Other Popular Names
- Ledderhose's disease
- Morbus Ledderhose
- Plantar Fibromatosis
Who does it affect?
Plantar fascial fibromatosis is a relatively uncommon non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules or cords start growing along tendons of the foot, the disease is minor, can be painful. Eventually, however, the cords thicken, the toes stiffen and bend, and walking becomes painful. The disease is named after Dr. Georg Ledderhose, a German surgeon, who described the condition for the first time in 1894. A similar disease is Dupuytren's disease, which affects the hand and causes bent hand or fingers.
A fibroma is a benign fibrous tissue tumor or growth, that can occur anywhere in the body, for example in the uterus they're called fibroids. On the plantar, or bottom surface of the foot, they are called plantar fibromas. Unlike plantar warts, which grow on the skin, these grow deep inside on a thick fibrous band called the plantar fascia. When non-surgical measures for treating plantar fibromas, such as orthotics have failed to provide adequate relief of symptoms, surgical removal is a reasonable option. Attempts may be made to surgically remove solitary nodules (a single lump or bump) with wide excision, however there is reported to be a high incidence of recurrence. Multiple plantar fibromas generally require more extensive excision of the entire fibrous band of plantar fascia (known as a Steindler plantar fascial stripping), inorder to insure complete removal and prevent recurrence.
As in most forms of fibromatosis, it is usually benign and its onset varies with each patient. The nodules are typically slow growing and most often found in the central and medial portions of the plantar fascia. Occasionally, the nodules may lie dormant for months to years only to begin rapid and unexpected growth. It need only be surgically removed if discomfort hinders walking.
Plantar fibromatosis is most frequently present on the medial border of the sole, near the highest point of the arch. The lump is usually painless and the only pain experienced is when the nodule rubs on the shoe or floor. The overlying skin is freely movable, and contracture of the toes does not occur in the initial stages. The typical appearance of plantar fibromatosis on Magnetic resonance imaging (MRI) is a poorly defined, infiltrative mass in the aponeurosis next to the plantar muscles.
Only 25% of patients show symptoms on both feet (bilateral involvement). The disease may also infiltrate the dermis or very rarely the flexor tendon sheath.
The histological and ultrastructural features of Ledderhose and Dupuytren's disease are the same, which supports the hypothesis that they have a common etiology and pathogenesis. As with Dupuytren's disease, the root cause(s) of Ledderhose's disease are not yet understood. It has been noted that it is an inherited disease and of variable occurrence within families, i.e. the genes necessary for it may remain dormant for a generation or more and then surface in an individual, or be present in multiple individuals in the same generation with varying degree.
There are certain identified risk factors. The disease is more commonly associated with:
- A family history of the disease
- Higher incidence in males
- Palmar fibromatosis 10-65% of the time.
- Peyronie's disease
- Epilepsy patients
- Patients of diabetes mellitus
There is also a suspected, although unproven, link between incidence and alcoholism, smoking, liver diseases, thyroid problems, and stressful work involving the feet.
Although the origin of the disease is unknown, there is speculation that it is an aggressive healing response to small tears in the plantar fascia, almost as if the fascia over-repairs itself following an injury.
In the early stages, when the nodule is single and/or smaller, it is recommended to avoid direct pressure to the nodule(s). Soft inner soles on footwear and padding may be helpful.
MRI and sonography (diagnostic ultrasound) are effective in showing the extent of the lesion, but cannot reveal the tissue composition. Even then, recognition of the imaging characteristics of plantar fibromatoses can help in the clinical diagnosis.
The surgical procedure involves a long, often curvilinear, incision on the bottom of the foot. The incision extends from the heel to the ball of the foot. The consultant will dissect through the fatty tissue layer on the bottom of the foot to expose the thick fibrous plantar fascia. The plantar fascia, which includes the multiple benign fibromas, extends from the bottom of the heel, through the arch, all the way to the ball of the foot. The fascia removal requires careful separation from deeper soft tissues structures, and small nerves. Once the fascia has been removed, the bottom of the foot is stitched closed. Often a drain is placed into the surgery site to help prevent blood and other fluids from collecting here. The surgical wound is bandaged and the patient must remain non-weight bearing on the foot (with crutches) for a minimum of three weeks. Normal post-operative care including rest, ice, elevation, and maintaining a clean surgical site would be followed. The drain is usually removed 3 to 5 days after the surgery. The stitches are removed between 2 and 3 weeks after the surgery.
Surgery of Ledderhose's disease is difficult because tendons, nerves, and muscles are located very closely to each other. Additionally, feet have to carry heavy load, and surgery might have unpleasant side effects. If surgery is performed, the biopsy is predominantly cellular and frequently misdiagnosed as fibrosarcoma. Since the diseased area (lesion) is not encapsulated, clinical margins are difficult to define. As such, portions of the diseased tissue may be left in the foot after surgery. Inadequate excision is the leading cause of recurrence.
Once the incision site is well healed, the patient may begin gentle calf muscle stretching exercises, and weight bearing with a soft soled shoe. Functional foot orthotics are generally recommended to help support the arch of the foot which has been weakened by removal of the plantar fascia. Although the patient will often resume walking about 1 month after the surgery, normal activities, including sports, will usually resume about three months after the surgery. There may be some residual tenderness in the area of the incision.
Post-surgical radiation treatment may decrease recurrence. There has also been variable success in preventing recurrence by administering gadolinium. Skin grafts have been shown to control recurrence of the disease.
In few cases shock waves also have been reported to at least reduce pain and enable walking again. Currently in the process of FDA approval is the injection of collagenase. Recently successful treatment of Ledderhose with cryosurgery (also called cryotherapy) has been reported.
Cortisone injections, such as Triamcinolone, and clobetasol ointments have been shown to stall the progression of the disease temporarily, although the results are subjective and large-scale studies far from complete. Injections of superoxide dismutase have proven to be unsuccessful in curing the disease while radiotherapy has been used successfully on Ledderhose nodules.
Some possible complications of the surgery include infection, swelling, and numbness on the bottom of the foot. The possibility of uncomfortable scarring on the bottom of the foot may also develop if the patient walks on the foot, damaging the incision, before the incision is properly healed. As previously mentioned, recurrence of the plantar fibroma is also possible, although this becomes less likely with removal of the entire plantar fascia. Other less common risks associated with this surgery should be personally reviewed with your own consultant, as individual factors may play a role.