A Doctor’s View: Lessons from a Painful Heel

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I love PRP. So far. Platelet rich plasma is a red liquid I have injected, to date, into five patient’s heels and four patient’s elbows. These people were probably going to need surgery. The foot patients had insertional Achilles tendonopathy, or tenderness and pain at the back of the heel. The others had tennis elbows. PRP seems to have cured every one.

To make PRP you draw a big tube of blood from your patient’s arm and put it into a machine that separates out a specific fraction of the blood holding the platelets. The treatment is quick (it takes about 20 minutes) and safe, but expensive — a few hundred dollars — and insurance plans generally don’t pay for it. But so far, in my limited personal experience, it’s batting 1.000. Every patient has told me he or she is better. Does this mean anything?

Maybe yes. Partly because it seems plausible biologically: the platelets we inject could have just the right biochemicals in them to heal these problems — naturally. And yes, because nine successes in a row is pretty convincing. Consider the opposite: if nine in a row had failed, I would certainly conclude the stuff does not work.

But mostly yes because I have good reason to believe the patients I injected with PRP were a) not going to get better in that same amount of time on their own andb) were neither afflicted nor cured by psychsomatic means.

But, then again, maybe no. The roots of problems treated with PRP shots are notoriously hard to identify. When you operate on that painful Achilles heel, it looks pretty normal. So does the tennis elbow. Even if you use a microscope to look at the spot that hurts, it’s hard to see anything wrong. (If you turn the microscope up to high power, you can usually, but not always, see some subtle changes — but these changes are seen in lots of other places that have no pain at all.) So logic dictates that if I can’t tell you why you have the painful heel, I can’t really know how or whether PRP made it better.

Another check in the no column: I may, knowingly or not, have selected patients for PRP who were just about to get better on their own anyway (so I simply have good timing) or who were particularly susceptible to placebo effect (I am not such a good psychologist as I think). Or maybe it was the vigorous prepping of the skin that I did before the injection that cured them; Lord knows plenty of massage therapists say they cure these problems by rubbing them.

Perhaps the most compelling reason to suggest that PRP is a sham is the fact that so many other treatments sometimes seem to work for the same pain: heel lifts, special massages, braces, exercises, needles with salt water, needles with sugar water, with cortisone, even plain needles, operations in which you drill the bone, cut the tendon, sew the tendon. There are scholarly papers in peer-reviewed journals “proving” the effectiveness of all of these.

Now I know, from personal experience, these other things have not worked that well — at least not nine-in-a-row well. But there are so many different ways legitimate docs treat these problems. Could PRP be that much better? We are going to find out soon.

How do I know a verdict is coming on PRP? Consider the history of a different pain: the bellyache.

Got abdominal pain? Did you feel a little queasy at first, then develop vague pain around your belly button; then a few hours later, did it move to the lower right-hand side of your abdomen? If you push down on that spot, does it hurt when you let go? Yes? You have appendicitis.

The pinky-size outpouching of your intestine has gotten plugged by a seed or something similar and it’s inflamed. Sooner or later it will burst, fill your abdomen with bacteria and probably kill you. There is exactly one treatment, one operation, that will save your life: appendectomy. Nobody, not the most holistic, crystal-waving alternative medicine shaman in the entire ashram, and certainly nobody with an M.D., will tell you much else about how to treat acute appendicitis. You’ve got to go in and take the appendix out. Period.

Did we always know this? Of course not. Before the 1880s, great physicians wrote honest, intelligent papers about the condition we can now look back at and retrospectively diagnose as appendicitis. There were many well-considered opinions about what caused it and many more on how to treat it. Before we understood the actual pathophysiology of appendicitis, medical treatment of it was rather like our treatment of Achilles tendonopathy today. Bloodletting, special diets, laxatives, poultices — there were well-known proponents of all of these for that fatal bellyache. A few patients survived, maybe even a series of nine, probably making an early physician think — the way I am about PRP for heel pain — “I’ve got it!”

Those weird treatments for the fatal bellyache were in many ways just like the braces, pills, shots and operations we use now for heel pain. Is PRP the appendectomy of tomorrow? Today I can definitely say … maybe. Thankfully, our current ignorance of the true pathophysiology of heel pain is less dangerous than that of appendicitis; it leaves folks limping around with a sore heel, not dead of peritonitis. Good, careful, mechanistic (not statistical) research explained the mechanism of appendicitis. The surgeons figured out what was wrong and what to do about it. Yes, heel pain is a harder problem, albeit less serious, than appendicitis. But we’re working on it. And as a patient you will know when we get it. Because instead of the many alternatives, there will be just one.

There’s an important lesson here for anyone who has ever punched his or her symptoms into a search engine. When there are a many ways to treat a problem, either they all work or none really do. When something works we all do it. When nothing works well there are usually only a few experts who do it — typically not on your insurance plan and far from home. Best think about this before booking your flight.

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