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Dear Podiatrists.

A 66 yo Finnish lady presented with a soft lump in the middle of her left foot Plantar suface. (I mention her nationality as one site said P.F. is more common in people of Northern European ethnicity)
She first noticed it at the beginning of March when it was quite painful. She had an ultrasound 3 weeks later which showed it was consistent with being a plantar fibroma.
Since then the discomfort has significantly reduced and only occurs if she presses really hard on the site. it is not a problem with daily activities. She does find that a slightly higher heel is more comfortable than the flat sneakers she usually wears.

From what I have read the P.F.'s are not recommended to be excised.

My question: In any one else's experience is there anything required now that the discomfort has resolved. Heel raise? Orthosis?

Thank You Jill

 

Jillian,

I have made orthoses for a number of patients with multiple plantar fibromatosis. I have found greatest success using softer laminated devices with plantar fascial groove and dells to accommodate the fibroma's. Typically, I'll use a triple laminate consisting of evazoate (next to the foot), poron and EVA (outside shell).

I don't know of published work contra-indicating surgical excision, but I do recall a conversation with Prof. Kirby some years ago during which he spoke of the relative simplicity of the excision. Times change, but I'm sure kevin will speak for himself. They do have a tendency to re-occur though and there's only so much scar tissue you want under your foot.

 

Hi Jillian:

"From what I have read the P.F.'s are not recommended to be excised."

If these are painful and conservative Tx is unsuccessful, excision is certainly a Tx option.
There is a recurrence possibility which increases with the number of masses present and a positive family history of palmer or plantar fibromatoses. In fact, in patients with more than three lesions on the same foot I basically do a fasciectomy and tell them there is a 50/50 chance of recurrence.

For a single, isolated fibroma (most of these occur at the level of the 1st Met-cun joint) the procedure is quite successful.

Steve

 

Plantar fibromas often will remain asymptomatic as long as the arch support of the shoe does not exert excessive compression forces on the plantar fibroma, causing pain. As Dr. Spooner notes, custom foot orthoses need to have accommodations built into their medial longitudinal arch in order to make them tolerable for patients with plantar fibromas.

I have good results with shrinking the size of plantar fibromas using intralesional injections of acetated steroid solution, such as DepoMedrol, being careful to stay away from the skin to avoid subcutaneous fat pad atrophy. One intralesional injection will typically cause a shrinkage in the lesion to approximately 1/2 its original size within 4 weeks time.

As Drs. Spooner and Arbes note, surgical excision is another treatment option if the plantar fibromas are bothersome for the patient or are resistant to conservative therapies. I try to avoid excising small fibromas since the loss in plantar fascial integrity may be significant mechanically and these are generally only cosmetic problems if proper shoes/orthoses are used. However, large symptomatic multilobed plantar fibromas require radical excision of the plantar fascia from the rearfoot to forefoot using typically a "Z"-type plantar incision, removing as much length of the plantar fascia as possible, to prevent regrowth of the plantar fibromas. These are some of the most interesting surgeries I perform since the visualization of the plantar arch anatomy that is offered during this procedure is like no other surgery. Plantar fibroma excision surgeries, when performed judiciously, are normally successful with minimal postoperative problems.

 

Thank you all for your responses. Jill