Plantar fascial fibromatosis, also known as Ledderhose's disease, Morbus Ledderhose, and plantar fibromatosis, is a relatively uncommon
[ ] non-malignant thickening of the feet's deep connective tissue, or
fascia
A fascia (; plural fasciae or fascias; adjective fascial; from Latin: "band") is a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches to, stabilizes, encloses, and separates muscles and other internal organs. ...
. In the beginning, where nodules start growing in the fascia of the foot the disease is minor. Over time walking becomes painful. The disease is named after
Georg Ledderhose
Georg Ledderhose (15 December 1855, Bockenheim (Frankfurt am Main), Bockenheim, Regierungsbezirk Wiesbaden, Germany – 1 February 1925, Munich, Germany) was a German surgeon.
Ledderhose studied in Strasbourg under Georg Albert Lücke (1829–189 ...
, a
German
German(s) may refer to:
* Germany (of or related to)
**Germania (historical use)
* Germans, citizens of Germany, people of German ancestry, or native speakers of the German language
** For citizens of Germany, see also German nationality law
**Ger ...
surgeon who described the condition for the first time in 1894.
A similar disease is
Dupuytren's disease, which affects the hand and causes bent hand or fingers.
As in most forms of
fibromatosis
The term fibromatosis refers to a group of soft tissue tumors which have certain characteristics in common, including absence of cytologic and clinical malignant features, a histology consistent with proliferation of well-differentiated fibroblast ...
, it is usually benign and its onset varies with each patient.
The nodules are typically slow growing
[ and most often found in the central and medial portions of the plantar fascia.][ Occasionally, the nodules may lie dormant for months to years only to begin rapid and unexpected growth.][ Options for intervention include radiation therapy, cryosurgery, treatment with collagenase clostridium histolyticum, or surgical removal only if discomfort hinders walking.]
Signs and symptoms
Plantar fibromatosis is most frequently present on the medial border of the sole, near the highest point of the arch.[ The lump is usually painless][ and the only pain experienced is when the nodule rubs on the shoe or floor.][ The overlying skin is freely movable, and contracture of the toes does not occur in the initial stages.][
]
The typical appearance of plantar fibromatosis on magnetic resonance imaging
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI) is a poorly defined, infiltrative mass in the aponeurosis
An aponeurosis (; plural: ''aponeuroses'') is a type or a variant of the deep fascia, in the form of a sheet of pearly-white fibrous tissue that attaches sheet-like muscles needing a wide area of attachment. Their primary function is to join musc ...
next to the plantar muscles.
Only 25% of patients show symptoms on both feet (bilateral involvement). The disease may also infiltrate the dermis
The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
or, very rarely, the flexor tendon sheath.
Risk factors
The histological and ultrastructural features of Ledderhose and Dupuytren's disease are the same, which supports the hypothesis that they have a common cause and pathogenesis.[ As with Dupuytren's disease, the root cause(s) of Ledderhose's disease are not yet understood. It has been noted that it is an inherited disease and of variable occurrence within families, i.e. the genes necessary for it may remain dormant for a generation or more and then surface in an individual, or be present in multiple individuals in the same generation with varying degree.]
There are certain identified risk factors. The disease is more commonly associated with -
* A family history of the disease[
* Higher incidence in males][
* Palmar fibromatosis 10-65% of the time.][
* ]Peyronie's disease
Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, ca ...
[
* ]Epilepsy
Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical ...
patients[
* ]Diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
[
There is also a suspected, although unproven, link between incidence and ]alcoholism
Alcoholism is, broadly, any drinking of alcohol (drug), alcohol that results in significant Mental health, mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognize ...
, smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
, liver
The liver is a major Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...
diseases, thyroid
The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thy ...
problems, and stressful work involving the feet.
Diagnosis
A combination of physical examination of the arch and plantar fascia, as well as ultrasound imaging by a physician is the usual path to diagnosis.
An MRI Scan (Magnetic Resonance Imaging) is usually the imaging of choice to determine between other possible conditions such as ganglion cysts. MRI tends to be more accurate than x-ray or ultrasound, showing the full extent of the condition.
Treatment
Although the origin of the disease is unknown, there is speculation that it is an aggressive healing response to small tears in the plantar fascia, almost as if the fascia over-repairs itself following an injury. There is also some evidence that it might be genetic.[
In the early stages, when the nodule is single and/or smaller, it is recommended to avoid direct pressure to the nodule(s). Soft inner soles on footwear and padding may be helpful.][
MRI and sonogram (diagnostic ultrasound) are effective in showing the extent of the ]lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
, but cannot reveal the tissue composition. Even then, recognition of the imaging characteristics of plantar fibromatoses can help in the clinical diagnosis.[
Surgery of Ledderhose's disease is difficult because tendons, nerves, and muscles are located very closely to each other. Additionally, feet have to carry heavy load, and surgery might have unpleasant side effects. If surgery is performed, the biopsy is predominantly cellular and frequently misdiagnosed as ]fibrosarcoma
Fibrosarcoma (fibroblastic sarcoma) is a malignant mesenchymal tumour derived from fibrous connective tissue and characterized by the presence of immature proliferating fibroblasts or undifferentiated anaplastic spindle cells in a storiform patte ...
.[ Since the diseased area (lesion) is not encapsulated, clinical margins are difficult to define. As such, portions of the diseased tissue may be left in the foot after surgery. Inadequate excision is the leading cause of recurrence.][
Radiotherapy has been shown to reduce the size of the nodules and reduce the pain associated with them. It is approximately 80% effective, with minimal side-effects.
Post-surgical radiation treatment may decrease recurrence.][ There has also been variable success in preventing recurrence by administering ]gadolinium
Gadolinium is a chemical element with the symbol Gd and atomic number 64. Gadolinium is a silvery-white metal when oxidation is removed. It is only slightly malleable and is a ductile rare-earth element. Gadolinium reacts with atmospheric oxygen ...
.[ Skin grafts have been shown to control recurrence of the disease.][
In few cases shock waves also have been reported to at least reduce pain and enable walking again. Currently in the process of FDA approval is the injection of ]collagenase
Collagenases are enzymes that break the peptide bonds in collagen. They assist in destroying extracellular structures in the pathogenesis of bacteria such as ''Clostridium''. They are considered a virulence factor, facilitating the spread of ...
. Recently successful treatment of Ledderhose with cryosurgery
Cryosurgery is the use of extreme cold in surgery to destroy abnormal or diseased tissue; thus, it is the surgical application of cryoablation. The term comes from the Greek words cryo (κρύο) ("icy cold") and surgery (''cheirourgiki'' – χ ...
(also called cryotherapy) has been reported.
Cortisone injections, such as Triamcinolone
Triamcinolone is a glucocorticoid used to treat certain skin diseases, allergies, and rheumatic disorders among others. It is also used to prevent worsening of asthma and COPD. It can be taken in various ways including by mouth, injection into ...
,[ and ]clobetasol
Clobetasol is a synthetic glucocorticoid corticosteroid. A propionate ester
In chemistry, an ester is a compound derived from an oxoacid (organic or inorganic) in which at least one hydroxyl group () is replaced by an alkoxy group (), a ...
ointments[ have been shown to stall the progression of the disease temporarily, although the results are subjective and large-scale studies far from complete. Injections of ]superoxide dismutase
Superoxide dismutase (SOD, ) is an enzyme that alternately catalyzes the dismutation (or partitioning) of the superoxide () radical into ordinary molecular oxygen (O2) and hydrogen peroxide (). Superoxide is produced as a by-product of oxygen me ...
have proven to be unsuccessful in curing the disease [ while radiotherapy has been used successfully on Ledderhose nodules.
Topical ]Verapamil
Verapamil, sold under various trade names, is a calcium channel blocker medication used for the treatment of high blood pressure, angina (chest pain from not enough blood flow to the heart), and supraventricular tachycardia. It may also be used ...
is also used to treat plantar fibromatosis.
See also
* Fibromatosis
The term fibromatosis refers to a group of soft tissue tumors which have certain characteristics in common, including absence of cytologic and clinical malignant features, a histology consistent with proliferation of well-differentiated fibroblast ...
* Dupuytren's contracture
Dupuytren's contracture (also called Dupuytren's disease, Morbus Dupuytren, Viking disease, palmar fibromatosis and Celtic hand) is a condition in which one or more fingers become progressively bent in a flexed position. It is named after Guilla ...
* Plantar fasciitis
Plantar fasciitis or plantar heel pain (PHP) is a disorder of the plantar fascia, which is the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the f ...
* List of cutaneous conditions
Many skin conditions affect the human integumentary system—the organ system covering the entire surface of the body and composed of skin, hair, nails, and related muscle and glands. The major function of this system is as a barrier against t ...
References
External links
{{Soft tissue disorders
Rare diseases
Dermal and subcutaneous growths