LEDDERHOSE DISEASE - PLANTAR FIBROMATOSIS


Information about Ledderhose Disease or Plantar Fibromatosis.

Ledderhose Disease, also known as Plantar Fibromatosis or Morbus Ledderhose is a disease in which painful hard nodules form on the bottom of the foot.

Ledderhose Disease or Plantar Fibromatosis is a disease process in which the body forms hard nodules or fibromas on the bottom of the foot, attached to the plantar fascia, the ligament spanning the arch.  The nodules are composed of fibrous (scar) type tissue.  It is classified as a "hyperproliferative" disorder, that is, a disorder where there is an overgrowth of tissue. The cause of this disease is not known but there are a number of known characteristics:


1) The nodules can start as small pea size nodules but gradually increase in size to marble shaped or larger lesions.

2) The lesions are benign. The term "fibroma" refers to a growth consisting of fibrous or scar tissue.

3) Patients can have multiple lesions.

4) The fibromas can occur on one or both feet.

5) There are similarities to another disease process in the hand known as Dupuytrens Contacture.*

6) The nodules appear to be composed of fibrous tissue or aggressive scar tissue.

7) The lesions, when surgically removed, have a high recurrence rate.

8) The incidence of Ledderhose Disease compared to Dupuytrens is relatively low so there is a paucity of research and literature on the subject.  Lack of knowledge about the problem may often lead to limited availability of treatment options.

Collagen is the main component of connective tissues in the body and is a structural protein. There are 28 types of collagen identified so far but 5 types are common in the body. Type 1 collagen is the main component of body tissues and is the main component of skin, hair, tendon and bone. Type 2 collagen is the main component of cartilage. Type 3 collagen, also called “reticulate” collagen is found in organs and often alongside type 1 collagen. Fibromas, the lesions of plantar fibromatosis show a high percentage of type 3 collagen and an abundance of fibroblasts, the cell associated with production of fibrous or scar tissue.


Type 3 collagen plays in important role in wound healing and tissue repair. The body reacts to damaged tissue in three phases. The first phase of wound healing involves hemostasis (reducing bleeding) followed by influx of cells (macrophages) which assist in the removal of damaged tissue and other cells involved in control of infection and the initiation of tissue repair. The second phase, the proliferative phase involves fibroblasts entering the wound and the production of scar tissue for the purpose of contracting the wound, the scar or fibrous tissue having a high percentage of type 3 collagen. The final phase of wound healing, the maturation phase, involves the replacement of type 3 collagen with type 1 collagen.


The formation of the thick fibrous nodules of plantar fibromatosis (Ledderhose disease) represents a localized defect in modulation of the healing process in that excessive scar tissue is deposited and not replaced with normal tissue. Considering this defect in the healing process, avoidance of procedures which cause tissue damage, ie. Surgical treatment, is an important consideration.


The term, "plantar fibromatosis" has been used more commonly in the US, while "Ledderhose disease," more commonly in Europe. Both terms refer to the same disease. The German physician, Georg Ledderhose, first described the disorder in 1897.


Plantar fibromatosis is generally considered a rare disease, occurring more commonly in men than women, rarely in children and more commonly in Caucasians. Ledderhose disease is associated with conditions such as Duypuytren's contracture which demonstrates similar, but not identical, lesions in the hand.  Other related conditions include penile fibromatosis or Peyronies disease.  It is important to consider such conditions as they show a similar underlying defect in the laying down of abnormal collagen despite appearing on different areas of the body.  Considering the relatively low volume of information and research on plantar fibromatosis, reading the literature about related conditions can provide valuable insights to treatment.



Ledderhose disease
Plantar fibromatosis
Plantar fibromatosis ultrasound image
Plantar fibromatosis ultrasound image
Ledderhose disease
Plantar fibromatosis or Ledderhose Disease

What we have found that works.

 

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.
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