A 43-year-old football coach presents with a three-month history of pain in the plantar aspect of his foot. This had progressively become worse over time and was not associated with any trauma. The pain was made worse by physical activity and was particularly bad when he wore football boots.
On examination there was a small, localised area of tenderness just distal to the medial calcaneal tuberosity. This was associated with a small area of palpable thickening.
X-ray images of the foot are normal. There is no calcaneal spurring or other abnormality. There is a focal area of heterogeneous echotexture and thickening seen in the plantar fascia which measures 13 x 6 x 11mm which was tender to probe palpation and demonstrates increased vascularity. This is approximately 2cm distal to the origin of the plantar fascia and the appearances are suggestive of a plantar fibroma.
This case was successfully managed with careful footwear selection and an orthotic. The pain progressively improved over a two-month period. During this time, he was able to resume wearing football boots and normal physical activity. The mass is still present, and palpable, but is no longer tender.
Plantar fibromatosis (also known as Ledderhose disease), is a rare pathology involving the plantar fascia. It is characterised by disordered fibrous tissue proliferation and the formation of nodules. It has a similar aetiology to Dupuytren’s in the hand however in contrast to that condition, it is rare to develop a contracture. While the condition is benign it can cause pain, loss of function and decreased quality of life. It is bilateral in approximately 25% of patients and is up to ten times more common in men.
In most cases this condition can be diagnosed based on clinical findings and confirmed with the use of ultrasound imaging. The characteristic finding is of a firm, localised mass related to the plantar fascia. MRI scans can also be used when there is uncertainty about the diagnosis. In many cases the fibroma does not need any specific treatment. While it is unlikely to ‘disappear’ or resolve, in many cases it does not cause any symptoms. As this case illustrates, simple treatments like changing footwear or using an orthotic device can be very helpful. Other non-surgical treatments including corticosteroid injections, shock wave therapy and physiotherapy interventions should also be considered. If the mass increases in size or becomes more painful, surgical treatment (to remove the fibroma) can be considered.
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