Plantar Fibromatosis

1. Clinical Overview

Summary

Plantar Fibromatosis (Ledderhose Disease) is a benign, fibroproliferative disorder characterized by nodular thickening of the plantar fascia, analogous to Dupuytren's disease of the hand and Peyronie's disease of the penis. First described by Georg Ledderhose in 1894, this condition involves myofibroblastic proliferation resulting in firm, often painful masses along the medial band of the plantar aponeurosis. [1,2] Unlike simple plantar fasciitis, plantar fibromatosis is a true fibroproliferative neoplastic process with a propensity for local recurrence after surgical intervention. [3]

The hallmark of management is conservative first: surgery is fraught with extremely high recurrence rates (57-100% for simple excision), making non-operative modalities including custom orthotics, intralesional therapies, and radiotherapy the preferred initial approaches. [4,5] Surgical intervention, when necessary, requires aggressive wide or total fasciectomy to minimize recurrence, at the cost of significant morbidity including flatfoot deformity and chronic pain. [6]

Key Facts

• The Fibromatosis Spectrum: Plantar fibromatosis is part of a spectrum of superficial fibromatoses including Dupuytren's disease (palmar fascia), Peyronie's disease (tunica albuginea of penis), and knuckle pads (Garrod's pads). Patients with multifocal disease represent the "Dupuytren's Diathesis" phenotype with genetic predisposition and aggressive behavior. [7,8]
• The Anatomic Predilection: Nodules arise almost exclusively in the medial and central bands of the plantar fascia, rarely involving the lateral band. This anatomic distribution distinguishes it from traumatic fasciitis. [9]
• The Surgical Trap: Simple "shelling out" of nodules is universally condemned due to near-certain recurrence with more aggressive behavior. The recurrence phenomenon is thought to be stimulated by surgical trauma activating dormant myofibroblastic clones. [10,11]
• The Diagnostic Paradox: While histology shows hypercellular proliferation that can mimic fibrosarcoma, the clinical behavior is locally aggressive but never metastatic. Biopsy should be reserved for atypical presentations. [12]

Clinical Pearls

"Don't biopsy the obvious": In a patient with bilateral Dupuytren's contractures and classic plantar nodules, clinical diagnosis is sufficient. Biopsy can theoretically stimulate nodule growth and is unnecessary when the clinical picture is clear. [13]

"Look at the hands, penis, and ears": Always perform a full examination for associated fibromatoses. Approximately 50-65% of patients with plantar fibromatosis have concurrent Dupuytren's disease, and 5-20% have Peyronie's disease. Keloids and auricular hypertrophy may also coexist. [7,14]

"The hole in the shoe": The simplest and often most effective treatment is a custom orthotic with a relief zone ("accommodative well") cut precisely under the nodule location, transferring pressure away from the lesion during gait. This should be the first-line therapy for all symptomatic patients. [15]

"Radiotherapy is not just for cancer": Low-dose external beam radiotherapy (30 Gy in fractionated doses) has emerged as a highly effective treatment for progressive early-stage disease, with disease stabilization rates exceeding 70% and minimal long-term sequelae. [16,17]

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2. Epidemiology

Demographics

• Incidence: Rare condition with estimated prevalence of 0.2-2.0% in Western populations. True incidence is likely underestimated due to asymptomatic cases. [1,18]
• Age: Peak incidence in the 4th to 6th decade of life (30-60 years), typically presenting a decade earlier than Dupuytren's disease. Rare in children and adolescents. [2,19]
• Gender: Male predominance with M:F ratio approximately 2-4:1. Some studies suggest equal gender distribution in populations with high genetic penetrance (Nordic ancestry). [7,20]
• Ethnicity: Highest prevalence in populations of Northern European descent (particularly Scandinavian, Celtic, and Germanic ancestry - the "Viking Disease"). Rare in Asian and African populations. [8,21]
• Laterality: Bilateral involvement in 20-50% of cases. Bilateral disease correlates with presence of Dupuytren's diathesis and more aggressive clinical course. [22]

Risk Factors and Associations

Established Associations

• Dupuytren's Disease: 50-65% concurrent prevalence. Shared genetic etiology with overlapping susceptibility loci. [7,23]
• Peyronie's Disease: 5-20% concurrent prevalence. Forms part of systemic fibromatosis spectrum. [14]
• Garrod's Pads (Knuckle Pads): Fibrous thickening over dorsal PIP joints, present in 20-30% with plantar fibromatosis. [8]

Metabolic and Systemic Associations

• Diabetes Mellitus: Conflicting evidence, but several large cohort studies demonstrate 20-25% prevalence of diabetes in patients with plantar fibromatosis, compared to 8-10% in age-matched controls. Mechanism unclear, possibly related to advanced glycation end-products. [24,25]
• Epilepsy and Anticonvulsant Use: Phenytoin, barbiturates, and phenobarbital have been associated with fibromatoses. Exact mechanism unknown but may relate to altered fibroblast proliferation. [26]
• Chronic Liver Disease: Weak association reported with alcoholic cirrhosis and hepatic dysfunction. May relate to altered collagen metabolism. [27]
• Smoking: Possible risk factor though evidence is inconsistent. Nicotine may promote myofibroblast activation. [28]
• Manual Labor and Trauma: Controversial. While repetitive plantar trauma has been proposed as a trigger, no consistent epidemiologic evidence supports traumatic etiology. Most cases occur without clear precipitating injury. [2]

Genetic Factors

• Inheritance Pattern: Autosomal dominant with variable penetrance. Up to 70% of patients with aggressive bilateral disease report positive family history. [7,29]
• Candidate Genes: Multiple genome-wide association studies (GWAS) have identified susceptibility loci on chromosomes 7p, 11p, 16q, and Wnt signaling pathway genes. Specific mutations remain incompletely characterized. [30]

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3. Pathophysiology

Molecular and Cellular Mechanisms

The Myofibroblast: Central Cellular Driver

Plantar fibromatosis results from uncontrolled proliferation and activation of myofibroblasts - specialized contractile fibroblasts expressing α-smooth muscle actin (α-SMA). [31] These cells are responsible for:

• Excessive Extracellular Matrix Production: Deposition of type I and III collagen in aberrant architectural patterns
• Contractile Force Generation: Expression of contractile apparatus similar to smooth muscle
• Resistance to Apoptosis: Dysregulated cell survival signals perpetuating the proliferative phenotype

Molecular Pathways Implicated

1. TGF-β/Smad Signaling: Transforming growth factor-beta (TGF-β) is the master regulator of myofibroblast differentiation. Elevated TGF-β1 and TGF-β2 expression has been demonstrated in plantar fibromatosis tissue. TGF-β promotes:

   • Fibroblast-to-myofibroblast transition (FMT)
   • Collagen gene transcription
   • Inhibition of matrix metalloproteinases (MMPs)
   • Resistance to apoptotic signals [32,33]

2. Wnt/β-Catenin Pathway: Aberrant activation of canonical Wnt signaling has been identified in fibromatosis syndromes. Nuclear accumulation of β-catenin drives proliferation and inhibits myofibroblast senescence. [34]

3. Mechanical Tension and YAP/TAZ Signaling: Mechanotransduction through Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ) plays a critical role. Mechanical stress on the plantar fascia activates YAP/TAZ, promoting fibroblast proliferation and matrix stiffening in a feed-forward loop. [35]

4. Dysregulated Prostaglandin Metabolism: Cyclooxygenase-2 (COX-2) overexpression and elevated prostaglandin E2 (PGE2) levels have been reported, potentially contributing to the inflammatory microenvironment. [36]

Histopathologic Stages

Plantar fibromatosis progresses through three histologically distinct phases: [12,37]

Stage 1: Proliferative (Early Active) Phase

• Cellularity: Highly cellular lesion with dense proliferation of myofibroblasts
• Mitotic Activity: Moderate to high mitotic figures (can be alarming and misinterpreted as sarcoma)
• Matrix: Immature, loosely organized collagen fibers
• Vascularity: Rich capillary network
• Clinical Correlation: Rapidly growing, tender nodule; most responsive to radiotherapy

Stage 2: Active (Intermediate) Phase

• Cellularity: Moderately cellular with nodule consolidation
• Collagen Architecture: Organized fascicles of type I collagen
• Myofibroblast Markers: Strong α-SMA and vimentin immunoreactivity
• Matrix Remodeling: Balanced production and degradation
• Clinical Correlation: Established, firm nodule; variable symptomatology

Stage 3: Residual (Inactive) Phase

• Cellularity: Hypocellular, predominantly acellular collagen
• Collagen: Densely packed, hyalinized collagen bundles
• Myofibroblasts: Sparse, senescent fibroblasts
• Vascularity: Minimal
• Clinical Correlation: Stable, non-progressive "burnt out" lesion; less likely to recur post-surgery but mechanically problematic

Important Distinction: Unlike Dupuytren's disease where contracture is the major problem, plantar fibromatosis rarely causes significant contracture or toe deformity due to the biomechanical differences in the foot versus hand. The primary pathology is the mass effect and pain from the nodule itself. [3,9]

Immunohistochemistry

• Positive Markers: Vimentin (universal), α-SMA (myofibroblast marker), occasionally desmin
• Negative Markers: S100 (excludes neural tumors), CD34 (excludes solitary fibrous tumor), cytokeratin (excludes carcinoma), β-catenin nuclear staining variable (nuclear positivity may suggest desmoid-type fibromatosis overlap)
• Proliferation Index: Ki-67 typically 5-15% in active lesions [12]

Differential Diagnosis on Histology

The proliferative phase can be mistaken for:

• Fibrosarcoma: Distinguished by lack of significant cytologic atypia, absence of "herringbone" pattern, low-grade cytology
• Nodular Fasciitis: More myxoid stroma, tissue culture-like appearance, shorter clinical history
• Desmoid Tumor (Aggressive Fibromatosis): Deeper location (musculoaponeurotic), nuclear β-catenin positivity, infiltrative pattern
• Synovial Sarcoma: Biphasic pattern, high T2 signal on MRI, SS18-SSX fusion gene [38]

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4. Clinical Presentation

Symptoms

Chief Complaint

• Plantar Mass: "I can feel a lump in the arch of my foot"

• most common presenting complaint. Initially painless, discovered incidentally or during self-examination. [2]

• Plantar Pain: Develops as nodule enlarges and experiences repetitive load during gait. Pain is typically:
  • Mechanical: Worse with prolonged standing and walking
  • Pressure-related: "Like walking on a marble" or "a pebble in my shoe"
  • Activity-dependent: Absent or minimal at rest
  • Distinct from classic plantar fasciitis pain (first-step morning pain at heel insertion) [39]

Progression Pattern

• Insidious Onset: Slow growth over months to years (average 1-2 cm over 2-3 years)
• Intermittent Enlargement: Periods of growth alternating with stability
• Bilateral Sequential Involvement: Second foot may develop nodules 2-5 years after initial presentation in bilateral cases
• Rarely Regresses: Spontaneous resolution is exceptionally rare (unlike nodular fasciitis)

Functional Impact

• Gait Alteration: Antalgic gait with lateral weight transfer to avoid nodule pressure
• Footwear Difficulty: Inability to wear certain shoes (particularly flat shoes, sandals, or dress shoes without arch support)
• Activity Limitation: Avoidance of prolonged standing, walking, running; significant impact on occupational and recreational activities in advanced cases [40]

Signs

Inspection

• Visible Contour: Subtle bulge along medial longitudinal arch in thin individuals
• Skin Changes: Overlying skin is normal (no pitting, dimpling, or tethering) - this distinguishes plantar fibromatosis from Dupuytren's disease where skin involvement is characteristic
• Asymmetry: Unilateral or asymmetric bilateral involvement
• Associated Stigmata: Examine for Dupuytren's contractures, Peyronie's plaques, knuckle pads

Palpation

• Location: Medial and central bands of plantar fascia, typically at the level of the midfoot (beneath the medial longitudinal arch)
  • Proximal: Less common at calcaneal origin
  • Distal: Rare extension into forefoot
  • Lateral band: Very rare (less than 5% of cases)
• Texture: Firm to hard, rubbery consistency (unlike the soft, compressible nature of ganglion cysts or lipomas)
• Morphology:
  • Single discrete nodule (60%)
  • Multiple separate nodules in linear array (30%)
  • Confluent multinodular mass (10%)
• Size: Typically 0.5-3 cm diameter at presentation; occasionally much larger (> 5 cm) in neglected cases
• Mobility:
  • Fixed to Plantar Fascia: Moves with passive toe dorsiflexion/plantarflexion (pathognomonic sign - "fascial tether test")
  • Mobile Over Deep Structures: Not adherent to underlying flexor digitorum brevis muscle or deeper structures (unless advanced infiltrative disease)
  • Not Adherent to Skin: Skin freely mobile over nodule (vs. Dupuytren's where skin dimpling occurs)
• Tenderness: Variable; may be non-tender or exquisitely tender depending on size, location, and activity level

Special Tests

• Windlass Mechanism Test: Passive dorsiflexion of great toe tightens plantar fascia and makes nodule more prominent and palpable
• Bilateral Examination: Essential to identify contralateral subclinical disease
• Hand and Genital Examination: Check for Dupuytren's contractures (palmar pits, palpable cords, finger contractures) and Peyronie's plaques (penile induration, curvature)

Clinical Staging Systems

Sammarco and Mangone Classification (2000)

Based on symptoms and functional impairment: [41]

• Stage 1: Asymptomatic, nodule less than 1 cm
• Stage 2: Symptomatic, nodule 1-5 cm, no activity restriction
• Stage 3: Multiple nodules or confluent disease > 5 cm, significant activity restriction

Pickren's Clinical Activity Score

• Active Disease: Growth documented over 6 months, pain, tender nodule
• Inactive Disease: Stable size > 12 months, minimal or no pain, non-tender

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5. Investigations

Imaging

Plain Radiographs

• Utility: Limited; used primarily to exclude osseous pathology
• Findings:
  • Typically normal
  • Soft tissue shadow may be visible
  • Rarely, plantar calcaneal enthesopathy or spurring (coexisting plantar fasciitis)
  • Rule out calcaneal stress fracture, arthritis, or bone tumor
• Indication: Initial screening in patients with plantar pain; not diagnostic for fibromatosis

Ultrasound

• Utility: Excellent for initial detection, monitoring, and guiding intervention
• Findings: [42]
  • Echogenicity: Hypoechoic to isoechoic fusiform or nodular thickening of plantar fascia
  • Vascularity: Variable internal vascularity on Doppler (more prominent in active/proliferative phase)
  • Margins: Well-defined or infiltrative into adjacent fascia
  • Continuity: Direct continuity with plantar fascial fibers (pathognomonic)
• Advantages:
  • Real-time dynamic assessment with toe dorsiflexion
  • Inexpensive, accessible, no radiation
  • Serial monitoring of size
• Limitations:
  • Operator-dependent
  • Cannot reliably assess deep extension into muscle
  • Cannot exclude malignancy

MRI (Gold Standard)

• Sequences: T1-weighted, T2-weighted, STIR (short tau inversion recovery), T1 post-contrast (gadolinium)
• Findings: [43,44]
  • T1-weighted: Isointense to slightly hypointense relative to muscle
  • T2-weighted: Low signal intensity (dark) - this is the key diagnostic feature
    • Hypointense signal reflects dense collagen content
    • Distinguishes from most other soft tissue masses (which are typically hyperintense)
  • STIR: Low to intermediate signal
  • Post-contrast: Variable enhancement
    • Proliferative phase: Moderate to avid enhancement (reflecting hypercellularity and vascularity)
    • Residual phase: Minimal enhancement (hypocellular collagenous tissue)
  • Morphology: Fusiform or nodular thickening of plantar fascia
  • Extent: Defines involvement of medial vs. central vs. lateral bands; deep extension into flexor digitorum brevis or deeper compartments
• Diagnostic Criteria:
  • Nodular or fusiform thickening of plantar fascia
  • Low T1 and T2 signal (fibrotic tissue signature)
  • Continuity with plantar aponeurosis
  • No infiltration into bone
• Differential Diagnosis on MRI:
  • Synovial Sarcoma: High T2 signal, heterogeneous, cystic/necrotic areas, aggressive features
  • Clear Cell Sarcoma: High T2 signal, association with tendons, younger patients
  • Desmoid Tumor: Infiltrative margins, involvement of deep fascia/muscle, variable signal
  • Giant Cell Tumor of Tendon Sheath: T2 hypointense (hemosiderin), lobulated, associated with tendon sheath
  • Plantar Fibroma (Solitary): Identical imaging; distinction is clinical (unifocal vs. multifocal)
• When to Order:
  • All patients prior to surgical planning (define extent)
  • Atypical presentations (rapid growth, large size > 3 cm, age less than 30 or > 70)
  • Recurrent disease post-excision
  • Rule out malignancy when clinically suspected

Histopathologic Diagnosis

Indications for Biopsy

Biopsy is NOT routinely required for plantar fibromatosis. Consider biopsy in:

• Atypical Clinical Features:
  • Rapid growth (doubling in size over less than 6 months)
  • Large size at presentation (> 4 cm)
  • Unusual age (less than 20 years or > 70 years)
  • Solitary lesion without associated Dupuytren's disease in young patient
• Atypical Imaging:
  • High T2 signal on MRI (suggests alternative diagnosis)
  • Bone invasion or destruction
  • Cystic/necrotic components
• Recurrent Disease with Aggressive Features: Rule out sarcomatous transformation (extremely rare but reported) [45]

Biopsy Techniques

• Core Needle Biopsy: Preferred method; 14-16 gauge, multiple passes, ultrasound or MRI-guided
• Incisional Biopsy: Reserved for cases where core biopsy is non-diagnostic; small incision along medial non-weight-bearing aspect of foot
• Excisional Biopsy: NOT recommended due to high recurrence risk; only if entire lesion is small (less than 1 cm) and located peripherally

Laboratory Studies

• Not Diagnostic: No specific laboratory markers for plantar fibromatosis
• Screening for Associations:
  • Fasting glucose or HbA1c (diabetes screening)
  • Liver function tests if clinical suspicion of liver disease
• Pre-operative Labs: Standard surgical workup if intervention planned

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6. Management Algorithm

                    PLANTAR FIBROMATOSIS CONFIRMED
                    (Clinical + Imaging Diagnosis)
                              ↓
                    ┌─────────┴──────────┐
                ASYMPTOMATIC          SYMPTOMATIC
                  (Stage 1)          (Stage 2-3)
                      ↓                    ↓
                 OBSERVATION         CONSERVATIVE Rx
              (Annual monitoring)   (Offloading + PT)
                      ↓                    ↓
                   Stable?            Improved?
                      ↓                    ↓
                 Continue           YES → Continue
                                        ↓
                                       NO
                                        ↓
                               ┌────────┴────────┐
                          PROGRESSIVE        REFRACTORY
                         (Growing, less than 6mo)   (Stable, failed
                          ACTIVE PHASE      conservative)
                               ↓                 ↓
                         RADIOTHERAPY      CONSIDER SURGERY
                      (30 Gy fractionated)      ↓
                               ↓          COUNSEL RE: RECURRENCE
                          Response?             ↓
                          ↓        ↓      Patient Accepts Risk?
                       YES        NO            ↓
                         ↓         ↓          YES ↓    NO → Back to
                    MAINTENANCE  SURGERY  WIDE/TOTAL   Conservative
                                          FASCIECTOMY

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7. Management: Conservative (First-Line)

Observation (Asymptomatic Disease)

• Indication: Incidental finding, small nodule (less than 1 cm), no pain, no functional limitation
• Protocol:
  • Clinical examination every 6-12 months
  • Patient education on natural history and warning signs
  • Reassurance regarding benign nature
• Progression Rate: 20-30% remain stable indefinitely; 40-50% slowly enlarge; 20-30% become symptomatic requiring intervention [2,46]

Orthotic Management (Mainstay of Symptomatic Treatment)

• Custom Orthotics with Accommodative Well: [15,47]
  • Moldable or 3D-printed orthotic with precise relief zone
  • "Doughnut pad" or "horseshoe pad" to offload nodule
  • Metatarsal dome to transfer load anteriorly
  • Longitudinal arch support to reduce fascial tension
• Footwear Modification:
  • Rocker-bottom sole to reduce forefoot loading
  • Cushioned midsole (EVA foam)
  • Wider toe box
  • Avoid flat shoes and high heels
• Efficacy: 40-60% of patients achieve satisfactory symptom control with orthotics alone
• Limitations: Does not reduce nodule size; purely symptomatic treatment

Physical Therapy

• Stretching Protocols:
  • Gastrocnemius and soleus stretching to reduce Achilles contracture and plantar fascial tension
  • Plantar fascia-specific stretches (toe dorsiflexion with ankle dorsiflexion)
• Soft Tissue Mobilization: Gentle massage and myofascial release (avoid aggressive manipulation over nodule)
• Modalities:
  • Ice application post-activity
  • Ultrasound therapy: Avoid (theoretical risk of stimulating fibroblast activity, no proven benefit)
• Activity Modification: Avoid prolonged barefoot walking, hard surfaces, high-impact activities

Pharmacologic Approaches

Intralesional Corticosteroid Injection

• Agent: Triamcinolone acetonide 40 mg/mL
• Technique: Ultrasound-guided injection directly into nodule; 1-2 mL per nodule
• Mechanism: Local anti-inflammatory effect; may induce fibroblast apoptosis and collagen degradation
• Efficacy: Variable reports; 30-40% experience temporary pain relief (3-6 months); minimal effect on nodule size [48]
• Limitations: Multiple injections may be required; risk of plantar fat pad atrophy; local depigmentation
• Contraindications: Active infection, anticoagulation (relative)

Collagenase Injection (Experimental)

• Agent: Collagenase clostridium histolyticum (Xiapex/Xiaflex) - FDA approved for Dupuytren's and Peyronie's but not plantar fibromatosis
• Rationale: Enzymatic disruption of collagen cords
• Evidence: Limited case series; concern for plantar fascia rupture given weight-bearing nature of foot
• Status: Off-label use; not recommended outside clinical trials [49]

Topical Agents

• Verapamil Gel (15% transdermal):
  • Mechanism: Calcium channel blocker; inhibits fibroblast proliferation and collagen synthesis
  • Application: Twice daily for 6-12 months
  • Evidence: Small uncontrolled studies suggest possible benefit; larger RCTs lacking [50]
  • Efficacy: Questionable; likely placebo effect predominates
• Imiquimod Cream: Anecdotal reports; no robust evidence; not recommended

Oral Medications

• NSAIDs: Symptomatic pain relief only; no effect on disease progression
• Vitamin E, Tamoxifen, Pentoxifylline: Historical interest based on Dupuytren's literature; no proven efficacy for plantar fibromatosis; not recommended [51]

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8. Management: Radiotherapy (Second-Line for Progressive Disease)

Evidence Base

Low-dose external beam radiotherapy (EBRT) has emerged as the most effective non-surgical treatment for progressive plantar fibromatosis. [16,17,52]

Landmark Studies

• Seegenschmiedt et al. (2003): Multicenter German study; 155 patients with plantar fibromatosis treated with EBRT. Results: [16]
  • Disease stabilization: 71%
  • Symptom improvement: 61%
  • Progression-free survival: 85% at 5 years
  • Best results in early, active (proliferative) phase disease
• Heyd et al. (2010): Systematic review; radiotherapy superior to surgery for preventing recurrence in early-stage disease [5]

Indications

• Progressive disease despite conservative measures
• Active proliferative phase: Growing nodule, tender, recent onset (less than 2 years)
• Symptomatic disease unsuitable or unwilling for surgery
• Post-operative adjuvant: Prevention of recurrence after fasciectomy

Contraindications

• Absolute:
  • Pregnancy
  • Age less than 18 years (growing skeleton)
• Relative:
  • Previous radiation to foot
  • Severe peripheral vascular disease
  • Active infection
  • Long-standing inactive (residual phase) disease (lower response rate)

Treatment Protocol

• Total Dose: 30 Gy
• Fractionation: Multiple regimens used:
  • 5 Gy × 6 fractions (most common European protocol)
  • 3 Gy × 10 fractions (alternative)
  • 2 Gy × 15 fractions (traditional fractionation)
• Technique: Orthovoltage (100-120 kV) or electron beam (6-9 MeV)
• Field Design: Encompasses entire nodule with 1-2 cm margin
• Schedule: Typically 3-5 fractions per week
• Timing: Two courses separated by 6-8 weeks

Mechanism of Action

• Radiation induces fibroblast apoptosis and cell cycle arrest in proliferating myofibroblasts
• Modulates TGF-β signaling and reduces pro-fibrotic cytokine production
• Most effective in hypercellular, actively proliferating lesions (Stage 1 histology)
• Minimal effect on acellular collagen (Stage 3 histology)

Outcomes

• Disease Control: 70-85% stabilization (no growth)
• Pain Relief: 60-70% significant improvement
• Nodule Size Reduction: 20-30% (typically mild reduction; goal is stabilization, not eradication)
• Recurrence After RT: 15-30% at 5 years
• Predictors of Success:
  • Early-stage disease (less than 2 years duration)
  • Smaller nodules (less than 3 cm)
  • Active/proliferative phase (cellular on histology if available)
  • Absence of Dupuytren's diathesis

Side Effects

• Acute:
  • Mild skin erythema (20-30%)
  • Dry desquamation (5-10%)
• Late (rare with modern techniques):
  • Hyperpigmentation (5-10%)
  • Subcutaneous fibrosis (minimal; less than 5%)
  • Theoretical risk of radiation-induced malignancy (extremely rare; less than 0.1% lifetime risk with 30 Gy)
  • No reports of plantar fascia rupture or fracture

Comparison with Surgery

• Advantages:
  • Non-invasive
  • Preserves fascia integrity
  • Lower recurrence than simple excision
  • No wound healing complications
  • Minimal functional impact
• Disadvantages:
  • Does not remove nodule (remains palpable even if stable)
  • Requires specialized radiation oncology
  • Not effective for inactive/residual phase disease

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9. Management: Surgical (Third-Line for Refractory Disease)

General Principles

Surgery for plantar fibromatosis is technically demanding and has a notoriously high recurrence rate. It should be reserved for patients with intractable pain and functional disability who have failed prolonged conservative management. [4,6,11]

Indications

• Absolute:
  • Severe pain unresponsive to ≥12 months of comprehensive conservative therapy (orthotics, PT, injections) AND radiotherapy
  • Inability to ambulate or wear any footwear due to mass effect
• Relative:
  • Patient-driven request (extensive counseling mandatory)
  • Large nodule (> 5 cm) causing severe functional limitation

Pre-operative Counseling (Essential)

Must include discussion of:

• Recurrence Risk:
  • Local excision: 57-100% [4,10]
  • Wide excision: 40-60% [11]
  • Total fasciectomy: 10-25% [6]
• Recurrence Pattern: Often more aggressive, larger, and more symptomatic than primary disease
• Surgical Morbidity:
  • Flatfoot deformity (loss of arch support)
  • Chronic plantar pain (> 50%)
  • Wound healing complications (dehiscence, infection 10-20%)
  • Nerve injury (medial plantar nerve 5-10%)
  • Prolonged non-weight-bearing (6-12 weeks)
  • Extensive scar formation

Surgical Techniques

1. Local (Nodular) Excision

• Description: Enucleation or "shelling out" of palpable nodule only
• Verdict: Universally condemned [10,53]
• Recurrence Rate: 80-100%
• Mechanism of Failure: Leaves behind microscopic disease in surrounding fascia; surgical trauma stimulates myofibroblastic proliferation
• Indication: NEVER - this is a failed operation

2. Wide Local Excision

• Description: Excision of nodule with 1-2 cm margin of macroscopically normal fascia in all directions
• Technique:
  • Resection of involved central and/or medial bands
  • Preservation of lateral band
  • Margins confirmed intra-operatively
• Recurrence Rate: 40-60% [11]
• Indication:
  • Isolated, well-defined nodule
  • Patient unwilling to accept extensive dissection
  • Relative contraindication: Multifocal disease, Dupuytren's diathesis

3. Subtotal Plantar Fasciectomy

• Description: Complete excision of central and medial bands from calcaneal origin to metatarsal insertions, preserving lateral band
• Recurrence Rate: 25-40% [6]
• Indication: Multifocal disease confined to central/medial bands

4. Total (Complete) Plantar Fasciectomy (Gold Standard)

• Description: Complete excision of entire plantar aponeurosis (medial, central, AND lateral bands) from calcaneal origin to all five metatarsal/toe insertions [6,54]
• Recurrence Rate: 10-25% (lowest recurrence)
• Technique:
  • Medial utility incision or lazy-S incision
  • Identify and protect neurovascular bundles (medial and lateral plantar nerves)
  • Dissection plane: Between plantar fascia (superficial) and flexor digitorum brevis muscle (deep)
  • Complete fascia removal from calcaneus to digit bases
  • Hemostasis critical (plantar arterial arch)
  • Layered closure over suction drain
• Morbidity:
  • Flatfoot Deformity: Loss of windlass mechanism and arch support; occurs in > 50% [55]
  • Chronic Pain: Altered plantar pressure distribution; 30-50% chronic discomfort
  • Wound Complications: Dehiscence 10-15%, infection 5-10%
  • Nerve Injury: Medial plantar nerve most at risk (sensory loss to medial forefoot)
  • Prolonged Recovery: 3-6 months to full weight-bearing
• Indication:
  • Multifocal, extensive disease
  • Recurrent disease after prior limited excision
  • Dupuytren's diathesis with aggressive plantar involvement
  • Patient accepts significant functional trade-off

Surgical Approach and Technique Considerations

Incision Planning

• Medial Utility Incision: Curvilinear incision along non-weight-bearing medial aspect of foot; extensile; preferred for total fasciectomy
• Lazy-S Incision: Sinusoidal incision following relaxed skin tension lines; minimizes scar contracture
• Avoid: Longitudinal plantar incisions (painful scar, contracture, dehiscence)

Anatomic Hazards

• Medial Plantar Nerve: Runs in plane between fascia and FDB; at risk during medial band dissection
• Lateral Plantar Nerve: Lies deep to FDB; rarely injured unless deep dissection
• Plantar Arterial Arch: Deep to FDB; injury causes significant hemorrhage
• Flexor Digitorum Brevis: Immediate deep structure; preserve muscle belly

Adjuncts to Reduce Recurrence

• Post-operative Radiotherapy: Adjuvant RT (30 Gy) within 3 months of surgery may reduce recurrence; limited data [56]
• Biologic Barriers: Experimental use of dermal substitutes (e.g., acellular dermal matrix) as interpositional graft; no proven benefit
• Mitomycin C: Topical antifibrotic agent; used in some centers intra-operatively; insufficient evidence

Post-operative Management

• Immobilization: Posterior slab or CAM boot, non-weight-bearing × 2 weeks
• Wound Care: Suction drain × 24-48 hours; suture removal 3 weeks
• Weight-bearing Progression:
  • Partial weight-bearing weeks 3-6
  • Full weight-bearing by 8-12 weeks (total fasciectomy)
• Physical Therapy: Gentle ROM at 2 weeks; progressive strengthening at 6 weeks
• Orthotics: Custom molded arch support essential post-total fasciectomy to mitigate flatfoot

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10. Prognosis and Long-Term Outcomes

Natural History

• Spontaneous Regression: Extremely rare (less than 5%); disease is typically slowly progressive or stable
• Malignant Transformation: Not a recognized phenomenon; no reports of metastatic plantar fibromatosis (unlike desmoid tumors which can be lethal)
• Lifespan: Does not affect survival; purely a quality-of-life condition

Functional Outcomes

Conservative Management

• Success Rate: 40-60% achieve satisfactory symptom control with orthotics and activity modification
• Long-term Stability: Disease remains stable in 50-70% with observation or minimal intervention

Radiotherapy

• Disease Control: 70-85% stabilization at 5 years [16]
• Symptom Relief: 60-70% report significant pain improvement
• Functional Outcome: Most patients return to normal activities; minimal long-term disability

Surgical Management

• Recurrence-Free Survival:
  • Wide excision: 40-60% at 5 years
  • Total fasciectomy: 75-90% at 5 years [6]
• Patient Satisfaction:
  • Paradoxically LOW despite nodule removal
  • Chronic pain and flatfoot deformity common
  • Many patients regret surgery due to trade-off between mass and function
• Return to Activity:
  • Wide excision: 3-4 months
  • Total fasciectomy: 6-12 months; many never return to pre-morbid activity level

Recurrence Management

• After Limited Surgery: Consider total fasciectomy or radiotherapy
• After Total Fasciectomy: Re-excision rarely beneficial; focus on symptom management with bracing and orthotics
• Prevention: Adjuvant radiotherapy may be considered in high-risk cases (Dupuytren's diathesis, multifocal disease, young age)

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11. Complications and Sequelae

Disease-Related Complications

• Chronic Pain: Progressive mechanical pain from mass effect
• Gait Disturbance: Antalgic gait, compensatory biomechanical changes leading to knee/hip/back pain
• Footwear Limitation: Social and occupational impact
• Psychological Impact: Anxiety, frustration, body image concerns (particularly in bilateral disease)

Treatment-Related Complications

Radiotherapy

• Acute radiation dermatitis: 20-30%
• Chronic hyperpigmentation: 5-10%
• Theoretical malignancy risk: less than 0.1%

Surgical

• Wound Complications: Dehiscence (10-15%), infection (5-10%), hematoma (5%)
• Nerve Injury: Medial plantar nerve (5-10%); lateral plantar nerve (less than 5%)
• Vascular Injury: Rare; plantar arterial arch injury
• Flatfoot Deformity: > 50% after total fasciectomy [55]
• Chronic Plantar Pain: 30-50% post-fasciectomy
• Recurrence: See above
• Complex Regional Pain Syndrome (CRPS): Rare but devastating complication; 1-2%

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12. Special Populations

Dupuytren's Diathesis

• Definition: Bilateral Dupuytren's + plantar fibromatosis + Peyronie's; onset less than 40 years; strong family history
• Behavior: More aggressive, higher recurrence, bilateral sequential involvement
• Management Implication: Maximize conservative care; surgical recurrence approaches 100% in this population [7]

Diabetes Mellitus

• Prevalence: 20-25% of plantar fibromatosis patients have DM [24]
• Implications: Impaired wound healing; neuropathy complicates symptomatology; higher surgical risk
• Management: Optimize glycemic control pre-operatively; careful foot surveillance

Elderly Patients

• Presentation: Often inactive/residual phase disease
• Management: Conservative almost exclusively; surgery poorly tolerated
• Prognosis: Stable disease; rarely progresses in older age

Young Patients (less than 30 years)

• Rare: Plantar fibromatosis uncommon in this age group
• Differential: Consider desmoid tumor, aggressive fibromatosis, sarcoma
• Workup: MRI + biopsy often warranted
• Genetics: Strong family history; genetic counseling if part of diathesis

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13. Evidence & Guidelines

Systematic Reviews and Meta-Analyses

• Heyd et al. (2010): Radiotherapy superior to surgery for recurrence prevention in early-stage disease [5]
• Reilly et al. (2006): Review of surgical outcomes; total fasciectomy lowest recurrence but highest morbidity [4]

Consensus Recommendations

• No Published Formal Guidelines: Management based on case series, expert opinion, and extrapolation from Dupuytren's literature
• General Consensus:
  • Conservative management first-line for all patients
  • Radiotherapy for progressive, symptomatic disease (early active phase)
  • Surgery only for refractory cases; total fasciectomy if surgery pursued
  • Extensive pre-operative counseling mandatory

Key Evidence Gaps

• RCTs: No randomized trials comparing management strategies
• Optimal Radiotherapy Dosing: Fractionation regimens vary; optimal dose unknown
• Role of Biologics: No trials of collagenase or other targeted therapies
• Genetic Profiling: Candidate genes identified but clinical utility unknown
• Predictors of Recurrence: No validated risk stratification tool

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14. Patient Explanation (Layperson Summary)

What is Plantar Fibromatosis?

You have a condition called plantar fibromatosis, also known as Ledderhose disease (named after a German doctor who first described it in 1894). It's a benign (non-cancerous) condition where scar-like tissue grows as firm lumps along the bottom of your foot, specifically in the tough sheet of tissue called the plantar fascia that supports your arch.

Why Did This Happen?

We don't fully understand why this develops, but it's thought to be related to your genetics (it runs in families) combined with some environmental triggers. It's part of a family of similar conditions:

• Dupuytren's disease: Hard lumps and contractures in the palm of the hand (the "Viking Disease")
• Peyronie's disease: Hardening of tissue in the penis causing curvature About 50% of people with Ledderhose disease also have Dupuytren's disease in their hands.

Is It Dangerous?

No. This is not cancer and will never spread to other parts of your body. However, it can be painful and make walking difficult as the lump grows.

The "Don't Cut" Rule

Here's the most important thing to know: We try very hard NOT to remove these lumps surgically. Why? Because when we cut them out, they almost always grow back - and usually bigger and more painful than before. Studies show that 8 out of 10 people who have simple excision will have the lump return within a few years.

What Are My Treatment Options?

First: Make the Lump Comfortable (Not Remove It)

• Special Shoe Inserts (Orthotics): We create a custom insole with a hole or soft area precisely where the lump is, so you're not walking directly on it. Think of it like cutting a hole in your shoe rather than cutting the lump out of your foot.
• Shoe Modifications: Wearing supportive, cushioned shoes (not flat shoes or high heels)
• Steroid Injections: Sometimes we inject cortisone directly into the lump to reduce pain and possibly shrink it slightly

Second: Radiation Therapy (If It Keeps Growing)

• If the lump is actively growing and causing problems despite orthotics, we can use low-dose radiation (X-ray beams) to kill the growing cells and stop it from getting bigger
• This is the same technology used for cancer but at much lower doses
• Success rate: About 7 out of 10 people have their lump stop growing and pain improve
• Side effects: Minimal; slight skin darkening in the treated area

Last Resort: Surgery

• Only if nothing else has worked and you cannot walk or wear shoes
• The operation required is EXTENSIVE: We have to remove the entire sheet of plantar fascia from your heel all the way to your toes (not just the lump) to minimize the chance of it growing back
• Risks:
  • Even with extensive surgery, 1-2 out of 10 people still get recurrence
  • Your foot arch may collapse (flatfoot), causing chronic pain
  • Long recovery: 3-6 months before you can walk normally
  • Many patients end up with more pain after surgery than before

What Should I Expect?

• Timeline: This is a slow-growing condition. It may stay the same size for years, or slowly enlarge over time.
• Both Feet: There's a 20-50% chance your other foot will develop lumps over time
• It's Manageable: Most people can control symptoms with shoe inserts and minor lifestyle changes without needing surgery

Questions to Ask Your Doctor

• "Have you examined my hands for Dupuytren's disease?"
• "How big is my lump, and is it growing?"
• "Am I a good candidate for radiotherapy?"
• "If I need surgery in the future, what exactly would be removed?"

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15. Examination Focus (Viva Vault)

Q1: What are the components of "Dupuytren's Diathesis" and why is it important?

A: Dupuytren's Diathesis represents a genetically predisposed aggressive phenotype of fibromatosis, characterized by:

1. Bilateral Dupuytren's disease (hands)
2. Plantar fibromatosis (feet) - bilateral
3. Peyronie's disease (penis)
4. Garrod's pads (knuckle pads over PIP joints)
5. Early onset (less than 40 years)
6. Strong family history (autosomal dominant)

Clinical Importance:

• Predicts extremely high surgical recurrence rate (approaching 100%)
• Should influence treatment toward maximal conservative management
• Requires counseling about systemic nature of disease
• Consider radiotherapy over surgery in virtually all cases

Q2: Differentiate plantar fibromatosis from plantar fasciitis on clinical examination and imaging.

A:

Key Distinguishing Feature: Palpable discrete mass vs. diffuse tenderness without mass

Q3: Why is MRI signal characteristic in plantar fibromatosis, and what is the main differential diagnosis?

A: MRI Signal:

• T1: Iso- to hypointense (similar to muscle)
• T2: Hypointense (dark) - pathognomonic
• Mechanism: Dense collagen with minimal water content produces low signal on T2

Main Differential Diagnosis:

• Synovial Sarcoma:
  • High T2 signal (bright)
  • Heterogeneous enhancement
  • Cystic/necrotic areas
  • Age less than 30 years typically
  • Associated with tendons/joints
  • SS18-SSX fusion gene on molecular testing

Other Differentials (all typically bright on T2):

• Clear cell sarcoma
• Epithelioid sarcoma
• Desmoid tumor (can be variable signal)
• Giant cell tumor of tendon sheath (dark on T2 due to hemosiderin, but lobulated and associated with tendon sheath, not fascia)

Rule: Soft tissue mass that is dark on T2 = fibrotic process (fibromatosis, fibroma, old hematoma, GCTTS with hemosiderin)

Q4: What are the surgical recurrence rates for different excision techniques, and what factors predict recurrence?

A: Recurrence Rates (5-year data):

• Local/nodular excision: 80-100% (contraindicated)
• Wide excision (2cm margin): 40-60%
• Subtotal fasciectomy (central+medial bands): 25-40%
• Total fasciectomy (all bands): 10-25%

Factors Predicting Recurrence:

1. Surgical Extent: Inadequate margin #1 predictor
2. Dupuytren's Diathesis: Recurrence nearly universal
3. Age less than 40 years: More aggressive biology
4. Bilateral Disease: Indicates systemic predisposition
5. Multifocal Nodules: Higher disease burden
6. Histologic Phase: Proliferative phase more likely to recur than residual phase
7. Previous Recurrence: Each recurrence more aggressive

Mechanism of Recurrence:

• Microscopic disease left in fascia
• Surgical trauma stimulates dormant myofibroblast clones
• Genetic predisposition persists

Q5: What is the rationale and evidence for radiotherapy in plantar fibromatosis?

A: Rationale:

• Targets proliferating myofibroblasts in active (proliferative) phase
• Induces apoptosis and cell cycle arrest in dividing cells
• Modulates TGF-β signaling pathway
• Minimal effect on acellular collagen (inactive phase)

Evidence:

• Seegenschmiedt et al. (2003): 155 patients, 71% disease stabilization, 61% symptom improvement at 5-year follow-up [16]
• Heyd et al. (2010): Systematic review showing radiotherapy superior to surgery for preventing progression in early disease [5]

Protocol:

• Dose: 30 Gy total
• Fractionation: 5 Gy × 6 fractions (two courses of 3 fractions separated by 6-8 weeks)
• Technique: Orthovoltage or electron beam
• Field: Nodule + 1-2cm margin

Outcomes:

• Best Results: Early disease (less than 2 years), small nodules (less than 3cm), proliferative phase
• Goal: Stabilization (stop growth) and pain relief, NOT nodule eradication
• Side Effects: Minimal (skin erythema 20%, hyperpigmentation 5-10%)

Comparison to Surgery:

• Lower recurrence than local excision
• Preserves fascia integrity (no flatfoot)
• Non-invasive
• Does not remove mass (remains palpable but stable)

Q6: Describe the surgical anatomy relevant to total plantar fasciectomy.

A: Superficial to Deep Layers:

1. Skin: Thick, specialized glabrous skin of plantar foot
2. Subcutaneous Fat: Organized into septal compartments (shock absorption)
3. Plantar Aponeurosis: The target structure
   • Origin: Medial calcaneal tubercle
   • Bands: Medial, Central (largest), Lateral
   • Insertion: Plantar plates of MTP joints, proximal phalanges
4. Flexor Digitorum Brevis (FDB): Immediately deep to fascia; key anatomic landmark
5. Neurovascular Plane: Between FDB and quadratus plantae

Critical Structures at Risk:

• Medial Plantar Nerve:
  • Branch of posterior tibial nerve
  • Runs between fascia and FDB along medial border
  • Most commonly injured structure (5-10%)
  • Supplies sensation to medial forefoot and plantar aspect of toes 1-3
• Lateral Plantar Nerve:
  • Deeper, between FDB and quadratus plantae
  • At risk during lateral band dissection
  • Supplies sensation to lateral forefoot
• Plantar Arterial Arch:
  • Deep to FDB
  • Rarely injured unless dissection goes too deep

Surgical Plane:

• Correct: Between plantar fascia (superficial) and FDB muscle belly (deep)
• Too Superficial: Risk of skin necrosis
• Too Deep: Risk of nerve and vascular injury

Biomechanical Consequence:

• Plantar fascia is critical component of windlass mechanism
• Provides static support to longitudinal arch
• Complete removal → loss of arch support → flatfoot deformity

Q7: A 45-year-old man presents 18 months after wide local excision with a larger, more painful recurrent nodule. What are your management options?

A: This is a common and challenging scenario.

Assessment:

1. History:
   • Severity of symptoms (pain, functional limitation)
   • Impact on quality of life
   • Previous conservative measures
   • Presence of Dupuytren's/Peyronie's (diathesis?)
   • Expectations and understanding of recurrence risk
2. Examination:
   • Size and extent of recurrence
   • Bilateral disease?
   • Hand examination (Dupuytren's?)
3. Imaging:
   • MRI to define extent and rule out malignancy (though extremely rare, sarcoma must be considered in aggressive recurrence)

Management Options:

Option 1: Conservative Management (Preferred Initial Approach)

• Custom orthotics with accommodative well
• Activity modification
• Intralesional corticosteroid injection
• Physical therapy
• Rationale: Avoid repeat surgery given even higher recurrence risk

Option 2: Radiotherapy

• If nodule is actively growing (proliferative phase)
• 30 Gy fractionated EBRT
• Rationale: 70% disease stabilization; non-invasive; preserves function
• Best Option for recurrent disease in most cases

Option 3: Revision Surgery (Total Plantar Fasciectomy)

• Indication: Only if failed RT and severe refractory symptoms
• Counseling:
  • Recurrence risk after total fasciectomy for revision: 25-40% (higher than primary surgery)
  • Flatfoot deformity highly likely
  • Chronic pain in > 50%
  • Long recovery
  • Nerve injury risk higher in revision surgery (scarring)
• Technique: Must be total fasciectomy (not repeat wide excision)
• Adjuvant: Consider post-operative radiotherapy

Option 4: Accept and Live With It

• For some patients, accepting a stable lump with orthotic management is preferable to the morbidity of total fasciectomy
• Shared Decision-Making critical

Recommended Approach:

1. Orthotics + conservative care × 3-6 months
2. If progressive → Radiotherapy
3. If failed RT and intractable symptoms → Total fasciectomy + adjuvant RT
4. Extensive counseling at each step

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16. References

1. Ledderhose G. Zur Pathologie der Aponeurose des Fusses und der Hand. Arch Klin Chir. 1894;48:853-6.

2. Espert M, Anderson RB. Plantar fibromatosis: etiology, diagnosis, and treatment. Foot Ankle Clin. 2021;26(1):93-113. doi:10.1016/j.fcl.2020.10.003

3. Stahl S, Karsh-Zafrir I. Ledderhose disease: plantar fibromatosis. CMAJ. 2018;190(25):E769. doi:10.1503/cmaj.180112

4. Reilly RM, Stern PJ, Goldfarb CA. A retrospective review of the management of Dupuytren's nodules. J Hand Surg Am. 2005;30(5):1014-1018. doi:10.1016/j.jhsa.2005.03.016

5. Heyd R, Dorn AP, Herkströter M, et al. Radiation therapy for early stages of morbus Ledderhose. Strahlenther Onkol. 2010;186(1):24-29. doi:10.1007/s00066-009-2027-6

6. Zgonis T, Jolly GP, Garbalosa JC. The surgical management of plantar fibromatosis. J Foot Ankle Surg. 2005;44(5):388-391. doi:10.053/j.jfas.2005.07.012

7. Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytren's diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am. 2006;31(10):1626-1634. doi:10.1016/j.jhsa.2006.09.006

8. Gudmundsson KG, Arngrimsson R, Sigfusson N, et al. Epidemiology of Dupuytren's disease: clinical, serological, and social assessment. The Reykjavik Study. J Clin Epidemiol. 2000;53(3):291-296. doi:10.1016/s0895-4356(99)00145-6

9. Dürr HR, Krödel A, Trouillier H, Lienemann A, Refior HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int. 1999;20(1):13-17. doi:10.1177/107110079902000103

10. Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int. 2000;21(7):563-569. doi:10.1177/107110070002100705

11. Van der Veer WM, Bloem JJ, Ulrich MM, Molema G, van Zuijlen PP, Middelkoop E. Potential cellular and molecular causes of hypertrophic scar formation. Burns. 2009;35(1):15-29. doi:10.1016/j.burns.2008.06.020

12. Pickren JW, Smith AG, Stevenson TW Jr, Stout AP. Fibromatosis of the plantar fascia. Cancer. 1951;4(4):846-856. doi:10.1002/1097-0142(195107)4:4less than 846::aid-cncr2820040419> 3.0.co;2-7

13. Murphey MD, Ruble CM, Tyszko SM, et al. From the archives of the AFIP: musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics. 2009;29(7):2143-2173. doi:10.1148/rg.297095138

14. Bias WB, Nyberg LM Jr, Hochberg MC, Walsh PC. Peyronie's disease: a newly recognized autosomal-dominant trait. Am J Med Genet. 1982;12(2):227-235. doi:10.1002/ajmg.1320120211

15. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated conditions in patients with plantar fibromatosis. Foot Ankle Int. 2003;24(2):135-137. doi:10.1177/107110070302400203

16. Seegenschmiedt MH, Olschewski T, Guntrum F. Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study. Int J Radiat Oncol Biol Phys. 2001;49(3):785-798. doi:10.1016/s0360-3016(00)01464-2

17. Betz N, Ott OJ, Adamietz B, et al. Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years. Strahlenther Onkol. 2010;186(2):82-90. doi:10.1007/s00066-010-2069-4

18. Gudmundsson KG, Jónsson T, Arngrímsson R. Association of Morbus Ledderhose with Dupuytren's contracture. Foot Ankle Int. 2013;34(10):1387-1391. doi:10.1177/1071100713492757

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