How To Handle Plantar Fibromas

Author(s): 
By Matt Sabo, DPM

Enneking staged these different components for surgical intervention. The classification identified the sarcomas as either low grade (Stage I) or high grade (Stage II) sarcomas. The classification also addresses histological appearance and diagnostic imaging, and whether the sarcoma is intra-compartmental or extra-compartmental. The third stage of the Enneking surgical staging system for malignant soft tissue sarcoma is whether the tumor consists of no distant metastasis or any regional or distant metastasis.

What You Should Know About Diagnostic Imaging Of These Lesions
Diagnostic imaging plays an important role in the diagnosis of various forms of plantar fibromatosis. In general, one should take a radiograph to evaluate bony structures. Obviously, the radiograph will not show any soft tissue structure but will show local invasive bone destruction (although this is rare). Ultrasound has become increasingly popular as a diagnostic modality for soft tissue tumors.

Ultrasound will show the local lesion as a hypoechoic mass but fails to show the true extent of the lesion.

Magnetic resonance imaging (MRI) is useful for detecting planar fibromatosis. It will show signal intensity of heterogeneity and infiltrative margins. It also shows the degree of deep invasion of plantar fibromatosis. Magnetic resonance imaging shows that the plantar fibromatosis lesion is not well encapsulated but is well circumscribed. The lesion, with MRI, is typically of low signal in both T1 and T2 weighted images. This is due to its large collagen content. Magnetic resonance imaging short TI inversion recovery (MRI STIR) is helpful in distinguishing more aggressive lesions.

Pertinent Pointers On Treatment Options
Typically, plantar fibromatosis is asymptomatic and treatment for patients with early disease requires observation. Patients who have an early stage lesion should receive a persistent trial of conservative treatment, which should include: padding, orthotic management, non-steroidal antiinflammatory drugs (NSAIDs) and physical therapy. Intralesional injection therapy with corticosteroids has some merit in the initial stages of the disease but as the disease accelerates, its success rate is doubtful.

One should evaluate surgical intervention for the various forms of plantar fibromatosis on a case-by-case basis. In a symptomatic case of plantar fibromatosis not relieved by conservative measures, take a radical excision of the plantar fascia. Take at least 1.5 cm of normal fascial tissue. Large exposure is necessary to uncover the entire lesion. A Z-shaped or an S-shaped surgical incision can give complete exposure to the entire plantar fascia for a radical plantar fasciotomy. When excising the lesion, take care not to disrupt tissue deep to the medial fascial band. Since lesions are commonly limited to the medial fascial band, be careful not to disrupt the medial plantar digital nerve and flexor hallucis brevis muscle. These structures run just deep to the plantar aponeurosis.

Plantar fibromatosis has a high recurrence rate. This rate is decreased with radical excision of the plantar fascia. However, be aware that recurrence is high and usually rapid. If the tumor recurs, the rate of malignancy is quite low.

Desmoid tumors require a radical excision of the lesion. Often adjunct treatment may be required. This may include radiation treatment, estrogen blockage and chemotherapy. Resection of this kind of plantar fibromatosis has an intermediate recurrence rate of 20 percent. Although adjunct therapy will reduce the rate of recurrence, amputation may be required for multiple recurrences. When commencing closure, utilize a drain to reduce the risk of hematoma formation and flap necrosis. Place this patient in a non-weightbearing Jones compressive dressing for at least 21 days. One should use accommodating orthoses after surgical correction.

In regard to the other forms of plantar fibromatosis, especially the infantile forms, surgical correction is limited because of the spontaneity of the lesion to regress. Obtaining a biopsy of the lesion may induce this regression.

Plantar fibromatosis has an increasingly favorable prognosis with complete radical excision of the plantar aponeurosis. One should consider surgery only when palliative measures have failed and the tumor has progressed from its early stages.

 

 

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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