Cath Lab Digest

What You Should Know About Plantar Fibromas And Recalcitrant Plantar Heel Pain

By Brian McCurdy, Senior Editor

Investigating plantar fibromas as an etiology for recalcitrant heel pain, the authors of a recently published study suggest that 25 percent of recalcitrant heel pain is neoplastic in origin. The study authors also maintain that patients presenting with proximal plantar fibromas require excision and not fasciotomy.

   The retrospective study, which was published in the Journal of Foot and Ankle Surgery, involved 101 pathology specimens from 97 patients who had been diagnosed with recalcitrant plantar fasciitis. The specimens were medial and central bands of the fascia obtained from transverse plantar fasciectomies performed between July 1994 and March 2008, according to the study. Researchers note that one-quarter of the cases had a histological appearance of plantar fibroma.

   The authors noted three groups of histologic findings of the specimens: neoplastic involvement (25 percent); inflammation without neoplastic involvement (21 percent); and “other,” which consisted of having no inflammatory or neoplastic response (54 percent).

   All of the patients had failed a three- to six-month conservative treatment regimen, which consisted of anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom-molded orthotics and physical therapy, according to the study. Researchers note that only four patients underwent bilateral plantar fasciectomies and no patients required a revisional procedure.

   As lead study author Martin Pressman, DPM, explains, his patients are mostly happy with fasciotomy. He says his team is currently performing percutaneous fasciotomy with ultrasound guidance for those patients with recalcitrant plantar fasciitis who have not responded to conservative care.

    “Our dilemma is we now know that 25 percent of these patients may have a benign tumor (fibroma),” notes Dr. Pressman. “It is clearly not appropriate to incise a tumor and leave it.”

   If one performs a partial fasciotomy, Matthew Sabo, DPM, says recurrence can happen and the patient would need a radical plantar fasciotomy. With a radical plantar fasciotomy, he says scars can cause difficulties and there can be progressive development of hammertoes. Injections, topical modalities and/or orthotics can help with scarring while one can correct hammertoes either by an arthroplasty or arthrodesis, according to Dr. Sabo, who practices at Western Pennsylvania Hospital in Pittsburgh. He says the advantages of plantar fasciectomy include relief of pain and improved quality of life.

   Patients who fail fasciotomy may have a fibroma, notes Dr. Pressman, an Assistant Professor of Orthopaedics and Rehabilitation at the Yale School of Medicine. He is currently investigating core needle aspiration biopsy as a method to diagnose fibroma and re-evaluation of MRIs in cases with histologically documented proximal fibroma. Dr. Pressman says this may help determine when a fasciectomy is appropriate.

   Dr. Pressman notes patients with proximal plantar fibromas of the heel are better served with fasciectomy as total removal of the fibrous mass under the heel is curative. Disadvantages of fasciectomy are the disruption of the fascia and the biomechanical consequences, according to Dr. Pressman. Although such sequelae are infrequent, he notes they can also occur with fasciotomy even if the lateral band is spared.

   Dr. Sabo cites disadvantages of plantar fasciectomy that may include recurrence, scar formation, infection, hematoma and delayed wound healing.

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