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== Definition/Description  ==
Ledderhose diseaese, also known as plantar fibromatosis or Morbus Ledderhose, is a (mostly) small slow-growing thickening of the superficial fibromatoses which is actually a soft tissue tumor of the plantar aponeurosis similar in appearance to the disease which occurs in the palm of the hand ([http://www.physio-pedia.com/Dupuytren%E2%80%99s_Contracture disease of Dupuytren]). Basically it can be described as a benign fibroblastic proliferative disorder in which fibrous nodules may develop in the plantar aponeurosis, more specifically on the medial plantar side of the foot arch and on the fore foot region. The symptoms are swelling, pain is not usual and also a contraction is not applicable in the first stage. <ref name="4">Haedicke, G.J., Sturim, H.S. (1989). Plantar fibromatosis: an isolated disease. Plast Reconstr Surg. Level of evidence: 4</ref> <ref name="6">Knobloch, K. and Vogt, K.M. (2012). High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose’s disease). BMC Res Notes. Level of evidence: 2A</ref> <ref name="9">Griffith, J.F., Wong, T.Y., Wong, S.M., and Metrweli, C. (2002). Sonography of plantar fibromatosis. AJR Am J Roentgenol. Level of evidence: 2A</ref> <ref name="10">Murphey, M.D., Ruble, C.M., Tyszko, S.M., Zbojniewicz, A.M., Potter, B.K., and Miettinen, M. (2009). Musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics. Level of evidence: 2C</ref><br>
== Clinical Relevant Anatomy  ==
The plantar fascia, or aponeurosis is synonymous with the deep fascia of the sole of the foot. The plantar fascia is a strong connective tissue structure that consists of pearly white longitudinally organized fibers. It begins at the medial tuberosity of the calcaneus where it is thinner and extends into a thicker center portion. This thicker portion is flanked by thinner lateral and medial portions. The thicker central portion of the plantar fascia then extends, into five different bands surrounding the digital tendons, to the plantar plates of the metatarsophalangeal joints and the bases of the proximal phalanges. <ref name="1">Yusuf Ziya Tatli - Sameer Kapasi, The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies, Human Press 2:3-9 (2008). Level of evidence 2A</ref> <ref name="9" /> <ref name="13">Eugene G. McNally, Shilpa Shetty. (2010). Plantar Fascia: Imaging Diagnosis and Guided Treatment. Department of Radiology, Nuffield Orthopaedic Centre, Oxford, Oxfordshire, United Kingdom. Level of evidence 1B</ref><br>
<br>
[[Image:Plantar and medial views.jpg]]
'''Figure 1:''' Plantar and medial views of the foot demonstrating the origin and insertion of the plantar fascia and the location of nerves in proximity to the heel. <ref name="1" />
<br>
== Epidemiology/ etiology  ==
Ledderhose’s disease, is named after a German surgeon, Dr. Georg Ledderhose. He described the condition first in 1894 as an uncommon hyperproliferative plantar aponeurosis <ref name="2">Fausto de Souza, D. et al. (2010). Ledderhose Disease: An Unusual Presentation. The journal of Clinical and Aesthetic Dermatology, 3. Level of evidence: 3B</ref> <ref name="6" />
Ledderhose’s disease is listed as a “rare disease” by the Office of Rare Diseas-es (ORD) of the National Institutes of Health (NIH), which means that it affects less than 200,000 people in the United State’s population. <ref name="2" />
Plantar Fibromatosis occurs less frequently than the palmar disease, with a prevalence of 0.23% and usually more frequently in middle aged male individuals (30 – 50 years). So men are affected twice as often as females and incidence increases with advancing age. Bilateral involvement is seen in 25% of patients.<ref name="5">Walker, E.A., Petscavage, J.M., Brian, P.L., Logie, C.I., Montini, K.M., Murphey, M.D. (2012). Imaging features of superficial and deep fibromatoses in the adult population. Sarcoma. Level of evidence: 2A</ref> <ref name="10" />
Due to the lack of information about the formation of this condition, the etiology is still controversial. But the plantar disease seems to have a multifactorial etiology, for example diabetis mellitus, genetic and traumatic causes (like a puncture wound or a micro-tear), family history and cancer incidence. <ref name="5" /> <ref name="10" /> <ref name="12">Pack, G.T. and Ariel, I.M. (1964). Treatment of cancer and allied diseases Volume VIII: Tumors of the soft somatic tissues and bone / by thirty-nine authors. P.B. Hoeber. Level of evidence: 4</ref><br> <br>Patients with the [http://www.physio-pedia.com/Dupuytren%E2%80%99s_Contracture contracture of Dupuytren], [http://www.physio-pedia.com/Diabetes diabetes mellitus], epilepsy, alcoholics with liver disease, stressfull work and keloids have more risk to develop the disease of Ledderhose and/or the disease of Peyronie's. <ref name="5" /> <ref name="6" /> <ref name="9" /> <ref name="10" /><br>
== Characteristics/Clinical Presentation  ==
There will be a visible bulge, a soft- tissue mass composed of one or more subcutaneous nodules, on the medial (60%) or central (40%) plantar area of the foot same as a reduced capacity of bending the foot. The nodules may be multiple in 33% of cases and are typically slow growing. <ref name="2" /> <ref name="4" /> <ref name="7">Van der Veer, W.M., Hamburg, S.M., de Gast, A., and Niessen, F.B. (2008). Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. Level of evidence: 2A</ref> <ref name="8">Beckmann, J., Kalteis, T., Baer, W., Grifka J., and Lerch, K. (2004). Plantar fibromatosis: therapy by total plantarfasciectomy. Zentralbl Chir. Level of evidence: 4</ref> <ref name="10" /><br>
Not all of the patients do have symptomatic complains. Complains such as pain can occur after standing or walking for a long time, or when those nodules happen to grow and stiffen the affected structures of the foot (due to a lack of space) such as neurovascular bundles, muscles or tendons. Nevertheless this disease typically do not cause symptoms such as contractures and patients do frequently have normal radiographs.<ref name="5" /> <ref name="10" />
Plantar fibromatosis is thought to have three phases:
1) Proliferative phase: with nodular fibroblastic proliferation<br>2) Active phase: with collagen synthesis and deposition<br>3) Mature phase: with reduced fibroblastic activity and collagen maturation <ref name="9" /><br>
<br>
[[Image:Subcutaneous nodules.png]]
'''Figure 2''': Subcutaneous nodules on the lateral aspect of the right foot and medial aspect of left foot and retraction. <ref name="2" /><br>
== Differential Diagnosis  ==
Ledderhose’s disease is sometimes associated with other forms of fibromatosis, such as:<br>• [http://www.physio-pedia.com/Dupuytren%E2%80%99s_Contracture Dupuytren’s disease]<br>• Peyronie's disease<br>• knuckle pads <ref name="2" />
Some others main differential diagnoses are: <br>• [http://www.physio-pedia.com/Plantarfasciitis plantar fasciitis ]<br>• chronic rupture of the plantar fascia <ref name="9" /> <br>
== Diagnostic Procedures<br>  ==
<br>The identification of characteristics of plantar fibromatosis on imaging can give several important information for the clinical diagnosis.<br>
Cross sectional imaging ([http://www.physio-pedia.com/Ultrasound_Scans ultrasonography], compute tomography, [http://www.physio-pedia.com/MRI_Scans MRI]) reveals the lesions location, extension and involvement of neighboring structures.<br>
Evaluation is therefor most commonly performed with ultrasound and MRI. Sonographic imaging demonstrates a well-defined (64%) or poorly defined (36%) fusiform mass in the soft tissues adjacent to the plantar aponeurosis. <br>


Plantar fibroma may be heterogeneous and hypoechoic (76%) or isoechoic (24%) relative to the plantar fascia . Posterior acoustic enhancement (20%), cystic components, and intratumoral hypervascularity (8%) have also been described. <ref name="5" /> <ref name="9" /> <ref name="10" /> <ref name="11">Robbin M.R., Murphey M.D., Temple H.T., Kransdorf M.J., Choi J.J. (2001). Imaging of Musculoskeletal Fibromatosis. RadioGraphics, the journal of continuing medical education in radiology. Level of evidence: 1B</ref><br>  
== Introduction ==
[[File:Plantar fibromatosis foot.jpeg|thumb|Plantar fibromatosis R plantar region marked for radiotherapy ]]
Plantar fibromatosis is a benign fibroblastic, connective tissue proliferative disorder of the superficial plantar aponeurosis of the foot, more specifically on the medial plantar side of the foot arch and on the forefoot region. It belongs to a family of similar diseases ie Peyronie (penile fibromatosis) and [[Dupuytren’s Contracture|Dupuytren]].<ref name=":9">Meyers AL, Marquart MJ. Plantar fibromatosis. InStatPearls [Internet] 2020 Jun 30. StatPearls Publishing. </ref>


[[Image:Doppler image.png]]  
* Presentation is slow, and patients usually only present when the disease becomes locally aggressive, causing pain and swelling in the medial non-weight bearing plantar surface of the feet.<ref name=":9" />
* Phases: Proliferative phase: Nodular fibroblastic proliferation; Active phase:  Collagen synthesis and deposition; Mature phase: Reduced fibroblastic activity and collagen maturation.<ref name=":2">Griffith JF, Wong TY, Wong SM, Wong MW, Metreweli C. [https://pdfs.semanticscholar.org/0f8a/fd5ccf99154ac5097d1fc4f60516dda1b017.pdf Sonography of plantar fibromatosis.] American Journal of Roentgenology 2002;179(5):1167-72.</ref>


'''Figure 3''': A 54-year-old male who presents with left foot pain for one year. A longitudinal ultrasound color Doppler image demonstrates a soft tissue mass with heterogeneous echotexture and internal color Doppler flow (arrow). <ref name="5" />  
== Etiology ==
The exact etiology leading to plantar fibromatosis is unknown. It seems to have a multifactorial etiology, including congenital and traumatic causes as well as prolonged immobilization followed by trauma.<ref name=":9" /><ref name=":0">Murphey MD, Ruble CM, Tyszko SM, Zbojniewicz AM, Potter BK, Miettinen M. [https://pubs.rsna.org/doi/full/10.1148/rg.297095138 Musculoskeletal fibromatoses: radiologic-pathologic correlation.] Radiographics 2009;29(7):2143-83.</ref><ref>Hoeber PB. Tumors of the soft somatic tissues and bone. In: Pack GT, Ariel IM. Treatment of cancer and allied diseases. Volume VIII, 1964. p. 8-14.</ref> Patients with the [http://www.physio-pedia.com/Dupuytren%E2%80%99s_Contracture Dupuytren's contractures], [[Diabetes|diabetes mellitus]], [[epilepsy]], alcoholics with [[Liver Disease|liver disease]], stressfull work and keloids, stressfull work have a higher risk to develop the disease of Ledderhose and/or a Peyronie's disease.<ref name=":0" /><ref name=":1">Knobloch K, Vogt PM. [https://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-5-542 High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose’s disease).] BMC research notes 2012;5(1):542.</ref>


<br>  
== Epidemiology ==
Plantar fibromatosis is rare, affecting less than 200,000 people in the United States. It typically presents in middle-aged patients, most commonly in the 4th and 5th decades of life. <ref name=":9" /> It can be seen in both children and adults, although there is a recognized male predilection (M: F of 2:1), with an increased incidence with advancing age.<ref name=":3" /><ref name=":4" />
== Characteristics/Clinical presentation&nbsp; ==
[[File:Plantar fibromatosis.JPG|thumb|alt=|Plantar fibromatosis]]Nodules or masses of plantar fibromatosis are usually located in the middle to the medial aspect of the plantar arch, possibly extending to involve the skin or deep structures of the foot. Lesions may be symptomatic because of a mass effect or invasion of adjacent muscles or neurovascular structures. In contrast to Dupuytren disease, flexion deformities usually do not occur and patients frequently have normal radiographs. <ref name=":0" /><ref name=":3">Radiopedia Plantar fibromatosis Available:https://radiopaedia.org/articles/plantar-fibromatosis (accessed 16.5.2022)</ref>


[[Image:T1 weighted.png]]
Patients commonly present symptoms after experiencing increased pain in the plantar surface of the foot after long walks. Specific activities, eg long walks, standing for long periods, specific shoe wear, and walking barefoot, can exacerbate the symptoms. The diagnosis is made clinically by evaluating the plantar surface of the foot for fibromas.  


'''Figure 4:''' Sagittal T1-weighted fat saturation postcontrast sequence demonstrates a fusiform, enhancing lesion with linear extension along the plantar aponeurosis (arrow). <ref name="5" />  
The foot should be examined for tenderness over bony prominences and tendon insertions. Hindfoot alignment, as well as the presence of an Achilles or gastrocnemius contracture, should be evaluated as these can contribute to symptoms.<ref name=":9" />


<br>
==Differential Diagnosis==
Plantar Fibromatosis is sometimes associated with other diseases such as:


[[Image:T1 weighted 2.png]]  
• [http://www.physio-pedia.com/Dupuytren%E2%80%99s_Contracture Dupuytren’s disease]


'''Figure 5''': Short axis T1-weighted sequence reveals lesion signal intensity similar to skeletal muscle. There is heterogeneity with several foci of low signal (curved arrows) within the lesion. <ref name="5" />
• Peyronie's disease


<br>  
• Knuckle pads <ref>Fausto de Souza, D. et al. (2010). Ledderhose Disease: An Unusual Presentation. The journal of Clinical and Aesthetic Dermatology, 3. Level of evidence: 3B</ref>


[[Image:T1 weighted 3.png]]
Some others main differential diagnoses include: <ref>Young JR, Sternbach S, Willinger M, Hutchinson ID, Rosenbaum AJ. The etiology, evaluation, and management of plantar fibromatosis. Orthopedic Research and Reviews. 2019;11:1.</ref>


'''Figure 6''': T1- weighted postcontrast fat saturation sequence demonstrate marked heterogeneous enhancement (arrow).<ref name="5" />
* [[Epilepsy]]
* [[Diabetes]]
* [[Alcoholism|Alcohol Addiction]]
* [[Plantar Fasciitis]]


== Medical Management  ==
• Chronic rupture of the plantar fascia


{| cellspacing="1" cellpadding="1" border="0" align="right" width="40%" class="FCK__ShowTableBorders" |- | align="right" | | {{#ev:youtube|we8NXXYfCgk|250}} <ref>Nagler Foot Center. Plantar Fibromatosis - Dr. Sherman Nagler. Available from: http://www.youtube.com/watch?v=we8NXXYfCgk [last accessed 11/01/17]</ref> |}
== Diagnostic procedures ==
[[File:Plantar fibromatosis surgery.JPG|thumb|alt=|Plantar fibromatosis surgery]]Lesions, extension, characteristics, structures involved and local recurrence can be identified on the following scans:<ref name=":0" /><ref name=":2" />
* [[Ultrasound Scans|Ultrasound]]
* [[MRI Scans|MRI]]: Well-defined nodule tcontinuous with the plantar fascia; Low signal intensity on T1-weighted sequences; Low to intermediate signal intensity on T2-weighted sequences.
* [[CT Scans|CT scan]]: Used for tissue comparison; identify tissue mass (non-specific) in characteristic area; attenuation equal or higher than in skeletal muscles.


Even though a recovery with a non-invasive treatment is possible, certain severity of the lesion will demand a different approach. Therefore surgical treatment is indicated in cases of persistent pain or if large, infiltrative lesions cause significant disability and that are refractory to non-operative management or if conservative measures fail. The standard procedure and the most functional surgery nowadays includes a partial fasciectomy of the plantar aponeurosis in order to release the tension. After partial resection, there is a high recurrence rate with an increased risk of complications and more aggressive ingrowth into anatomical structures. Some authors recommend a complete fasciectomy as the primary procedure of choice. Postoperative radiotherapy can be used to diminish the chance of recurrence. <ref name="2" /> <ref name="6" /> <ref name="7" /> <ref name="8" /> <ref name="10" /> <ref name="11" /> <ref name="16">Seegenschmiedt MH, Attassi M,. (2003), Radiation therapy for Morbus Ledderhose – Indication and clinical results. Essen, Germany. Level of evidence 2B</ref><br>


Also medical treatment can consist of non steroidal anti-rheumatic drugs or local cortisone-injections. <ref name="3">Thomas G.MCP., Robroy L.M., Mark W.C., Dane K.W., James J.R., Joseph J.G., (2008) , Heel Pain – Plantar Fasciitis : Clinical Practice Guidelines Linked to the International Classification of Function, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association, J Orthop Sports Phys Therp. Level of evidence : 2</ref>
==Physiotherapy management==
Conservative measures are initiated first which include physiotherapy. In patients presenting with no or mild pain can be managed very well conservatively in the form of padded shoes with soft insole or tailored insoles which will redistribute the weight from the prominent nodules.


During the first phase (1-3rd day) the foot of the patient will be placed in a position to function. Mainly this phase will consist of: prevent post-operative oedema by raising the foot, ask the patient to mobilize the toes. If none postoperative immobilization is provided: an active mobilization will be required from the first days. <br>
The treatment of a mild case of Ledderhose disease consists of:<ref name=":4">Walker EA, Petscavage JM, Brian PL, Logie CI, Montini KM, Murphey MD. Imaging features of superficial and deep fibromatoses in the adult population. Sarcoma 2012.</ref><ref name=":7">Xhardez Y. Vade-mecum de kinésithérapie et de rééducation fonctionnelle (5e édition). Prodim: Paris, 2002.</ref>
* Massage using cortisone cream
* Gentle passive stretching of the retracted structures
* Isometric exercises of the toe extensors
* Symptom relief in the form of padded shoes with soft insole or tailored insoles which will redistribute the weight from the prominent nodules.
* Extra Corporeal Shock Wave Therapy (ESWT). Originally stems from its effective use as a treatment in Peyronie. The original protocol for shock wave therapy was described using 2000 pulses at a frequency of 3 Hz at 7-day intervals for 2 weeks. This study found a softening of nodes in the patients who chose to undergo this treatment option.  
'''Post Surgical Intervention:''' After surgical intervention: non-weight bearing for 3 weeks until the incision heals. After healing has occurred, full weight-bearing is allowed. Rehabilitate foot as assessment dictates.


Prefabricated or custom foot orthoses can be used to provide short-term (3 months) reduction in pain and improvement in function. There appear to be no differences in the amount of pain reduction or improved function created by custom foot orthoses in comparison to prefabricated orthoses. There is currently no evidence to support the use of prefabricated or custom foot orthoses for long-term (1 year) pain management or function improvement. <ref name="3">Thomas G.MCP., Robroy L.M., Mark W.C., Dane K.W., James J.R., Joseph J.G., (2008) , Heel Pain – Plantar Fasciitis : Clinical Practice Guidelines Linked to the International Classification of Function, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association, J Orthop Sports Phys Therp. Level of evidence : 2</ref> <ref name="2" /> <ref name="6" /><ref name="7" /> <ref name="8" />
The wound healing phase (8-15th day) will consist of: mobilization of the free articulations, circulatory and scar tissue massage (although there is only weak evidence for massage in scar management), lymphatic drainage, pneumatic/air pressure therapy, recovery of the joint capsulas, cartilage and muscles of the toes (slow and painless passive mobilization, active mobilization, work on the posture extension), ionization, lasers, ultrasound if there is a bad wound healing.  


== Physical Therapy Management  ==
Calf muscle and/or plantar fascia-specific stretching can be applied to provide short-term (2-4 months) pain relief and improvement in calf muscle flexibility. The dosage for this stretching can be either 3 times a day or 2 times a day utilizing either a sustained (3 minutes) or intermittent (20 seconds) stretching time, as neither dosage produced a better effect.<ref name=":5">Eugene G. McNally, Shilpa Shetty. (2010). Plantar Fascia: Imaging Diagnosis and Guided Treatment. Department of Radiology, Nuffield Orthopaedic Centre, Oxford, Oxfordshire, United Kingdom. Level of evidence 1B</ref><ref>Haedicke, G.J., Sturim, H.S. (1989). Plantar fibromatosis: an isolated disease. Plast Reconstr Surg.</ref>


Treatment of plantar fibromatosis is conservative in the majority of patients and consists of stretching, physiotherapy, footwear modifications, pads, or orthotics aimed at relieving symptoms. <ref name="2" /> <ref name="8" /> <ref name="10" /><br>
The phase after the wound healing will consist of: circulation and scar massage, bath of hot water or paraffin with active movements, total recovery of the articular amplitudes (by using analytic and global active-passive exercises and postural extension if needed with a dynamic brace), recovery of the muscle force (manually and later on with growing mechano-therapy appliances).


Shockwave therapy seems also to have an effective effect on plantar fibromatosis, by reducing the pain and soften the nodules. <ref name="6" /> <ref name="15">Knobloch K., Vogt PM., (2012), High-energy focused extracorporal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose’s disease). Hannover Medical School, Germany. Level of evidence 2B</ref><br>  
There is minimal evidence to support the use of manual therapy to provide short-term (1 to 3 months) pain relief and improved function. Suggested manual therapy procedures include anterior and posterior glides of tarsometatarsal, metatarsalphalangeal and interphalangeal joints. <ref name=":5" />


The wound healing phase; 8-15th day, will consist of: mobilization of the free articulations, circulatory and scar tissue massage (although there is only weak evidence for massage in scar management), lymphatic drainage, pneumatic/air pressure therapy, recovery of the joint capsulas, cartilage and muscles of the toes (slow and painless passive mobilization, active mobilization, work on the posture extension), ionization, lasers, US if there is a bad wound healing. <br>


Calf muscle and/or plantar fascia-specific stretching can be applied to provide short-term (2-4 months) pain relief and improvement in calf muscle flexibility. The dosage for this stretching can be either 3 times a day or 2 times a day utilizing either a sustained (3 minutes) or intermittent (20 seconds) stretching time, as neither dosage produced a better effect. <ref name="3" /> <ref name="14">Shin TM, Bordeaux JS.(2012). The role of massage in scar management: a literature revision. Department of Dermatology, Cleveland, Ohio, USA. Level of evidence 1A</ref>  
{{#ev:youtube|pjoLXaeD4E0|380}} <ref> Donald Pelto. Plantar Fibroma . Available from: http://www.youtube.com/watch?v=pjoLXaeD4E0 [last accessed 11/01/17]</ref>


The phase after the wound healing, will consist of: a circulation and scar massage, bath of hot water or paraffine with active movements, total recovery of the articular amplitudes (by using analytic and global active-passive exercises and postural extension if needed with a dynamic brace), recovery of the muscle force (manually and later on with growing mechano-therapy appliances).<br>


There is minimal evidence to support the use of manual therapy to provide short-term (1 to 3 months) pain relief and improved function. Suggested manual therapy procedures include anterior and posterior glides of tarsometatarsal, metatarsalphalangeal and interphalangeal joints.<ref name="3" /><br>  
This video explains the different causes of Plantar fibromatosis such as injury, trauma and other unsure causes. It also explains that PF is usually diagnosed by examination and by taking an MRI. The different treatment used are cortisone injections, use of orthotics, Physiotherapy Management and Surgery as last option although it has a high risk of recurrence.<be>


== References<br> ==
== References  ==


<references /><br>  
<references />


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Latest revision as of 22:44, 27 June 2023

Original Editor - Anja Vanroelen

Top Contributors - Anja Vanroelen, Laura Ritchie, Kirenga Bamurange Liliane, Kim Jackson, Lucinda hampton, Admin, Evan Thomas, WikiSysop and 127.0.0.1

Introduction[edit | edit source]

Plantar fibromatosis R plantar region marked for radiotherapy

Plantar fibromatosis is a benign fibroblastic, connective tissue proliferative disorder of the superficial plantar aponeurosis of the foot, more specifically on the medial plantar side of the foot arch and on the forefoot region. It belongs to a family of similar diseases ie Peyronie (penile fibromatosis) and Dupuytren.[1]

  • Presentation is slow, and patients usually only present when the disease becomes locally aggressive, causing pain and swelling in the medial non-weight bearing plantar surface of the feet.[1]
  • Phases: Proliferative phase: Nodular fibroblastic proliferation; Active phase:  Collagen synthesis and deposition; Mature phase: Reduced fibroblastic activity and collagen maturation.[2]

Etiology[edit | edit source]

The exact etiology leading to plantar fibromatosis is unknown. It seems to have a multifactorial etiology, including congenital and traumatic causes as well as prolonged immobilization followed by trauma.[1][3][4] Patients with the Dupuytren's contractures, diabetes mellitus, epilepsy, alcoholics with liver disease, stressfull work and keloids, stressfull work have a higher risk to develop the disease of Ledderhose and/or a Peyronie's disease.[3][5]

Epidemiology[edit | edit source]

Plantar fibromatosis is rare, affecting less than 200,000 people in the United States. It typically presents in middle-aged patients, most commonly in the 4th and 5th decades of life. [1] It can be seen in both children and adults, although there is a recognized male predilection (M: F of 2:1), with an increased incidence with advancing age.[6][7]

Characteristics/Clinical presentation [edit | edit source]

Plantar fibromatosis

Nodules or masses of plantar fibromatosis are usually located in the middle to the medial aspect of the plantar arch, possibly extending to involve the skin or deep structures of the foot. Lesions may be symptomatic because of a mass effect or invasion of adjacent muscles or neurovascular structures. In contrast to Dupuytren disease, flexion deformities usually do not occur and patients frequently have normal radiographs. [3][6]

Patients commonly present symptoms after experiencing increased pain in the plantar surface of the foot after long walks. Specific activities, eg long walks, standing for long periods, specific shoe wear, and walking barefoot, can exacerbate the symptoms. The diagnosis is made clinically by evaluating the plantar surface of the foot for fibromas.

The foot should be examined for tenderness over bony prominences and tendon insertions. Hindfoot alignment, as well as the presence of an Achilles or gastrocnemius contracture, should be evaluated as these can contribute to symptoms.[1]

Differential Diagnosis[edit | edit source]

Plantar Fibromatosis is sometimes associated with other diseases such as:

• Dupuytren’s disease

• Peyronie's disease

• Knuckle pads [8]

Some others main differential diagnoses include: [9]

• Chronic rupture of the plantar fascia

Diagnostic procedures[edit | edit source]

Plantar fibromatosis surgery

Lesions, extension, characteristics, structures involved and local recurrence can be identified on the following scans:[3][2]

  • Ultrasound
  • MRI: Well-defined nodule tcontinuous with the plantar fascia; Low signal intensity on T1-weighted sequences; Low to intermediate signal intensity on T2-weighted sequences.
  • CT scan: Used for tissue comparison; identify tissue mass (non-specific) in characteristic area; attenuation equal or higher than in skeletal muscles.


Physiotherapy management[edit | edit source]

Conservative measures are initiated first which include physiotherapy. In patients presenting with no or mild pain can be managed very well conservatively in the form of padded shoes with soft insole or tailored insoles which will redistribute the weight from the prominent nodules.

The treatment of a mild case of Ledderhose disease consists of:[7][10]

  • Massage using cortisone cream
  • Gentle passive stretching of the retracted structures
  • Isometric exercises of the toe extensors
  • Symptom relief in the form of padded shoes with soft insole or tailored insoles which will redistribute the weight from the prominent nodules.
  • Extra Corporeal Shock Wave Therapy (ESWT). Originally stems from its effective use as a treatment in Peyronie. The original protocol for shock wave therapy was described using 2000 pulses at a frequency of 3 Hz at 7-day intervals for 2 weeks. This study found a softening of nodes in the patients who chose to undergo this treatment option.

Post Surgical Intervention: After surgical intervention: non-weight bearing for 3 weeks until the incision heals. After healing has occurred, full weight-bearing is allowed. Rehabilitate foot as assessment dictates.

The wound healing phase (8-15th day) will consist of: mobilization of the free articulations, circulatory and scar tissue massage (although there is only weak evidence for massage in scar management), lymphatic drainage, pneumatic/air pressure therapy, recovery of the joint capsulas, cartilage and muscles of the toes (slow and painless passive mobilization, active mobilization, work on the posture extension), ionization, lasers, ultrasound if there is a bad wound healing.

Calf muscle and/or plantar fascia-specific stretching can be applied to provide short-term (2-4 months) pain relief and improvement in calf muscle flexibility. The dosage for this stretching can be either 3 times a day or 2 times a day utilizing either a sustained (3 minutes) or intermittent (20 seconds) stretching time, as neither dosage produced a better effect.[11][12]

The phase after the wound healing will consist of: circulation and scar massage, bath of hot water or paraffin with active movements, total recovery of the articular amplitudes (by using analytic and global active-passive exercises and postural extension if needed with a dynamic brace), recovery of the muscle force (manually and later on with growing mechano-therapy appliances).

There is minimal evidence to support the use of manual therapy to provide short-term (1 to 3 months) pain relief and improved function. Suggested manual therapy procedures include anterior and posterior glides of tarsometatarsal, metatarsalphalangeal and interphalangeal joints. [11]


[13]


This video explains the different causes of Plantar fibromatosis such as injury, trauma and other unsure causes. It also explains that PF is usually diagnosed by examination and by taking an MRI. The different treatment used are cortisone injections, use of orthotics, Physiotherapy Management and Surgery as last option although it has a high risk of recurrence.<be>

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Meyers AL, Marquart MJ. Plantar fibromatosis. InStatPearls [Internet] 2020 Jun 30. StatPearls Publishing.
  2. ↑ 2.0 2.1 Griffith JF, Wong TY, Wong SM, Wong MW, Metreweli C. Sonography of plantar fibromatosis. American Journal of Roentgenology 2002;179(5):1167-72.
  3. ↑ 3.0 3.1 3.2 3.3 Murphey MD, Ruble CM, Tyszko SM, Zbojniewicz AM, Potter BK, Miettinen M. Musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics 2009;29(7):2143-83.
  4. ↑ Hoeber PB. Tumors of the soft somatic tissues and bone. In: Pack GT, Ariel IM. Treatment of cancer and allied diseases. Volume VIII, 1964. p. 8-14.
  5. ↑ Knobloch K, Vogt PM. High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose’s disease). BMC research notes 2012;5(1):542.
  6. ↑ 6.0 6.1 Radiopedia Plantar fibromatosis Available:https://radiopaedia.org/articles/plantar-fibromatosis (accessed 16.5.2022)
  7. ↑ 7.0 7.1 Walker EA, Petscavage JM, Brian PL, Logie CI, Montini KM, Murphey MD. Imaging features of superficial and deep fibromatoses in the adult population. Sarcoma 2012.
  8. ↑ Fausto de Souza, D. et al. (2010). Ledderhose Disease: An Unusual Presentation. The journal of Clinical and Aesthetic Dermatology, 3. Level of evidence: 3B
  9. ↑ Young JR, Sternbach S, Willinger M, Hutchinson ID, Rosenbaum AJ. The etiology, evaluation, and management of plantar fibromatosis. Orthopedic Research and Reviews. 2019;11:1.
  10. ↑ Xhardez Y. Vade-mecum de kinésithérapie et de rééducation fonctionnelle (5e édition). Prodim: Paris, 2002.
  11. ↑ 11.0 11.1 Eugene G. McNally, Shilpa Shetty. (2010). Plantar Fascia: Imaging Diagnosis and Guided Treatment. Department of Radiology, Nuffield Orthopaedic Centre, Oxford, Oxfordshire, United Kingdom. Level of evidence 1B
  12. ↑ Haedicke, G.J., Sturim, H.S. (1989). Plantar fibromatosis: an isolated disease. Plast Reconstr Surg.
  13. ↑ Donald Pelto. Plantar Fibroma . Available from: http://www.youtube.com/watch?v=pjoLXaeD4E0 [last accessed 11/01/17]


 

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