Orthobiologics in the Foot & Ankle Treatment Algorithm

APEX Biologix
10 min read

Orthobiologics continue to expand the treatment landscape between conservative care and surgical intervention, particularly in foot and ankle pathology.

In a recent APEX educational webinar, foot and ankle surgeon Jason Piraino, DPM and Ariana DeMers, DO, RMSK explored how platelet-rich plasma (PRP) and protein concentrate (PC) can be applied within a structured, pathology-driven algorithm.

Understanding PRP

PRP is often misunderstood as a standardized treatment. In reality, it represents a spectrum of biologic formulations derived from autologous blood.

Key Variables:

  • Platelet concentration
  • Leukocyte content
  • Injection technique
  • Target tissue

As emphasized in the discussion, outcomes are not solely dependent on PRP itself but on how well the formulation is matched to the biological environment.

PRP functions through signaling, not direct tissue regeneration - initiating angiogenesis, cell recruitment, and collagen synthesis.

Matching Biology to Pathology

A central theme of the webinar was the mismatch problem.

Different tissues require different biologic strategies:

  • Joint pathology → inflammatory, degenerative → requires modulation
  • Tendon pathology → hypovascular, degenerative → requires stimulation

Using the same PRP formulation across all indications often leads to inconsistent results.

Clinical success depends on selecting the right biologic for the right tissue.

Leukocyte-Rich vs Leukocyte-Poor PRP

PRP formulation should be tailored based on indication:

Leukocyte-Rich PRP (LR-PRP)

Common applications:

  • Chronic tendinopathies
  • Plantar fasciitis
  • Wound environments

Primary goal:
Stimulate inflammation and support the healing cascade.

Leukocyte-Poor PRP (LP-PRP)

Common applications:

  • Intra-articular injections
  • Post-surgical environments

Primary goal:
Reduce inflammation and support joint homeostasis.

This distinction is critical for optimizing outcomes and minimizing unnecessary inflammatory response.

The Role of Protein Concentrate 

Protein concentrate (PC) represents an emerging adjunct in orthobiologic therapy.

Derived from platelet-poor plasma, PC concentrates key anti-inflammatory mediators such as:

  • IL-1 receptor antagonist (IL-1ra)
  • Alpha-2-macroglobulin (A2M)

Clinical Role of Protein Concentrate:

  • Modulates inflammatory signaling
  • Reduces catabolic activity
  • Supports joint environment stability

PRP promotes healing.
Protein concentrate helps protect the joint from further breakdown.

Combining PRP and Protein Concentrate:

When used together:

  • PRP → drives biologic signaling and repair
  • PC → reduces inflammation and protease activity

This combination may help optimize the intra-articular environment, particularly in early osteoarthritis.

Clinical Applications in Foot and Ankle

Early Osteoarthritis

Common treatment areas:

  • First MTP joint
  • Ankle joint
  • Subtalar joint

Typical approach:

  • Leukocyte-poor PRP + PC
  • Best suited for early to moderate disease

Evidence suggests potential for:

  • Pain reduction
  • Functional improvement
  • Delayed surgical intervention

Plantar Fasciitis

One of the most supported indications for PRP in foot and ankle.

Key Considerations:

  • Strong evidence vs corticosteroids
  • Improved long-term outcomes
  • Ultrasound guidance enhances precision

PRP may offer a more durable approach compared to symptom-focused interventions.

Tendinopathies

Common Applications:

  • Posterior tibial tendon
  • Peroneal tendons

Reported Outcomes:

  • ~82% improvement reported across multiple tendon types
  • Best results seen in chronic, degenerative conditions

Achilles Tendinopathy

Evidence remains mixed

Current Findings:

  • Some studies show no significant difference vs placebo
  • Others suggest comparable outcomes to conservative care

This highlights the importance of:

  • Dosing
  • Formulation selection
  • Adjunctive therapies

Lateral Ankle Instability

PRP may support:

  • Pain reduction
  • Functional improvement in early recovery

Particularly relevant in athletes and acute injury settings.

Patient Optimization and Outcomes

Biologic variability begins with the patient.

Important considerations:

  • Hydration status
  • NSAID avoidance
  • Smoking cessation
  • Metabolic health

Even short-term interventions, such as light exercise prior to blood draw, may influence platelet yield.

Patient Education Matters

Effective communication is essential.

Rather than focusing on technical details, framing should emphasize:

  • Why healing has stalled
  • How biologics support the body’s natural processes
  • Expected timelines and post-procedure experience

This improves patient understanding and alignment with treatment expectations.

Integrating Orthobiologics into Practice

Dr. DeMers outlined a structured framework:

Key Components:

  1. Patient selection
  2. Clear education and expectations
  3. Standardized procedural workflow
  4. Post-procedure protocol
  5. Outcome tracking

This approach supports consistency and scalability within clinical practice.

Key Takeaways

  • PRP is not a single therapy, but a customizable biologic tool
  • Matching formulation to pathology is essential
  • Protein concentrate adds an anti-inflammatory dimension
  • Strong evidence exists for plantar fasciitis and early OA
  • Patient selection and education drive outcomes

Conclusion: A Structured Approach to Orthobiologics in Foot and Ankle Care

As orthobiologic therapies continue to gain traction across musculoskeletal medicine, successful implementation depends on more than simply adopting PRP into practice. Outcomes are heavily influenced by patient selection, biologic formulation, tissue pathology, procedural technique, and post-procedure management.

This discussion reinforces the importance of approaching PRP and PC as customizable biologic tools rather than one-size-fits-all treatments. From plantar fasciitis and tendon pathology to early osteoarthritis and joint preservation strategies, biologic therapies may offer clinicians an opportunity to bridge the gap between conservative care and surgical intervention through a more pathology-driven, evidence-guided framework.

Continue Your Education with APEX

Access the full on-demand educational webinar and explore additional clinician-focused resources, including research articles, procedural videos, and expert-led education inside the APEX Resource Library.

Watch the full webinar on-demand:
APEX Resource Library

Explore additional educational resources:
APEX Resource Library Resources

References

References

1. Gupta, A. Autologous protein solution (APS) and osteoarthritis of of the knee: a scoping review of current clinical evidence. Cureus. 2024;16(2):e53579. doi:10.7759/cureus.53579

2. Fangzhou, C., et al. Clinical outcomes and magnetic resonance imaging evaluation of autologous protein solution treatment for knee osteoarthritis. Cureus. 2025;17(5):e84698. doi:10.7759/cureus.84698

3. Fukawa, T., et al. Safety and efficacy of intra-articular injection of platelet-rich plasma in patients with ankle osteoarthritis. Foot Ankle Int. 2017;38(6):596-604. doi:10.1177/1071100717700377

4. Repetto, I., et al. Conservative treatment of ankle osteoarthritis: can platelet-rich plasma effectively postpone surgery? J Foot Ankle Surg. 2017;56(2):362-365. doi:10.1053/j.jfas.2016.11.015

5. Hohmann, E., et al. Platelet-rich plasma versus corticosteroids for the treatment of plantar fasciitis: a systematic review and meta-analysis. Am J Sports Med. 2021;49(5):1381-1393. doi:10.1177/0363546520937293

6. Hurley, E., et al. Platelet-rich plasma versus corticosteroids for plantar fasciitis: a systematic review of randomized controlled trials. Orthop J Sports Med. 2020;8(4):2325967120915704. doi:10.1177/2325967120915704

7. Mautner, K., et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013;5(3):169-175. doi:10.1016/j.pmrj.2012.12.010

8. Blanco-Rivera, J., et al. Treatment of lateral ankle sprain with platelet rich plasma: a randomized clinical study. Foot Ankle Surg. 2020;26(7):750-754. doi:10.1016/j.fas.2019.09.004

9. Shirazi, Z. & Quirolgico, K. Efficacy of platelet rich plasma in athletes with sesamoid fractures: a case series. Int J Foot Ankle. 2023;7(1):077. doi:10.23937/2643-3885/1710077

10. Siclari, A., et al. A 24-month follow-up after treatment of hallux rigidus with resection arthroplasty in combination with a resorbable polymer-based implant and platelet-rich plasma. Foot Ankle Surg. 2018;24(5):389-393. doi:10.1016

Disclaimer

This blog post is a summary of an educational webinar and is intended for informational purposes for healthcare professionals only. The perspectives shared reflect the clinical experience and opinions of the presenters and do not necessarily represent the views of APEX Biologix. This content is not medical advice and is not intended to establish a standard of care, diagnose, or recommend treatment for any individual patient. Clinicians should evaluate all therapies using independent clinical judgment, applicable regulations, and the most current available evidence.