Foot and ankle problems are load-bearing problems. Every structure here is asked to tolerate your body weight several thousand times a day, which is why so few of them settle on their own and why the mechanical cause matters as much as the painful tissue.
Where it hurts, and what it does under load, narrows things down faster than any scan.
- Under the heel, worst on the first steps in the morning. Plantar fascia.
- Back of the heel or a few centimetres above it, stiff to start and sore the day after activity. Achilles tendon — and insertional and mid-portion problems behave differently.
- Behind and below the outer ankle bone, after repeated sprains. Peroneal tendons.
- Inside of the ankle, with the arch flattening. Posterior tibial tendon, and this one progresses.
- Deep in the front of the ankle, stiff, worse on slopes and stairs. The ankle joint itself.
- Fine on flat ground, painful on grass, gravel or a slope. The subtalar joint below the ankle.
Most of what follows is diagnosed by examination and ultrasound in the room. The tendons here sit close to the surface, which makes them straightforward to image accurately — and a tendon you can see is a tendon you can inject accurately.
Several sections below say an injection is not the answer. Where the evidence points to loading, a brace, an orthotic or an operation, that is what you will be told.
Plantar fasciitis
Heel pain at its worst for the first ten steps of the morning, easing as you move and returning after sitting. The fascia is degenerating where it attaches to the heel bone rather than simply being inflamed, which is why it takes months rather than days and why anti-inflammatories so often disappoint.
Calf and fascia stretching, supportive footwear, an orthotic and a night splint are the foundation and resolve most cases given enough time. Of everything on this page, plantar fasciitis has the strongest evidence for PRP — in the pooled trials it outperforms a corticosteroid injection at three and six months. Its real advantage over steroid is durability and safety rather than a bigger peak effect: repeated steroid into a heel can thin the fat pad you walk on and, uncommonly, rupture the fascia. Class IV laser may potentially help alongside loading. Surgery is rarely needed. More on plantar fasciitis, and the medial injection approach →
Achilles tendinopathy
Pain and thickening either in the mid-portion of the tendon, a few centimetres above the heel, or where it inserts into the heel bone. Stiff and sore for the first steps of the day, better once warm, worse the day after activity.
Progressive loading is the best-supported treatment and it is not optional. A structured eccentric or heavy-slow loading programme, done properly for three months, outperforms every injection that has been studied.
On PRP, the honest position: the placebo-controlled trials in Achilles tendinopathy have not shown a clear advantage over a dummy injection. Those trials each gave a single injection and none reported the platelet dose delivered, which is a real limitation — but it is a reason to be cautious about the trials rather than a reason to promise you a result. Insertional Achilles tendinopathy has not been studied with PRP at all. Class IV laser may potentially help symptoms alongside a loading programme.
Corticosteroid is not injected into or around the Achilles here. It has never been shown to help this condition and it carries a genuine concern about tendon rupture.
Achilles partial tears and rupture
A partial tear is a different problem from tendinopathy and needs to be identified, because the early management is protective rather than progressive — often a boot, with loading reintroduced in stages. There is no controlled evidence for injecting anything into a partially torn Achilles.
A complete rupture is usually unmistakable: a sudden blow to the back of the ankle, often with an audible snap, and an inability to push off. It is a surgical decision made on a clock and it is an urgent referral, not an injection problem.
Peroneal tendon tears and tendinopathy
Pain and swelling behind and below the outer ankle bone, usually after repeated sprains or in a foot with a high arch and a heel that sits inward. Some patients feel or hear the tendons snapping over the bone.
Assessment uses dynamic ultrasound — the tendons are watched while the ankle moves, which is the only way to see them subluxing. MRI is added when a tear needs characterising.
Bracing, targeted strengthening and correcting the underlying alignment with an orthotic are the non-operative treatments, and addressing the alignment is what stops it recurring. Class IV laser may potentially help. There is no controlled evidence for orthobiologic injection in peroneal tendon problems. A tendon that is subluxing, or torn to a significant degree, is a surgical problem and a referral.
Posterior tibial tendon dysfunction
The tendon on the inside of the ankle that holds up the arch stretches out and fails. The arch flattens, the heel drifts outward, and the patient cannot do a single-leg heel rise on that side. Early on it hurts on the inside of the ankle; later it hurts on the outside as the bones begin to impinge.
This one genuinely progresses, and the stage determines everything. A custom orthotic or brace, calf stretching and targeted strengthening can hold an early, flexible deformity for years. Once the deformity becomes fixed, bracing manages it but does not reverse it. There is no published evidence for orthobiologic injection in this condition. Progressive deformity is a surgical problem, and being referred at the right stage matters more here than anywhere else on this page.
Flexor hallucis longus tendinopathy
Pain deep behind the inner ankle bone, worse pushing off, often with pain or catching when the big toe is moved. Common in dancers and anyone who spends time up on their toes. Ultrasound shows the tendon gliding in its sheath behind the ankle, which is how it is distinguished from posterior tibial problems that sit a centimetre away.
Activity modification, calf and tendon loading, and addressing footwear and technique are the treatments. There is no published human evidence of any kind for orthobiologic injection in this tendon — not weak evidence, none — and that is stated because it is offered elsewhere anyway.
Ankle arthritis
Ankle arthritis is usually post-traumatic — the late result of a fracture or years of instability — rather than simple wear, and it frequently presents in people far younger than knee or hip arthritis does. It produces deep front-of-ankle pain, stiffness, and difficulty on slopes and stairs. Weight-bearing X-rays show the joint under load rather than lying down, which is the view that matters.
Activity modification, a stiff-soled or rocker-soled shoe, bracing and a guided corticosteroid injection are the non-operative options.
On orthobiologics, the honest position: a well-designed trial comparing PRP against a saline injection in ankle arthritis found no benefit at six months, and none at a year either. That is the clearest negative result in this area and you should know about it before anyone offers you the treatment. Ankle arthritis that has failed non-operative care is a surgical conversation — fusion or replacement — and a referral.
Subtalar arthritis
The joint below the ankle, which lets the foot adapt to uneven ground. Arthritis here often follows a heel bone fracture. The giveaway is pain walking on grass, gravel or a slope while flat ground is tolerable.
A guided diagnostic injection is genuinely useful here, because subtalar and ankle pain are difficult to separate on examination alone and the answer changes what gets treated. Bracing, a rocker-soled shoe and activity modification are the non-operative options. There is no evidence for orthobiologic injection into the subtalar joint, and the ankle data does not transfer — different joint. Fusion is the durable surgical answer.
Ankle sprains and chronic instability
After repeated sprains the outer ankle ligaments heal long rather than tight, and the ankle gives way on uneven ground or in a turn. Swelling settles; the confidence does not.
Peroneal strengthening and balance retraining come first and work for most people, because they restore the control the ligament used to provide. Bracing helps during the rebuilding. An ankle that continues to give way despite a proper programme has mechanical instability, and that needs a surgical opinion rather than an injection — repeated instability is also how ankle arthritis starts, which is the reason not to leave it.
All PRP is not the same
Two of the conditions on this page have placebo-controlled trials that came back negative, and those trials have something in common with each other: each gave a single injection, and neither reported how many platelets were in it.
That matters, because where the dose has actually been measured it changes the answer. In knee osteoarthritis — where Dr. Buford was one of the authors of a systematic review covering 32 randomised trials and 3,589 patients — under-dosed PRP performs like saline, and adequately dosed PRP does not. The trials that injected a preparation barely richer in platelets than ordinary blood found nothing. The one that drew more blood, spun it twice and delivered several times the platelet dose still showed benefit at five years, with roughly half the cartilage loss.
Most of the negative trials did not report the dose, so it is possible that they were not really studying an effective PRP dose at all. Whether the threshold established in the knee applies to a tendon or to the ankle joint has not been tested, and that will not be claimed here. But “PRP did not work in that trial” and “PRP does not work” are different statements.
Ask what platelet dose you are getting. Ask how they know. All PRP is not the same — what your dose actually was →
What is offered here
- Assessment by a board-certified orthopedic surgeon, including how the foot behaves under load rather than only how it looks on a table.
- Ultrasound in the room, including dynamic examination of the peroneal tendons and the Achilles in motion, which a static scan cannot show.
- Guided diagnostic injection where the source of pain is genuinely in question — most often separating subtalar from ankle.
- Platelet-rich plasma and bone marrow concentrate where indicated, with the evidence for your particular problem described as it actually stands. Detail and cost on PRP and orthobiologics for the foot and ankle.
- Class IV MLS laser, which may potentially help symptoms alongside a loading programme. Class IV MLS laser therapy.
- Referral, promptly and with your records, where an operation is the right answer.
What is not offered
- Foot and ankle surgery — this practice is orthobiologics, shoulder surgery and knee surgery. Foot and ankle operations are not performed here and you will be referred to a surgeon who does them, with your imaging and workup handed over personally rather than left to you to arrange.
- Corticosteroid into or around the Achilles tendon — no demonstrated benefit for tendinopathy and a genuine rupture concern.
- Injectable allograft products — amniotic fluid, Wharton's jelly, exosomes and regenerative protein arrays. Why not, in full, below.
What we do not offer, and why
This field has a marketing problem, so rather than just listing exclusions it is worth stating the standard being applied.
We do not use any product that lacks a clear FDA regulatory pathway for use in humans and clear human clinical outcomes data showing that it is safe and that it works for the indication being treated. Both halves, not either one. That single sentence accounts for most of what is on the market and not on the menu here.
Amniotic fluid, Wharton's jelly, exosomes and regenerative protein arrays
These are marketed heavily, often as “stem cell” injections, and patients are frequently quoted a great deal of money for them. None of them is used here. There are two reasons, and the second matters more than the first.
The regulatory reason. The FDA regulates these products as biologic drugs. None of them currently holds an approved orthopedic indication. That is a description of their regulatory status rather than a matter of opinion, and it holds whatever a clinic's marketing says about it.
The evidence reason, which is the more significant one. Treatment here is based on evidence, and there is no published literature for any of these injectable allograft options in orthopedics showing that any of them works better than PRP or bone marrow concentrate. Not equivalent-but-cheaper, not better-in-a-subgroup — the comparison that would justify using them has not been made in their favour. PRP and bone marrow concentrate, by contrast, have a substantial published human literature behind them.
So even setting the regulatory question aside entirely, there is no evidence-based argument for choosing one of these over a treatment prepared from your own tissue.
Adipose (fat) based treatments, also called microfat
Texas Orthobiologics does not currently offer adipose-based orthobiologics. That is a practice decision, and it is worth separating from the regulatory picture, because the two kinds of adipose treatment are not in the same position.
Adipose preparations produced with a device carrying FDA clearance or approval are regulatory compliant. An adipose-based biologic is often called microfat, after the way clinicians in the United States must process the tissue. It is a legitimate orthobiologic option and some clinicians have success with it.
Treatments based on stromal vascular fraction — SVF — are not currently regulatory compliant. This is now settled, and it is worth being specific about how it got there, because clinics still advertise these injections.
In 2024 a federal appeals court held that SVF is a drug under federal law, and that it does not qualify for the same-surgical-procedure exception that same-day fat procedures had relied on. The Supreme Court declined to review that decision in 2025. On 28 August 2026 the district court entered a permanent injunction on remand in United States v. California Stem Cell Treatment Center, Inc., which also names Cell Surgical Network Corporation. That is not a warning letter or an opinion — it is a standing federal court order.
The practical meaning for a patient is simple. An SVF injection is an unapproved drug unless it goes through the drug approval pathway, whatever the clinic offering it advertises about same-day processing or minimal manipulation. That argument has been made, and it lost.
Every injection here is made from your own tissue
Every biologic injection performed at Texas Orthobiologics is autologous — prepared from the patient's own blood or bone marrow on the day of treatment.
That is deliberately a statement about injections rather than a blanket position on donor tissue. Donor cartilage used as a structural graft in cartilage transplantation surgery is a different proposition entirely: it is regulated under an established pathway, it is implanted rather than injected, and it carries decades of published human outcomes data. It meets the standard above. An injectable donor cell product does not.
Get seen urgently for these
A sudden snap at the back of the ankle with an inability to push off — that is an Achilles rupture and the timing of the decision matters. Inability to bear weight after an injury, which may be a fracture rather than a sprain. A hot, swollen, exquisitely painful joint with fever. New numbness or a foot that will not lift. None of those is an injection problem.
Common questions
Does PRP actually work for plantar fasciitis?
It has the best evidence of any orthobiologic use in the foot. In the pooled randomized trials PRP outperformed a corticosteroid injection at three and six months for both pain and function. Its advantage is durability and safety rather than a larger immediate effect, because repeated steroid into a heel can thin the fat pad you walk on and occasionally rupture the fascia. Stretching, footwear and an orthotic still come first.
I have Achilles tendinopathy. Should I get PRP?
Start with a proper loading program, because that has the strongest evidence and three months of it done correctly outperforms every injection studied. The placebo-controlled PRP trials in Achilles tendinopathy have not shown a clear advantage over a dummy injection, although each gave only a single injection and none reported the platelet dose delivered. We do not inject corticosteroid around the Achilles because of the rupture concern.
Can an injection help my ankle arthritis?
A guided corticosteroid injection can settle a flare and is often worth doing. On orthobiologics the honest answer is that the best trial compared PRP against a saline injection in ankle arthritis and found no benefit at six months or at a year, using two injections. You should know that before anyone offers it to you. Ankle arthritis that has failed non-operative care is a surgical conversation.
My ankle keeps rolling. Is that something an injection fixes?
Usually not. After repeated sprains the ligament heals long rather than tight, and the reliable treatment is peroneal strengthening and balance retraining, which restores the control the ligament used to provide. That works for most people. An ankle that gives way despite a proper program has mechanical instability, and that needs a surgical opinion rather than an injection.
Do you do foot and ankle surgery yourself?
No. This practice is orthobiologics, shoulder surgery and knee surgery. Foot and ankle operations are not performed here, so if your problem needs one you will be told plainly and referred to a foot and ankle surgeon, with your imaging and workup handed over personally rather than left to you to arrange. Being told an injection will not help is part of the assessment, not a failure of it.
