Ledderhose’s disease, Morbus Ledderhose, plantar aponeurosis, plantar fascial fibromatosis.
What is Plantar Fibromatosis?
Also known as Ledderhose’s disease for the German surgeon, Dr. Georg Ledderhose, who first described the condition in 1894, plantar fibromatosis/fibroma (PF) is a benign thickening of the deep connective tissue in the arch of the foot (called the “plantar fascia”).
This is a fibrotic tissue disorder, but non-cancerous. It normally starts as nodules or cords growing along the foot tendons and can be painful. Then, the fibrous knots can thicken, stiffening and bending the toes to make walking an unpleasant, problematic prospect. A similar affliction, Dupuytren’s disease, affects the hand and causes bent hand or fingers.
The excess collagen or fibrotic tissue (referred to as “fibroma”) can collect as a single mass or in clusters, developing in one or both feet and, unlike the related Peyronie’s disease, usually will not go away or get smaller without treatment. Hard in texture, these non-malignant tumors are oftentimes painless until aggravated or enlarged by activities like walking and running, as the fibers of the fascia become further herniated.
Plantar fibromatosis differed from plantar fasciitis in that the former is cyst(s) in the plantar fascia bands, whereas the latter is the chronic swelling and thickening of the plantar fascia.
What Causes Plantar Fibromatosis?
While no definitive conclusion exists to explain their origin, damage to the tendon is a common reason for their occurrence, and therefore believed to be a primary culprit. Such trauma may be from a puncture through the sole of the foot or from repetitive impact of activities such as running or climbing. In addition, the thickening and tightening of the plantar fascia from plantar fasciitis may lead to tears in the tissue from which plantar fibromatosis then surface.
It may be genetic as well, since PF patients also tend to have a parent or a close relative with the condition. Those with a family history of fibrotic tissue disorders are thought to be genetically predisposed to this disease. The condition is associated with Dupuytren’s disease too, as 5% of the patients with Dupuytren’s have plantar fibromatosis, and historical and ultrastructural evidence support the theory that both afflictions share a common pathological root.
Medications often used for treating high blood pressure in the drug class known as beta adrenergic blocking agents (or beta-blockers) and the drug Dilantin have been reported to cause fibrotic tissue disorders. Anti-seizure medications (such as phenytoin) are suspected to promote the production of excess collagen that can lead to plantar fibromatosis.
Although not conclusively proven, alcoholism, smoking, liver diseases, and thyroid problems may contribute to the cause.
Lastly, some speculations hold that PF could be an aggressive healing response to small tears in the plantar fascia, almost as though the fascia was trying to over-repair itself.
Who Gets Plantar Fibromatosis?
While the condition can strike people of all ages, according to studies it is diagnosed most often in the middle-aged and elderly population, possibly as high as 25% of all folks in that demographic, and men are approximately 10 times more at risk than women. It also follows that juvenile aponeurotic fibroma is more common in boys than in girls. Caucasians of northern European descents tend to fall victim to this and other fibrotic diseases more often than other ethnicities, while Asians are rarely affected.
Patients of chronic liver disease, diabetes, epilepsy and other seizure disorders have a higher rate of contracting the condition as well. In 10% of the cases, those with plantar fibromatosis also demonstrated Dupuytren’s Contracture — similar lumps in the palms of their hands.
Are There Different Types of Plantar Fibromatosis?
The term plantar fibromatosis actually encompassed different conditions:
Ledderhose’s disease (LD) is the most commonly associated condition and a relatively common plantar equivalent of Dupuytren’s Contracture. Often, LD patients also have other fibrotic disorders such as knuckle pads or induratio penis plastica.
Superficial fibromatosis (SF) is uncommon and appears as one or more flat nodules of fibrous consistency and variable size, though some forms have been observed to not be overgrowth but inflammatory myofibroblastic tumors. SF targets children and young adults more so than it does older people.
Juvenile aponeurotic fibroma (JAF) and aggressive infantile fibromatosis (AIF) are considered PF when lesions are present on the sole of the foot. Like SF, JAF occurs most frequently in youths; the hard nodules grow slowly and adhere to deep structures. AIF is an exceptional condition that begins in an infant’s first year of life; it is the only PF with an invasive course, growing rapidly to pervade the tendons and muscles in the foot but fortunately does not spread to other parts of the body.
Hamartomatous plantar fibromatosis lesions are a rarity. They look like raised soft-to-firm masses, covered by pink, slightly dark, or normal-colored skin, and can become large enough to induce disability.
What are the Symptoms of Plantar Fibromatosis?
The most conspicuous signs of plantar fibromatosis are the firm nodular masses you can feel just under the skin on the bottom of the foot or on the medial border of the sole, near the highest point of the arch, and perhaps cause pain when standing, walking, or running.
These noticeable lumps can remain the same size or become larger over time, or additional fibromas may develop. They are not always painful, but when they are, it is usually because the knots are rubbing against the shoes worn or on the floor (when barefoot). The agony can stay constant or even intensify while standing or walking. At the early stages, the overlaying skin can move freely and contracture of the toes does not happen until later.
How Do You Diagnose a Plantar Fibromatosis?
To diagnose a plantar fibromatosis, the foot-and-ankle surgeon will examine the foot and press on the affected area. Occasionally this can produce pain that runs down to the toes.
MRI (magnetic resonance imaging) and sonography (diagnostic ultrasound) have traditionally been useful in detecting plantar fibromatosis. The fibroma typically appears as a poorly defined, infiltrative mass in the layer of flat, broad tendons next to the foot muscles. The images will reveal the extent and depth of the invasion, which often penetrates layers of tendons. Biopsy of the masses, however, is not recommended, since the act may cause the fibroma to enlarge.
How Do You Treat Plantar Fibroma?
Many different treatments for plantar fibromatosis have been used and can be categorized as either invasive or noninvasive. Given the high rate of recurrence from surgery, most doctors agree that a non-invasive approach should be considered first, reserving surgery and other invasive options for the most severe cases. Professional treatments include functional foot orthotics, corticosteroid injections, and surgery to remove the mass. Non-surgical treatments will help relieve the pain of PF, but they will not make the nodules disappear.
Self-Care at Home
Because in most cases the only pain found with PF is when the nodule is irritated by direct pressure from the shoe or floor, alleviation and avoidance will serve as the initial treatment. Soft inner soles on footwear and padding should cushion the cyst from agitation and lighten the contact.
Calf stretching is a common treatment method, especially when the condition is due to heavy pressure from the calf to the foot: Put your forefoot on a wedge or small block and the heel on the ground, then lean forward, stand up, straighten the knee and hold the position for 60 seconds. Repeat it for 4-6 times a day on separate occasions. Wearing night splints or a heel lift that raises the heel and consequently reduces the forces applied by the calf to the foot should also enhance the result.
Custom foot orthotics will also take the strain off of the plantar fascia ligament and sometimes shrink the nodules in size.
Topical Professional Treatments
No medical care, even professional, is thought to be completely effective against plantar fibromatosis. Early treatments have included anti-inflammatory medication, orthotics, and physical therapy.
Doctors have tried cortisone injections with triamcinolone and clobetasol ointments, a painful, invasive approach that has shown to stall the condition temporarily, but the results are largely subjective and the long-term prospect remains questionable.
Radiotherapy, on the other hand, has recorded successes on Ledderhose nodules.
Some podiatrists may suggest transdermal verapamil gel. However, it has not yet been approved by the FDA, is quite expensive, and you must apply it for several months with no guarantee of it working.
Surgical success for PF requires removing most of the plantar fascia, since a simple excision of a nodule without extracting the entire ligament usually results in recurrence. For that reason, surgery should be an option only when the condition becomes unbearably painful. In most cases, it is performed as an out-patient procedure with an incision on the bottom of the foot. The patient is expected to be non-weightbearing for about 3 weeks afterward, all the while wearing a functional foot orthotic to help compensate for the loss of the plantar fascia. This can lead to other podiatric problems in the meantime, however, as the patient copes with limited foot functions.
How to Prevent Plantar Fibromatosis
Wear comfortable footwear and maintain the proper walking posture to minimize irritation of the sole and heel, especially when you already noticed lumps and bumps on a foot.
Check with your podiatrist or doctor at the earliest opportunity, who can diagnose and confirm a plantar fibromatosis, and advice you on the proper care.
Exercise and stretch your calves to reduce the forces exerted on your feet. Regular reflexology, shiatsu and foot massage can also keep the foot tissue flexible.
Dietary problems may be a cause for excessive nodular collagen build-up, so consult a nutritionist as well.