caused by inflammation of the plantar fascia, connective tissue that runs from the heel to the toes and supports the foot arch.
“Plantar fasciitis is exceptionally painful,” said Dr Beth Gusenoff, clinical assistant professor of plastic surgery at Pitt. “When you get up from a sitting position or from sleeping, it’s a sharp, searing pain that some people describe as being like a nail going right through their heel.”
The acute form of PF can be treated with stretching, shoe orthotics or cortisone injections. But about 10% of patients progress to the chronic form in which the foot’s collagen degenerates and the plantar fascia thickens. For these patients, surgical release of the plantar fascia with a small cut can help, but this surgery comes with risks, according to Beth Gusenoff.
“Recently, there has been a plea from podiatrists to stop cutting the plantar fascia because some people get a lot of scar tissue, which causes pain,” she said. “And if too much is cut, the foot can become destabilised, so people end up with what’s almost like a floppy foot.”
Inspired by the regenerative properties of fat stem cells, the Gusenoffs developed a technique that uses fat harvested from a patient’s belly or other body area.
“In fat, there are stem cells and growth factors that help bring in fresh blood supply, which drives a mode of wound healing with reduced scarring,” said Jeffrey Gusenoff. “We use a blunt needle to perforate the plantar fascia, which makes a small injury to stimulate the healing process. Then, when we pull the needle back, we inject a little bit of the patient’s fat.”
To test this method, the team recruited 14 patients with chronic PF and split them into two groups. Group 1 participants received the procedure at the beginning of the study and were followed for 12 months, and their Group 2 counterparts received the procedure after a six-month observation period and were followed for an additional six months.
“We found that Group 1 had improvements in quality of life and sports activity, decreased plantar fascia thickness and reduced pain levels," said Jeffrey Gusenoff. “And a lot of the measures that were improving six months after the procedure got even better by 12 months.”
Similarly, Group 2 showed decreased plantar fascia thickness and increased sports activity six months after the procedure, and there was a slight, but not statistically significant, improvement in pain levels. With a larger sample size and a longer follow-up time, the researchers said it’s likely they would have seen stronger improvements in this group.
According to the Gusenoffs, this study provides proof-of-concept that fat injections can treat PF, and they now are planning a larger clinical trial to validate these findings. With enough evidence, they hope that the procedure will be deemed a medical necessity so that it can be covered by insurance and become more widely available in the future.
In previous work, the Gusenoffs showed that fat injections can help solve another type of foot pain caused by loss of the fat pads that cushion the ball of the foot and heel.
Study details
Perforating Fat Injections for Chronic Plantar Fasciitis: A Randomized, Crossover Clinical Trial
Beth Gusenoff, Danielle Minteer, Jeffrey Gusenoff.
Published in Plastic & Reconstructive Surgery in February 2022.
Abstract
Summary
Plantar fasciitis affects 2 million patients per year. Ten percent of cases are chronic, with thickened plantar fascia. Treatment may lead to prolonged recovery, foot instability, and scar. The authors hypothesised that perforating fat injections would decrease plantar fascia thickness, reduce pain, and improve quality of life. Adults with plantar fascia greater than 4 mm for whom standard treatment had failed were included in a prospective, randomised, crossover pilot study. Group 1 (intervention) was followed for 12 months. Group 2 was observed for 6 months, injected, and then followed for 6 months. Validated patient reported outcome measures, ultrasound, and complications were assessed. Group 1 had nine female patients and group 2 had five patients.
A total of 2.6 ± 1.6 ml of fat was injected per foot at one to two sites. In group 1, plantar fascia thickness decreased from screening at 6 and 12 months (p < 0.05). Group 2 had decreased plantar fascia thickness from screening to 6 months after injection (p < 0.05). Group 1 had pain improvements at 6 and 12 months compared with screening (p < 0.01). Group 2 reported no pain difference after injections (p > 0.05). Group 1 had improved activities of daily living and sports activity at 6 and 12 months compared with screening (p < 0.003). Group 2 noted increased sports activity 6 months after injection compared with screening (p < 0.03).
In conclusion, perforating fat injections for chronic plantar fasciitis demonstrate significant improvement in pain, function, and plantar fascia thickness.
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