What is Plantar Fibromatosis?

Plantar fibromatosis, also known as Ledderhose disease, is a harmless condition that affects the connective tissue in the bottom of your foot. It is related to other conditions like Peyronie’s and Dupuytren’s diseases, which involve the formation of similar fibrous lumps. The German doctor, George Ledderhose, first identified this condition in 1897, after studying 50 patients experiencing foot pain.

If you have Ledderhose disease, you may develop hard lumps along the arch of your foot. You might have one lump or several, and they could be in one foot or both. The lumps usually develop slowly and become noticeable when the area starts to feel painful and swollen, especially on the inner side of your foot where you don’t generally bear your weight.

Your foot has a thick band of connective tissue known as the plantar fascia that acts like a shock absorber when you walk or run. The plantar fascia is made up of mostly collagen fibers arranged in a dense structure. It starts at your heel bone and extends to the base of your toes. It is divided into three key sections: inner (medial), middle (central), and outer (lateral). The inner band is the thickest and strongest, while the outer band is thinner and less prominent. All these parts work together to distribute the pressure evenly across your foot and maintain its arch while moving. Furthermore, the plantar fascia has a rich supply of blood vessels and nerves, which aid in healing and allow you to feel different sensations in your foot.

In plantar fibromatosis, hard lumps can form within the plantar fascia, causing pain, discomfort, and limited movement. Certain structures within the foot are closely linked to this condition. These include the muscles and tendons that move the foot, and the nerves that provide sensation. Also, the blood vessels which bring blood to the tissues are essential as they provide the food and oxygen for tissue survival.

What Causes Plantar Fibromatosis?

Doctors are not exactly sure what causes plantar fibromatosis, a condition where clusters of tough tissue form in the foot’s arch. However, certain factors seem to be linked to the condition. These include repeated injury or stress to the foot, inherited traits, certain types of medication, alcoholism, diabetes, and other conditions that cause abnormal cell growth.

Risk Factors and Frequency for Plantar Fibromatosis

Plantar fibromatosis is an uncommon condition that affects less than 200,000 people in the United States. It usually appears in adults who are in their 40s and 50s, but there have been cases in children as young as 9 months old. Men are twice as likely to get this disease as women. Furthermore, about 25% of people with this disease have it in both feet.

The disease seems to be more common in people with diabetes, epilepsy, or alcohol use disorder. It has also been found in families, suggesting it may be inherited. The condition is also more common in people of northern European background and often occurs together with Dupuytren hand contracture, another disease that affects the hands.

Plantar fibromatosis affects less than 200,000 people in the United States.
It mainly occurs in adults in their 40s or 50s.
There have been reports of it occurring in children as young as 9 months.
Men are twice as likely to get this condition as women.
About 25% of patients have the disease in both feet.
The condition is common in those with diabetes, epilepsy, or alcohol use disorder.
There is evidence to suggest it may be inherited.
The condition is more prevalent in people of northern European descent.
Individuals with Dupuytren disease requiring hand surgery are more likely to have Ledderhose disease (plantar fibromatosis).

Signs and Symptoms of Plantar Fibromatosis

Plantar fibromatosis is a condition characterized by a slow-growing lump in the central or inner part of the foot. This lump ranges from 0.5 to 3 cm in diameter and there can be one or many of them. Smaller lumps might cause local pressure or swelling on the foot. As the condition progresses, the patient might experience increased pain, swelling, and difficulties in walking or bearing weight. Often, patients have severe pain in the sole of the foot after standing or walking for extended periods. The pain might worsen when the patient puts pressure on the lump or on the arch of the foot, such as when walking barefoot on hard surfaces or wearing stiff shoes.

A physical examination of the foot and ankle usually involves observing the foot, feeling the soft tissue and bones, and assessing the range of motion and the way the patient walks. The lumps are typically visible or can be felt during the examination. Some patients might have contracted toes, especially the big toe. Furthermore, the examination should also look at the hands as 15% of people with a condition that causes the fingers to contract, called Dupuytren contracture, can also have Ledderhose disease.

Testing for Plantar Fibromatosis

The process to diagnose a condition mostly relies on understanding your medical history and checking your physical wellbeing. In some cases, additional methods like imaging tests and tissue samples can be used to confirm the diagnosis. Two common imaging tests used are magnetic resonance imaging (MRI) and ultrasound.

In an MRI, a plantar fibroma, which is a non-cancerous lump in the arch of the foot, may look like a distinct, rounded area or a mass of irregularly shaped tissue in the plantar fascia, the connective tissue located on the sole of your foot. This can either have low signal intensity, meaning it shows up darker on the scan, or a signal similar to muscle tissue. Other distinguishing features of a plantar fibroma on an MRI include it being well-defined, appearing darker on T1 images and slightly lighter on T2 images. Sometimes, a contrast agent like gadolinium may be used with the MRI to make the fibroma stand out more. The MRI scan can also be helpful for planning any surgical removal of the fibroma and identifying how far plantar contractures (tightening of the tissue) have progressed.

Ultrasound may also be used. This imaging test can help determine the depth, size, and number of nodules that are present. These nodules usually appear similar to the surrounding tissue (isoechoic) and look different from one area to another (heterogeneous) on an ultrasound. In specific cases, hyperechoic septa, which are areas that produce strong echoes, may also be present. Generally, blood flow isn’t visible when using a Doppler ultrasound, a special type of ultrasound that shows blood flow. An ultrasound scan has the advantages of being quick, affordable, and able to be performed during your medical appointment.

Sometimes, an X-ray can be taken to see if there’s anything wrong with the underlying bone or if there are any hard deposits in the soft tissue that may be causing the symptoms. In certain situations, a biopsy, which is a procedure to collect a small sample of tissue for closer examination, might be performed to rule out cancer.

Treatment Options for Plantar Fibromatosis

There are several non-surgical treatments for a foot condition called plantar fibromatosis, which causes fibrous nodules to develop in the arch of the foot. These treatments mostly aim to lessen symptoms such as pain or discomfort rather than removing the nodules or stopping them from getting worse. Common treatments include medications to reduce inflammation, physical therapy, and changes to footwear or physical activities. Let’s take a look at some of these approaches in more detail:

Orthotics or Pads

If the disease is in its early stages and the symptoms are minor, patients can use foot padding inside their shoes to alleviate pressure on the affected parts of the foot. Other helpful footgear includes shoes with increased padding or shoes specifically designed to reduce stress on the arch of the foot.

Steroids

Some studies suggest that steroid medications can help reduce the size of plantar fasciomas, which are the nodules caused by plantar fibromatosis. These steroids work by decreasing the activity of fibroblasts, which are the cells that produce fibromas. However, injections of steroids can lead to certain complications, including rupture of the arch of the foot, fat loss, and changes in skin color.

Collagenase

This treatment uses an enzyme to break down collagen, which is a protein that makes up fibromas. Collagenase has been used with success to treat similar diseases, but there isn’t much evidence on its effectiveness for plantar fibromatosis yet. Treatment involves getting collagenase injections every month for several months and can help improve mobility and reduce pain.

Verapamil

A drug commonly used to treat high blood pressure, verapamil can stimulate the activity of collagenase and decrease the production of collagen. Applying a cream containing verapamil or injecting it into the fibroma can decrease its size significantly. However, using verapamil may cause contact dermatitis, a skin rash caused by contact with a certain substance.

Extracorporeal Shock Wave Therapy

This non-invasive treatment uses shock waves to stimulate a biological response in the nodule and encourage healing. This therapy may alleviate pain and soften the nodules without reducing their size.

Radiation Therapy

Exposing the affected area to low doses of electron beam radiation may slow the progression of the disease, especially in its early stages. Research has found that radiation can decrease the size of the nodules in many cases. Side effects can include redness and dryness of the skin.

Tamoxifen

This anti-estrogen drug may help by inhibiting certain proteins that encourage fibroma growth. However, this treatment is still experimental for plantar fibromatosis, and no studies have been conducted on its effectiveness for this condition yet.

If you’re feeling pain due to a lump in your foot arch, it’s important to rule out multiple diagnoses to figure out the root of the problem. These could include:

Plantar fasciitis (inflammation of a thick band of tissue that connects your heel bone to your toes)
Tarsal tunnel syndrome (a compression, or squeezing, on the posterior tibial nerve)
Calcaneus fracture (a fracture of the heel bone)
Various types of tumors such as leiomyoma, simple fibroma, liposarcoma, neurofibroma, rhabdomyosarcoma, fibrosarcoma, and nodular fasciitis

By considering your medical history, getting image tests, and conducting a biopsy, medical professionals can distinguish between these possible conditions.

Surgical Treatment of Plantar Fibromatosis

Plantar fibromatosis is a condition that may require surgery if standard non-surgical treatments are not effective, or if the condition makes daily tasks more difficult. For example, if the condition causes walking to become difficult or a person is unable to regularly wear their usual shoes. The surgery could involve one of the following options:

– Local excision: This simply means the surgeon removes the whole lump or “nodule” from the foot. However, it’s important to note that the lump could return in 60% to 100% of cases.

– Wide excision: This is a more extensive surgery where the surgeon removes the lump plus a 2 centimeter margin around it. The recurrence rate in this case is up to 60%.

– Complete fasciectomy: This is when the surgeon removes the entire plantar fascia, which is the connective tissue in the foot that the lump is attached to. This procedure has the lowest risk of the lump returning, at 25%.

The decision on which type of surgery is best for a person depends on several factors. A grading system created by Sammarco and Mangone helps determine the extent of the disease. Factors include how much the plantar fascia is affected, if the skin or muscles are involved, and how deep the lump is. Lumps might return after surgery, which is the most common concern with these procedures. Therefore, some doctors favor the complete fasciectomy as it has the lowest recurrence rate.

A newer, challenging technique involves the use of endoscopy to partially remove the plantar fascia. This procedure uses large devices inserted through small cuts. It’s considered for persistent fibromas, which are non-cancerous lumps, but isn’t suitable for lumps attached to the skin surface, those invading deep foot muscles, or ones involved with blood vessels or nerves. Compared to an open surgery, an endoscopic surgery results in better wound healing and minimal scarring due to the smaller incisions needed.

When planning for surgery, careful thought should be given to where incisions will be made, especially in areas where weight is put on the foot. Long cuts in the skin can lead to thick, noticeable scars. Cuts going across or in a zigzag pattern near the middle of the foot could risk skin death due to interrupting the blood supply to the area.

What to expect with Plantar Fibromatosis

If you have Ledderhose disease, your doctor will likely start treating you with conservative (non-invasive) therapies during your first appointment. However, if treatments like medication are not effective, or if the condition is interfering with everyday tasks like wearing shoes or walking, surgery may be considered. It’s important to know that the disease has a high chance of returning, irrespective of whether it was treated non-surgically or surgically.

Possible Complications When Diagnosed with Plantar Fibromatosis

The main issue with untreated plantar fibromatosis, a condition affecting the foot, is the chronic pain that comes from a growing lesion. It can also lead to other issues. These may include problems with wound healing, hypertrophic scarring, and the return of the condition after treatment. However, the growths from plantar fibromas are generally benign, meaning they aren’t cancerous.

Surgery, especially local excision, has high rates of the condition coming back. This return of the condition is more common in patients with multiple growths and a family history of the disease. On top of this, there could be complications following surgery. These may range from trapped nerves and issues with the wound healing (including wounds reopening and painful scarring) to the loss of the foot’s arch height. Damage to the plantar nerve – a nerve in the foot – could also lead to numbness or a thickened area of nerve tissue (neuroma).

Potential Complications:

Chronic pain from lesion growth
Issues with wound healing
Hypertrophic scarring
Recurrence after treatment
Recurrence after surgery
Trapped nerves
Wound-healing problems and painful scarring post-surgery
Loss of foot’s arch height
Numbness or neuroma due to plantar nerve damage

Recovery from Plantar Fibromatosis

After surgery, the patient is advised not to put any weight on the side that was operated on until the surgical wound heals. This healing process typically takes around 3 weeks. Once healed, the patient can start bearing weight on that side again and resume their normal activities.

Preventing Plantar Fibromatosis

To prevent a condition known as plantar fibromatosis – which often causes thickening or small bumps on the bottom of the foot – you should aim to:

* Maintain a healthy weight: Less pressure on the feet helps prevent this condition.
* Use well-fitted shoes: Good supportive shoes will spread weight evenly, reducing strain on the bottom part of the foot, the “plantar fascia”.
* Manage existing health conditions: Conditions such as diabetes and obesity could increase the risk of developing plantar fibromatosis, so it’s important to diagnose and treat them in a timely manner.
* Increase physical activity slowly: Don’t rush into strenuous foot-related activities to avoid overusing and injuring your feet.
* Regular exercises: Doing routine strengthening and stretching exercises could help to ensure your foot and calf muscles, as well as your plantar fascia, stay flexible.
* Take care of your feet: Regular foot care can help prevent inflammation in your feet and avoid worsening your condition.

If you’re experiencing persistent foot pain, it’s important to speak with a healthcare professional. They can help determine if you might have plantar fibromatosis and guide you on the best course of action to manage or treat it.