Explore Real Clinical Cases

Explore real cases with stories and pictures

Explore Our On-Line Learning Content

Enhance your knowledge of tumors and their management

Plantar fibroma - Foot and Ankle

Summary

Plantar fibromatosis is a non-encapsulated thickening and proliferation of the central and medial bands of the plantar fascia.

Patient's present in their second third and fourth decade.
Most patients are asymptomatic, but some have activity related pain. One third to half of the patients have bilateral nodules.
The lesion appears as a poorly defined area of thickening of the planter fascia with low signal intensity on both T1 and T2 weighted sequences.
Initial management should consist of shoe modifications and pain medication.
Complete Information on this Tumor
Introduction and Definition: 

Plantar fibromatosis (also known as Ledderhose's disease) is a non-encapsulated thickening and proliferation of the central and medial bands of the plantar fascia. This lesion is histologically similar to Dupuytren's contracture. Some patients have an inherited tendency to both palmar and plantar fibromas.

Incidence and Demographics: 
Patient's present in their second third and fourth decade, but these lesions may also occur in children, even babies. In 2 large series approximately 30 to 35% of these lesions occurred in patients under 30. Men are twice as commonly affected as women. Patients with palmar fibromas (Dupuytren's) are more likely to have plantar fibromas. Epilepsy, alcohol abuse, and diabetes may also be contributing factors. Trauma and occupational injury have been identified as possible causative factors, but the evidence to support these links is of poor quality. No particular occupational group has been identified, and the most common location of the lesion is in a portion of the plantar aponeurosis that is least likely to be injured.
Symptoms and Presentation: 

Most patients are asymptomatic, but some have activity related pain. One third to half of the patients have bilateral nodules. Pain occurs with weightbearing activities. When the lesions are large enough to press on the plantar nerves, there may be numbness or dysesthesia in the distal portions of the foot. In one pediatric patient, a large lesion caused contracture of the toe flexor tendons and loss toe extension in the lesser toes.

X-Ray Appearance and Advanced Imaging Findings: 
Plain radiographs do not define this lesion well, but two high quality, orthogonal radiographs are recommended, to rule out the presence of intralesional calcifications, which are a characteristic of synovial sarcoma but not of plantar fibroma.
Laboratory Findings: 
None recommended
Differential Diagnosis: 
synovial sarcoma
Preferred Biopsy Technique for this Tumor: 
Open
Treatment Options for this Tumor: 
Initial management should consist of shoe modifications and pain medication. Surgical removal is reserved for large lesions that are causing significant disability that have failed a well-documented course of non-operative care. Because recurrence is frequent following inadequate surgical removal, practitioners who are not prepared to undertake an aggressive and comprehensive resection of the lesion should not attempt to the procedure. Aggressive resection with a wide margin, as shown in the accompanying photos, is necessary to avoid recurrence, but may associated with significant complications. Although the procedure of choice has been given a term "radical fasciectomy", radical resection margins are not achieved. The actual margin achieved is typically a marginal to wide margin, where wide margins are achieved at the fascial boundaries of the lesion, but marginal margins are achieved on the skin surface of the lesion in order so that the skin may be closed without grafting, and marginal margins are achieved at the deep surface of the lesion in order to preserve the medial and lateral neurovascular bundles.
Preferred Margin for this Tumor: 
best available - see treatment discussion -
Outcomes of Treatment and Prognosis: 
In one series, the overall recurrence rate was 60%. The recurrence rate following "total plantar fasciectomy was 25%. "Local" or conservative resection was associated with a recurrence rate of 100%. (van der Veer et al, Plast Reconstr Surg. 2008 Aug;122(2):486-91.)