Plantar Fibromas: Causes, Symptoms, and Management
Introduction
Plantar fibromas are typically painless masses found on the plantar aspect of the foot (1). Plantar fibromas occur more commonly in men and in patients aged 30 to 50 years old (1). Fibromas histologically appear as a benign proliferation of fibroblastic tissue (1). Fibromas form through a proliferative phase of cellular growth followed by replacement with fibrous tissue (4). During the active stage there may be contraction within the plantar aponeurosis in a process similar to a Dupuytren contracture (9). The diagnosis of multiple plantar fibromas has historically been called plantar fibromatosis and Ledderhose disease (3).
Diagnosis
Patients typically complain of a soft tissue mass within the midfoot (1). Approximately 72% of plantar fibromas are found in the medial portion of the midtarsus region of the foot (2). Patients may complain of pain with weight bearing or when pressure is applied (3).
Diagnosis is typically assisted with an MRI or ultrasound. Standard radiographs will not show a fibroma as they typically have no calcification (7). An MRI can be used to make the diagnosis of a plantar fibroma. Contrast is typically required, as on a T2 image the fibroma is less bright than fluid (1). MRI can be valuable to also rule out a sarcoma (3).
Contrast enhanced MRI image of a plantar fibroma (1)
An ultrasound can also be used to make the diagnosis of a plantar fibroma. The typical findings of a plantar fiboma with ultrasound are a hypo or isoechoic mass that can appear as nodular thickening of the plantar fascia (1). There is typically no cystic change or calcification of the mass (3). The plantar fascia may appear to be disrupted from the fibroma (10).
Ultrasound image of a plantar fibroma (10)
Treatment
There is no gold standard treatment for plantar fibromatosis. Early lesions can be treated with offloading orthotics (4). The orthotics aim to offload the nodule and also act as a shock absorber for the foot (9). In recalcitrant cases, a rocker bottom shoe can help offload the pressure through the plantar aponeurosis (9). Endoscopic fasciotomies can be considered for definitive treatment of a large plantar fibroma (2). There are ongoing studies looking at fibrinolytics for the treatment of plantar fibromas (6).
Conclusion
Plantar fibromas are typically painless masses found within the plantar aponeurosis. Diagnosis is typically made with an MRI or ultrasound. Excision can be used for large and painful fibromas.
By Gregory Rubin, DO
rubinsportsmed.com
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References
1) Haun, Daniel W., et al. “Symptomatic Plantar Fibroma with a Unique Sonographic Appearance.” Journal of Clinical Ultrasound: JCU, vol. 40, no. 2, Feb. 2012, pp. 112–14. PubMed, https://doi.org/10.1002/jcu.20853.
2) Hafner, Shaun, et al. “Proximal Plantar Fibroma as an Etiology of Recalcitrant Plantar Heel Pain.” The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeons, vol. 50, no. 2, 2011, pp. 153–57. PubMed, https://doi.org/10.1053/j.jfas.2010.12.016.
3) Nduka, Jude C., et al. “Diagnosing Plantar Fibromas – Beware of Sarcomas.” Foot (Edinburgh, Scotland), vol. 49, Dec. 2021, p. 101736. PubMed, https://doi.org/10.1016/j.foot.2020.101736
4) Lui, T. H. “A Large Solitary Fibroma of the Deep Compartment of the Sole.” Foot (Edinburgh, Scotland), vol. 31, June 2017, pp. 1–5. PubMed, https://doi.org/10.1016/j.foot.2016.12.001.
5) Khan, Zeeshan, et al. “Tumours of the Foot and Ankle.” Foot (Edinburgh, Scotland), vol. 25, no. 3, Sept. 2015, pp. 164–72. PubMed, https://doi.org/10.1016/j.foot.2015.06.001.
6) Taljanovic, Mihra S., et al. “Ultrasound in the Evaluation of Musculoskeletal Soft-Tissue Masses.” Seminars in Roentgenology, vol. 52, no. 4, Oct. 2017, pp. 241–54. PubMed, https://doi.org/10.1053/j.ro.2017.08.002.
7) Murai, Naoki O., et al. “Bone and Soft Tissue Tumors About the Foot and Ankle.” Radiologic Clinics of North America, vol. 56, no. 6, Nov. 2018, pp. 917–34. PubMed, https://doi.org/10.1016/j.rcl.2018.06.010.
8) Veith, Nils T., et al. “Plantar Fibromatosis–Topical Review.” Foot & Ankle International, vol. 34, no. 12, Dec. 2013, pp. 1742–46. PubMed, https://doi.org/10.1177/1071100713505535.
9) Espert, Melissa, et al. “Current Concepts Review: Plantar Fibromatosis.” Foot & Ankle International, vol. 39, no. 6, June 2018, pp. 751–57. PubMed, https://doi.org/10.1177/1071100718768051.
10) McNally, Eugene G. Practical Musculoskeletal Ultrasound. Second edition, Churchill Livingstone, Elsevier, 2014.
