Plantar Fibromatosis: Ledderhose Disease

Plantar fibromatosis (PF), also known as Ledderhose disease or Morbus Ledderhose, is a rare, benign and slow-growing fibroproliferative disorder characterized by the formation of firm nodules within the plantar fascia, the thick connective tissue on the bottom of the foot. These nodules are composed of disordered fibrous tissue and can become painful, especially during weight-bearing activities.

Associated Conditions

PF is often seen in conjunction with other fibromatoses and systemic conditions, including:

• Dupuytren’s contracture (palmar fibromatosis)
• Peyronie’s disease (penile fibromatosis)
• Frozen shoulder (adhesive capsulitis)
• Diabetes mellitus
• Epilepsy
• Chronic alcohol use
• Smoking
• Use of anticonvulsant medications like phenobarbital

 

Location

Plantar fibromatosis most commonly involves the medial and central bands of the plantar aponeurosis, the thick fibrous tissue that runs along the sole of the foot from the heel (calcaneus) to the toes. These areas are particularly important in supporting the longitudinal arch and involvement here can affect gait and weight-bearing.

Pathophysiology and Growth Factors

The development of fibromas (nodules) in PF is driven by abnormal fibroblastic activity, triggered by a combination of mechanical stress and biochemical signals. Several growth factors and inflammatory mediators are involved:

• Platelet-Derived Growth Factor (PDGF) - promotes fibroblast proliferation and tissue remodeling.
• Transforming Growth Factor-β (TGF-β) - stimulates collagen synthesis and myofibroblast differentiation.
• Interleukin-1α and 1β (IL-1α, IL-1β) - pro-inflammatory cytokines that further stimulate fibroblast activity.
• Free oxidized radicals - contribute to cellular stress and tissue damage, possibly triggering fibrotic responses.

These factors lead to the proliferation of fibroblasts and the production of excessive collagen, particularly type III collagen, forming fibrotic nodules in the plantar fascia.

Histological Phases of Plantar Fibromatosis

PF shows histological features similar to Dupuytren’s disease and progresses through three distinct phases:

1. Phase I: Proliferative Phase
2. Phase II: Active Phase
3. Phase III: Maturation or Residual Phase

Causes of Plantar Fibromatosis 

The causes are not fully understood, but several factors have been associated with its development:

• Genetic predisposition - family history may increase risk.
• Repetitive trauma or micro-injury - to the plantar fascia.
• Chronic plantar fasciitis - may trigger fibrous tissue proliferation.
• Diabetes mellitus
• Epilepsy - especially in those on long-term phenytoin therapy.
• Alcoholism
• Liver disease - such as cirrhosis.
• Use of certain medications - like phenobarbital or beta-blockers.
• Dupuytren’s contracture - as part of a broader fibromatosis syndrome.

 

Clinical Presentation

Nodule Characteristics

• Location: Medial and central bands of the plantar aponeurosis.
• Size: Typically 0.5–3.0 cm, but can range from 0.3 to 5.0 cm.
• Consistency: Firm, well-encapsulated.
• Growth: Slow-growing; usually develops gradually over months to years.
• Position: Nodules can be:

         > Subcutaneous

         > Buried within fascia

         > Intra-aponeurotic

• Tissue involvement: Typically does not involve skin or smooth muscle, unlike Dupuytren’s disease. This helps explain the low incidence of toe contractures.

Symptoms

Early stages

• May be painless
• Feeling of fullness or localized pressure
• Mild discomfort in footwear

Progression

• Pain during weight-bearing, walking, or standing
• Tenderness over the nodules
• Pain worsens with:

         > Nodule enlargement

         > Tight shoes or walking barefoot

         > Prolonged standing

• Difficulty walking in advanced stages

Advanced cases

• Rarely, toe flexion contractures may occur
• Bilateral cases (~25%) may cause greater functional impairment

 

Diagnosing Plantar Fibromatosis

 

Differential Diagnoses for Plantar Fibromatosis

• Plantar Fasciitis
• Plantar Fibroma
• Lipoma
• Ganglion Cyst
• Morton's Neuroma
• Soft Tissue Sarcoma
• Foreign Body Granuloma
• Tarsal Tunnel Syndrome
• Dupuytren’s Disease (if present elsewhere)
• Reactive or Traumatic Scar Tissue

 

Physiotherapy Management of Plantar Fibromatosis

Goals

1. Alleviate pain
2. Reduce mechanical stress on the plantar fascia
3. Improve foot function
4. Maintain mobility and prevent compensatory dysfunction
5. Delay or avoid surgical intervention

Patient Education

• Condition Overview - educate patients about the benign but potentially progressive nature of PF.
• Footwear Advice - encourage the use of cushioned footwear with arch support; avoid walking barefoot, especially on hard surfaces.
• Activity Modification - reduce or modify activities that increase plantar pressure (e.g., running, jumping, prolonged standing).

 

Load Management

Activity Modification

• Temporarily reduce high-impact or weight-bearing activities that worsen symptoms.
• Recommend interval-based standing and ambulation.

Gait Adjustments

• Identify and correct altered gait patterns.
• Use gait retraining to redistribute plantar pressure, particularly off the medial longitudinal arch.

 

Offloading & Orthotic Support

Offloading Pads

• Foam or gel pads for small fibromas.
• Custom orthotics with targeted cut-outs for larger fibromas to offload pressure.

Arch Supports

• Semi-rigid orthoses to reduce plantar fascia tension.

Additional Supports

• Heel cups or metatarsal pads to redistribute pressure and improve comfort.

 

Manual Therapy

Soft Tissue Techniques

• Gentle soft tissue mobilization around (not over) the fibroma.
• Myofascial release of the calf, achilles tendon, and plantar fascia.

Joint Mobilizations

• Ankle (talocrural), subtalar and midfoot joints if mobility restrictions are noted.

 

Stretching Exercises

Plantar Fascia Stretch

• Roll foot over a frozen bottle or massage ball (3–5 mins).

Calf Muscle Stretching

• Gastrocnemius stretch (knee straight).
• Soleus stretch (knee bent).
• Hold for 30 seconds, repeat 3–5 times daily.

Toe Extension Stretch

• Stretch big toe into extension while massaging the plantar fascia.

 

Strengthening Exercises

Intrinsic Foot Muscle Activation

• Towel curls
• Marble pickups

Arch Control

• Short foot exercises (doming) to activate the medial longitudinal arch.

Proximal Strengthening

• Gluteal and core strengthening to support lower limb biomechanics and reduce distal load, examples - glute bridges, side-lying hip abduction, planks.

 

Neuromuscular Re-education

Balance Training

• Single-leg stance (eyes open/closed)
• Wobble board and foam surface balance tasks

Posture & Gait Correction

• Emphasize proper foot alignment during stance and gait.
• Include barefoot awareness drills on soft surfaces for proprioceptive training.

 

Electrotherapy

Therapeutic Ultrasound

• Pulsed ultrasound to aid soft tissue healing and reduce pain.

Low-Level Laser Therapy (LLLT)

• May reduce inflammation and modulate pain in fibromatosis.

Iontophoresis

• Use of corticosteroids (e.g., dexamethasone) to reduce inflammation.
• Consider in combination with other modalities.

 

Taping Techniques

Low-Dye Taping

• To support the medial arch and offload the plantar fascia during functional activities.

Arch Taping

• Improves arch integrity and reduces direct pressure over fibromas.

 

Monitoring & Outcome Tracking

• Pain Scales - use VAS or NPRS to track symptom changes.
• Palpation - monitor tenderness, fibroma consistency and size.
• Function - assess changes in gait, standing tolerance and walking endurance.
• Progression - reassess every 4–6 weeks; adjust treatment based on symptom response and load tolerance.

 

Indications for Referral

Refer to a medical specialist if:

• No symptom improvement after 12 weeks of conservative therapy.
• Rapidly enlarging fibromas.
• Severe, persistent pain or functional limitation.
• Consider steroid injections, radiotherapy, or surgical consultation.