Point-Counterpoint: Is Conservative Care The Best Approach For Plantar Fibromatosis?

Yes.

This author says conservative treatment can reduce the symptomatology and shrink the plantar fibroma whereas wide excision surgery has a high recurrence rate and increased potential for wound healing issues and nerve entrapment.

By Michael S. Downey, DPM, FACFAS

Plantar fibromatosis is a benign, locally invasive soft tissue tumor characterized by fibroblast proliferation within the plantar fascia. The vast majority of plantar fibromas are asymptomatic and require no treatment other than to reassure the patient as to the benign nature of the affliction.

   When clinicians encounter a plantar fibroma that they cannot diagnose clinically, a magnetic resonance image (MRI) or musculoskeletal ultrasound can confirm the soft tissue character of the nodular mass as homogenous and collagenous in nature. Only atypical masses or those that remain suspicious after diagnostic imaging studies necessitate biopsy. Treatment beyond biopsy is only indicated if the plantar fibromatosis is symptomatic, locally invasive or prominent in shoes or with weightbearing.

   When treatment is necessary, one should use conservative treatment initially for the significant preponderance of plantar fibromatoses. Conservative treatment can be divided into biomechanical and pharmacological measures. Pharmacological treatment can be further subdivided into topical, oral and injectable medications. Although much of the conservative treatment lacks direct supporting evidence-based medicine and studies to support its efficacy, many of the modalities available have some evidence to support their use.

   Non-surgical treatment typically begins with modalities aimed at offloading the plantar fibromatosis.

   One can construct a simple, removable donut pad for an isolated or smaller plantar fibroma. For larger lesions, over-the-counter insoles or custom-molded orthotics may be needed to decrease hyperpronation and the tension on the plantar fascia, potentially decreasing the symptoms associated with the plantar fibromatosis.1

Assessing The Impact Of Topical And Injectable Medications

Although there are many pharmacological options for the conservative management of plantar fibromatosis, it is important that the treating physician understand their indications, contraindications, intended effect and dosage. Currently, topical and injectable medications merit the greatest consideration for the management of the symptomatic and/or enlarged plantar fibromatosis.

   Recently, much attention has been given to the transdermal topical delivery of verapamil. Verapamil belongs to a class of drugs known as calcium channel blockers. Research has shown calcium channel blockers, in both in vivo and in vitro studies, to inhibit fibroblasts and the synthesis and secretion of extracellular matrix macromolecules, including the components of fibrous tissue disorders, collagen, glycosaminoglycans and fibronectin.

   There have been no reported studies on the effectiveness of topical transdermal verapamil or intralesional verapamil injections for plantar fibromatosis. However, logically, it would appear the use of topical transdermal verapamil gel and intralesional verapamil injections may have some effectiveness in the management of plantar fibromas. Since the primary effect of the medication is to inhibit fibroblast activity, the effectiveness would likely be greatest in the proliferative or involutional (active) phases of the fibromas’ development and less helpful in chronic fibromatosis that has entered the residual (end) phase.

   Recently, the use of topical transdermal 15% gel (150 mg verapamil per cc of gel) has been promoted and become popular. The recommended dosage is 1.0 cc of the gel twice daily to the skin directly over the plantar fibromatosis for six to 12 months.1 I have effectively used this protocol of topical verapamil to decrease the symptomatology associated with plantar fibromatoses and to soften the nodular mass volume. To date, I have not seen topical transdermal verapamil gel completely resolve a plantar fibroma.

   Injection therapy would seem to be the optimal delivery method for plantar fibromatosis as it allows the intralesional administration of the desired pharmacologic agent. Detractors of injection therapy for plantar fibromatosis argue that it is more difficult and painful to inject a fibrous lesion, and the injected medication may not infiltrate sufficiently to treat the entire fibroma. Many have attempted using medications via intralesional injection for plantar fibromatoses.

   Currently, the intralesional infiltration of a corticosteroid into the plantar fibromatosis appears to be the most popular injectable medication. Ketchum and Donahue conducted a four-year study with 63 patients (75 hands) suffering from Dupuytren’s palmar fibromatosis contracture of the hand, a similar but perhaps not entirely identical condition to plantar fibromatosis.2 Physicians injected triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) directly into each nodule in doses ranging from 60 mg to 120 mg per injection. They repeated the injections at six-week intervals for a total of three injections. If further injections were deemed necessary, these only occurred after a six-month hiatus. The patients in their series had a mean of 3.2 total injections per fibroma.

   Ninety-seven percent of the hands demonstrated 60 to 80 percent regression of the fibromas with softening and flattening of the nodules.2 Not surprisingly, 50 percent of the patients experienced a reactivation of the disease within one to three years after their last injection, necessitating one or more additional injections. Additionally, as one would expect, 50 percent of patients reported a transient depigmentation or temporary subcutaneous fat atrophy at the injection site.

   Ketchum and Donahue did describe two patients who were not included in their four-year study. These patients had spontaneous flexor tendon ruptures after treatment but without the six-month respite after the third injection.2 The authors felt that the likely causes of the patients’ tendon ruptures were additional injections after the initial three that were given without waiting six months after the third injection, and possible failure to keep the medication solely within the lesion.

What About Corticosteroid Injections?

Although there are no major studies looking at the use of corticosteroid injections for plantar fibromatosis, numerous authors mention the treatment modality in their papers as a viable conservative treatment option.3-7

   Pentland and Anderson described a patient with bilateral multi-nodular plantar fibromas.4 The patient received five intralesional injections of 15 mg to 30 mg of triamcinolone acetonide in each nodule. The authors used triamcinolone 40 mg/cc diluted 3:1 with 1% lidocaine for a final concentration of 30 mg/cc. They injected each nodule with 0.5 cc to 1.0 cc. Each injection occurred a month apart.They noted softening of the nodules during their injection course. Four months after their last injection, they noted the nodules were smaller.

   Triamcinolone acetonide appears to be the preferred corticosteroid for the intralesional injection of a plantar fibroma. It would also appear that the intralesional injection of triamcinolone into a plantar fibroma would be most effective for a chronic fibroma in the residual (end) phase of the fibroma’s development as this is when the fibroma is primarily composed of maturing collagen.

   I currently use triamcinolone acetonide for the intralesional injection of plantar fibromas. A series of three to five injections with each injection spaced three to six weeks apart appears to be most effective. While the optimal dosage for each injection has yet to be determined, I currently use 15 mg to 30 mg per nodule and this appears to be a reasonable initial dose based upon the literature available. As Pentland and Anderson found, the nodules consistently soften and shrink (although they seldom resolve entirely), and the symptomatology resolves.4

A Closer Look At The Efficacy Of Collagenase

On the treatment horizon is the possible intralesional injection of collagenase. The January 2011 issue of Harvard Men’s Health Watch presented an article entitled “Unfolding bent fingers: new handiwork for bacteria.”8 In 2010, the Food and Drug Administration (FDA) approved the use of collagenase Clostridium histolyticum to treat Dupuytren’s contracture of the hand. Currently, the medication does not have FDA approval for use in the treatment of plantar fibromatosis. One of the enzymes produced by Clostridium histolyticum is collagenase and collagenase destroys the collagen that makes up the fibrous material of the superficial (fascial) fibromatoses, including palmar and plantar fibromatoses.

   In a large 2009 prospective, randomized, double-blind, placebo-controlled trial, Hurst and colleagues studied 308 patients with Dupuytren’s palmar fibromatosis.9 Each patient received three injections of 0.58 mg collagenase Clostridium histolyticum or placebo at 30-day intervals into their contracted fibrotic cord. The primary endpoint was a reduction in contracture to within five degrees of normal. Sixty-four percent of the collagenase injection group achieved this endpoint in comparison to 6.8 percent of the placebo group. The most commonly reported adverse events were localized swelling, pain, bruising, pruritus and transient regional lymph node enlargement and tenderness. The authors also reported three other more serious complications: two tendon ruptures and one case of complex regional pain syndrome (CRPS).

   Several additional studies have supported these results and have confirmed that collagenase Clostridium histolyticum injections are well tolerated and effective for the management of Dupuytren’s contracture.10,11 Studies are currently underway to assess the value of collagenase in the management of plantar fibromatosis. Depending upon the results and safety profiles attained, the intralesional injection of collagenase may become the non-surgical treatment of choice in the near future.

   A recent abstract at the 2012 American College of Foot and Ankle Surgeons’ Annual Conference in San Antonio, Texas highlighted the potentially positive benefit of collagenase for the conservative management of plantar fibromatosis.12

   Other conservative modalities that may offer some hope for the management of the plantar fibroma include cryosurgery and radiofrequency ablation. There is very limited evidence supporting their efficacy at this time but the strong desire to avoid the potential adverse sequelae of more invasive surgical procedures makes these approaches desirable and worthy of further investigation.

When The Literature Reveals About Surgery And High Recurrence Rates

In my opinion, we relegate surgery to those patients who fail conservative treatment or have lesions that severely impair their immediate function. Historically, researchers advocated simple excision through a plantar medial incision.13,14

   However, authors have reported limited local excision with very high rates of recurrence with the fibromatosis often worsening.15 Following simple excision, van der Veer and colleagues reported a 100 percent recurrence rate, Aviles and associates reported a 57 percent rate of recurrence, Allen and colleagues reported a 54 percent rate of recurrence, and Aluiso and co-workers reported a 40 percent recurrence rate.13,16-18

   The consensus reason for the high rate of recurrence is incomplete excision.3,5,19-22 This most likely is explained by the lack of encapsulation of the lesion and the fact that it extends into what appears to be grossly normal surrounding plantar fascia that is in actuality histologically abnormal.3,5,23 Despite this growing body of evidence, many foot and ankle surgeons continue to employ limited local excision. Although some of these will be successful, the high recurrence rate makes a more invasive approach more palatable when patients require surgery.

   Most experienced surgeons today advocate greater exposure and more wide excision of the plantar fibromatosis when surgery is necessary.3,5,13,20-27 Since the preferred approach is wide excision, the primary remaining issues that we still debate today are how much of the plantar fascia to remove and what is the best incisional approach for removing the mass and surrounding plantar fascia.

   Regarding how much normal fascia one must remove around the nodular mass, Landers and associates felt the margins needed to be “at least 1 to 2 cm.”20 Sammarco and Mangone advocated dividing the fascia “at least 1.5 cm beyond the most distal part of the tumor.”3 Lee and colleagues recommended “at least a 2 cm margin of normal fascia proximal and distal to the nodule.”24

   Removal of these amounts of the plantar fascia will necessitate larger incisions and the resulting greater potential for wound healing problems, skin compromise and nerve entrapment make conservative measures appear desirable.

   Even with wide excision and subtotal plantar fasciectomy, recurrence remains a problem. Alexander and colleagues reported an 8 percent recurrence rate with complete plantar fasciectomy.28 Sammarco and Mangone found a slight decrease in the height of the arch after subtotal plantar fasciectomy, both clinically and radiographically, in their series of 14 patients (19 feet), although they reported no associated symptomatology.3

In Summary

Although conservative treatment does not always resolve a plantar fibroma, conservative treatment does frequently reduce or eliminate the symptomatology, and soften and/or shrink the nodular mass. We should not abandon surgery for this condition but due to the need for wide excision of the plantar fibromatosis with good margins and the high incidence of incisional problems, wound problems, recurrence and potential mechanical changes to the foot, we should usually reserve surgery for recalcitrant cases that fail conservative treatment attempts.

   Dr. Downey is the Chief of the Division of Podiatric Surgery at Penn Presbyterian Medical Center in Philadelphia. He is in private practice in Philadelphia, Radnor and Doylestown, Pa.

References
1. Downey MS, Contento RJ. Plantar fibromatosis. In Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV (eds.): McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, fourth edition. Wolters Kluwer Health - Lippincott Williams & Wilkins, Philadelphia, 2013, pp. 1486-1496.
2. Ketchum LD and Donahue TK. The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg Am. 2000; 25(6):1157-1162.
3. Sammarco GJ and Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int. 2000; 21(7):563-569.
4. Pentland AP and Anderson TF. Plantar fibromatosis responds to intralesional steroids. J Am Acad Dermatol. 1985; 12(1 Pt 2):212-214.
5. Johnston FE, Collis S, Peckham NH and Rothstein AR. Plantar fibromatosis: literature review and a unique case report. J Foot Surg. 1992; 31(4):400-406.
6. Fetsch JF, Laskin WB and Miettinen M. Palmar-plantar fibromatosis in children and preadolescents: a clinicopathologic study of 56 cases with newly recognized demographics and extended follow-up information. Am J Surg Pathol. 2005; 29(8):1095-1105.
7. Graells Estrada J, Garcia Fernandez D, Badia Torroella F and Moreno Carazo A. Familial plantar fibromatosis. Clin Exp Dermatol. 2003; 28(6):669-670.
8. Unfolding bent fingers: new handiwork for bacteria. Harv Mens Health Watch. 2011; 15(6):7-8.
9. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, Smith TM and Rodzvilla J. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009; 361(10):968-979.
10. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J and Jones N. Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren’s disease. J Hand Surg Am. 2010; 35(12):2027-2038.
11. Thomas A and Bayat A. The emerging role of Clostridium histolyticum collagenase in the treatment of Dupuytren disease. Ther Clin Risk Manag. 2010; 6:557-572.
12. O’Neill AM, Weary SR, Niehaus LP. The use of collagenase in the treatment of plantar fibromas. Poster presentation, American College of Foot and Ankle Surgeons Annual Scientific Conference, March 1-4, 2012, San Antonio, Texas.
13. Aviles E, Arlen M and Miller T. Plantar fibromatosis. Surgery. 1971; 69(1):117-120.
14. Chung EB and Enzinger FM. Proliferative fasciitis. Cancer. 1975; 36(4):1450-1458.
15. Warthan TL, Rudolph RI and Gross PR. Isolated plantar fibromatosis. Arch Dermatol. 1973; 108(6):823-825.
16. Van der Veer WM, Hamburg SM, de Gast A and Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. 2008; 122(2):486-491.
17. Allen RA, Woolner LB and Ghormley RK. Soft-tissue tumors of the sole; with special reference to plantar fibromatosis. J Bone Joint Surg Am. 1955; 37-A(1):14-26.
18. Aluisio FV, Mair SD and Hall RL. Plantar fibromatosis: treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int. 1996; 17(11):672-678.
19. Delgadillo LA and Arenson DJ. Plantar fibromatosis: surgical considerations with case histories. J Foot Surg. 1985; 24(4):258-265.
20. Landers PA, Yu GV, White JM and Farrer AK. Recurrent plantar fibromatosis. J Foot Ankle Surg. 1993; 32(1):85-93.
21. Haedicke GJ and Sturim HS. Plantar fibromatosis: an isolated disease. Plast Reconstr Surg. 1989; 83(2):296-300.
22. Pickren JW, Smith AG, Stevenson TW, Jr. and Stout AP. Fibromatosis of the plantar fascia. Cancer. 1951; 4(4):846-856.
23. Burns AE and Harvey CK. Plantar fibromatosis. Surgical considerations and a case report. J Am Podiatry Assoc. 1983; 73(3):141-146.
24. Lee TH, Wapner KL and Hecht PJ. Plantar fibromatosis. J Bone Joint Surg Am. 1993; 75(7):1080-1084.
25. Sugiura I. Desmoplastic fibroma. Case report and review of the literature. J Bone Joint Surg Am. 1976; 58(1):126-130.
26. Zgonis T, Jolly GP, Polyzois V, Kanuck DM and Stamatis ED. Plantar fibromatosis. Clin Podiatr Med Surg. 2005; 22(1):11-18.
27. Durr HR, Krodel A, Trouillier H, Lienemann A and Refior HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int. 1999; 20(1):13-17.
28. Alexander IJ, Johnson KA, Shives TC, Reiman HM and Johnson JE. Aggressive fibromatosis of the plantar aspect of the foot. A case report. Bull Hosp Jt Dis Orthop Inst. 1987; 47(2):103-108.

No.

Citing a lack of evidence-based studies on conservative care, this author says various studies in the literature have advocated surgical techniques and recommendations to reduce recurrence risk.

By Byron Hutchinson, DPM, FACFAS

The clinical presentation of plantar fibromatosis typically dictates the effectiveness of management in most patients. Most forms of fibromatosis are slow growing but at some point can begin rapid and unexpected growth. The etiology is unknown but there is a predictable progression of this painful condition.

   Clinical and pathologic studies have classified plantar fibromatosis into three stages: proliferative, involutional and residual. The first stage is described by cellular proliferation, the second stage by nodule formation and the third stage by tissue contraction.1,2

   Conservative care for this condition is palliative and not curative. There are no evidenced-based studies on any conservative therapy for plantar fibromatosis and most discussion on options is purely anecdotal.

   In contrast, there are numerous articles on the surgical management of plantar fibromatosis. Based on many of these studies, we have surgical techniques that have become more successful due in part to recommendations made within these articles to avoid reported complications.3-6

Surgical Recommendations For Decreasing The Risk Of Recurrence

In particular, Lauf and colleagues note that techniques to lessen the recurrence of plantar fibromatosis include the use of split-thickness skin grafts and placing Marlex mesh although they concede such procedures have potential complications, including recurrence, foreign body reactions, scarring and inadequate soft tissue coverage.3 The authors advocate using dermal fat grafting following primary excision. They say this reduces the chance of recurrence while preserving the anatomic architecture of the foot and maintaining a soft, supple weightbearing surface with the formation of minimal scar tissue.

   Similarly, Delgadillo and colleagues note that the preferred treatment for plantar fibromatosis is surgical extirpation of the mass.4 However, they note that it can be difficult to define the outer limits of the lesion and incomplete excision frequently results in postoperative recurrence of the lesion. They argue that a complete fasciectomy of the involved fascia is an effective technique to reduce the likelihood of a recurring fibromatosis lesion.

   It is my opinion that early on when there is a small isolated nodule, conservative care can be effective but once there is a coalescence of these nodules or they become bigger than 1 cm in depth, conservative management is ineffective and frankly is rarely even palliative. When patients cannot walk because of the pain, the only option becomes surgical intervention for a consistent, predictable outcome. This is also true for those individuals who have a family history of the disease or other conditions such as Peyronie’s disease. These patients tend to do extremely poor with conservative care in particular and can have a higher recurrence with surgical intervention unless they receive a total fasciectomy.

   Sammarco and Mangone proposed an operative staging system for plantar fibromatosis.7 The authors’ staging system, ranging from stage I to IV, incorporates the extent of plantar fascia involvement, the presence of skin adherence and the depth of tumor extension. They note the stage of the tumor in the study correlated well with postoperative wound healing, skin necrosis and recurrence. Preoperative and intraoperative staging helps decrease the risk for wound dehiscence and recurrence.

   There are a number of good evidence-based studies that support aggressive excision of the plantar fascia through several modified plantar approaches.8-9 A study by Van der Veer and colleagues focused on 27 patients with plantar fibromatosis who had 40 operations on 33 feet.8 The authors noted that treating a primary lesion with total plantar fasciectomy was associated with the lowest recurrence rate (25 percent) while local resection of the lesion was associated with the highest recurrence rate (100 percent). The study concluded that surgical treatment of plantar fibromatosis is indicated only when the lesions are highly symptomatic and conservative measures have failed to resolve the condition.

   The blood supply to the plantar skin overlying the medial band of the plantar fascia comes from multiple areas and this allows for adequate exposure with minimal risk to flap survival. The angiosomes have been well documented in this area.10 This does not mean that skin slough is not a risk. In certain cases when the nodules involve the subcutaneous tissue, complete removal can compromise the skin flap, causing a slough of the skin.

Keys To Success With The Surgical Technique

The incisional approach typically occurs along the medial band of the plantar fascia extending to just behind the metatarsal heads and ending proximally at the insertion of the plantar fascia. There are several modified approaches but in general, they all provide good access to the plantar fascia.

   The nodules are not well encapsulated so the key to success is taking an adequate amount of normal fascia around the diseased nodular fascia. This does decrease the chance of recurrence. Although there is a 15 percent recurrence rate for these lesions, I have had much more predictable results with surgical intervention than with conservative management.

   The vast majority of the nodules involve the central band of the plantar fascia and can be large enough to cause compression neuropathy to the medial plantar nerve. In my opinion, this requires surgical release rather than conservative care to avoid long-term damage to the nerve. When the lesions are attached to the overlying dermis, one must remove the involved skin as well and this area needs skin grafts to prevent local recurrence.

   Dr. Hutchinson is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in Foot and Ankle Surgery by the American Board of Podiatric Surgery. He is the Secretary and President of the International Foot and Ankle Foundation for Education and Research. He is in private practice in Burien, Wash.

References
1. Landers PA, Yu GV, White JM, Farrer AK. Recurrent plantar fibromatosis. J Foot Ankle Surg. 1993; 32(1):85-93.
2. Headicke GJ, Sturim HS. Plantar fibromatosis: an isolated disease. Plast Reconstr Surg. 1989; 83(2):296-300.
3. Lauf E, Freedman BM, Steinberg JS. Autogenous free dermal fat grafts in the surgical approach to plantar fibromatosis. J Foot Ankle Surg. 1998; 37(3):227-34.
4. Delgadilo LA, Arenson DJ. Plantar fibromatosis: surgical considerations with case histories. J Foot Surg. 1985; 24(4):258-65.
5. Wapner KL, Ververeli PA, Moore, JH et al. Plantar fibromatosis a review of primary and recurrent surgical treatement. Foot Ankle Int. 1995; 16(9):548-51.
6. Durr HR, Krodel A, Trouillier H, Lienemann A, Refior, HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int 2001;20:13-7.
7. Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000; 21(7):563-9.
8. Van der Veer WM, Hamburg SM, de Gast A, Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. Aug 2008; 122(2):486-91.
9. Zgonis T, Jolly GP, Vasilios P, Kanuck DM. Plantar fibromatosis. Clin Podiatr Med Surg 2005; 22(1):11-18.
10. Hidalgo DA, Shaw WW. Anatomic basis of plantar flap design. Plast Reconstr Surg. 1986; 78:627-36.

   Editor’s note: For further reading, see “How To Handle Plantar Fibromas” in the August 2007 issue of Podiatry Today, “How To Differentiate Soft Tissue Neoplasms” in the January 2008 issue and “When Injection Therapy Can Help Relieve Painful Lesions” in the June 2002 issue.