By performing a thorough evaluation, Dr. Fihman will be able to determine which type of mass or tumor you have and provide you with an accurate diagnosis. A clinical exam, along with an x-ray or MRI is usually required to make an accurate diagnosis. Biopsies are rarely used to diagnose this type of growth. Fihman will palpate the bottom of your foot, placing pressure on any area that feels as if an abnormality is present.
If you feel any pain or discomfort, she will note the problem and ask you to return in a few weeks to again observe the situation. If the problem still exists or continues to worsen over that period of time.
An x-ray or MRI will be ordered to determine the exact location and size of the mass. If the mass appears to be calcified, it may be a more serious condition, synovial cell carcinoma. If this is the case, other measures will need to be taken immediately. Plantar fibromatosis is a more aggressive form of the condition. With fibromatosis, the mass grows much faster and larger than a fibroma. It can also involve deeper levels of muscle tissue and wrap around the nerves that go to the toes.
This can result in more widespread pain and discomfort. The masses associated with fibromatosis often grow back if they are surgically removed. In the majority of diagnosed plantar fibromas, Dr. Fihman will observe the mass to determine whether it is still growing. Orthotics that take the pressure off of the insole of the foot may be used to relieve the pressure and intense pain.
Steroid injections are sometimes used to relieve the pain and minimize any inflammation that may be present. The fibromas may begin to shrink after steroids have been used, but will return to normal size after the medication wears off.
Physical therapy is also beneficial for keeping the area flexible and maintaining mobility. The use of orthotics and physical therapy is a beneficial combination for many reasons. Signs and Symptoms The characteristic sign of a plantar fibroma is a noticeable lump in the arch that feels firm to the touch. This mass can remain the same size or get larger over time, or additional fibromas may develop. People who have a plantar fibroma may or may not have pain.
When pain does occur, it is often caused by shoes pushing against the lump in the arch, although it can also arise when walking or standing barefoot. Diagnosis To diagnose a plantar fibroma, the foot and ankle surgeon will examine the foot and press on the affected area.
Sometimes this can produce pain that extends down to the toes. An MRI or biopsy may be performed to further evaluate the lump and aid in diagnosis. A multitude of conservative treatment strategies supported by varying levels of evidence have been described mostly in small-scale trials. These therapies include steroid injections, verapamil, radiation therapy, extracorporeal shock wave therapy, tamoxifen, and collagenase. When conservative measures fail, surgical removal of fibromas and adjacent plantar fascia is often done, although recurrence is common.
This review aims to provide a broad overview of the clinical features of this disease as well as the current treatment strategies being employed in the management of this condition. Plantar fibromatosis PF , or Ledderhose disease as it is eponymously known, is a rare pathology of the plantar aponeurosis characterized by disordered fibrous tissue proliferation and the subsequent formation of nodules.
The plantar fascia is a broad fibrous aponeurosis that originates from the medial and anterior aspects of the calcaneus, divides into five digital slips at the metatarsophalangeal joints, and inserts distally into the periosteum at the base of the proximal phalanges Figure 1.
Notes: Adapted from Gramatikoff. The primary function of the plantar fascia is to maintain the longitudinal plantar arch. When an individual dorsiflexes his or her toes, the plantar fascia tightens, the distance between calcaneus and metatarsals is decreased, and the medial longitudinal arch is elevated.
This dynamic mechanism has been described as the windlass mechanism, reflecting its similarity to tightening a cable in an efficient, predictable manner.
This series of events is critical for maintenance of the gait cycle, where even minor arch collapse can cause great inefficiency in ambulation. The prevalence and etiology of PF is not currently understood. Other associated conditions include frozen shoulder, alcohol addiction, diabetes, epilepsy, smoking, repeated trauma, and long-term phenobarbital use. The characteristic nodule in PF is approximately 0. While the mass is initially painless, it becomes painful as it enlarges. Multiple fibromas may develop over time and can contribute to an exacerbation in symptoms.
Physical examination is of paramount importance in the diagnosis of plantar fascia fibromatosis. The practitioner must perform a visual assessment of the foot, which can identify swelling, skin breakdown, bruising, or deformity.
Bony prominences must be palpated along with tendinous insertions along the heel and midfoot. The differential diagnosis must include calcaneal stress fracture, tarsal tunnel syndrome, and plantar fasciitis. Although the presence of a single or multiple well-defined nodules along the plantar fascia is pathognomonic for fibromatosis, other pathology may be present concurrently. The squeeze test can identify a calcaneal stress fracture, and is performed with the examiner performing medial and lateral heel compression along the posterior tuberosity of the calcaneus.
Swelling and warmth may also be present. Tarsal tunnel is identified by the presence of pain and numbness that radiate to the plantar heel with percussion of the tibial nerve in the tarsal tunnel. Plantar fasciitis presents with tenderness over the medial aspect of the calcaneal tuberosity. The natural history of the disease has been described as three distinct phases. An active phase follows, in which nodule formation occurs. Finally, there is a residual phase marked by collagen maturation, scar formation, and tissue contracture.
Though diagnosis of PF is based on history and physical examination, imaging is useful in confirmation and, in some cases, a biopsy may be indicated to rule out malignancies. PF is easily distinguished on imaging from other lesions affecting the plantar fascia. Ultrasound and MRI are both acceptable imaging modalities to aid in the diagnosis of plantar fibromas.
On an MRI, plantar fibromas appear as focal, oval-shaped areas of disorganization embedded in the plantar fascia; however, larger, more lobulated lesions continuous with the plantar fascia are also recognized.
Oftentimes, these lobulated lesions are of low signal intensity due to their fibrous nature although signal isointense with the muscle can also be observed Figure 2. Note: The fibroma has low-to-intermediate signal relative to muscle. Reproduced with permission; Case courtesy of Radswiki, Radiopaedia. On ultrasound, characteristic presentation of PF involves multiple lesions embedded on the plantar fascia, with sharp juxtaposition between the less reflective fibroma and the much brighter plantar fascia surrounding it Figure 3.
Recent advances in spatial and contrast resolution in musculoskeletal ultrasounds have allowed physicians to better characterize plantar fibromas. This sign likely demonstrates the hyperechoic, fibrous regions of the fibroma on a background of hypoechogenic cellular matrix. Several non-surgical options exist for the symptomatic management of PF, with varying degrees of scientific evidence to support their use. Many of these modalities have been used with differing degrees of success for other hyperproliferative fibrous tissue disorders.
Given the low morbidity associated with many of these measures, it is prudent for the physician and the patient to use conservative measures prior to recommending surgery. Steroid injections are common as an initial treatment strategy in the management of PF.
The objective of the treatment is to shrink the size of the nodules or fibromas, thus decreasing the associated pain experienced with ambulation. Prior studies have shown that these results may be brief, as recurrence of the nodule to its original size has been observed within the first 3 years after treatment.
Current recommendations for intralesional steroid injections call for a total of 3—5 injections administered approximately 4—6 weeks apart at a concentration of 15—30 mg per nodule. Patients should be counseled that the use of multiple injections has been associated with an increased risk of fascial or tendon rupture. Thus, certain treatments for hyperkeratotic scars have been employed on fibromas. One recent study demonstrated that using steroid injections along with verapamil on hypertrophic scars was more effective at reducing the size of the scar than either treatment alone.
They are characterized by an infiltrative pattern of growth with repeated local recurrences and the proliferation of uniform but well differentiated spindled cells mainly myofibroblasts and a variable amount of collagen among the proliferating cells. These lesions are locally aggressive but typically lack the capacity to metastasize.
Ledderhose first described plantar fibromatosis as a non-malignant thickening of deep connective tissue or plantar fascia. It is a minor, non-painful tumor commonly referred to as Ledderhose disease. As the disease progresses, it may cause thickening of the cord and contractures of the digits, which, in turn, can cause pain. Men typically get the disease at an earlier age than women.
However, researchers have reported the occurrence of the disease in patients with repeated trauma, long-term alcohol consumption, chronic liver disease, diabetes and epilepsy. The clearest factor with the disease lies with heredity. Essential Insights On Differentiating Between Plantar Fibromas Superficial plantar fibromatosis is more common in the younger population than in the elderly population.
Although it is classified as a tumor that shows fibroblastic proliferation and overgrowth, myofibroblast proliferation is common with some forms. Cerebriform mesodermic hamartomas is a form of plantar fibromatosis that represents a kind of mesodermal nevus when one sees it on the sole of the foot.
The cause is unknown. The plaque develops on the upper or lower side of the penis in layers containing erectile tissue. It begins as a localized inflammation and can develop into a hardened scar. One may distinguish desmoid tumors from plantar fibromatosis by the different anatomical site, treatment response and more aggressive pathological characteristics.
Desmoid tumors are present in and around the large muscle of the trunk and extremities. In the foot, the desmoid tumor represents a tumor deep in the plantar arch and is not superficial as one would see with plantar fibromatosis.
Desmoid tumors are also associated with a rare condition called Gardner syndrome. According to Montgomery, et al. Juvenile aponeurotic fibroma is a rare tumor that presents in patients who are 20 years of age or younger.
The fibroma forms a hard, discrete mass on the plantar sole that is amenable to surgical excision with functional preservation. Aggressive infantile fibromatosis is a rare single or multiple nodule mass that has a rapid growth and occurs within the first year of life. Histologically, it resembles fibrosarcoma. Surgical excision is recommended with local aggression but some may regress with observation. As the disease progresses in the elderly population, plantar contracture develops in approximately 25 percent of the patient population.
The incidences of superficial plantar fibromatosis and cerebriform mesodermic hamartomas are unknown. Its clinical representation of a plantar fibromatosis is rare. Typically, the various forms of plantar fibromatosis are asymptomatic.
They present as a mass of a solitary lesion or multiple nodules within the medial and or central bands of the plantar aponeurosis. Symptomatic patients have difficulty wearing shoes and the ability to stand or ambulate because of the irregularity of the contour of the plantar arch.
Plantar fibromatosis is typically bilateral. Local infiltrates often recur with just local resection. However, performing a complete plantar fasciotomy will reduce recurrence. Superficial plantar fibromatosis may grow gradually and recur when one excises them. Both aggressive infantile fibromatosis and fibrosarcoma have an infiltrative course but only aggressive infantile fibromatosis does not metastasize.
In regard to plantar fibromatosis, one would see this in the middle-aged to elderly population. Juvenile aponeurotic fibroma is more prominent in younger males than young females.
Aggressive infantile fibromatosis and cerebriform mesodermic hamartomas are the only exceptions in that they only occur within the first year of life. Differentiating Lesions From A Histological Perspective In regard to plantar fibromatosis, the proliferation of tumor cells grows both superficial and deep from the aponeurosis. It will replace the adipose tissue.
However, it will not affect the overlying epidermal and dermal layers. Areas of the disease may be similar to fibrosarcoma in which the cellular structures are closely packed together with a dense fibrocytic component. Some areas can be scar-like and acellular.
Superficial plantar fibromatosis is commonly located in the posteromedial and plantar portion of the heel. The nodules are usually asymptomatic with round to flattened lesions with a fibrous consistency. In juvenile aponeurotic fibroma, the cellular structures are oat-shaped.
In the aggressive forms, there is an increase in mitotic activity and they are more cellular. The nodular lesions are hard, slow growing and adhere to the deep structures of the foot. Aggressive infantile fibromatosis appears within the first year of life.
The lesion is a fast growing tumor that rapidly infiltrates the subcutaneous fat, aponeurosis and muscle. Its course is similar to fibrosarcoma but metastasis does not occur. Enneking classified benign soft tissue tumors in three stages: latent, active and local aggressive growth. With stage I, the latent stage, the tumors are usually static or inactive and asymptomatic. In Stage II, the active stage, the lesions are actively growing and cause clinical symptoms.
In Stage III, the local aggressive growth stage, lesions are locally aggressive, histologically immature and show progressive growth not limited to normal boundaries. Malignancy is rare in the various forms of plantar fibromatosis. The staging of malignant tumors acts as a baseline for determining prognosis and treatment protocols.
Soft tissue sarcomas are based on a number of variables. These variables include: histological grade, tumor size, tumor depth, compartment status and the presence or absence of metastasis. Enneking staged these different components for surgical intervention.
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