Ci a ion: Pa do-Camps, F.;
Pa do-Bosch, F. New In il a ion
Technique in he T ea men o he
Plan a Fascia Synd ome Based on
Pla ele -Rich Plasma. J. Clin. Med.
2024,13, 170. h ps://doi.o g/
10.3390/jcm13010170
Academic Edi o s: Ca lo Biz and
Pie o Ruggie i
Recei ed: 30 No embe 2023
Re ised: 24 Decembe 2023
Accep ed: 26 Decembe 2023
Published: 28 Decembe 2023
Copy igh : © 2023 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
Jou nal o
Clinical Medicine
A icle
New In il a ion Technique in he T ea men o he Plan a Fascia
Synd ome Based on Pla ele -Rich Plasma
F ancesc Pa do-Camps 1,2 and F ancesc Pa do-Bosch 3,*
1Uni e si y Clinic, Complu ense Uni e si y o Mad id, Plaza Ramón y Cajal, s/n, 28040 Mad id, Spain;
d pa docamps@d pa docamps.com
2Depa amen o O hopedic Su ge y and T auma ology, Ca alan Ins i u e o Heal h, A . Josep Lapo e 2,
43204 Reus, Spain
3
Depa amen o P ojec and Cons uc ion Enginee ing, Uni e si a Poli ècnica de Ca alunya (Ba celonaTech),
C. Jo di Gi ona 1-3, 08034 Ba celona, Spain
*Co espondence: ancesc.pa [email p o ec ed]
Abs ac : Pain in he a achmen o he plan a ascia in he calcaneus ep esen s 10% o all spo s
inju ies, a ec s 10% o oo unne s, and will a ec a ound 20% o he wo ld popula ion. The e is
no e ec i e conse a i e ea men o i . This pape jus i ies a new de ini ion and name o his
pa hology, Plan a Fascia Synd ome (PFS), p esen s a me hodology o i s diagnosis, and p esen s he
clinical and unc ional e ec i eness o a new conse a i e ea men based on pla ele - ich plasma
(PRP). In o al, 25 pa ien s ( om an ini ial sample o 260) diagnosed wi h ecalci an PFS las ing o
mo e han 12 mon hs we e ea ed wi h a single in il a ion o 2 mL o PRP, acco ding o a new echnic
p oposed. The s udy was app o ed by he e hical commi ee o clinical esea ch o he e e ence
hospi al. The pa ien s we e con olled a e 15, 30, 90, and 180 days, e iewing on each occasion
pain, hickness o he plan a ascia, and ac i e ex ension o he ankle join . A o al o 15 days a e
in il a ion, 85% o pa ien s had no clinical signs equi ing ea men . A e 90 days o in il a ion, no
pa ien s showed clinical signs. This imp o emen in he pa ien s’ condi ion las ed o 180 days. All
pa ien s a e ea men can ully esume no mal ac i i y wi h no pain.
Keywo ds: pla ele - ich plasma; PRP; in il a ion; plan a ascia synd ome; conse a i e ea men
1. In oduc ion
Fee a e he mos dis al unc ional uni s in he lowe pa o he human body. They a e
he basic mechanism ha main ains he balance in he bipedal posi ion. Fee ’s mo emen s
a e combined and sequen ial. Desynch oniza ion in hese mo emen s leads o a degen-
e a ion o he s uc u es, which in u n esul s in pain. Foo pain can be disabling, which
explains why he e a e so many pa ien s seeking medical and su gical help.
One equen ly pain ul ana omical s uc u e o he oo is he en hesis o he si e o
a achmen o he plan a ascia (aponeu osis) in he calcaneus. This pain occu s due o
s i ness a e p olonged es . The pain o igina es in di e en pa hologies ha a ec bo h
he ascia and he calcaneus, as well as o he adjacen s uc u es. This inju y ha ms 7%
o he popula ion o e 65 yea s old who expe ience pain in his a ea o he oo [
1
]. In
oo - acing a hle es, his inju y accoun s o 25% o all oo inju ies [
2
] and app oxima ely 8
o 10% o all inju ies. Despi e he impo ance o his inju y, he elie o he symp oms akes
abou 1 yea [3], and he ou come is no always p omising.
The pa hology o he en hesis be ween he plan a ascia and he calcaneus (ci cled
a ea in Figu e 1) a ising om opposing ensions o he a ious o ces ha con e ge a
his poin has been in es iga ed o mo e han 100 yea s wi hou a clea desc ip ion o i s
ae iology, a well-de ined diagnos ic me hodology, o a p ecise ea men p o ocol. To da e,
his pa hology has been e e ed o as plan a ascii is [4,5] o plan a asciosis [6,7].
J. Clin. Med. 2024,13, 170. h ps://doi.o g/10.3390/jcm13010170 h ps://www.mdpi.com/jou nal/jcm
J. Clin. Med. 2024,13, 170 2 o 14
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 2 o 14
Figu e 1. Loca ion o he Plan a Fascia Synd ome in he hind oo .
A e ha ing s udied he pa hological signs o his synd ome and conside ed i s de -
ini ions, he au ho s ha e named his pa hology Plan a Fascia Synd ome (PFS) wi h he
ollowing de ini ion: “Sha p and s abbing pain a e es ing he oo on he loo , loca ed in he
an e io lowe ace o he heel, and i adia ing and/o p ojec ing o he middle o he sole o he oo ”
[8]. Pain is he p ima y symp om in pa ien s wi h PFS and is associa ed on many occasions
wi h igh ness o s i ness o he plan a a ea, a educ ion in mobili y o he a ch o he
ankle [9], and a ce ain deg ee o p og essi e unc ional impai men . This de ini ion is
suppo ed by Nuclea Magne ic Resonance (MRI) s udies, whe e i is possible o de ec
he p esence o bone oedema, subchond al lesions, and a ious o he bone pa hologies
ha coexis wi h he in lamma o y pa hology, some imes ch onic, o he plan a ascia
i sel .
The connec i e issue and he muscle- endinous ib es o he plan a ascia ha e good
egene a i e capaci y, howe e , depending on he ex en o he pa hology, assis ance may
be needed o a oid incomple e egene a ion [10]. On he o he hand, he calcaneus p e-
sen s chond al inju ies o di icul egene a ion due o ascula de ici , which would ben-
e i om he angiogenic g ow h ac o s (GFs) [11]. In he las decade, con ibu ions om
molecula biology ha e enabled he de elopmen o new echniques. These echniques
include he applica ion in he inju ed a ea o pla ele - ich plasma (PRP) p epa a ions. I s
u ili y has been demons a ed in di e en ields such as bone egene a ion [12,13], oph-
halmologic su ge y o he limbus and co nea [14,15], ca diopulmona y su ge y [16], max-
illo acial su ge y [17,18], den is y [19], auma ology, accele a ing he healing o bo h
muscle and endon inju ies, and in os eo-degene a i e join inju ies [20–23].
Nowadays, PRP is seen as a non-indus ial pla ele concen a e wi h a pla ele con-
cen a ion g ea e han he basal coun . When ac i a ed, i eleases GFs wi h an i-in lam-
ma o y, analgesic, and egene a i e p ope ies. In daily p ac ice, i is ecognised ha hese
e ec s can, in gene al, s imula e he issue epai p ocesses in bo h bone and so issues,
dec ease he in ec ion a es in ollowing ea men s [24], educe pain and in lamma ion,
and, inally, educe blood loss [25,26].
Conside ing he clea egene a i e powe o PRP, he good esul s ob ained wi h
PRP, which is conside ed a conse a i e ea men [27,28], in o he musculoskele al pa-
hologies, and he ac ha PFS is a pa hology cha ac e ised by de e io a ion o so issue
( ascia) and ha d issue (calcaneus), his pape aims o demons a e he e ec i eness om
a clinical and unc ional poin o iew o a conse a i e ea men based on only one in-
il a ion o 2 mL o pla ele - ich plasma (PRP) in pa ien s diagnosed wi h Plan a Fascia
Synd ome (PFS) wi h a new injec ion p ocedu e.
The en hesis be ween he plan a ascia and he calcaneus is a biomechanical si e sub-
jec o di e en ac ions, cu ing, and wis ing o ces. I s dynamic balance is main ained
due o i s elas ic p ope ies. The biomechanical ac ion o he en hesis equi es signi ican
ene gy consump ion, which in u n esul s in wea and ea o he de e io a ion o he
inse ional ib es. Many au ho s belie e ha hese ib es may be epai ed and/o eco -
e ed h ough he ex e nal applica ion o PRP. This applica ion o PRP also aims o imp o e
Figu e 1. Loca ion o he Plan a Fascia Synd ome in he hind oo .
A e ha ing s udied he pa hological signs o his synd ome and conside ed i s
de ini ions, he au ho s ha e named his pa hology Plan a Fascia Synd ome (PFS) wi h he
ollowing de ini ion: “Sha p and s abbing pain a e es ing he oo on he loo , loca ed in he
an e io lowe ace o he heel, and i adia ing and/o p ojec ing o he middle o he sole o he
oo ” [
8
]. Pain is he p ima y symp om in pa ien s wi h PFS and is associa ed on many
occasions wi h igh ness o s i ness o he plan a a ea, a educ ion in mobili y o he a ch
o he ankle [
9
], and a ce ain deg ee o p og essi e unc ional impai men . This de ini ion
is suppo ed by Nuclea Magne ic Resonance (MRI) s udies, whe e i is possible o de ec
he p esence o bone oedema, subchond al lesions, and a ious o he bone pa hologies ha
coexis wi h he in lamma o y pa hology, some imes ch onic, o he plan a ascia i sel .
The connec i e issue and he muscle- endinous ib es o he plan a ascia ha e good
egene a i e capaci y, howe e , depending on he ex en o he pa hology, assis ance may
be needed o a oid incomple e egene a ion [
10
]. On he o he hand, he calcaneus p esen s
chond al inju ies o di icul egene a ion due o ascula de ici , which would bene i om
he angiogenic g ow h ac o s (GFs) [
11
]. In he las decade, con ibu ions om molecula
biology ha e enabled he de elopmen o new echniques. These echniques include he
applica ion in he inju ed a ea o pla ele - ich plasma (PRP) p epa a ions. I s u ili y has
been demons a ed in di e en ields such as bone egene a ion [
12
,
13
], oph halmologic
su ge y o he limbus and co nea [
14
,
15
], ca diopulmona y su ge y [
16
], maxillo acial
su ge y [
17
,
18
], den is y [
19
], auma ology, accele a ing he healing o bo h muscle and
endon inju ies, and in os eo-degene a i e join inju ies [20–23].
Nowadays, PRP is seen as a non-indus ial pla ele concen a e wi h a pla ele concen-
a ion g ea e han he basal coun . When ac i a ed, i eleases GFs wi h an i-in lamma o y,
analgesic, and egene a i e p ope ies. In daily p ac ice, i is ecognised ha hese e ec s
can, in gene al, s imula e he issue epai p ocesses in bo h bone and so issues, dec ease
he in ec ion a es in ollowing ea men s [
24
], educe pain and in lamma ion, and, inally,
educe blood loss [25,26].
Conside ing he clea egene a i e powe o PRP, he good esul s ob ained wi h PRP,
which is conside ed a conse a i e ea men [
27
,
28
], in o he musculoskele al pa hologies,
and he ac ha PFS is a pa hology cha ac e ised by de e io a ion o so issue ( ascia) and
ha d issue (calcaneus), his pape aims o demons a e he e ec i eness om a clinical and
unc ional poin o iew o a conse a i e ea men based on only one in il a ion o 2 mL
o pla ele - ich plasma (PRP) in pa ien s diagnosed wi h Plan a Fascia Synd ome (PFS)
wi h a new injec ion p ocedu e.
The en hesis be ween he plan a ascia and he calcaneus is a biomechanical si e
subjec o di e en ac ions, cu ing, and wis ing o ces. I s dynamic balance is main ained
due o i s elas ic p ope ies. The biomechanical ac ion o he en hesis equi es signi ican
ene gy consump ion, which in u n esul s in wea and ea o he de e io a ion o he
inse ional ib es. Many au ho s belie e ha hese ib es may be epai ed and/o eco e ed
h ough he ex e nal applica ion o PRP. This applica ion o PRP also aims o imp o e
he os eoca ilaginous issue whe e he plan a ascia is inse ed o pe o m i s physio-
logical ac ion o ac ion-dis ac ion and whe e o he o ces, such as cu ing and wis ing
o ces, con e ge.
J. Clin. Med. 2024,13, 170 3 o 14
2. Ma e ials and Me hods
2.1. Type o S udy
The au ho s conduc ed a mul icen e in e en ional clinical s udy wi h olun ee
pa ien s diagnosed wi h G ade III Plan a Fascia Synd ome (see Sec ion 2.2) and subjec ed
hem o ea men based on a single in il a ion o 2 mL o pla ele - ich plasma (PRP), clas-
si ied as pu e pla ele - ich plasma acco ding o he pla ele concen a es’ classi ica ion [
29
].
The de ice used was P o eal
®
(Ga à, Spain), homologa ion e e ence CE 0318. All pa ien s
me he inclusion c i e ia: pain e alua ion using he VAS
global
equal o o g ea e han 15
poin s; ul asound e alua ion showing a p oximal hickening o he plan a ascia g ea e
han o equal o 4 mm, measu ed 5 mm away om he medial ube osi y o he calca-
neus in he longi udinal sec ion; pa hology du a ion o equal o o g ea e han 6 mon hs;
men and women o e 18 yea s old; willing o pa icipa e in he s udy a e signing he
in o med consen . They did no mee any exclusion c i e ion: p esence o sys emic, degen-
e a i e, neu ological, and senso y diseases impac ing o mani es ing he ankle and oo ;
mo pho- unc ional al e a ions impac ing he ankle and oo leading o signi ican clinical
disc epancies in he lowe limbs, dysme ies, o ob ious clinical scoliosis; ha ing ecei ed
any medical, o hopaedic and/o nonsu gical in asi e ea men o he en hesis condi ion
be ween he plan a ascia and he calcaneus in he las h ee mon hs; p esen ing any ype
o pla ele o coagula ion diso de ; o ha ing di icul ies in unde s anding he ea men
ins uc ions. The s udy, ca ied ou be ween May 2013 and Decembe 2014, was app o ed
by he e hical commi ee o clinical esea ch o he ‘Hospi al Clínico San Ca los’ in Mad id
(in e nal code: 13/179-e). The s udy s a ed wi h 260 pa ien s wi h po en ial diagnosis o
PFS, acco ding o he p ima y heal h ca e doc o s in he ins i u ions whe e he s udy was
conduc ed. A e he ele an echnical checks, de eloped by he esea che s (see Figu e 2),
we e conduc ed, 25 pa ien s we e selec ed o being ea ed wi h PRP.
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 3 o 14
he os eoca ilaginous issue whe e he plan a ascia is inse ed o pe o m i s physiolog-
ical ac ion o ac ion-dis ac ion and whe e o he o ces, such as cu ing and wis ing
o ces, con e ge.
2. Ma e ials and Me hods
2.1. Type o S udy
The au ho s conduc ed a mul icen e in e en ional clinical s udy wi h olun ee pa-
ien s diagnosed wi h G ade III Plan a Fascia Synd ome (see Sec ion 2.2) and subjec ed
hem o ea men based on a single in il a ion o 2 mL o pla ele - ich plasma (PRP),
classi ied as pu e pla ele - ich plasma acco ding o he pla ele concen a es’ classi ica ion
[29]. The de ice used was P o eal
®
(Ga à, Spain), homologa ion e e ence CE 0318. All
pa ien s me he inclusion c i e ia: pain e alua ion using he VAS
global
equal o o g ea e
han 15 poin s; ul asound e alua ion showing a p oximal hickening o he plan a ascia
g ea e han o equal o 4 mm, measu ed 5 mm away om he medial ube osi y o he
calcaneus in he longi udinal sec ion; pa hology du a ion o equal o o g ea e han 6
mon hs; men and women o e 18 yea s old; willing o pa icipa e in he s udy a e signing
he in o med consen . They did no mee any exclusion c i e ion: p esence o sys emic,
degene a i e, neu ological, and senso y diseases impac ing o mani es ing he ankle and
oo ; mo pho- unc ional al e a ions impac ing he ankle and oo leading o signi ican
clinical disc epancies in he lowe limbs, dysme ies, o ob ious clinical scoliosis; ha ing
ecei ed any medical, o hopaedic and/o nonsu gical in asi e ea men o he en hesis
condi ion be ween he plan a ascia and he calcaneus in he las h ee mon hs; p esen ing
any ype o pla ele o coagula ion diso de ; o ha ing di icul ies in unde s anding he
ea men ins uc ions. The s udy, ca ied ou be ween May 2013 and Decembe 2014, was
app o ed by he e hical commi ee o clinical esea ch o he ‘Hospi al Clínico San Ca los’
in Mad id (in e nal code: 13/179-e). The s udy s a ed wi h 260 pa ien s wi h po en ial
diagnosis o PFS, acco ding o he p ima y heal h ca e doc o s in he ins i u ions whe e
he s udy was conduc ed. A e he ele an echnical checks, de eloped by he esea ch-
e s (see Figu e 2), we e conduc ed, 25 pa ien s we e selec ed o being ea ed wi h PRP.
Figu e 2. Selec ion scheme o he 25 pa ien s.
Ou o he ini ial 260 pa ien s, 152 we e excluded as hei pain assessmen using
VAS
global
did no each he equi ed minimum o 15 poin s (see Sec ion 2.2). Addi ionally,
35 pa ien s we e disca ded as hei plan a ascia hickness measu ed less han 4 mm. An-
o he 21 pa ien s we e excluded due o medica ion ( ecei ed co icos e oid in il a ion o
ook nons e oidal an i-in lamma o y d ugs). Fu he mo e, 9 pa ien s we e excluded o
Figu e 2. Selec ion scheme o he 25 pa ien s.
Ou o he ini ial 260 pa ien s, 152 we e excluded as hei pain assessmen using
VAS
global
did no each he equi ed minimum o 15 poin s (see Sec ion 2.2). Addi ionally,
35 pa ien s we e disca ded as hei plan a ascia hickness measu ed less han 4 mm.
Ano he 21 pa ien s we e excluded due o medica ion ( ecei ed co icos e oid in il a ion
o ook nons e oidal an i-in lamma o y d ugs). Fu he mo e, 9 pa ien s we e excluded o
ongoing o hopaedic ea men , 3 o p esen ing pla ele o coagula ion diso de s, 9 due o
lack o willingness o pa icipa e in he s udy, and 6 o di icul ies in comp ehension.
J. Clin. Med. 2024,13, 170 4 o 14
2.2. Plan a Fascia Synd ome: Diagnosis and Classi ica ion
The p ima y diagnosis o PFS is basically clinical, bu nowadays con i ma ion by
means o he so-called complemen a y diagnosis es s is equi ed.
Pain in he medial calcaneal ube osi y can be e alua ed wi h he 10-poin Visual
Analogue Scale (VAS), whe e he pa ien is asked o sco e his/he le el o pain, wi h 0
meaning ‘no pain’ and 10 meaning ‘se e e pain’. The global assessmen o pain (VAS
Global
)
akes place in h ee s ages o occasions, as shown in Equa ion 1. The i s pain assessmen
(VAS
1
) is conduc ed when he pa ien ge s ou o bed, pu s he a ec ed oo on he loo , and
akes his/he i s s eps; he second pain assessmen (VAS
2
) is conduc ed when he pa ien
pu s he a ec ed oo on he loo a e a p olonged es (minimum du a ion o 30 min);
and he hi d pain assessmen (VAS
3
) is conduc ed when he pa ien ’s medial calcaneal
ube osi y is ouched o p essed du ing he clinical examina ion. This clinical-explo a o y
p o ocol has been designed acco ding o di e en wo ks [3,30,31].
VASGlobal =
3
∑
i=1
VASi(1)
Based on he esul o his iple assessmen , each pa ien can be classi ied in o h ee
g oups: G oup A (VAS
Global ≤
15 poin s), G oup B (15 poin s < VAS
Global ≤
20 poin s), and
G oup C (VASGlobal > 20 poin s).
The second elemen ha allows he doc o o make a clea diagnosis o PFS is he
hickness, in millime es, o he a e age s ip o he plan a ascia measu ed using ul a-
sonog aphy (US) in he longi udinal plane a a dis ance o 5 mm om he medial calcaneal
ube osi y. The US examina ion was de eloped by specialis doc o s om he adiodiagno-
sis se ice o he medical cen es in which he s udy was ca ied ou . They ollowed he
p o ocol ou lined in he Eu opean echnical guide o musculoskele al ul asound o he
ankle and oo . The de ices used we e he Esao e MyLab gold 25 model and he Esao e
Tecohnus MPX (San Jus Des e n, Spain). This is an objec i e elemen ha when in he
hands o an expe , can be conside ed as pa hognomonic in con i ming a diagnosis o
PFS. A hickness lowe han 3 mm can be conside ed no mal [
32
]. O he s udies [
33
,
34
]
conside a posi i e diagnosis o PFS when he hickness is highe han 4 mm. Based on
hese assessmen s, PFS can be classi ied in o 3 g oups acco ding o plan a ascia hickness
(PFT): G oup 1 (PFT
≤
3 mm), G oup 2 (3 mm < PFT
≤
4 mm), and G oup 3 (PFT > 4 mm).
The combina ion o bo h classi ica ions de ines h ee g ades o PFS, as shown in
Figu e 3, which a e: G ade I (mild), G ade II (mode a e), and G ade III (se e e).
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 4 o 14
ongoing o hopaedic ea men , 3 o p esen ing pla ele o coagula ion diso de s, 9 due
o lack o willingness o pa icipa e in he s udy, and 6 o di icul ies in comp ehension.
2.2. Plan a Fascia Synd ome: Diagnosis and Classi ica ion
The p ima y diagnosis o PFS is basically clinical, bu nowadays con i ma ion by
means o he so-called complemen a y diagnosis es s is equi ed.
Pain in he medial calcaneal ube osi y can be e alua ed wi h he 10-poin Visual An-
alogue Scale (VAS), whe e he pa ien is asked o sco e his/he le el o pain, wi h 0 mean-
ing ‘no pain’ and 10 meaning ‘se e e pain’. The global assessmen o pain (VASGlobal) akes
place in h ee s ages o occasions, as shown in Equa ion 1. The i s pain assessmen (VAS1)
is conduc ed when he pa ien ge s ou o bed, pu s he a ec ed oo on he loo , and akes
his/he i s s eps; he second pain assessmen (VAS2) is conduc ed when he pa ien pu s
he a ec ed oo on he loo a e a p olonged es (minimum du a ion o 30 min); and
he hi d pain assessmen (VAS3) is conduc ed when he pa ien ’s medial calcaneal ube -
osi y is ouched o p essed du ing he clinical examina ion. This clinical-explo a o y p o-
ocol has been designed acco ding o di e en wo ks [3,30,31].
VAS =VAS

 (1)
Based on he esul o his iple assessmen , each pa ien can be classi ied in o h ee
g oups: G oup A (VASGlobal ≤ 15 poin s), G oup B (15 poin s < VASGlobal ≤ 20 poin s), and
G oup C (VASGlobal > 20 poin s).
The second elemen ha allows he doc o o make a clea diagnosis o PFS is he
hickness, in millime es, o he a e age s ip o he plan a ascia measu ed using ul a-
sonog aphy (US) in he longi udinal plane a a dis ance o 5 mm om he medial calcaneal
ube osi y. The US examina ion was de eloped by specialis doc o s om he adiodiag-
nosis se ice o he medical cen es in which he s udy was ca ied ou . They ollowed he
p o ocol ou lined in he Eu opean echnical guide o musculoskele al ul asound o he
ankle and oo . The de ices used we e he Esao e MyLab gold 25 model and he Esao e
Tecohnus MPX (San Jus Des e n, Spain). This is an objec i e elemen ha when in he
hands o an expe , can be conside ed as pa hognomonic in con i ming a diagnosis o PFS.
A hickness lowe han 3 mm can be conside ed no mal [32]. O he s udies [33,34] conside
a posi i e diagnosis o PFS when he hickness is highe han 4 mm. Based on hese as-
sessmen s, PFS can be classi ied in o 3 g oups acco ding o plan a ascia hickness (PFT):
G oup 1 (PFT ≤ 3 mm), G oup 2 (3 mm < PFT ≤ 4 mm), and G oup 3 (PFT > 4 mm).
The combina ion o bo h classi ica ions de ines h ee g ades o PFS, as shown in
Figu e 3, which a e: G ade I (mild), G ade II (mode a e), and G ade III (se e e).
Figu e 3. Classi ica ion o he Plan a Fascia Synd ome.
2.3. P ocedu e—In il a ion Technique
This pape p esen s a new he apeu ic echnique o he ea men o PFS based on
knowledge o he pa hogenesis and o he ana omy o he sole o he oo and is in ended
Figu e 3. Classi ica ion o he Plan a Fascia Synd ome.
2.3. P ocedu e—In il a ion Technique
This pape p esen s a new he apeu ic echnique o he ea men o PFS based on
knowledge o he pa hogenesis and o he ana omy o he sole o he oo and is in ended o
add ess he causes o he disease h ough bio- egene a i e he apy using PRP in il a ion.
Al hough PRP in il a ion has been ese ed o G ade III pa ien s, he e is no eason why
i canno be used in pa ien s in ea lie s ages o less se e e o ms o PFS.
J. Clin. Med. 2024,13, 170 5 o 14
2.3.1. P epa a ion o he Pa ien
The pa ien lies on a s e che in a supine decubi us posi ion wi h he a ec ed membe
in ex e nal o a ion and he knee lexed abou 70
◦
. Wi h his mo emen , he oo will be in a
side suppo posi ion wi h he in e nal ace looking upwa ds ( he punc u e o PRP injec ion
will be pe o med in his in e nal a ea). The su gical ield o he oo o be ea ed will be
p epa ed acco ding o he same p o ocol used in any o he mino ou pa ien su ge y. A e
he pa ien has been adequa ely p epa ed and wi h he medial ace o he calcaneus ully
exposed, he loca ion o he an e io -in e nal calcaneal ube osi y ( he poin o maximum
pain) will be de e mined by palpa ion o by ul asonog aphy. This is he e e ence poin
o he PRP in il a ion. Jus be o e he in il a ion, local supe icial anaes hesia will be
pe o med by sp aying he skin wi h chlo oe hyl Chemi osa
®
(Labo a o ios ERN, Ba celona,
Spain), whe e e hyl chlo ide is applied un il he skin begins o whi en [
35
]. The pa ien will
no expe ience any pain when he needle is in oduced.
2.3.2. PRP Adminis a ion
PRP ac i a ion. PRP is ac i a ed wi h calcium chlo ide 5% and acco ding o he
es ablished p o ocol. The in il a ion mus be pe o med be ween 6 and 10 min a e he
PRP has been ac i a ed.
In il a ion poin . The in il a ion should be pe o med a he an e io -inne edge o
he calcaneus aking speci ic incision and/o pene a ion lines ollowing he skin olds
as a e e ence. Plan a load a eas should be a oided in o de o minimise he isk o
inju y o any asculo-ne ous s uc u e and o educe he isk o in ec ion. Ano he eason
o ecommending his ana omical a ea is he ac ha plan a skin is connec ed o he
unde lying ascia by means o many s ong ib ous ascicles called e inacula cu is ha ac
as pa i ions di iding he subcu aneous a in o small i egula chambe s o compa men s
con aining iny essels o he de mis. They also p e en mo emen be ween he skin and
ascia. These chambe s a e la ge in he ea pa o he oo , below he calcaneus, whe e
hey ac as minia u e shock abso be s. So, i he in il a ion is gi en in he en al ace o
he calcaneus, he shock-abso bing unc ion can be comp omised and lead o heel pain
synd ome [36].
Technique o execu ion. The needle is inse ed pe pendicula ly o he skin (a an angle o
90
◦
), wo cen ime es om he plan a plane (lowe edge o he calcaneus), in he ansi ion
a ea be ween he skin o he medial ace o he heel and he skin o he plan a a ea and
acco ding o a linea plane be ween 1 and 3 mm om he medial ube osi y (see Figu e 4).
An expe auma ologis should no need o use ul asonog aphy (US) o ensu e he co ec
posi ioning o he needle; howe e , US could help new p ac i ione s.
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 5 o 14
o add ess he causes o he disease h ough bio- egene a i e he apy using PRP in il a-
ion. Al hough PRP in il a ion has been ese ed o G ade III pa ien s, he e is no eason
why i canno be used in pa ien s in ea lie s ages o less se e e o ms o PFS.
2.3.1. P epa a ion o he Pa ien
The pa ien lies on a s e che in a supine decubi us posi ion wi h he a ec ed mem-
be in ex e nal o a ion and he knee lexed abou 70°. Wi h his mo emen , he oo will
be in a side suppo posi ion wi h he in e nal ace looking upwa ds ( he punc u e o PRP
injec ion will be pe o med in his in e nal a ea). The su gical ield o he oo o be ea ed
will be p epa ed acco ding o he same p o ocol used in any o he mino ou pa ien su -
ge y. A e he pa ien has been adequa ely p epa ed and wi h he medial ace o he cal-
caneus ully exposed, he loca ion o he an e io -in e nal calcaneal ube osi y ( he poin
o maximum pain) will be de e mined by palpa ion o by ul asonog aphy. This is he
e e ence poin o he PRP in il a ion. Jus be o e he in il a ion, local supe icial anaes-
hesia will be pe o med by sp aying he skin wi h chlo oe hyl Chemi osa
®
(Labo a o ios
ERN, Ba celona, Spain), whe e e hyl chlo ide is applied un il he skin begins o whi en
[35]. The pa ien will no expe ience any pain when he needle is in oduced.
2.3.2. PRP Adminis a ion
PRP ac i a ion. PRP is ac i a ed wi h calcium chlo ide 5% and acco ding o he es ab-
lished p o ocol. The in il a ion mus be pe o med be ween 6 and 10 min a e he PRP
has been ac i a ed.
In il a ion poin . The in il a ion should be pe o med a he an e io -inne edge o
he calcaneus aking speci ic incision and/o pene a ion lines ollowing he skin olds as
a e e ence. Plan a load a eas should be a oided in o de o minimise he isk o inju y
o any asculo-ne ous s uc u e and o educe he isk o in ec ion. Ano he eason o
ecommending his ana omical a ea is he ac ha plan a skin is connec ed o he unde -
lying ascia by means o many s ong ib ous ascicles called e inacula cu is ha ac as
pa i ions di iding he subcu aneous a in o small i egula chambe s o compa men s
con aining iny essels o he de mis. They also p e en mo emen be ween he skin and
ascia. These chambe s a e la ge in he ea pa o he oo , below he calcaneus, whe e
hey ac as minia u e shock abso be s. So, i he in il a ion is gi en in he en al ace o
he calcaneus, he shock-abso bing unc ion can be comp omised and lead o heel pain
synd ome [36].
Technique o execu ion. The needle is inse ed pe pendicula ly o he skin (a an angle
o 90°), wo cen ime es om he plan a plane (lowe edge o he calcaneus), in he an-
si ion a ea be ween he skin o he medial ace o he heel and he skin o he plan a a ea
and acco ding o a linea plane be ween 1 and 3 mm om he medial ube osi y (see Fig-
u e 4). An expe auma ologis should no need o use ul asonog aphy (US) o ensu e
he co ec posi ioning o he needle; howe e , US could help new p ac i ione s.
Figu e 4. Theo e ical needle inse ion poin o he injec ion o PRP.
Figu e 4. Theo e ical needle inse ion poin o he injec ion o PRP.
When he punc u e is pe o med a an angle o 90
◦
, he needle eaches he plan a ascia
so ha when he he apis ies o p ess he plunge o he sy inge he e is conside able
esis ance (Figu e 5a) and is unable o injec he PRP. Fo his eason, he needle mus be
wi hd awn abou 5 mm and immedia ely einse ed a an angle o 5
◦
in he caudal di ec ion
so ha he plasma can be injec ed wi hou esis ance. The i s millili e o he PRP is

J. Clin. Med. 2024,13, 170 6 o 14
injec ed wi h he needle in his posi ion (Figu e 5b). Then, he needle mus be wi hd awn
abou 5 mm un il i e u ns o a plane pe pendicula o he skin and einse ed a an angle
o 5
◦
in he en al di ec ion so ha he emaining millili e o PRP can also be injec ed
wi hou esis ance (Figu e 5c).
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 6 o 14
When he punc u e is pe o med a an angle o 90°, he needle eaches he plan a
ascia so ha when he he apis ies o p ess he plunge o he sy inge he e is consid-
e able esis ance (Figu e 5a) and is unable o injec he PRP. Fo his eason, he needle
mus be wi hd awn abou 5 mm and immedia ely einse ed a an angle o 5° in he caudal
di ec ion so ha he plasma can be injec ed wi hou esis ance. The i s millili e o he
PRP is injec ed wi h he needle in his posi ion (Figu e 5b). Then, he needle mus be wi h-
d awn abou 5 mm un il i e u ns o a plane pe pendicula o he skin and einse ed a
an angle o 5° in he en al di ec ion so ha he emaining millili e o PRP can also be
injec ed wi hou esis ance (Figu e 5c).
Figu e 5. PRP adminis a ion: (a) plan a ascia palpa ion; (b) caudal injec ion; and (c) en al injec-
ion.
The in il a ion is gi en a an angle o 5° bo h in he caudal and en al di ec ions
because ha allows he PRP o be injec ed in o wo ana omical ca i ies big enough o e-
cei e he 2 mL. Fo his eason, he e is no need o p ess ha d on he plunge o he sy inge
(which con i ms ha he PRP has been injec ed in he igh place). Wi h his echnique,
PRP is applied o he whole plan a ascia inse ed in he calcaneus, as well as in all he
medial ube osi y, which a e p ecisely he ana omical elemen s a ec ed by he degene a-
i e pa hology equi ing ea men .
2.4. Da a Collec ion
The 25 pa ien s (see Table 1 o he demog aphic ea u es o he popula ion) selec ed
o pa icipa e in he obse a ional s udy ecei ed in il a ions in acco dance wi h he
abo e-desc ibed echnique.
Table 1. Demog aphic ea u es.
Age (Yea s) Weigh (kg) Heigh (m) BMI (kg/m
2
) Symp. Du a.
(Mon hs)
Mean ± σ 48.9 ± 9.74 76.44 ± 15.10 1.64 ± 0.09 28.24 ± 4.65 15.76 ± 11.91
BMI: Body Mass Index; Symp. Du a.: Du a ion o symp oms.
The e olu ion o he mos signi ican clinical a iables was s udied o a pe iod o 6
mon hs om Day 0 a 4 con ol isi s (Day 15, 30, 90, and 180). The a iables we e pain as
measu ed by he VAS (global assessmen o pain, desc ibed a he s a o his sec ion), he
plan a ascia hickness (PFT) in millime es measu ed by ul asonog aphy in he longi u-
dinal plane, and he ac i e ex ension o he ankle bo h in passi e soleus (AES) and passi e
gas ocnemius (AEG) as e alua ed wi h he help o a goniome e . The esul s o his e al-
ua ion a e p esen ed in Table 2 unde he o m o x ± σ, whe e x is he mean and σ is he
s anda d de ia ion.
Figu e 5. PRP adminis a ion: (a) plan a ascia palpa ion; (b) caudal injec ion; and (c) en al injec ion.
The in il a ion is gi en a an angle o 5
◦
bo h in he caudal and en al di ec ions
because ha allows he PRP o be injec ed in o wo ana omical ca i ies big enough o ecei e
he 2 mL. Fo his eason, he e is no need o p ess ha d on he plunge o he sy inge
(which con i ms ha he PRP has been injec ed in he igh place). Wi h his echnique,
PRP is applied o he whole plan a ascia inse ed in he calcaneus, as well as in all he
medial ube osi y, which a e p ecisely he ana omical elemen s a ec ed by he degene a i e
pa hology equi ing ea men .
2.4. Da a Collec ion
The 25 pa ien s (see Table 1 o he demog aphic ea u es o he popula ion) selec ed
o pa icipa e in he obse a ional s udy ecei ed in il a ions in acco dance wi h he
abo e-desc ibed echnique.
Table 1. Demog aphic ea u es.
Age (Yea s) Weigh (kg) Heigh (m) BMI (kg/m2)Symp. Du a.
(Mon hs)
Mean ±σ48.9 ±9.74 76.44 ±15.10 1.64 ±0.09 28.24 ±4.65 15.76 ±11.91
BMI: Body Mass Index; Symp. Du a.: Du a ion o symp oms.
The e olu ion o he mos signi ican clinical a iables was s udied o a pe iod o
6 mon hs om Day 0 a 4 con ol isi s (Day 15, 30, 90, and 180). The a iables we e
pain as measu ed by he VAS (global assessmen o pain, desc ibed a he s a o his
sec ion), he plan a ascia hickness (PFT) in millime es measu ed by ul asonog aphy in
he longi udinal plane, and he ac i e ex ension o he ankle bo h in passi e soleus (AES)
and passi e gas ocnemius (AEG) as e alua ed wi h he help o a goniome e . The esul s
o his e alua ion a e p esen ed in Table 2unde he o m o
x±σ
, whe e
x
is he mean
and σis he s anda d de ia ion.
2.5. S a is ical Analysis
The desc ip i e s a is ical analysis o he a iables eco ded du ing he s udy was
made using IBM SPSS 22.0 so wa e. The a iables we e exp essed as mean (
x
) and
s anda d de ia ion (
σ
). As i was a small sample (n< 30), he no mali y o he a iables was
checked wi h he Shapi o–Wilk es . When he a iables p esen ed a no mal dis ibu ion,
he S uden ’s - es was used o compa e he measu emen s; when he dis ibu ion was
J. Clin. Med. 2024,13, 170 7 o 14
no no mal, he compa ison was made wi h he Wilcoxon es . Whene e he esul s we e
s a is ically signi ican , all necessa y es s we e made o con i m ha he a iables we e
pa ame ic. In all hese es s, p- alues < 0.05 we e assumed o be s a is ically signi ican
wi h a con idence in e al o 95%.
Table 2. Da a was collec ed du ing he con ol isi s.
D0 D15 D30 D90 D180
VAS17.86 ±1.59 4.38 ±2.08 2.14 ±2.10 0.9 ±1.44 0.44 ±0.82
VAS26.98 ±1.49 3.54 ±2.37 2.1 ±2.08 0.86 ±1.32 0.52 ±0.82
VAS38.36 ±1.38 4.62 ±2.59 2.84 ±2.09 1.74 ±1.76 1.04 ±1.39
VASglobal 23.18 ±3.58 12.54 ±6.33 7.08 ±5.71 3.5 ±3.52 2 ±2.58
PFT 5.87 ±1.04 4.60 ±1.47 4.27 ±1.42 3.96 ±1.30 3.91 ±1.24
AES 12.16 ±4.97 15.36 ±4.5 17.44 ±4.23 18.4 ±4.25 18.84 ±3.99
AEG 6.36 ±5.84 9.76 ±4.98 11.8 ±3.98 12.36 ±3.91 13.36 ±3.55
3. Resul s
This sec ion desc ibes he e olu ion o each o he clinical a iables conside ed in he
sec ion ‘Da a collec ion’ du ing he en i e pe iod o he s udy (6 mon hs). Jus as in he
p e ious sec ion, he esul s a e exp essed as mean (x) and s anda d de ia ion (σ).
3.1. E olu ion o he Clinical Va iables be ween Consecu i e Visi s
Table 3shows he e olu ion (nega i e alues ep esen a dec ease and posi i e alues
ep esen an inc ease) o he s udy a iables (
x±σ
) be ween con ol isi s, as well as he
p- alue ha e lec s he s a is ical signi icance o he e olu ion. O he 28 p- alues p esen ed,
22 a e below 0.05, meaning ha he e olu ion o he a iables is s a is ically signi ican ,
which suppo s he e ec i eness o he ea men . Non-signi ican p- alues in he able
ha e been ma ked wi h an as e isk. All hese alues can be seen om Visi 3 (D30) onwa ds
and a e mos ly concen a ed be ween Visi s 4 (D90) and 5 (D180). This means ha while
he pa ien s’ condi ion con inues o imp o e un il he 6 mon h pe iod is o e , he mos
signi ican imp o emen akes place in he i s weeks.
Table 3. E olu ion o he alues in ela ion o he p e ious isi .
D0–D15 p-Value D15–D30 p-Value D30–D90 p-Value D90–D180 p-Value
VAS1−5.72 ±2.24 0.000 −2.24 ±1.73 0.000 −1.24 ±1.76 0.003 −0.46 ±1.49 0.138 *
VAS2−4.86 ±1.74 0.000 −1.44 ±1.85 0.000 −1.24 ±2.34 0.017 −0.34 ±1.04 0.117 *
VAS3−5.52 ±2.31 0.000 −1.78 ±2.58 0.008 −1.10 ±2.25 0.030 −0.7 ±1.19 0.007
VAS
global −16.10 ±5.42 0.000 −5.46 ±4.89 0.000 −3.58 ±5.47 0.007 −1.5 ±2.90 0.016
PFT −1.60 ±1.13 0.000 −0.33 ±0.61 0.000 −0.30 ±0.41 0.002 −0.05 ±0.320 0.424 *
AES 5.28 ±3.51 0.000 2.08 ±3.93 0.017 0.96 ±4.39 0.245 * 0.44 ±4.33 0.530 *
AEG 5.44 ±4.95 0.000 2.04 ±3.67 0.019 0.56 ±4.16 0.384 * 1.56 ±3.41 0.034
*p- alue no s a is ically signi ican wi h a con idence in e al o 95%.
A se ies o g aphs a e p esen ed o gi e a clea e image o he e olu ion o he esul s
o each a iable. The way he a e age o he ou VAS pain ypologies con inues o
dec ease (Figu e 6a) clea ly e lec s a g adual imp o emen . The e olu ion o hese a iables
be ween isi s (Figu e 6b) shows ha he imp o emen became p og essi ely less ma ked
bu con inued un il he las isi . The same ype o e olu ion (g adual imp o emen ) occu s
in he case o plan a ascia hickness (PFT), which is p esen ed in Figu e 7. Figu e 7a
p esen s he e olu ion o he dec ease in he PFT om D0 o D180, and Figu e 7b displays
he di e ence expe ienced in PFT be ween isi s.
J. Clin. Med. 2024,13, 170 8 o 14
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 8 o 14
bu con inued un il he las isi . The same ype o e olu ion (g adual imp o emen ) oc-
cu s in he case o plan a ascia hickness (PFT), which is p esen ed in Figu e 7. Figu e 7a
p esen s he e olu ion o he dec ease in he PFT om D0 o D180, and igu e 7b displays
he di e ence expe ienced in PFT be ween isi s.
Figu e 6. E olu ion o he ou VAS pain ypologies h oughou he s udy.
Figu e 7. E olu ion o he plan a ascia hickness h oughou he s udy.
Finally, Figu e 8a shows he e olu ion o he mobili y o he ankle (ac i e ex ension),
measu ed in bo h passi e soleus and passi e gas ocnemius. Bo h a iables show ha he
mobili y o he oo a ec ed by PFS inc eased in each con ol isi ollowing he in il a ion
wi h PRP. The e olu ion o his a iable be ween isi s (Figu e 8b) shows ha he im-
p o emen became p og essi ely less ma ked bu con inued un il he las isi .
Figu e 8. E olu ion o ankle mobili y h oughou he s udy
Figu e 6. E olu ion o he ou VAS pain ypologies h oughou he s udy.
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 8 o 14
bu con inued un il he las isi . The same ype o e olu ion (g adual imp o emen ) oc-
cu s in he case o plan a ascia hickness (PFT), which is p esen ed in Figu e 7. Figu e 7a
p esen s he e olu ion o he dec ease in he PFT om D0 o D180, and igu e 7b displays
he di e ence expe ienced in PFT be ween isi s.
Figu e 6. E olu ion o he ou VAS pain ypologies h oughou he s udy.
Figu e 7. E olu ion o he plan a ascia hickness h oughou he s udy.
Finally, Figu e 8a shows he e olu ion o he mobili y o he ankle (ac i e ex ension),
measu ed in bo h passi e soleus and passi e gas ocnemius. Bo h a iables show ha he
mobili y o he oo a ec ed by PFS inc eased in each con ol isi ollowing he in il a ion
wi h PRP. The e olu ion o his a iable be ween isi s (Figu e 8b) shows ha he im-
p o emen became p og essi ely less ma ked bu con inued un il he las isi .
Figu e 8. E olu ion o ankle mobili y h oughou he s udy
Figu e 7. E olu ion o he plan a ascia hickness h oughou he s udy.
Finally, Figu e 8a shows he e olu ion o he mobili y o he ankle (ac i e ex ension),
measu ed in bo h passi e soleus and passi e gas ocnemius. Bo h a iables show ha
he mobili y o he oo a ec ed by PFS inc eased in each con ol isi ollowing he in il-
a ion wi h PRP. The e olu ion o his a iable be ween isi s (Figu e 8b) shows ha he
imp o emen became p og essi ely less ma ked bu con inued un il he las isi .
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 8 o 14
bu con inued un il he las isi . The same ype o e olu ion (g adual imp o emen ) oc-
cu s in he case o plan a ascia hickness (PFT), which is p esen ed in Figu e 7. Figu e 7a
p esen s he e olu ion o he dec ease in he PFT om D0 o D180, and igu e 7b displays
he di e ence expe ienced in PFT be ween isi s.
Figu e 6. E olu ion o he ou VAS pain ypologies h oughou he s udy.
Figu e 7. E olu ion o he plan a ascia hickness h oughou he s udy.
Finally, Figu e 8a shows he e olu ion o he mobili y o he ankle (ac i e ex ension),
measu ed in bo h passi e soleus and passi e gas ocnemius. Bo h a iables show ha he
mobili y o he oo a ec ed by PFS inc eased in each con ol isi ollowing he in il a ion
wi h PRP. The e olu ion o his a iable be ween isi s (Figu e 8b) shows ha he im-
p o emen became p og essi ely less ma ked bu con inued un il he las isi .
Figu e 8. E olu ion o ankle mobili y h oughou he s udy
Figu e 8. E olu ion o ankle mobili y h oughou he s udy.
3.2. E olu ion o Clinical Va iables in Rela ion o he Day o T ea men
Wha e e he pa hology, i is pa icula ly impo an o measu e he e olu ion o he
pa ien s’ condi ion compa ed o he baseline. This pe iod is assumed o co espond o
hei wo s clinical s a us. Table 4shows he e olu ion o all he a iables a each o
J. Clin. Med. 2024,13, 170 9 o 14
he con ol isi s in ela ion o he beginning o he ea men (D0) and hei espec i e
s a is ical signi icance. In his case, all alues a e s a is ically signi ican (p- alue < 0.05).
This con i ms he a ou able e olu ion h oughou he s udy o he pa ien s unde going
he ea men desc ibed he ein.
Table 4. E olu ion o he a iables in ela ion o he s a o he ea men (D0).
D0–D15 p-Value D0–D30 p-Value D0–D90 p-Value D0–D180 p-Value
VAS1−3.48 ±1.94 0.000 −5.72 ±2.24 0.000 −6.96 ±1.91 0.000 −7.42 ±1.93 0.000
VAS2−3.42 ±2.20 0.000 −4.86 ±1.74 0.000 −6.10 ±2.06 0.000 −6.44 ±1.68 0.000
VAS3−3.74 ±2.70 0.000 −5.52 ±2.31 0.000 −6.62 ±2.22 0.000 −7.32 ±1.82 0.000
VAS
global −10.64 ±6.35 0.000 −16.10 ±5.42 0.000 −19.68 ±5.18 0.000 −21.18 ±4.65 0.000
PFT −1.27 ±1.01 0.000 −1.60 ±1.13 0.000 −1.91 ±1.07 0.000 −1.96 ±1.09 0.000
AES 3.20 ±4.42 0.000 5.28 ±3.51 0.000 4.97 ±4.25 0.000 6.68 ±5.28 0.000
AEG 3.40 ±4.95 0.000 5.44 ±4.95 0.000 5.85 ±3.91 0.000 7.00 ±5.22 0.000
The mean alue o all simple VASx dec eased by mo e han 6 poin s, while he mean
alue o VAS
global
dec eased by mo e han 21 poin s. The mean alue o PFT dec eases
by 1.96 mm. This educ ion is almos wice he size as he one gene a ed by low- ol age
elec ical impulses [
31
] (1.05 mm), un il now conside ed one o he mos signi ican in he
echnical li e a u e. Finally, in wha conce ns he ac i e ex ension o he ankle, he mean
mobili y inc eases by 6
◦
in he passi e soleus and 7
◦
in he passi e gas ocnemius. As a
inal obse a ion o esul s, i should be men ioned ha since he ou h isi (D90), none o
he pa ien s ha e had any clinical symp oms equi ing ea men .
4. Discussion
The diagnosis o Plan a Fascia Synd ome (PFS) is he esul o g ouping di e en
symp oms and signs o a mul i ac o ial pa hology loca ed in he en hesis be ween he
plan a ascia and he medial calcaneal ube osi y.
Any biomechanical al e na ion o one elemen o he ankle’s ex enso appa a us
( he plan a lexo ), which comp ises he iceps su ae, he calcaneus, and he plan a
ascia, could cause PFS. Fo ins ance, a con ac u e o he iceps su ae (composed o he
gas ocnemius, soleus, and plan a is muscles, con e ging wi h he Achilles endon) due
o excessi e ac i i y could dis up he posi ioning o he calcaneus du ing he walking
mo emen . This al e a ion could po en ially modi y he con ac ion–dis ension mechanisms
o he ascia, leading o he de elopmen o he pa hology. Howe e , as he e is no eal
knowledge o he pa hogenesis o PFS, no e en o he pa hology ha occu s in his
ana omical a ea, no consensus has been eached ei he in e ms o de ini ion o in e ms
o he name o apply o he inju ies ound in he plan a ascia and in he calcaneus. This
makes i easy o hink ha he e is no e ec i e conse a i e ea men capable o sol ing
his e y pain ul pa hology. In addi ion, due o he lack o igo ous s udies wo ldwide
based on scien i ic e idence, i has no been possible o make ca ego ical s a emen s abou
he ue use ulness o PRP in he ea men o di e en endon and aponeu osis diseases,
and, mo e speci ically, o he pa hology a ec ing he en hesis be ween he plan a ascia
and he calcaneus.
The i ues o he echnique p esen ed in his pape a e based, i s ly, on knowing
how o de ine he s uc u es damaged in he PFS, ha is he plan a ascia o aponeu osis
and he calcaneus; secondly, on he knowledge o he PRP he apeu ic capaci y bo h in
so issue ( he ascia) and in ha d issue ( he bone); and hi dly, and las ly, on ha ing
de e mined he adequa e dosage o PRP. The decision o adminis e no mo e han 2 mL o
PRP was suppo ed by he ana omical space exis en in he hind oo and by he his o y o
he angiogenic e ec o PRP.
The ea men o PFS wi h one in il a ion o 2 mL o PRP has led o clinical im-
p o emen s ha can be labelled as success ul when e alua ed acco ding o he published
c i e ia [
37
] because i has been objec i ely shown ha he imp o emen s achie ed a