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Hi, hoping to get some suggestions about a case that came up today...

A 54yo female presented with left midfoot pain. She has had a painful, palpable, soft tissue lesion for 8 weeks, and it is increasing in size. To brush softly causes pain, let alone to palpate the area. Wakes her at night in bed.

ultrasound shows "well defined lesion appearing to lie external to plantar fascia, approximately 16mm in size, uncertain in exact nature of lesion".

Patient reports no initial irritation of area, no history of foot pain, and no increase in activity or change of footwear over last months, and patient insists appropriate footwear is usually worn.

Plan is to get biopsy and possible surgical review.

?fibroma or ?acute plantarfascial rupture (free of other PF symptoms). Open to suggestions?!!

bill

 

biopsy --> fibroma (?) --> surgery

 

Most likely a plantar fibroma. In my experience surgical excision of plantar fibroma is very frustrating with painful scars and frequent recurrence. I personally will never excise another plantar fibroma. My current treatment of choice is transdermal verapamil compounded by my local pharmacist. PDL Labs in the U.S makes a version which is very expensive ($300 - $500 U.S. depending on the strength and size). My pharmicist charges $40 - $80 depending on the size and strength). The patient must vigourously massage a liberal amount of the ointment into the lesion twice a day. Most lesions get much smaller within 3 months and are usually gone in 6 months or so. Very large lesions may take longer and some never comletely resolve, but symptoms do. I have had some resolve in a days. Not a lot published yet about the mode of action except it has to do with calcium blocking. Also effective in Depeyton's in the hand and Peyronne's of the penis which I understand are both histologically similar if not the same as plantar fibromatosis. Verapamil has shrunk my Dupeytron's lesion to 80% of its original size in 4 months and pain is gone. The only problem with transdermal treatment is, you don't have a biopsy for defenitive diagnosis. You can always biopsy AND do transdermal treatment if you are unsure of the diagnosis.

 

What is the composition of the verapamil cream you are using? What base and how much drug? I will look into it here, I have a helpful pharmacist in the family. And how much of it are you using each time ?
Regards Phill

 

80 mg/ml Verapamil in an ointment base and have the patient massage 1 ml. into the affected lesion twice a day. I am not sure exactly what the base is, but my pharmacist's first attempt resulted in the Verapamil not dissolving in the base which gave a gritty feel to the ointment. Next attempt resulted in a very smooth ointment with the Verapamil dissolving into the base very well. Let me know how this works for you, Ron

 

I have the cream lined up, now I just have to talk to the biggest pair of plantar fibromas I've ever seen....I hope they cooperate...hx includes a go at just about everything....but not this..we'll see...I'll let you know what happens.
Thanks
Phill

 

I think you would be best served by removing the mass for biopsy. Often times what might appear as one process is indeed another. I had a patient a few months back with a large midfoot lesion dorsally 2 x 3 x 5 cm. While at first thought this would be a ganglion, no fluid or material was expressed with needle aspiration.

Open excision was performed and it turned out to be a Schwanoma. While a benign process, it was better to remove it for pathological exam.

Other times I have found what appear to be unusual lesions coming back from pathology as clear cell acanthoma, malignant melanoma, dermatofibroma etc. Even simple appearing ulcerations have come back as squamous cell carcinoma, or basal cell carcinoma.

It is better to biopsy and be certain.

 

This does sound like a fibroma.This type of mass is not uncommon in peri or post menopausal women.Do the biopsy to R/O anything worse.

 

This person has shown his bumps to every flavour of specialist there is and he has been assured they are not malignant, and he will not have surgery I made him some devices which he says help more than anything else he's tried, but this cream is worth a try.
Phill

 

Plantar fibromas will generally be asymptomatic unless there is something mechanically irritating it such as a shoe insole. Foot orthoses with plantar fibroma accommodations work well for these lesions, unless it is growing noticeably. I have injected these with intralesional cortisone (Depo-Medrol) with good results. Each injection will reduce the size of the fibroma by about 50% within a few months but care must be taken to during the injection to keep the cortisone away from the skin since plantar fat atrophy and skin hypopigmentation may occur. Haven't tried the verapamil but this treatment sounds interesting.

If the lesion, however, is acutely tender, inflamed and actively growing then you should suspect something other then a plantar fibroma. Plantar fibromas are embedded within the fascia (actually are integrated well within the fascia) and are not movable relative to the fascia. To determine this clinically, load the patients forefoot and digits into dorsiflexion to put the plantar fascia under tensile load and then see if the nodule can be moved significantly relative to the fascia (i.e. place either a medially and/or laterally directed manual force on the side of the nodule). A plantar fibroma will not move significantly relative to the fascia whereas other, more unusual nodules, will move.

The next step, would be to order an MRI. If the MRI can't be done, then the lesion should be biopsied and/or excised if it is suspected to not be a plantar fibroma. Much better to be safe than sorry if the nodule is inflamed, growing and very tender.

One more thing needs to be pointed out. I do surgically excise fibromas but recommend patients against it when possible due to the loss of function of the plantar fascia that results: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1464

If there are multiple large plantar fibromas that are symptomatic then it is best to surgically excise the whole plantar fascia. These patients may also have palmar fibromatosis (you should check every patient for this that has suspected plantar fibromas). By the way, even though I don't get to do radical plantar fasciectomies very often, it is one of the most interesting surgeries I have ever done....what a great anatomy lesson!

 

Hi there

I've recently dealt with the same situation a few months back. The patient presented with palpable masses along the medial longitudinal arch that were extremely painful and appeared to be more prominently exposed with dorsiflexion of the 1st MTP joint. I did a full weight bearing impression of the foot to make her a pair of semi-rigid orthoses. With the positive cast impressions, I added approximately 1/8" of plaster to the masses to help reduce the pressure while weight bearing. The patient was much more comfortable and I observed a reduction to the size of the masses.

Just thought I'd save you on the idea of surgery. Hope it helps!

C

C Ped (C)

 

Hi: I would like to recommend a simple method to help those of you with plantar fibroma problems. I have had this problem for about 6 years. Although it is a struggle, if you would like to try the following simple orthotic idea. Buy some sort of comfortable sports insert, I use one with an arch called Soft Sole an alternate that I think is also good quality is spenco. Fit the insert snuggly into the sneaker or shoe. Then put a drop of mineral oil on your fibroma or Vaseline and slip you foot into the shoe. Stand a bit, then remove the insert. I use this to identify where to cut out of the insert a hole slighly bigger than the fibroma. Cut his out to size and try it out. I have had a lot of success with this as a simple home made orthotic that you can alternate with any other one that the doctor provided. I actually found that I use this more. I have about 20 sports inserts with holes. A bit crazy. Since these are soft you should reduce the chance for any more fibromas. If your fibroma gets aggravated, ice it down with crushed ice in a zip lock bag. I used this for 6 years without increasing my fibroma in size and did a lot of golf walking. Unfortunately, now mine has finally gotten bigger due to some accidental shock abuse. So I may need the dreaded surgery. But I am interested in the Verapamil. If anyone can suggest a cheaper method with a formula for the pharmasict the does not infringe let me know. Well good luck.