How To Handle Plantar Fibromas

Author(s): 
By Matt Sabo, DPM

Plantar fibroma is a common occurrence in the plantar aponeurosis that usually consists of a solitary lesion or multiple nodules. The condition commonly derives from the medial and central fascial band of the aponeurosis, and is typically non-cancerous. Plantar fibromas are generally slow growing lesions that are typically asymptomatic. Most nodules cause pain because of the irregular contour of the foot with ambulation and standing.

The cause of plantar fibomas cannot typically be determined but trauma to the aponeurosis and, in some cases, patients on phenytoin (Dilantin) can develop lesions. Those with systemic conditions such as epilepsy, alcoholism, liver cirrhosis, hypothyroidism and diabetes mellitus may have an increased incidence of plantar fibromas.

Fibromatoses present through different stages of life. Plantar fibromatoses represent a heterogeneous group of local infiltrative pathology. When it comes to the histological view, plantar fibromatoses have mature collagen and fibroblasts with no malignant cytological features.

Plantar fibromatoses are a group of proliferative soft tissue disorders. They are characterized by an infiltrative pattern of growth with repeated local recurrences and the proliferation of uniform but well differentiated spindled cells (mainly myofibroblasts) and a variable amount of collagen among the proliferating cells. These lesions are locally aggressive but typically lack the capacity to metastasize.

Ledderhose first described plantar fibromatosis as a non-malignant thickening of deep connective tissue or plantar fascia. It is a minor, non-painful tumor commonly referred to as Ledderhose disease. As the disease progresses, it may cause thickening of the cord and contractures of the digits, which, in turn, can cause pain. Men typically get the disease at an earlier age than women. Similar to Dupuytren’s contracture, the incidence of plantar fibromatosis is about even for men and women with the disease being more progressive for men in their 70s.

Plantar fibromatosis, as well as Dupuytren’s contracture, has no clear pathophysiologic factors. However, researchers have reported the occurrence of the disease in patients with repeated trauma, long-term alcohol consumption, chronic liver disease, diabetes and epilepsy. The clearest factor with the disease lies with heredity.

Essential Insights On Differentiating Between Plantar Fibromas
Superficial plantar fibromatosis is more common in the younger population than in the elderly population. Although it is classified as a tumor that shows fibroblastic proliferation and overgrowth, myofibroblast proliferation is common with some forms.

Cerebriform mesodermic hamartomas is a form of plantar fibromatosis that represents a kind of mesodermal nevus when one sees it on the sole of the foot. It is associated with Peyronie’s disease, which is characterized by a plaque or hard lump that forms on the penis. The cause is unknown. The plaque develops on the upper or lower side of the penis in layers containing erectile tissue. It begins as a localized inflammation and can develop into a hardened scar.

One may distinguish desmoid tumors from plantar fibromatosis by the different anatomical site, treatment response and more aggressive pathological characteristics. Desmoid tumors are present in and around the large muscle of the trunk and extremities. In the foot, the desmoid tumor represents a tumor deep in the plantar arch and is not superficial as one would see with plantar fibromatosis. Desmoid tumors are also associated with a rare condition called Gardner syndrome.

According to Montgomery, et al., desmoid tumors and plantar fibromatosis are common in their histomorphologic grounds but differ in production, mass size and activity. These authors found that the APC/b-catenin pathway may play a role in the different growth characteristics of superficial versus deep fibromatosis, and that these two categories of fibromatosis are truly and genetically distinct.
Juvenile aponeurotic fibroma is a rare tumor that presents in patients who are 20 years of age or younger. The fibroma forms a hard, discrete mass on the plantar sole that is amenable to surgical excision with functional preservation.

Comments

Have you had any experience using topical Verapamil? I have had very good results redcuing the size and the symptoms of plantar fibromatosis using topical Verapamil from my local compounding pharmacist. In fact, I have not excised one in several years. Ronald W. Hines, DPM Oklahoma City, Oklahoma.

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