Ledderhose Frequently Asked Questions

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Plantar Fibromatosis, aka Ledderhose Disease
Put together with the help of the British Orthopedic Foot and Ankle Society, Bofas

 

Commonly asked questions:

What is plantar fibromatosis?

Plantar fibromatosis is a condition where the patient develops benign lumps under the arch of the foot, in a structure called the plantar fascial band. This is a strong sheet of tissue that sits between the skin and the tendons and bones under the foot, and gives strength to the foot and the arch.

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Why is it sometimes called Ledderhose Disease?

Plantar fibromatosis is sometimes called Ledderhose disease, especially in Europe, after Dr Georg Ledderhose, the doctor who first described the condition (in 1894 and in greater detail in 1897).

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What causes this condition?

The exact cause of the condition is unknown, but there is a genetic component. People who get this may also have a similar problem in their hands called Dupuytren’s disease, or have a family member with the same condition.

It can also be associated with skin thickening over the back of the finger joints (Garrod’s fat pads), initially described in 1904 by Archibald Garrod in relation to Dupuytren’s disease, and fibrosis of the soft tissues of the penis leading to abnormal curvature (Peyronie’s disease) described by Francois Gigot de la Peyronie in 1743.

Some patients say that their lump came up after an injury; the condition may be an exaggerated response to one single trauma or to chronic inflammation and so-called micro trauma. In a lot of cases there is no trauma involved at all and the lump comes up spontaneously.

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When do I need to see a specialist?

It is best to see your GP when you first become aware of any lumps. This is to ensure that an accurate diagnosis is made, as there are several possible reasons for lumps in the feet. After that, if the lump is not causing any pain or problems while standing or walking there may not be any need for treatment, so your GP or a podiatrist will be able to monitor your progress. If the lump is causing problems your GP will probably refer you to a foot and ankle specialist orthopedic surgeon.

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What tests can be performed to confirm the diagnosis?

In the vast majority of cases the diagnosis is made clinically, after reviewing the patient’s medical history (e.g. patient or family member has Dupuytren’s contracture of the hand) and examining the feet.  X Rays and scans are only occasionally required.  Ultrasound is the most convenient and informative investigation. Taking a biopsy is not a good idea, as this often aggravates the condition and causes the lumps to increase in size.

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What treatment options do I have?

There are several treatment options:

Orthotics are usually the first option to be tried and very few patients require any more than this.  Relief Orthotics are special insoles that are designed to take pressure off the affected area, and so reduce the pain when standing and walking.
Injection will occasionally be recommended. This may be of steroid or dextrose. The aim is to reduce the inflammation around the lump and thereby reduce its size. The injection is best given under ultrasound control. How long any improvement lasts is not predictable.

Radiotherapy can be performed if the lumps are growing and active. This helps to shrink and soften the lump(s) and in some cases may stop progression for many years. This treatment is not currently available on the NHS in the UK, but can be obtained privately.

Cryosurgery is used in some countries. This treatment freezes the lump(s) and surrounding nerves. Sometimes several treatments are needed. There is no consensus on whether this treatment is effective.

Shockwave treatment (Extracorporeal shockwave therapy – ESWT) has been found to be useful in some (but not all) studies, as a way of reducing pain and softening the fibromas (lumps). Shockwave therapy is used for a number of tendon problems and is available in some UK centres. The National Institute for Clinical Excellence (NICE) has approved shockwave for use in some conditions but has not made specific recommendations for its’ use in Plantar Fibromatosis (Ledderhose). You may wish to discuss this treatment with your Consultant.  Treatment usually involves three sessions (can be uncomfortable).

Surgery can be performed for plantar fibromatosis but is not recommended.  Removing the lumps does not cure the condition and there can be major problems after operations.  It is common for the lumps to grow back and be worse than before. 

Scars from the surgery can be tender, and sometimes skin grafting is required, leaving thin tissue only under the foot which is not good for walking upon.

If too much of the plantar fascia is removed then it cannot perform its’ important role in supporting the arch of the foot. This can lead to chronic pain.

For these reasons the British Foot and Ankle Surgery Society recommends that surgical treatment is generally not used for Plantar Fibromatosis.

If there are genuine concerns over the nature of a lump then the patients should be referred to a unit specialising in the management of soft tissue tumours. 

In extreme cases in patients with large lumps that interfere with walking despite maximum conservative measures, surgery may rarely be considered taking into account the above issues.

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