Addressing Tissue Injury in Chronic Plantar Fasciitis

by Dr. Emily Splichal, DPM MS

Typically, when symptoms last for 6 months or longer, patients are considered to have chronic plantar fasciitis. The longer symptoms persist, the more likely there is an associated change in the tissue composition. Many conservative treatment recommendations often fail to provide relief to those suffering from chronic plantar fasciitis.  This unpredictability has led many physicians to take a step back and look closer at the nature of tissue injury occurring in these cases.

Chronic Tissue Injury

It is generally believed that plantar fasciitis is initiated by excessive tensile strain within the fascia during repetitive loading, producing microscopic tears and an acute inflammatory response.

If the stress to the fascia persists, the repair process is unable to keep up with the ongoing injury, and instead produces stasis, immature blood vessels and fibrosis.  Tissue degeneration (fasciosis), rather than inflammation, then becomes the classic presentation in these patients.

Bringing Organization to Injury

Once damaged, the biological and biomechanical properties of fascia are never completely restored.  It is almost as if the healing processed stalled or is stuck.  One can also think of the tissue degeneration as disorganized tissue repair.

A key characteristic of disorganized tissue repair is fibrin deposition.  You can think of fibrin as the scaffolding to which the repaired tissue will form.   In chronic plantar fasciitis, the fibrin deposition is messy and inconsistent, and can contribute to further tissue stress.

Fibrinolysis, is a method of bringing organization to the chaotic fibrin deposition.  Although this is a natural process that occurs within the body, in chronic tissue injury cases this process can also be stalled. There are a few treatments to retrigger fibrinolysis. Some treatments that can be used are stem-cell therapy and protein-rich plasm (PRP) injections.  As an emerging treatment, both stem cell and PRP injections use the body’s natural healing ability while acting as a catalyst to soft tissue repair to deliver fast healing and long-lasting results to soft-tissue injuries.

In addition to stem cells and PRP, some enzymes, such as serrapeptase, also have fibrinolytic activity.  Serrapeptase is a proteolytic enzyme that is naturally found within the intestines of the silkworm.  This enzyme enables the emerging moth to dissolve its fibrous cocoon. It is thought that serrapeptase can be an exciting natural supplement to help the body increase fibrinolysis, more research needs to be done to solidify this connection.

If you find yourself experiencing chronic, non-responding plantar heel pain and have not yet integrated treatments that factor in the unique tissue changes associated with chronic plantar fasciitis, then I encourage you to consider these options.  Often times it is the specificity of our treatment that provides the greatest results. 

Not sure if you have acute or chronic plantar fasciitis, check out our recent blog article to find out.