We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Plantar Fibroma

From WikiSM
Jump to: navigation, search

Other Names

  • Plantar Fibromatosis
  • Ledderhose Disease
  • Morbus Ledderhose
  • Dupuytren’s disease of the plantar fascia

Background

  • This page covers plantar fibromas (PF), a benign proliferation of fibroblastic tissue in the plantar fascia

History

  • Initially described by George Ledderhose in 1897[1]
  • The broader family of fibroplastic proliferative diseases was first described by Plater in 1610, later named after Baron Guillaume Dupuytren[2]

Epidemiology

  • Most common soft tissue neoplasm of the foot (need citation)
  • Bilateral in 25-50% of cases (need citation)

Pathophysiology

View of multiple plantar nodules bilaterally[3]
  • General
    • An uncommon, benign hyperproliferative disease of the plantar aponeurosis
    • Frequently bilateral and mulinodular
    • Occurs in the central-medial, non weight bearing area of the plantar foot
    • Nodules range from 0.3 to 5.0 cm[4]

Etiology

  • General
    • Histologically appear as a benign proliferation of fibroblastic tissue
    • Characterized by myofibroblast and collagen proliferation
    • Form through a proliferative phase of cellular growth
    • Followed by replacement with fibrous tissue
  • Phases
    • Proliferative phase
      • Increased fibroblast activity and cell proliferation
    • Involutional/active phase
      • Nodule formation
      • Active phase may develop contraction within the plantar aponeurosis[5]
    • Residual or resting phase
      • Decreased fibroblast activity, collagen maturation, and scar/contracture formation

Associated Conditions

Pathoanatomy

  • Plantar Fascia
    • Central, medial and lateral bands
    • Medial band is most commonly affected
    • Originate: medial, anterior aspects of calcaneus
    • Insert: phase of the proximal phalanges

Risk Factors

  • Demographic[6]
    • Males >> females
    • Age 30 to 50
    • Caucasian
  • Systemic
  • Repetitive trauma

Differential Diagnosis

Differential Diagnosis Medial Foot Mass

  • Leiomyoma
  • Simple fibroma
  • Rhabdomyosarcoma
  • Neurofibroma
  • Liposarcoma

Differential Diagnosis Foot Pain


Clinical Features

  • History
    • Patients are often asymptomatic and nodules are found incidentally
    • Patients typically report a painless mass within the midfoot
    • There may be pain with weight bearing or application of pressure
  • Physical Exam
    • About 3/4 are found within the medial portion of the midtarsus region of the foot
    • Inspection may identify subcutaneous thickening or nodules
    • They may be painless or markedly tender
    • They can be subcuntaneous, buried within the fascia or intra-aponeurotic
    • Rarely, digital contractures
    • Important to evaluate foot and ankle range of motion
    • Evaluate for presence of Achilles tendon, gastrocnemius contractures

Evaluation

Characteristic magnetic resonance image demonstrating lesions (arrows) with heterogenous signal in the plantar foot. (A) Lesions tend to be hypointense on T1-weighted images. (B) Increased signal is seen on T2-weighted images.[5]
Transverse US image (A) at the level of the midfoot shows a mixed echogenic fusiform lobulated lesion along the superficial aspect of the plantar fascia (thick arrow) typical of a plantar fibroma. The lesion shows alternating bands of hypoechogenicity and hyperechogenicity (thin arrows), coined the comb sign. Artistic rendering of a comb is shown for illustration (B).[7]

Radiographs

  • Standard Radiographs Foot
    • Typically normal as the fibromas do not calcify
    • Presence of calcifications may suggest malignant condition

MRI

  • General
    • Nodular thickening on the medial aspect of the plantar aponeurosis (low signal on T1, low or medium signal on T2)
    • Best seen with contrast (T2 images show the fibroma to have less signal than fluid)
    • Useful to rule out malignancy (i.e. sarcoma)

Ultrasound

  • Findings[8]
    • Hypo- or iso-echoic mass that appears as nodular thickening of the plantar fascia
    • No cystic changes or calcification
    • Plantar fascia may appear disrupted
    • Useful in providing measurements of depth and size of the nodules[9]
  • Comb Sign
    • Alternating linear bands of hypoechogenicity and isoechogenicity relative to the plantar fascia
    • Represents hyperechoic, fibrous regions of fibroma

Classification

  • Not applicable

Management

Nonoperative

  • Indications
    • First line for nearly all cases
    • Lesions that are small, minimally symptomatic
  • NSAIDS
  • Activity Modification
    • Avoid jumping sports
  • Offloading Orthotics
    • Can be used to offload the fibroma and reduce symptoms
    • Act as a shock absorber
  • Carbon Foot Plate
    • Underneath orthotic, may decrease strain on plantar fascia
  • Rocker bottom Shoe
    • Offload pressure through the plantar aponeurosis
  • Physical Therapy
  • Hormonal Therapy
    • Anti-estrogen therapy primarily limited to basic science models or in dupuytren's disease
    • Degreef et al showed tamoxifen helped but the clinical benefit deteriorated over time[10]
  • Radiation Therapy
    • Reduces fibroblast activity, most effective at stage 1
    • Heyd et al showed complete pain remission in 60% of patients, improved gait abnormalities in 73.3% of patients[11]
    • Schuster demonstrated 94% satisfaction a mixed study of plantar fibroma and dupuytrens at 31 months[12]
  • Corticosteroid Injection
    • Not well studied in PF, knowledge extrapolated from dupuytrens disease and basic science literature
  • Collagenase Injection
    • Approved for dupuytren's, peyronie's disease; not studied in PF
  • Percutaneous Ultrasound Therapy
    • In a retrospective case series, Patel et al showed improvement of foot and ankle scores at an average follow up of 2.5 years[13]
    • Otherwise, there is a paucity of data to recommend this modality

Operative

  • Indications
    • Failure of conservative treatment
    • Activity limiting
  • Technique
    • Complete plantar fasciectomy
    • Local excision
    • Wide excision with margins

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Recurrence
    • Occurs in 60% of excised lesions[14]
    • Risk factors include bilateral disease, multiple nodules, family history
    • Risk is reduced with adjuvant radiation

Complications

  • Recurrence
    • Common after local excision, usually more aggressive
  • Malignant transformation
    • Rare

See Also

External


References

  1. Ledderhose, Georg. "Zur pathologie der aponeurose des fusses und der hand." Arch. klin. Chir. 55 (1897): 694-712.
  2. DUPUYTREN, BARON GUILLAUME, and DRS ALEXANDRE PAILLARD. "DE LA REATRACTION DES DOIGTS PAR SUITE D'UNE AFFECTION DE L'APONEUROSE PALMAIRE." Plastic and Reconstructive Surgery 42.3 (1968): 262-264.
  3. Akdag, Osman, et al. "Dupuytren-like contracture of the foot: Ledderhose disease." The Surgery Journal 2.03 (2016): e102-e104.
  4. English C, Coughlan R, Carey J, Bergin D. Plantar and palmar fibromatosis: characteristic imaging features and role of MRI in clinical management. Rheumatology (Oxford). 2012;51(6):1134-1136.
  5. 5.0 5.1 Espert, Melissa, et al. “Current Concepts Review: Plantar Fibromatosis.” Foot & Ankle International, vol. 39, no. 6, June 2018, pp. 751–57. PubMed, https://doi.org/10.1177/1071100718768051.
  6. Haun, Daniel W., et al. “Symptomatic Plantar Fibroma with a Unique Sonographic Appearance.” Journal of Clinical Ultrasound: JCU, vol. 40, no. 2, Feb. 2012, pp. 112–14. PubMed, https://doi.org/10.1002/jcu.20853.
  7. Cohen, Blake E., Naveen S. Murthy, and Gavin A. McKenzie. "Ultrasonography of plantar fibromatosis: updated case series, review of the literature, and a novel descriptive appearance termed the “Comb sign”." Journal of Ultrasound in Medicine 37.11 (2018): 2725-2731.
  8. McNally, Eugene G. Practical Musculoskeletal Ultrasound. Second edition, Churchill Livingstone, Elsevier, 2014.
  9. Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int. 2000;21(7):563-569.
  10. Degreef I, Tejpar S, Sciot R, De Smet L. High-dosage tamoxifen as neoadjuvant treatment in minimally invasive surgery for Dupuytren disease in patients with a strong predisposition toward fibrosis: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(8):655-662.
  11. Heyd R, Dorn AP, Herkstroter M, et al. Radiation therapy for early stages of morbus Ledderhose. Strahlenther Onkol. 2010;186(1):24-29.
  12. Schuster J, Saraiya S, Tennyson N, et al. Patient-reported outcomes after electron radiation treatment for early-stage palmar and plantar fibromatosis. Pract Radiat Oncol. 2015;5(6):e651-e658.
  13. Patel MM, Patel SM, Patel SS, Daynes J. A pilot study of a novel treatment method for refractory painful plantar fibromas. Austin J Orthopaed Rheumatol. 2015;2(2): 1014. ISSN: 2472-369X
  14. van der Veer WM, Hamburg SM, de Gast A, Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. 2008;122(2):486-491.
Created by:
John Kiel on 15 December 2022 07:34:33
Authors:
Last edited:
15 December 2022 08:51:20
Categories: