Plantar fibromatosis ultrasound image

Plantar fibromatosis or Ledderhose Disease

I am a podiatrist in private practice in San Antonio, Texas with about 30 years of experience. The last surgery I performed on plantar fibromatosis was a bit over 15 years ago at which time I concluded that most available surgical treatments are not effective. Simple excision of the nodules has about a 70 percent recurrence rate. Wide excision, that is, excision of the nodules with a portion of the plantar fascia can provide a higher success rate but is relatively disabling.**

It is important to focus on the composition of the nodules, scar or fibrotic type tissue. The more specific one can be with treatment, the potentially more effective the treatment and the less potential for side effects. I feel that surgical approaches or use of radiation on a benign lesion is too aggressive.

There are enzymes that have the capability to break down scar tissue. Our body produces such enzymes and other such enzymes can be synthesized or derived from animals. It is normal for scar tissue to be produced by the body as a component of tissue repair. The fibromas appear to represent a local lack of scar tissue modulation resulting is marked overproduction of scar tissue. The introduction of enzymes to reduce that process has been our primary approach for a number of years and one we have had good success with.

The primary enzyme we utilize is called hyaluronidase. We mix hyaluronidase with a local anesthetic such as lidocaine or Marcaine plus a small amount of a repository steroid, triamcinonlone acetonide and inject the solution into the nodules to gradually soften and shrink the nodules. Accuracy of the injections is augmented by use of sonography or diagnostic ultrasound.

The amount of fluid that can be injected into a nodule at one time is limited so the procedure is generally perform three times at an interval of three weeks between injections.

We are pleased with the success rate of this treatment and have had a number of patients from out of state visit us for the procedures. Treatment failures are rare but we have had a small number of patients obtain incomplete relief due to an insufficient number of injections.

The number of injections is proportional to lesion size. We have performed as few as two and as many as four on larger lesions.

More recently, we have added a means to achieve more rapid shrinkage of the nodules via a new technology that uses directed ultrasound to “emulsify” the lesions called TenexTX.

Adjunctive treatments may increase the effectiveness of the primary treatment and include use of topical Verapamil cream or gel. Topical verapamil has been shown to effectively shrink smaller nodules of Ledderhose disease. Its addition to more aggressive treatments may bring speedier shrinkage of nodules.***

*Similarities between Dupuytren’s contracture and Ledderhose disease/plantar fibromatosis:
**Surgical treatment of plantar fibromatosis or Ledderhose disease and the recurrence rates:

***Information concerning topical verapamil for plantar fibromatosis from PD Labs:

Fibroblasts are cells that create collagen which is the main structural protein in connective tissues to include ligaments and tendons. Such cells also secrete molecules which make up the extracellular matrix which is composed of cells that provide both structural and metabolic support to surrounding cells.

There are different types of collagen depending on tissue type. A disorder of fibroblastic activity can lead to the wrong types of collagen being placed in the tissue. Instead of collagen being laid down in an orderly fashion, the process can lay down the wrong amounts of collagen and in an incorrect fashion creating tissues like fibromas. A fibroma is an overgrowth of fibrous or scar tissue. While the tissue overgrowth (or hyperproliferative tissue) is benign, it can be very aggressive. Fibromas have been mistaken for fibrosarcomas (malignant fibrous tumors) in the past.

Enzymes are catalysts which help to regulate collagen production and breakdown. Enzymes are specific to certain tissues, causing specific reactions. Use of an enzyme targeted at overactive fibroblastic action may be the most specific treatment for Ledderhose Disease or plantar fibromatosis.