Plantar fibromatosis


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Original Editors

Top Contributors - Charlotte Sirago, Marie-Laure Sibret and Anja Vanroelen  

Definition/Description

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Clinically Relevant Anatomy

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Epidemiology /Etiology

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Characteristics/Clinical Presentation

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Differential Diagnosis

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Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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Key Research

Used databases: Pubmed, Medline and Pedro.
Keywords: Ledderhose disease, Plantar fibromatosis, Dupuytren’s contracture, Superficial Fibromatoses, Morbus Ledderhose, therapy, diagnosis, treatment 

Definition

The Ledderhose disease, also known as a plantar fibromatosis or Morbus Ledderhose, is a small slow-growing lesion of the superficial fibromatoses of the plantar aponeurosis.[10] It can be described as a benign fibroblastic proliferative disorder in which fibrous nodules may develop in the plantar aponeurosis, more specifically on the medial plantar side of the foot arch and on the fore foot region.[6]
 

Clinically revelant anatomy

The plantar fascia, or aponeurosis, is a thin band of fascia that extends from the inferior margin of the calcaneus to the plantar plates of the metatarsophalangeal joints and the bases of the proximal phalanges.[9]


Epidemiology/Etiology

Ledderhose’s disease, is named after a German surgeon, Dr. Georg Ledderhose. He described the condition first in 1894 as an uncommon hyperproliferative plantar aponeurosis.[1] ,[2]
It occurs less often than palmar disease, with a prevalence of 0.23% and usually more frequently in middle aged male individuals (30 – 50 years). Studies have shown that even though mens predisposition is bigger than women, among children there seem to be a female predilection.[10]
Due to the lack of information about the formation of this condition, the etiology is still controversial.[5] It seems to have a multifactorial etiology, including congenital and traumatic causes as also prolonged immobilization followed by trauma.[10] , [12] Patients with the contracture of Dupuytren, diabetes mellitus, epilepsy, alcoholics with liver disease, and keloids have more risk to develop the disease of Ledderhose and/or a Peyronie's disease. [6], [10]


Characteristics/Clinical Presentation 

There will be a visible bulge at the plantar area of the foot same as a reduced capacity of bending the foot.[3] ,[4], [7], [8] Not all of the patients do have symptomatic complains. Complains such as pain can occur after standing or walking for a long time, or when those nodules happen to grow and stiffen the affected structures of the foot (due to a lack of space) such as neurovascular bundles, muscles or tendons.[5] Nevertheless contractions abnormalities of the foot are not expected and patients do frequently have normal radiographs.[5]
Plantar fibromatosis is thought to have three phases: [9]
1) Proliferative phase: with nodular fibroblastic proliferation
2) Active phase:  with collagen synthesis and deposition
3) Mature phase: with reduced fibroblastic activity and collagen maturation


Differential Diagnosis

Same lesions may also appear at other places of the body:
Dupuytren’s contracture
• Peyronie's disease
• Garrod's pad [2], [3]
Some others differential diagnoses are: plantar fasciitis and chronic rupture of the plantar fascia.[9]



Diagnostic Procedures

As mentioned in the article of Murphey:“Cross sectional imaging (ultrasonography, computed tomography, MRI) reveals lesion location, extension and involvement of adjacent structures for staging and evaluation of local recurrence”. [10]
Even if lesion evaluation is usually done with ultrasound and MRI, the tissue composition cannot be revealed by those techniques.[1]
“Sonography imaging demonstrates a well-defined (64%) or poorly defined (36%) fusiform mass in the soft tissues adjacent to the plantar aponeurosis. CT images demonstrate a nonspecific soft tissue mass in the characteristic location with attenuation equal or higher than skeletal muscle”. [5]
“On MRI imaging plantar fibromatosis appears as a well-defined nodule that is continuous with the plantar fascia and has low signal intensity on T1-weighted sequences and low to intermediate signal intensity on T2 - weighted sequences”.[9]
The identification of characteristics of plantar fibromatosis on imaging can give several important information for the clinical diagnosis’.[1]


Medical Management 

Even though a recovery with a non-invasive treatment is possible, certain severity of the lesion will demand a different approach. The most functional surgery nowadays seems to consist of a large or partial fasciectomy (in order to release the tension) with or without grafts. [7] ,[ 11] Other type of surgery, such as removing the nodules do also exist. [7] ,[ 11]
However treatment by radiotherapy may also be possible [6], but it will mostly be used postoperatively in order to reduce the recurrence of the nodules.[2]

 
Physical Therapy Management 

The treatment of the Ledderhose disease is the same as  the treatment used to rehabilitate a person that suffers from a Dupuytren’s contracture, except the fact that for this disease the treatment will be applied to the foot. [11]


The treatment of a light form of the Ledderhose disease and treatment before a clinical intervention consist of: a massage with a cortisone cream, LPG relaxation and light passive stretching of the retracted structures, isometric muscle exercises of the extensors of the fingers, electrotherapy and the use of an elastic splint of extension. This treatment will barely be used due to the lack of efficacy onto a Dupuytren’s contracture. The only reason why this treatment would be used is to eventually reassure the patient and make the surrounding structures more flexible, which will lighten the disabling impact that the lesion could have. [11] Using footwear modifications, pads and orthotics can be used to relieving symptoms.[10] Shockwave therapy seems also to have an effective effect on plantar fibromatosis, by reducing the pain and soften the nodules. [6]

The serious forms of the Ledderhose disease will first have to be clinically cleaned, before being treated.


During the first phase (1-3th day) the foot of the patient will be placed in a bandage, plastered or not, always in a position to function.
In case of graft, an extra immobilization of approximately ten days with a compressive splint-dressing will be needed, and the mobilization will only start once there is a ¾ engraftment. Mainly this phase will consist of: prevent post-operative oedema by raising the foot, ask the patient to mobilize the toes in the dressing once anesthesia disappeared, if none postoperative immobilization is provided: an active mobilization will be required from the first days. [11]

The second phase (or wound healing phase; 8-15st day) will be composed of: eventually prolong the mobilization of the free articulations, circulatory and scar tissue massage, lymphatic drainage, pneumatic/air pressure therapy, recovery of the articulations and muscles of the toes (slow and painless passive mobilization, active mobilization, elastic constraint switchgear, work on the posture extension), ionization, lasers, US if bad wound healing. [11]   Passive stretching of toe extensor foot in plantar flexion can be applied. (Level of evidence :5) [14]


The third and last phase (after the wound healing) will consist of: a circulation and scar massage, bath of hot water or paraffine with active movements, total recovery of the articular amplitudes (by using analytic and global active-passive exercises and postural extension if needed with a dynamic brace), recovery of the muscle force (manually and later on with growing mechano-therapy appliances) and in order to finalize the treatment, a
more specific rehabilitation will also be required (dislocation of
the fingers, fine movements, movements that requires force and
ergotherapy (games, ...). [11]
Some home physical exercises could be: Level of evidence 5 [15]                 
• Exercise 1: towel curls [13]
• Exercise 2: marbles pick up.[13] Place some marbles on the ground next to a dish or cup and ask the patient to grip the marbles with the injured foot one by one at a time in order to drop them in the cub or dish. Once this is exercise has been done, the same exercise could be accomplish with the other (not injured) side.
• Exercise 3: golf ball roll.[13] Massage the ball of your feet by rolling the golf ball under your foot during 2 minutes.
Leaning onto the foot will be possible after a week, even though the mobilization and total leaning will only be possible after the threads have been removed. [11]


References 

Websites
1. Health Grades Inc. Right Diagnosis. Geraadpleegd 22 oktober 2012, http://www.rightdiagnosis.com/l/ledderhose_disease/intro.htm Level of evidence: 5
2. Fausto de Souza, D. et al. (September 2010). Ledderhose Disease: An Unusual Presentation. The journal of Clinical and Aesthetic Dermatology, 3. Geraadpleegd 16 oktober 2012, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945849 Level of evidence: 3B
3. Wikimedia Foundation Inc. Plantar Fibromatosis. Geraadpleegd 22 okt 2012, http://en.wikipedia.org/wiki/Ledderhose_disease Level of evidence: 5
13. Advanced Patient Education.com. Toe Home Physical Therapy Exercises. Geraadpleegd 23 december 2012. http://www.youtube.com/watch?v=D-n8G_V24uw Level of evidence: 5
14. Correct Toes with Dr. Ray McClanahan. Toe Extensor Stretch Geraadpleegd 23 december 2012. http://www.youtube.com/watch?v=h2kaEOd3GcI Level of evidence: 5
15. Afbeelding: WebMD, 2011. Fitness & Exercise: Towel Curl Geraadpleeg 23 december 2012. http://www.webmd.com/fitness-exercise/towel-curl Level of evidence: 5


Magazines
4. Haedicke, G.J. & Sturim, H.S. (1989). Plantar fibromatosis: an isolated disease. Plast Reconstr Surg, 83(2), 296-300 (PubMed). Level of evidence: 4
5. Walker, E.A., Petscavage, J.M., Brian, P.L., Logie, C.I., Montini, K.M., and Murphey, M.D. (2012). Imaging features of superficial and deep fibromatoses in the adult population. Sarcoma,  (PubMed) Level of evidence: 2A
6. Knobloch, K. & Vogt, K.M. (2012). High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose’s disease). BMC Res Notes, 5(1), 542. Level of evidence: 2A  
7. van der Veer, W.M., Hamburg, S.M., de Gast, A., and Niessen, F.B. (2008). Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg, 122(2), 486-491. Level of evidence: 2A

8. Beckmann, J., Kalteis, T., Baer, W., Grifka J., and Lerch, K. (2004). Plantar fibromatosis: therapy by total plantarfasciectomy. Zentralbl Chir, 129(1), 53-57. Level of evidence: 4
9. Griffith, J.F., Wong, T.Y., Wong, S.M., and Metrweli, C. (2002). Sonography of plantar fibromatosis. AJR Am J Roentgenol, 179(5), 1167-1172. Level of evidence: 2A
10. Murphey, M.D., Ruble, C.M., Tyszko, S.M., Zbojniewicz, A.M., Potter, B.K., and Miettinen, M. (2009). Musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics, 29(7), 2143-2173 Level of evidence: 2C


Books
11. Xhardez, Y., et collaborateurs. (2002). Vade-mecum de kinésithérapie et de rééducation fonctionnelle (5e édition). Prodim. Level of evidence: 4
12. Pack, G.T., & Ariel, I.M. (1964). Treatment of cancer and allied diseases Volume VIII: Tumors of the soft somatic tissues and bone / by thirty-nine authors. P.B. Hoeber (p. 8-14). Level of evidence: 4