Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Posted by Roelinde on 8/24/99 at 00:00 (010128)

Hello everyone!

Perhaps some of you remember some earlier messages I left here about my mothers feet problem. She has been treated several times now with Extracorporal Shock Wave Therapy (ESWT) in the Netherlands and is slowly improving. I recently got an email with lots of background information from Michael Doerfell, who is sales manager for High Medical Technologies in Switzerland, the company that has organised these treatments for my mother. They have asked me to forward this information to this message board, as it may contain valuable information to all of you. My mothers feet problem has now been diagnosed as plantar fibromatosis, which is actually not the same as plantar fasciitis (explained below). It may be that more of you actually suffer from this instead of PF.

Best wishes to all of you,

Roelinde

---------------------

This is what Michael Doerfell wrote to me:

I think I should give you some additional information about your mother*s disease and the shock wave treatments carried out with HMT*s ReflecTron. I hope you*ll find it informative and helpful, and please feel free to give us any comments along the way.

Usually a calcaneous spur (heel spur, plantar fasciitis) can be clearly seen on X-ray photographs. The X-rays of your mother*s feet didn*t show any sign of a spur. Dr Chin-A-Paw, surgeon of the Sint Lukas Ziekenhuis in Winschoten, found a thickening of the arch, some nodules and a contraction of the toes. He diagnosed a plantar fibromatosis, which is different to a plantar fasciitis.

What is plantar fibromatosis? In some European countries this condition is known as Ledderhose disease or Ledderhose Plantar Fibromatosis or Morbus Ledderhose.

Dupuytren was the first to note the nodular thickening of the plantar fascia when he published his description of hand and finger contractions in 1839. The thickening of the dense tissue just under the skin of the palm can draw the fingers, usually the ring and/or small fingers, down into flexion. When the finger draws down enough to hinder function, surgical excision of the thickened palmar fascia is the appropriate treatment.

In 1897 Ledderhose described the histological features of this condition as it applies to the foot.

Plantar fibromatosis is a benign nodular disorder of the plantar fascia (which is also known as the plantar aponeurosis). The plantar fascia is a thin, wide, long tissue that begins on the bottom (plantar) aspect of the heel and will continue forward through the arch to the ball of the foot. This tissue is a type of ligament that is made of bands of fibers that act as a shock absorber during weight bearing.

Plantar fibromatosis is most commonly found in the region of the arch but may occur at any point on the plantar fascia. These nodules often begin as pain free bumps under the skin but may become very painful during periods of high activity such as running, tennis, aerobics, and other similar activities. There may be redness and swelling in those regions but often will not show signs of irritation. It should be noted that this condition may occur in other parts of the body with subsequent renaming of the condition specific to that part.

Clinical Characteristics - It first appears as a single, firm, subcutaneous nodular thickening along the arch side of the foot. When manipulated, the mass appears to be affixed to the deeper tissues. As the condition progresses, multiple nodules may be noted. Size may vary from just a few millimeters up to over 10 cm (although this is quite rare). Age groups affected are from 10 - 70.

Etiology - This condition is probably hereditary but may be associated with trauma (simply in the form of high level activities such as tennis, running, and aerobics), infection, gout, lead poisoning, and a few metabolic diseases.

Treatment and Recurrence - Local surgical excision of the plantar fibroma is known to have recurrence rates from 60% - 85%. The high rate of recurrence has often been attributed to inadequate excision of the nodule. The nodule tends to extend into what appears to be normal fascial tissue but histologically the tissue is abnormal.

Due to the fact that your mother had pain all over the foot Dr Chin-A-Paw decided to treat the whole area from the heel to the toes (16th of November 1998) with 2000 shock waves.

For the treatment of a heel spur we usually administer 1500 shock waves to an area of 4 – 6 mm in diameter! Your mother received actually only a small amount of shock waves (= energy) compared to a ˜normal* ESW treatment of the heel. This explains why we had to re-treat your mother three times up to now.

When your mother came back for the second treatment (18th of January 1999) we found that the contraction of the toes was less then before ESW treatment. Dr Chin-A-Paw treated your mother meanly at the arch side of the feet with 1500 shock waves.

The third treatment took place on the 15th of March 1999. The nodules could be palpated and the thickening of the fascia was clearly visible. Dr Chin-A-Paw treated her with 1500 shock waves.

To our regret an over-enthusiastic orthopaedic shoemaker gave your mother too much support which caused too much stress to the arch. Dr Chin-A-Paw prescribed a medicine to improve the blood supply. As far as I know this was the only medication your mother received during ESWT.

On the 31st of May we treated your mother the fourth time with the ReflecTron. Your mother reported about ups and downs of the pain during the last weeks. Dr Chin-A-Paw administered 1500 shock waves per foot. We all hope that the pain will disappear and that her feet improve again.

During all treatments your mother was very brave. She never claimed about the pain and a shock wave treatment is not painless. Some patients need a local anaesthesia.

How will it develop? At present we do not have enough experience with the treatment of Morbus Ledderhose or Dupuytren*s contracture. Therefore we cannot give any prognosis about the healing process but we are confident that we are on the right track.

You may interested in how shock waves work. Unlike ESWL (Extracorporeal Shock Wave Lithotripsy) for urinary calculi, the mechanics of ESWT are not yet fully understood.

High Medical Technologies AG and others are conducting research to determine how exactly shock waves work. Currently, there are four hypotheses:

1) Shock waves stimulate the metabolic reaction of tissue (the sum of the chemical and physical changes occurring in tissue), causing development of stress fibers and/or change in membrane permeability. Hypervascularisation following the shock wave treatment

2) Shock waves create cavitation bubbles which break down/change the consistency of calcific deposits

3) Shock waves induce an analgesic effect by over-stimulating the axons (Gate-control Theory), thereby increasing the pain threshold.

Most properly it is a combination of all of them.

According to our experience in ESW treatments there is a certain threshold value in the energy density that has to be exceeded to stimulate healing processes. The sum of biological effects is correlated with the total amount of energy above the certain threshold. This is equivalent to a typical antibiotic therapy. The serum concentration has to be above a certain threshold to show an effect to the bacteria and the total dose administered corresponding to the number of effects.

P.S. If you want to learn more about ESWT, HMT High Medical Technologies AG and our products please visit our homepage at http://www.hmt-ag.ch


Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Andrea on 8/24/99 at 00:00 (010135)

I am unclear as to these nodules and how they discovered them. Can you feel these 'nodules' upon touching her feet. How did they get to this conclusion. I've never heard of this?

Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Beth on 8/24/99 at 00:00 (010146)

It seems to me that diagnosing foot problems is at the core of our problems. One podaitrist told me I had tarsal tunnel and PF, the neurologist ruled out tarsal tunnel and told me to get my thyroid checked. I bought the orthotics from the first podiatrist then the second told me my 'gait' wasn't too bad and I didn't even need orthotics. I've since taken them out of my shoes and have the same degree of daily pain.

Do most of you have pain in both feet? In my case it's my right foot-the one I broke about 15 years ago. Maybe I just am getting arthritis. I don't know and am getting desparate to just get an accurate diagnosis. I know not walking helps and it makes me cry to think about not being able to walk and play outdoors with my kids.

I'm glad your mom got a diagnosis. At least she knows.

Beth


Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Roelinde on 8/25/99 at 00:00 (010164)

Hello Andrea,

Yes, my mother can feel these nodules, or thickening of the fibers, when touching her feet. She says her whole fascia is very hard. The ESWT treatment she has received several times now has reduced the total 'hard' area, although there are still some parts left. From what I understand, this condition is rare, at least the extent to which my mother has it, is.

Roelinde


Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

John on 8/28/99 at 00:00 (010307)

if i follow the ligiment from my great toe all the way to where it attaches to the heel i can feel small nodules slightly larger than a grain of sand. physical thearpist tell me they note these on many people. i suspect they are calcifications which form all over the body as we age. pull up on your great toe and carefull follow the fascia down to your heel with your finger tips. some of you will find these nodules.

Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Andrea on 8/24/99 at 00:00 (010135)

I am unclear as to these nodules and how they discovered them. Can you feel these 'nodules' upon touching her feet. How did they get to this conclusion. I've never heard of this?

Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Beth on 8/24/99 at 00:00 (010146)

It seems to me that diagnosing foot problems is at the core of our problems. One podaitrist told me I had tarsal tunnel and PF, the neurologist ruled out tarsal tunnel and told me to get my thyroid checked. I bought the orthotics from the first podiatrist then the second told me my 'gait' wasn't too bad and I didn't even need orthotics. I've since taken them out of my shoes and have the same degree of daily pain.

Do most of you have pain in both feet? In my case it's my right foot-the one I broke about 15 years ago. Maybe I just am getting arthritis. I don't know and am getting desparate to just get an accurate diagnosis. I know not walking helps and it makes me cry to think about not being able to walk and play outdoors with my kids.

I'm glad your mom got a diagnosis. At least she knows.

Beth


Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

Roelinde on 8/25/99 at 00:00 (010164)

Hello Andrea,

Yes, my mother can feel these nodules, or thickening of the fibers, when touching her feet. She says her whole fascia is very hard. The ESWT treatment she has received several times now has reduced the total 'hard' area, although there are still some parts left. From what I understand, this condition is rare, at least the extent to which my mother has it, is.

Roelinde


Re: My mothers feet problem is now diagnosed as plantar fibromatosis (long message!)

John on 8/28/99 at 00:00 (010307)

if i follow the ligiment from my great toe all the way to where it attaches to the heel i can feel small nodules slightly larger than a grain of sand. physical thearpist tell me they note these on many people. i suspect they are calcifications which form all over the body as we age. pull up on your great toe and carefull follow the fascia down to your heel with your finger tips. some of you will find these nodules.