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Plantar Fibroma

From WikiSM

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)

Introduction

View of multiple plantar nodules bilaterally[3]
Anatomy of the plantar aspect of the foot demonstrating the bands of the plantar fascia.[4]

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[5]

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[6]
    • Residual or resting phase
      • Decreased fibroblast activity, collagen maturation, and scar/contracture formation

Associated Conditions

  • [[1]]
  • Peyronie's Disease

Anatomy of the 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[7]
    • 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: Physical Exam Foot

  • 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

Special Tests

  • Needs to be updated

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.[6]
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).[8]

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[9]
    • 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[10]
  • 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[11]
  • 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[12]
    • Schuster demonstrated 94% satisfaction a mixed study of plantar fibroma and dupuytrens at 31 months[13]
  • 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[14]
    • 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

Prognosis and Complications

Prognosis

  • Recurrence
    • Occurs in 60% of excised lesions[15]
    • 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

Internal

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. ↑ Latt, L. Daniel, et al. "Evaluation and treatment of chronic plantar fasciitis." Foot & ankle orthopaedics 5.1 (2020): 2473011419896763.
  5. ↑ 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.
  6. ↑ 6.0 6.1 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ McNally, Eugene G. Practical Musculoskeletal Ultrasound. Second edition, Churchill Livingstone, Elsevier, 2014.
  10. ↑ Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int. 2000;21(7):563-569.
  11. ↑ 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.
  12. ↑ Heyd R, Dorn AP, Herkstroter M, et al. Radiation therapy for early stages of morbus Ledderhose. Strahlenther Onkol. 2010;186(1):24-29.
  13. ↑ 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.
  14. ↑ 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
  15. ↑ 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
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Last edited:
8 May 2025 01:21:48
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