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Plantar Fibromatosis

Posted by Andrew Walter on 2/06/03 at 07:57 (108178)

For the Foot Doctors:

I am 36 yo healthy active male and have a 3 x 3 x 1 cm (length / width / height) left plantar fibroma begining ~ 3cm from the heel and ending ~ 1cm from the ball of the foot. I have tried a punched out orthotic, vigorous massage therapy, stretching and daily use of NSAIDs / COX-2 inhibitors in various combinations with little, if any, relief (basically, the #$%$% things just continues to slowly get bigger). I can still perform my normal activities (running, biking, hiking, snowboarding, Yoga etc) to limits that my recently repaired left ACL (14 months ago) will allow, but I am living with increasing minimal to moderate, constant pain in this area.

For better or for worse, I am a gynecologic surgeon and am intimately aware of the pros and cons of surgery. I also have multiple friends who are Orthopods (including one who is a foot/ankle specialist) and have seen 3 DPMs; all (except 1 DPM), reccommended against surgical removal due to the short term morbidity (e.g. keloid,wound breakdown, etc) and the reasonably high recurrence rate (~25-30% with subtotal fasciaectomy).

I have 3 questions: (1) I have read on this site that injections with Kenalog/Hyaluronidase will decrease the size of these tumors; will this work for such a large fibroma? What kind of side effects can I expect from this (local or systemic infection? adrenal suppression?) and how many treatments are typically required? (2) Would there be any benefit to another trial of orthotics? (3) Would there be any benefit to a trial of lithotripsy? (4) If it gets to the point of not being able to live with this thing, what is the long-term impact of removing the plantar fascia in terms of a return to running, biking etc? (As a side note, I have read several ortho and podiatric texts as well as multiple journal articles and have not found this answered at all!!)

Thanks for your help,

Andy

Re: Plantar Fibromatosis

Dr. Z on 2/06/03 at 10:24 (108199)

Hi

I will try and keep this vey simple. If the area of fibroma is very large as you have indicated then surgical excision isn't the best or a choice period, especially with your lack of severe pain or nerve entrapement.

The use of Hyaluronidase with Kenalog is a good choice to use in the areas that are painful or preventing shoe wear with pain

ESWT isn't a procedure that will help you. ESWT is used for insertional plantar fasciitis. All of the studies ( limited) that I have read indicate that ESWT isn't effective

So what to do ? You are young active and stand alot. I like plastizole inserts or maybe a gel inserts. This will help to reduce the shock absorption in the damaged areas of the plantar fasia.

Don't worry about adrenal suppression or infection with the local injections. I am more concerned that your fibroma's are so large and that there are just too much of an area to reduce the size where it will make a difference. However a trial is reasonable at the largest areas or areas that are most painful. Feel free to ask any questions you may have

Re: Plantar Fibromatosis

Dr A. on 2/06/03 at 19:07 (108274)

I agree with Dr. Z regarding local steriod infiltration. If you get some regression of the fibroma you can repeat it in 3 months. If you were older, maybe a patellar wt. bearing brace would offload the area. This is an option if you want to avoid surgery at all cost. You are right about the recurrence rates of fibromas, but many people still have them excised and still do very well, so don't rule it out.

Does this mean that you will answer any gynecological questions I may have?
(for my wife)

Re: Plantar Fibromatosis

Andrew Walter on 2/07/03 at 09:45 (108334)

Dr Z...thanks for your reply. The problem with the punched out orthotics was that they were overall too thick, given the large size of the fibroma. But the plastizole or gel inserts sounds like a great idea...where do I purchase these and what brands should I try?

Thanks,

Andy

Re: Plantar Fibromatosis

Andrew Walter on 2/07/03 at 09:49 (108336)

Dr A...thanks for the advice; I would be happy to answer any questions that you might have (about your wife, of course...do not think I could offer to much for you).

Still one question unanswered, what are the biomechancial consequences of removing a large chunk or all of the plantar fascia like I will need. What % of patient can return to my level of activity? From what little I have read in the literature and in these posting about this, it does not seem to promising.

Thanks,

Andy

Re: Plantar Fibromatosis

Dr. Z on 2/07/03 at 12:48 (108358)

The plastizole inserts can be purhased at any orthopedic shoe store. We use this for Diabetic ulcerations. The ulcer or in your case fibroma will make a impression into the plastioze due to your weight and body heat. This will help to make an impression and shift the weight away from the area. You may need a prescription. So just write on your pad. One pair of plasatizole inserts. They last about six months and need to be replaced. Cost about $50. There is a Dr. Kipper advertizment on this sitet for a gel type orthosis. You can find the link on the product page. I believe there is a money back type thing and the cost is I believe $250

Re: Plantar Fibromatosis

Dr. A on 2/07/03 at 21:55 (108426)

you are right about the possible consequences of losing the windless mechanism that functions not only during wt. bearing but also during swing phase. my goal would be to attempt to ellipse out the fibroma and primarily close the fascia. Afterward, orthotics would be a good idea and should be more tolerable without the mass present. I'll keep my eyes open for some article for you, but I don't know any data off-hand. good luck

An MRI might help plan the surgery or help visualize the proportion of the fibroma to the fascia.

Re: Plantar Fibromatosis

BGCPed on 2/07/03 at 22:55 (108434)

What area are you located? What is your general foot strcture and arch ht? I make the fo and then before covering dorsiflex your great toe and run a line of lipstick on the flexor.
It will usually show the fibro and leave a big mark on the fo. That is grooved out with a foredom, this will usually deal with it rather well

Re: we will leave it up to Scott to start a gynecology board

Ed Davis, DPM on 2/08/03 at 11:46 (108473)

A larger fibroma may need several injections in order to achieve sufficient size reduction. Since the lesions are dense and fibrotic, only so much fluid can be 'pumped' into them -- we also prefer not to see much fluid leakage into the surrounding tissues due to the atrophying effect of the triamcinolone. Occasionally a post. tibial block makes the injections more comfortable.
Ed

Re: Plantar Fibromatosis

Dr. Z on 2/08/03 at 13:28 (108481)

Now this is the man who can help you.!! Richard this is one that appears to be from the the heel up to the toes.

Re: Plantar Fibromatosis

Dr. Z on 2/06/03 at 10:24 (108199)

Hi

I will try and keep this vey simple. If the area of fibroma is very large as you have indicated then surgical excision isn't the best or a choice period, especially with your lack of severe pain or nerve entrapement.

The use of Hyaluronidase with Kenalog is a good choice to use in the areas that are painful or preventing shoe wear with pain

ESWT isn't a procedure that will help you. ESWT is used for insertional plantar fasciitis. All of the studies ( limited) that I have read indicate that ESWT isn't effective

So what to do ? You are young active and stand alot. I like plastizole inserts or maybe a gel inserts. This will help to reduce the shock absorption in the damaged areas of the plantar fasia.

Don't worry about adrenal suppression or infection with the local injections. I am more concerned that your fibroma's are so large and that there are just too much of an area to reduce the size where it will make a difference. However a trial is reasonable at the largest areas or areas that are most painful. Feel free to ask any questions you may have

Re: Plantar Fibromatosis

Dr A. on 2/06/03 at 19:07 (108274)

I agree with Dr. Z regarding local steriod infiltration. If you get some regression of the fibroma you can repeat it in 3 months. If you were older, maybe a patellar wt. bearing brace would offload the area. This is an option if you want to avoid surgery at all cost. You are right about the recurrence rates of fibromas, but many people still have them excised and still do very well, so don't rule it out.

Does this mean that you will answer any gynecological questions I may have?
(for my wife)

Re: Plantar Fibromatosis

Andrew Walter on 2/07/03 at 09:45 (108334)

Dr Z...thanks for your reply. The problem with the punched out orthotics was that they were overall too thick, given the large size of the fibroma. But the plastizole or gel inserts sounds like a great idea...where do I purchase these and what brands should I try?

Thanks,

Andy

Re: Plantar Fibromatosis

Andrew Walter on 2/07/03 at 09:49 (108336)

Dr A...thanks for the advice; I would be happy to answer any questions that you might have (about your wife, of course...do not think I could offer to much for you).

Still one question unanswered, what are the biomechancial consequences of removing a large chunk or all of the plantar fascia like I will need. What % of patient can return to my level of activity? From what little I have read in the literature and in these posting about this, it does not seem to promising.

Thanks,

Andy

Re: Plantar Fibromatosis

Dr. Z on 2/07/03 at 12:48 (108358)

The plastizole inserts can be purhased at any orthopedic shoe store. We use this for Diabetic ulcerations. The ulcer or in your case fibroma will make a impression into the plastioze due to your weight and body heat. This will help to make an impression and shift the weight away from the area. You may need a prescription. So just write on your pad. One pair of plasatizole inserts. They last about six months and need to be replaced. Cost about $50. There is a Dr. Kipper advertizment on this sitet for a gel type orthosis. You can find the link on the product page. I believe there is a money back type thing and the cost is I believe $250

Re: Plantar Fibromatosis

Dr. A on 2/07/03 at 21:55 (108426)

you are right about the possible consequences of losing the windless mechanism that functions not only during wt. bearing but also during swing phase. my goal would be to attempt to ellipse out the fibroma and primarily close the fascia. Afterward, orthotics would be a good idea and should be more tolerable without the mass present. I'll keep my eyes open for some article for you, but I don't know any data off-hand. good luck

An MRI might help plan the surgery or help visualize the proportion of the fibroma to the fascia.

Re: Plantar Fibromatosis

BGCPed on 2/07/03 at 22:55 (108434)

What area are you located? What is your general foot strcture and arch ht? I make the fo and then before covering dorsiflex your great toe and run a line of lipstick on the flexor.
It will usually show the fibro and leave a big mark on the fo. That is grooved out with a foredom, this will usually deal with it rather well

Re: we will leave it up to Scott to start a gynecology board

Ed Davis, DPM on 2/08/03 at 11:46 (108473)

A larger fibroma may need several injections in order to achieve sufficient size reduction. Since the lesions are dense and fibrotic, only so much fluid can be 'pumped' into them -- we also prefer not to see much fluid leakage into the surrounding tissues due to the atrophying effect of the triamcinolone. Occasionally a post. tibial block makes the injections more comfortable.
Ed

Re: Plantar Fibromatosis

Dr. Z on 2/08/03 at 13:28 (108481)

Now this is the man who can help you.!! Richard this is one that appears to be from the the heel up to the toes.