Plantar fibromatosis, also known as Ledderhose disease, is a benign condition involving the growth of fibrous tissue on the soles of the feet. Although it is non-cancerous, it can lead to pain, discomfort, and difficulty in performing daily activities due to the formation of firm lumps or nodules. This condition can range from asymptomatic to severely debilitating. The most effective way to manage plantar fibromas is often through surgical intervention, particularly when non-operative measures like orthotics or corticosteroid injections fail to provide relief. However, surgery for plantar fibromatosis is challenging due to the high recurrence rates and potential complications associated with the disease.
What is Plantar Fibromatosis?
Plantar fibromatosis is a disorder where benign fibrous tissue forms in the plantar fascia, which is a thick band of tissue that runs along the bottom of the foot. These fibrous growths, known as plantar fibromas, develop slowly and may cause a feeling of a lump or mass on the bottom of the foot. For many, these growths are not painful, but over time they can become bothersome, especially when they interfere with walking or the fitting of shoes.
The condition can affect one or both feet, and it may appear at any age, though it is most common in people aged 40 to 60. Additionally, individuals with a family history of the disease, those suffering from Dupuytren’s contracture, or people with certain health conditions such as diabetes or epilepsy are at a higher risk for developing plantar fibromatosis.
Causes and Risk Factors
The exact cause of plantar fibromatosis remains unknown, though several factors have been suggested to contribute to its development. These include:
- Genetic predisposition: A family history of the condition increases the likelihood of its development.
- Other fibrous disorders: Conditions like Dupuytren’s contracture, a similar disease affecting the hands, may increase the risk.
- Trauma or injury: Physical trauma to the foot may trigger the formation of fibromas.
- Endocrine or metabolic disorders: Certain conditions that affect metabolism or hormone levels may play a role.
Symptoms of Plantar Fibromatosis
The symptoms of plantar fibromatosis vary greatly from person to person. Some individuals may not experience any pain at all, while others may face significant discomfort. Common symptoms include:
- Pain: Pain is often felt while standing, walking, or running, especially if the fibroma becomes larger or presses against the foot’s bones or nerves.
- Lumps or nodules: These are typically found on the arch of the foot and may vary in size.
- Difficulty fitting shoes: As the fibromas grow, they can make it harder to wear certain types of footwear, causing discomfort.
- Tightness in the foot: In some cases, the growths can lead to a reduction in flexibility, making it difficult to move the foot normally.
Treatment Options
Non-Operative Treatments
In the early stages, plantar fibromatosis is often managed with non-surgical methods aimed at relieving symptoms rather than eradicating the growth itself. These treatments include:
- Orthotics: Custom-made insoles that can help redistribute pressure on the foot, providing relief from pain during walking.
- Corticosteroid injections: These injections may help reduce inflammation and relieve pain, but they do not eliminate the fibromas.
- Physical therapy: Exercises to improve foot flexibility and strength may help manage symptoms.
Surgical Treatments
Surgery is generally considered when non-surgical methods fail, or if the fibromas cause significant pain or interfere with walking. There are several surgical options available, and the choice of procedure depends on factors such as the size and location of the fibromas, as well as whether the condition is recurrent. The main surgical treatments include:
- Local Excision: This involves removing the fibromas by cutting through the skin and the underlying tissue. However, the recurrence rate of fibromas after local excision is quite high, ranging from 57% to 100%.
- Wide Excision: A more extensive procedure where not only the fibroma is removed but also a margin of surrounding healthy tissue. This technique has a lower recurrence rate than local excision but is still not entirely reliable.
- Subtotal Fasciectomy: This procedure removes the affected portion of the plantar fascia, along with the fibromas. It is considered the most effective treatment for recurrent fibromatosis, with a lower rate of recurrence compared to local or wide excision.
Recurrence and Postoperative Care
Recurrence of plantar fibromatosis after surgery is a significant concern. The disease is known for its high recurrence rates, and even after surgical removal, there is a risk that new fibromas will develop in the same area. The factors most commonly associated with recurrence include:
- Multiple fibromas on the foot.
- Bilateral involvement, where both feet are affected.
- Positive family history of plantar fibromatosis.
To minimize the chances of recurrence, subtotal fasciectomy is often the preferred surgical method, as it removes a larger portion of tissue and helps to eradicate the disease more effectively. However, patients must be prepared for the possibility of further treatment, especially if the fibromas return.
Risks and Complications of Surgery
Like any surgery, there are risks associated with the treatment of plantar fibromatosis, including:
- Wound healing problems: Delayed healing and wound infection are common after surgical procedures, especially when skin grafts are required.
- Skin necrosis: This can occur when the skin loses its blood supply due to the extensive dissection required for tumor removal.
- Nerve injury: Care must be taken during surgery to avoid damaging the nerves in the foot, which could lead to numbness or pain.
- Changes in foot structure: Surgery, especially subtotal fasciectomy, can sometimes lead to changes in the arch of the foot, which may require additional treatment or the use of orthotic devices.
Conclusion
Plantar fibromatosis is a challenging condition that can significantly impact an individual’s quality of life. While non-surgical treatments are often effective for managing symptoms, surgery is sometimes necessary, especially for recurrent or more severe cases. Subtotal fasciectomy remains the most effective surgical option for treating plantar fibromatosis, particularly in cases where the disease recurs. However, patients should be aware of the risks of recurrence and complications, and they should work closely with their healthcare providers to determine the most appropriate course of treatment.
Through careful management, both surgical and non-surgical, most individuals with plantar fibromatosis can lead a comfortable, functional life.
Do you have more questions?
Q. What is Subungual Exostectomy?
A. Subungual Exostectomy is a surgical procedure to remove a bony growth (exostosis) beneath the toenail, typically caused by repeated trauma or pressure, leading to pain and difficulty walking.
Q. What causes Subungual Exostosis?
A. The condition is often caused by repeated trauma to the toe or pressure from footwear, resulting in the formation of a bony lump under the toenail. Genetic factors and certain health conditions may also contribute.
Q. How is Subungual Exostectomy performed?
A. The procedure involves making a small incision in the affected toe to remove the bony growth under the nail. In some cases, the toenail may also be partially or fully removed to access the exostosis.
Q. What is the recovery time after Subungual Exostectomy?
A. Recovery typically takes 1 to 2 weeks for initial healing, with full recovery occurring within 4 to 6 weeks. Patients are advised to protect the toe and avoid pressure on the area during the recovery phase.
Q. Are there any risks associated with Subungual Exostectomy?
A. Risks include infection, bleeding, nail deformities, recurrence of the exostosis, and damage to surrounding tissues. However, these complications are rare and can usually be managed with proper care.
Q. What is the success rate of Subungual Exostectomy?
A. The procedure has a high success rate, with most patients experiencing significant pain relief and improvement in toe function. However, there is a risk of recurrence in some cases if the exostosis is not completely removed.
Q. Can Subungual Exostectomy be done on both feet at the same time?
A. While it is technically possible to perform the procedure on both feet, it is generally recommended to treat one foot at a time to allow for proper healing and minimize the risk of complications.
Q. Will I be able to walk immediately after Subungual Exostectomy?
A. You may experience some discomfort immediately after surgery, and you will need to limit weight-bearing on the affected foot for a few days. Most patients can begin walking gently after the initial recovery phase.
Q. Will I need to wear a cast or boot after Subungual Exostectomy?
A. You may be required to wear a special shoe or boot for several weeks after surgery to protect the toe and prevent pressure on the healing area, ensuring proper recovery.
Q. Can I drive after Subungual Exostectomy surgery?
A. Most patients can drive once they are no longer taking pain medications and feel comfortable moving their foot. This typically happens after a few days to a week, depending on the individual’s healing process.
Q. Will the excised area leave a scar?
A. Yes, there will be a small scar where the incision was made to remove the exostosis, but it typically heals well and becomes less noticeable over time.
Q. How soon can I return to normal activities after Subungual Exostectomy?
A. Most patients can return to normal, non-strenuous activities within 1 to 2 weeks, but high-impact activities or those that put pressure on the toe should be avoided for several weeks.
Q. Can the excision of Subungual Exostosis affect my toenail?
A. In some cases, the toenail may be temporarily or permanently altered, especially if it is removed to access the exostosis. However, this is generally not a significant issue for most patients.
Q. Are there any long-term effects of Subungual Exostectomy?
A. The long-term effects are generally positive, with most patients experiencing relief from pain and improved toe function. However, there is a risk of recurrence, especially if the growth was not completely excised.
Q. Is physical therapy required after Subungual Exostectomy surgery?
A. Physical therapy is usually not required after Subungual Exostectomy unless there is significant post-surgical stiffness or weakness. However, patients may benefit from exercises to improve mobility and strength in the foot during recovery.
Dr. Mo Athar
