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Hi all.

I have seen a 15 y.o male with a 12x10x10mm fibrous lump plantar aspect of left foot - just distal to the 2nd Met/Phalangeal joint. Present for about "4-5 months" & is causing irritation at times when running & walking.

I thought of a Plantar Fibroma & this seems to have been confirmed via an MRI I advised on (copy of report below). I must confess I have only seen a Plantar Fibroma case on possibly 2-4 occasions... I wasn't aware of condition appearing at such a young age. Being that the family has some Scandinavian background I also question on history of Dupuytren's Contracture ('Viking hand' condition) - no history can be recalled.

Subsequently for the treatment in the first & only consult as yet, I have fabricated a deflective device/orthotic via a off shelf Formthotic. On phoning mother I was told this has helped but there are still some symptoms present when running & playing (i.e. bicycling, skateboarding).

Hence I am seeking the professional opinion of colleagues who have also treated this condition... as well as for one this young & active (i.e. 15 y.o male). OR do others have another possible diagnosis worth investigating. I am aware of the surgical option (as far as Plantar Fibroma is concerned) but this appears sketchy as far as success is concerned (i.e. reoccurrence, scaring... & for someone this young???).

If surgery isn't a good option then accommodative options are best (???). I could also improve on my orthotic treatment option – as I wanted to provide some testable form of treatment within the first consult (& before diagnosis via MRI was gained) thus I didn't have much time to focus on this aspect within the timeframe. Have a custom device/orthotic with certain materials been of particular benefit based on other's experience with a condition like this?

Thanks.

Regards,
Matt.

 

Matt:

I tend to doubt that this is a plantar fibroma since 1) it is distal to the metatarsophalangeal joint at the level of the insertion of the plantar plate into the proximal phalanx [All the plantar fibromas I have ever seen have been proximal to the metatarsophalangeal joints.] and 2) the patient is really much younger than when we first start seeing plantar fibromas (early 30s is the earliest I have seen a plantar fibroma.

By the way, I have seen hundreds of plantar fibromas.

My guess it is a foreign body granuloma from stepping on a sharp object in this area of the plantar foot while barefoot. In addition, you should consider an epidermal inclusion cyst.

If this painful lesion doesn't get smaller over time, it will undoubtedly need to be excised via a plantar incision.

 

Thanks Dr Kirby for your valued opinion – much appreciated (sorry for the length of time taken responding). Yes, I tend to agree with you due to your above stated points i.e. 1/ lesion too far distal & 2/ patient too young... hence the puzzlement (it just doesn’t sit well with Plantar Fibroma).

Forgot I took a photo of the area. Here it is...



Whilst there doesn’t appear (as yet) any foreign body picked up via MRI, your suggestions of "Foreign body granuloma" & "epidermal inclusion cyst" sound much closer to the mark (particularly in line of the lifestyle of this young male). I will look further into these two suggestions.

Once again, thanks Dr Kirby.

(Oh, BTW... should I also be thanking/acknowledging P.A’s Dr Spooner as well? I noticed that a Dr Simon K. Spooner was involved with the "epidermal inclusion cyst" paper. Is it the same Dr Spooner on P.A?)

Kind regards,
Matt.

 

I agree the presentation location is not typical for plantar fibromatosis. A metatarsal cookie pad or an orthotic will help only in the short run. Was there a family history of malignancy or any lymphatic tenderness? There might be worse things to add to the differential diagnosis. Surgery to excise the mass sounds good to me.

 

Thanks Dr Debrule for your thoughts. I will check up on your suggestions; the mother does work in a medical field & probably would have informed me of any familial "malignancy or any lymphatic tenderness" based on my previous direction of questioning - yet, I will check.