Summary

Plantar Fibromatosis (Ledderhose Disease) is a benign, fibroproliferative disorder of the plantar fascia, characterized by the formation of firm, nodular masses on the sole of the foot. It is the foot equivalent of Dupuytren's Disease (Hand) and Peyronie's Disease (Penis). The nodules typically grow slowly on the medial band of the fascia and can become painful with weight bearing. Unlike simple plantar fasciitis, this is a neoplastic-like process. Management is tricky: Surgery is notoriously difficult due to a very high recurrence rate (up to 60-100%) and risk of painful scarring. Therefore, conservative care (offloading) and Radiotherapy are prioritized. [1,2,3]

Key Facts

• The Diathesis: Ledderhose disease is often part of a systemic condition called "Dupuytren's Diathesis". Patients with bilateral Ledderhose, bilateral Dupuytren's, and Peyronie's have a strong genetic predisposition and aggressive disease course.
• The Location: Nodules almost always form in the Medial and Central bands of the plantar fascia. They are rarely lateral.
• The Trap: Excision of a Ledderhose nodule is a trap for the unwary surgeon. It grows back with a vengeance, often larger than before ("Recurrent Fibromatosis"). Wide resection (Total Fasciectomy) is required if surgery is chosen.

Clinical Pearls

"Don't biopsy the obvious": If a patient has classic bilateral Dupuytren's and a classic plantar nodule, biopsy is unnecessary and can stimulate growth. Clinical diagnosis is sufficient.

"Look at the Hands": Always examine the hands of a patient with lumps in the foot. 50% of Ledderhose patients have Dupuytren's.

"The Hole in the Shoe": The simplest treatment is often cutting a hole in the insole of the shoe to float the lump, rather than cutting the lump out of the foot.

                 LUMP IN ARCH
                      ↓
            HISTORY + MRI DIAGNOSIS
          ┌───────────┴───────────┐
       PAINLESS                PAINFUL
          ↓                       ↓
     OBSERVATION             OFFLOADING
   (No treatment)        (Orthotic Cut-out)
                                  ↓
                               FAILED?
                                  ↓
                          RADIOTHERAPY
                        (Early progressive)
                                  ↓
                               FAILED?
                                  ↓
                            SURGERY
                      (Total Fasciectomy)

Protocol

• Offloading: Custom orthotics with a "sweet spot" or relief channel cut out under the nodule.
• Steroid Injections: Can soften the nodule and reduce pain. Intralesional Triamcinolone.
• Verapamil: Transdermal gel. Weak evidence.

Indications

• Progressive, symptomatic disease.
• Prevention of recurrence post-surgery.

Evidence

• Seegenschmiedt et al: Shown to be highly effective at halting progression and reducing nodule size in early active disease.
• Dose: 30 Gy in split fractions.

Indications

• Intractable pain failing all other measures.
• Inability to wear shoes.

Techniques

1. Local Excision (Shelling out):
   • Contraindicated. Recurrence rate ~100%.
2. Wide Excision (Wide Fasciectomy):
   • Removing the nodule + 2cm margin of healthy fascia.
   • Recurrence: 50%.
3. Total Plantar Fasciectomy:
   • Removing the entire central and medial bands from heel to toes.
   • Recurrence: <10% (Gold Standard).
   • Risk: Flatfoot, prolonged healing, wound dehiscence.

Surgery vs Radiation

• Heyd et al: A systematic review confirmed that Radiotherapy is superior to surgery for preventing recurrence in early stage disease and should be considered the primary treatment for active nodules. Surgery is salvage.

The Fasciectomy Debate

• Van der Veer et al: Confirmed that local excision is futile. If surgery is done, specific fasciectomy is the minimum excision required.

The Lump

You have a condition called Ledderhose disease. It's benign (not cancer), but it's a type of growing scar tissue in the sole of your foot. It is related to the Viking Disease (Dupuytren's) in hands.

The "Don't Cut" Rule

We try very hard NOT to cut these out. If we cut it out, it gets angry and grows back bigger and more painful in 6 out of 10 people.

The Plan

1. Insoles: We will modify your shoe sole so you aren't walking on the lump.
2. Radiation: If it keeps growing, a dose of X-rays can kill the growing cells.
3. Surgery: Only as a last resort. We have to remove the entire sheet of tissue from your foot, not just the lump.

Q1: What are the components of "Dupuytren's Diathesis"? A: A genetic predisposition to aggressive fibromatosis. Includes:

1. Dupuytren's disease (Hands).
2. Ledderhose disease (Feet).
3. Peyronie's disease (Penis).
4. Garrod's Pads (Knuckle pads).

Q2: Differentiate Plantar Fibromatosis from Plantar Fasciitis. A:

• Fibromatosis: Palpable discrete nodules within the fascia. Pain is variable.
• Fasciitis: No distinct mass (diffuse thickening). Pain is classic "First step in morning" at the medial tubercle insertion.

Q3: What muscle layer lies immediately deep to the plantar fascia? A: The Flexor Digitorum Brevis (FDB). During fasciectomy, the dissection plane is between the fascia and the FDB muscle belly.

Q4: Why is MRI important pre-operatively? A: To determine the depth of infiltration (does it invade the muscle?) and to rule out Synovial Sarcoma or Clear Cell Sarcoma, which can mimic benign fibromatosis.

(End of Topic)