Plantar fibromatosis (Ledderhose disease)

Medical Information

Etiology

Genetic component through altered single nucleotide peptides (SNPs) with autosomal dominant inheritance and variable penetrance, similar to Dupuytren's disease in the hand, known as palmar fibromatosis.

Symptoms

Plantar fibromatosis exclusively with nodule formation in the foot cavity, typically located in an area extending from the heel to the level of the Lisfranc joint and transversely across the first to third metatarsal rays. In addition to clinical palpation findings, imaging can and should assist in ruling out benign or malignant tumors (sarcoma, Toepfer et al., 2017) as a differential diagnosis.

Apparatus-based Diagnostics

Ultrasound

Sonographically, similar to Dupuytren's nodules in the hand, Ledderhose nodules appear subcutaneously, located superficially above the plantar fascia, often hypoechoic, but sometimes isoechoic relative to the surrounding subcutaneous fat. A deeper location (underneath) the plantar fascia suggests a different process (e.g., sarcoma, Motolese 2013; Toepfer 2017). Modern ultra-high-resolution Doppler techniques, such as Superb Microvascular Imaging (SMI), show different expressions depending on the degree of activity.

Treatment of Ledderhose Disease

The treatment of plantar Ledderhose disease is similar to the treatment of the nodular stage of Dupuytren's disease in the hand, such as palmar fibromatosis, and Peyronie's disease in the penis.

In the nodular stage, the following treatment options can be offered for painful nodules and Ledderhose-related distress:

• Focused ESWT

• High-energy ESWT (generally three sessions separated by 1-2 weeks, follow-up after 6 months as a booster, Knobloch 2012). A South Korean study group has utilized an average of 8 (5-12) sessions of focused ESWT (Hwang et al., 2020).

• Plantar radiotherapy to inhibit progression

  (Heyd 2010, Seegenschmiedt 2013 & 2015, Rödel 2017).

• Surgical excision

  Surgical excision is associated with a recurrence rate of over 50%.

Shockwave Therapy for M. Ledderhose (plantar fibromatosis)

Indication:

Indication by a specialized physician.

Contraindication:

Malignant tumor in the focus.

Spatial requirements:

Certification criteria for a medical practice, such as hygiene plan, emergency management available according to DIN standards.

Patient preparation:

Differentiated and documented education and information.

Medical and assistant staff:

ESWT is a service that must be performed personally by the qualified physician with specialized knowledge.

Implementation of the therapy:

Positioning of the patient in a sitting or lying position, according to patient preferences.

Carroll P, Henshaw RM, Garwood C, Raspovic K, Kumar D. Plantar fibromatosis: pathophysiology, surgical and nonsurgical therapies: an evidence-based review. Foot Ankle Spec 2018 Jan 1.

Heyd R, Forn AP, Herkströter, Rödel C, Müller-Schimpfle M, Fraunholz I. Radiation therapy for early stages of Ledderhose disease. Strahlenther Onkol 2010;186(1):24-.

Hwang JT, Yoon KJ, Park CH, Choi JH, Park HJ, Park YS, Lee YT. Follow-up of clinical and sonographic features after ESWT in painful plantar fibromatosis. PLoS One 2020;15(8): e0237447.

Knobloch K. Ledderhose's disease - an update on therapeutic options. MMW Fortschr Med 2012;154(19):43-4.

Knobloch K, Vogt PM. High-energy focused ESWT reduces pain in plantar fibromatosis (Ledderhose's disease). BMC Res Notes 2012; 5:542.

Motolese A, Mola F, Cherubino M, Giaccone M, Pellegatta I, Valdatta L. Squamous cell carcinoma and ledderhose disease: a case report. Int J Low Extrem Wounds 2013;12(4):297-300.

Rödel F, Fournier C, Wiedemann J, Merz F, Gaipl US, Frey B, Keilholz L, Seegenschmiedt MH, Rödel C, Hehlgans S. Basis of radiation biology when treating hyperproliferative benign diseases. Front Immunol 2017; 8:519.

Seegenschmiedt MH, Micke O, Niewald M, Mücke R, Eich HT, Kriz J, Heyd R, German Cooperative Group on Radiotherapy of benign diseases. DEGRO guidelines for the radiotherapy of non-malignant disorders: part III: hyperproliferative disorders. Strahlenther Onkol 2015;191(7):541-8.

Seegenschmiedt MH, Attassi M. Radiation therapy for Ledderhose disease-indication and clinical results. Radiation Oncol 2013;179(12):847-53.

Toepfer A, Harrasser N, Dreyer F, Mogler C, Walther M, von Eisenhart-Rothe R. Epithelioid sarcoma of the plantar fascia mimicking Morbus Ledderhose - a severe pitfall for clinical and histopathological misinterpretation. Foot Ankle Surg 2017;23(4): e25-30.