Plantar Fibromatosis (Plantar Fibroma)

Plantar fibromatosis (Ledderhose disease) is a benign condition in which firm, non-cancerous lumps called plantar fibromas form within the plantar fascia. This is the thick band of tissue that runs along the arch of the foot. Many lumps stay small and painless. Others grow and become sore when walking barefoot or wearing shoes.

The lumps are made of excess fibrous tissue. They usually grow slowly, often in the middle and inner part of the arch, and there may be one or several. Plantar fibromatosis is closely related to Dupuytren's contracture of the hand. Unlike Dupuytren's, however, it rarely pulls the toes into a bent position. A review in Orthopedic Research and Reviews (Young and colleagues) notes that men are affected more often than women and that both feet are involved in about a quarter of cases.

What are the symptoms?

• A firm lump in the arch of the foot that does not move with the skin
• Pain when walking or standing barefoot
• Discomfort or pressure when wearing shoes
• A nodule that grows, or new nodules that appear over time

Many people notice the lump by chance and have no pain at all.

What causes plantar fibromas?

The exact cause is not fully understood. Recognised associations include:

• A genetic tendency, with links to Dupuytren's contracture and Peyronie's disease
• Repetitive trauma or small injuries to the plantar fascia
• Certain medicines, particularly some anti-seizure drugs
• Diabetes, frozen shoulder, liver disease and alcohol use, according to a review in Clinical Practice (Tomac and colleagues)

How is it diagnosed?

Diagnosis is made on clinical examination. It is confirmed with an ultrasound or MRI scan to assess the size and extent of the fibroma and to rule out other causes of a lump in the foot. Young and colleagues describe ultrasound as particularly good at showing small nodules within the fascia. MRI is useful for larger or more extensive disease. Any lump that is growing quickly, is very large or does not look typical on a scan needs further investigation.

Non-surgical treatment

Most plantar fibromas are managed without surgery. The aim is to keep the foot comfortable by taking pressure off the lump:

• Custom orthotics with a cut-out or soft area to offload the nodule
• Cushioned footwear with arch support
• Stretching and physiotherapy to reduce tension in the plantar fascia
• Topical treatments, such as verapamil cream, although evidence is limited
• Steroid injections, which can reduce pain but often do not shrink the fibroma

Young and colleagues note that any benefit from steroid injections can be short-lived. Nodules may return to their original size within a few years. They also found little published data on verapamil, which is borrowed from its use in related conditions.

Low-dose radiotherapy

In selected cases, a short course of localised low-dose radiotherapy may be considered. It is used particularly for early or actively growing nodules, and most often in specialist centres. A randomised trial of 84 patients in Radiotherapy and Oncology (de Haan and colleagues) compared radiotherapy with a sham treatment. At 12 months, pain had improved meaningfully (by at least two points on a 0–10 scale, or to zero) in 74% of feet treated with radiotherapy, compared with 56% with sham treatment. Quality of life and barefoot walking were also better than with sham. The most common side effects were skin redness, dryness, burning and a temporary increase in pain; most were mild and had settled by 18 months. Young and colleagues note a very small long-term risk of radiation-related cancer, which should be discussed before treatment.

Is surgery ever needed?

The options described in the literature range from removing the nodule alone, to removing it with a margin of surrounding tissue, to removing most or all of the plantar fascia (fasciectomy).

The main concern is recurrence. Young and colleagues report recurrence rates of 57–100% after removal of the nodule alone. Rates were lower, though still variable, at 8–80% after wider excision. Tomac and colleagues also state that recurrence is expected after surgery. For this reason, operations are usually a last resort.

What is the outlook?

Plantar fibromas are usually slow-growing and non-cancerous. Regular monitoring and supportive footwear are often enough to keep the foot comfortable. If the lump grows, new lumps appear or the symptoms change, reassessment with Mr Hester is advised.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Young JR, Sternbach S, Willinger M, Hutchinson ID, Rosenbaum AJ. The etiology, evaluation, and management of plantar fibromatosis. Orthopedic Research and Reviews. https://pmc.ncbi.nlm.nih.gov/articles/PMC6367723/
2. Tomac A, Ion AP, Opriș DR, Arbănași EM, Ciucanu CC, Bandici BC, Coșarcă CM, Covalcic DC, Mureșan AV. Ledderhose's disease: an up-to-date review of a rare non-malignant disorder. Clinical Practice. https://pmc.ncbi.nlm.nih.gov/articles/PMC10605618/
3. de Haan A, van Nes JGH, Kolff MW, van der Toorn PP, Westenberg AH, van der Vegt AE, Groen H, Overbosch J, van der Laan HP, Werker PMN, Langendijk JA, Steenbakkers RJHM. Radiotherapy for Ledderhose disease: results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial. Radiotherapy and Oncology. https://doi.org/10.1016/j.radonc.2023.109718