MedStar Health DocTalk
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MedStar Health DocTalk
Plantar Fibromatosis with Dr. Paul Carroll
Foot pain is a common issue that many of us face at some point in our lives. While plantar fasciitis is often the culprit, there's another- probably under-reported condition that deserves attention: plantar fibromatosis, also known as Ledderhose disease. In our latest podcast episode, Debra Schindler takes a dive deep into this lesser-known condition with MedStar Health podiatric foot and ankle surgeon, Dr. Paul Carroll.
Plantar fibromatosis affects approximately 200,000 people in the United States and is characterized by the growth of fibromas—benign nodules—on the plantar fascia, the thick band of tissue that runs along the bottom of your foot. Unlike plantar fasciitis, which typically causes heel pain that improves throughout the day, plantar fibromatosis presents as a constant pain in the middle part of the foot. Patients often describe feeling a pea-sized bump on the bottom of their foot, which can become painful as it grows.
Dr. Carroll explains that while this condition is generally benign, it can be quite painful and debilitating if left untreated. The demographic most affected includes males, diabetics, individuals with chronic alcohol use, and those who have experienced trauma to the foot. Interestingly, there is also a significant correlation between plantar fibromatosis and Dupuytren's contracture, a condition affecting the hands.
So, what should you do if you suspect you have plantar fibromatosis? Dr. Carroll advises seeking medical attention as soon as you notice any unusual bumps or persistent pain in your foot. Early diagnosis can help manage the condition more effectively and may prevent it from worsening. While there are several treatment options available, including conservative measures like custom orthotics and steroid injections, surgical options are often considered when other treatments fail. However, surgery comes with its own set of challenges, including a high recurrence rate of the fibromas.
One of the more promising treatments discussed in the episode is the use of hyaluronidase injections, which help to shrink and soften the fibromas, making them less symptomatic. Dr. Carroll shares his experiences and success stories with this treatment, providing hope for those suffering from this condition.
If you're experiencing unexplained foot pain or have noticed a bump on the bottom of your foot, don't ignore it. Tune in to our latest episode with Dr. Paul Carroll to learn more about plantar fibromatosis, its symptoms, and the various treatment options available. Your foot health is essential, and early intervention can make all the difference.
Listen to the full episode now and take the first step towards better foot health!
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
comprehensive, relevant and insightful conversations about. Health and medicine happen here on medstarhealth.com. Real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Along the bottom of our feet is a thick band of tissue called the plantar fascia. It connects the heel bone to the base of your toes and acts sort of like a shock absorber. Its not unusual to hear someone say that they have plantar fasciitis, especially among runners. Its the most common form of heel pain and is caused by the fascia becoming inflamed. But today were going to talk about another condition of the fascia, one that affects about 200,000 people in the US. Its known as plantar fibromatosis, also known as lederhose disease. If you have foot pain or you've ever felt a nodule just under the skin at the bottom middle of your foot, stay with us. We're about to get all the details on plantar fibromatosis with podiatric foot and ankle surgeon doctor Paul Carroll. Today on MedStar health DocTalk talk. I'm your host, Debra Schindler. Thanks for being here, doctor Carroll.
>> <dr. carroll="" paul=""></dr.>:Thanks for having me.
>> Debra Schindler:A patient comes to you with stabbing pain on the bottom of the foot. Do you automatically think plantar fasciitis or plantar fibromatosis? How are they different?
>> <dr. carroll="" paul=""></dr.>:It's a great question. Majority of the patients that come in with heel pain are generally going to be plantar fasciitis. generally about 1 million office visits a year are attributed to plantar fasciitis. less commonly will be plantar fibromatosis. But they are two distinct, issues and they do have different, presenting features. Plantar, fasciitis generally is around the heel and it's characterized by pain. First step of the morning. So you put your foot down, you have a pain, you kind of walk it out, it feels a little bit better. Plantar bromatosis usually is kind of the middle part of the foot and kind of the instep, and that's a constant pain throughout the day. generally you can feel a little bit of a bump on the middle part of the arch versus with plantar fasciitis where there won't be any sort of palpable, mass m or anything on the heel.
>> Debra Schindler:And that bump, is what we are referring to as a fibroma.
>> <dr. carroll="" paul=""></dr.>:Correct.
>> Debra Schindler:And what exactly is that?
>> <dr. carroll="" paul=""></dr.>:So what a fibroma is, is like you talked about before, the plantar fascia, which is a ligament like structure in the bottom of your foot. It has cells in it that help control, like the maintenance of the health of the, structure as well as kind of reparative. And sometimes these cells produce, an abundant amount of collagen, which is a building block or maintenance of the ligament. And it grows and becomes large. And over time it can become symptomatic because it grows to a certain point where it's protruding down into the kind of the weight bearing surface of your foot. So when you step on it, you feel this hard nodule and that will elicit pain.
>> Debra Schindler:What's the first thought? Cancer.
>> <dr. carroll="" paul=""></dr.>:Most people say cancer. This is a benign condition, majority of the time, on the bottom of the foot, the plantar fibromas are the most common and, very rarely do they ever turn into cancer.
>> Debra Schindler:Does it affect both feet? Usually for a patient or just one?
>> <dr. carroll="" paul=""></dr.>:Majority of the time it is 1ft is about 25% to 50% of the time will affect both feet.
>> Debra Schindler:And who are usually the patients? What's the demographic?
>> <dr. carroll="" paul=""></dr.>:I guess you could say majority of the patients are of male gender, diabetic, patients who have had, chronic alcohol use, chronic phenobarbital use, which is a medication, overweight obesity patients and patients, who have had trauma to the foot. And trauma could be as simple as being on their feet a lot of. Or they're out using a shovel and kind of bouncing it on the bottom part of their foot. And this is not infrequent, but if you do this for years and years at a time, it can form. And patients who are in their kind of their mid, forties and older, generally of the age group that seems to have plantar fibromatosis more often than not.
>> Debra Schindler:So I'm picturing someone listening to this and thinking, that could be what I've been struggling with on the bottom of my foot. How would they know? Is it something that they can see? How would you describe it for a person and what do they need to know?
>> <dr. carroll="" paul=""></dr.>:Most of the time, it's mostly by feel. So if a patient takes their finger and kind of presses the bottom, they can feel a little bit of a bump. most patients talk about it as being like a pea sized or a p shaped bump on the bottom part of their foot. And if you press on it, sometimes it's not painful. As it gets bigger, it could be painful. but if you can usually feel something that's, something there, that's usually a characteristic of it, and it's slow growing over time, meaning overdose. The years, you might notice, hey, this is getting a little bit larger, but very slowly. that's generally a characteristic of plantar vibromatosis.
>> Debra Schindler:So when is the right time to see a doctor about it? Do they need to see a doctor? Could it go away on their own?
>> <dr. carroll="" paul=""></dr.>:The right time to see it is first when you identify or you first notice it, even if it's not symptomatic, it's not a bad idea to have a doctor look at it. They generally don't go away on their own. And when we surgically treat them, there is a higher reoccurrence rate of these. So we generally try to do conservative, treatment. But in general, as soon as you notice it, it doesn't hurt to have someone take a look at it just to rule out the worst case scenario. Majority of the time, these are just benign, fibromas.
>> Debra Schindler:Well, that's discouraging to hear that they could come back after a surgery.
>> <dr. carroll="" paul=""></dr.>:Yes.
>> Debra Schindler:Same exact place?
>> <dr. carroll="" paul=""></dr.>:Same exact place. because the cells that are responsible for, wound healing are the same cells that produce this fibroma. So when they start to replicate and heal up, they could aggressively create a fibroma all over again.
>> Debra Schindler:How do you diagnose it? Do you need to get imaging or anything, or do you just feel it with your hands and you already.
>> <dr. carroll="" paul=""></dr.>:No, most of the time, it's a clinical diagnosis, meaning you'll be examined by a doctor. They will, palpate, ask you questions, examine the location where you're having it. Majority of the time, it's clinical. If the clinician is uncertain, advanced imaging, such as an MRI or an ultrasound, will provide further information. An x ray also, can be useful in kind of ruling out any sort of bone involvement, which is very, very rare.
>> Debra Schindler:I wanted to ask, too, when I was asking, should they see a doctor or will it go away on their own? Should they see a podiatrist specifically, or is this a condition that could be managed by primary care?
>> <dr. carroll="" paul=""></dr.>:It doesn't hurt to see your primary care doctor. If the primary care doctor, evaluates it and feels that it is beyond what they could offer, then a referral to a podiatrist, I think, is necessary. But as long as someone's evaluating it, this condition does have association with, Duputrin's contractures of the hand, which a primary care doctor might be more familiar with. So this might be something that they might be able to direct you, seeing the right specialist for listeners to know.
>> Debra Schindler:Dupuytren's contracture is a condition where nodules grow on ligaments in the hand and cause the fingers to curl in. And they can be treated with something called a collagenase. They're injected, maybe a week later, the doctor will bust them, sort of pop them under the skin. Right. And then the hand can open up. Is there a similar treatment to that for the foot? And do the toes curling in a similar way?
>> <dr. carroll="" paul=""></dr.>:Great question. So very rarely do the toes actually curl in or contract with a plantar fibromatosis currently. Now the collagenase is being tested in clinical trials, so it hasn't come out on the market specifically for the foot. so we generally don't follow a similar protocol to injecting and then trying to break down, manipulate them. I'm not sure when that is coming out, when the, pharmaceutical company is going to be releasing or it's going to come to market, but that is something that's been tested and there's been some positive, results using that.
>> Debra Schindler:All right, so what are the treatments? I'd like to go down a list of options for plantar fibromatosis and get your thought on each one, if that's okay. All right, let me know if I've missed any radiotherapy.
>> <dr. carroll="" paul=""></dr.>:Radiotherapy is good. That mostly is in conjunction with surgery. So what radiotherapy is, is very similar to radiation therapy, for cancer. They help inhibiting the cells from regenerating as well as multiplying. So radiotherapy has been shown in plantar fibrotosis to limit regrowth. And that's mostly associated with surgery and then radiation after. So it's an adjunct therapy.
>> Debra Schindler:And how does that work, like getting an x ray?
>> <dr. carroll="" paul=""></dr.>:Kind of very similar to that. So very similar to, you see a radiation oncologist, who would treat someone with cancer and do radiation, and they would set up a regiment where you would come, and it would be very similar to getting an, x ray beam, at a scheduled time for, for treatment.
>> Debra Schindler:It sounds like a painless option, maybe.
>> <dr. carroll="" paul=""></dr.>:So there is. So, unfortunately, with radiation therapy or radiotherapy, there is risk of neuropathy. It does potentially injure the nerves. I've had several patients, you know, unfortunately, that have developed neuropathy after that. And that does occur, where they lose the sensation of the bottom of their feet.
>> Debra Schindler:Do they also get the burning sensation? Because the losing the sensation doesn't sound horrible if it means the fibromatosis is gone and you don't have pain and you don't have to go through surgery.
>> <dr. carroll="" paul=""></dr.>:Yes. Sometimes patients have burning and chronic pain related to this as well.
>> Debra Schindler:Well, then that's not an optimal option, I suppose. All right, what about partial fasciectomy?
>> <dr. carroll="" paul=""></dr.>:Partial fasciectomy is a surgical option where we remove a portion of the plantar fascia or that ligament like structure in the bottom of the foot. There are several ways we can remove or several sections. We can. We can remove the plantar fibroma itself. or we can remove the plantar fibroma as well as two to 3 healthy plantar fascia around it. Or you could do something called a subtotal or total fasciectomy, where we remove the ligament entirety with local excision, meaning you just remove the plantar fibroma. Reoccurrence rates are extremely high. They are very close to 100% because the cells that produce the fibroma are still present and they are responsible for repairing. So they're going to repair and cause a, usually a larger, more aggressive fibroma in that area with wide excision, where we resect out several centimeters around of healthy tissue. recurrence rates are around 50% to 75%. And then when you remove the ligament itself, the complete ligament reoccurrence rates are very low. Unfortunately, when you remove that ligament, it also destabilizes the foot, meaning that ligament like structure, the plantar fascia, helps support the archite, so you can get some instability of the foot when you're walking. And a lot of times, patients wear custom, orthotics or shoes, specifically for them, after the surgery, if.
>> Debra Schindler:They don't have that ligament, they can't move their foot in a certain way. What happens?
>> <dr. carroll="" paul=""></dr.>:So they're able to move. It's just when you walk, it doesn't feel stable. It feels like the bones are moving when you're trying to walk. Because what happens is, is that ligament kind of supports the arch, and when you walk, the bones become stable. The joints are stabilized. So when you walk, it will give you a sound foot to walk on. When the ligament is gone, those bones don't lock into position. So sometimes it can feel unstable or the foot can feel loose when you're walking.
>> Debra Schindler:Okay, what about a steroid injection?
>> <dr. carroll="" paul=""></dr.>:Steroid injections work very well. Generally, a, steroid has been shown to soften the fibroma as well as make it smaller. They do reoccur, meaning that over, you know, several months to several years, the fibroma can start to regrow again. And patients come back for periodic steroid injections, but, steroid injections have been found to provide temporary relief.
>> Debra Schindler:What about ten x?
>> <dr. carroll="" paul=""></dr.>:So the ten x procedure is like an ultrasound. I've used it before. I have found that sometimes it can be challenging in recurrent fibromas or someone who's had a fibroma removed and it's come back and using the ten x procedure, it uses, ah, ultrasound to, dissolve the fibroma. It worked well on smaller lesions or smaller fibromas, probably a centimeter or less. That way, it will remove, it, it's less dense than the. Than if a fibroma reoccurred. and you can do this under ultrasound, and it kind of leaves small incisions. So it's not. You don't have the big incisions like you would if you want to completely remove something.
>> Debra Schindler:Xiaoflex.
>> <dr. carroll="" paul=""></dr.>:So xiaflex is the brand name for collagenase. So collagenase is an enzyme that is responsible for breaking down collagen, which is one of the building blocks, for, tissue. And, fibromas have plenty of it. So a collagenase injection would be responsible for dissolving the collagen, reducing the size, as well as reducing, the firmness of the mass. right. Now, for the plantar fibromatosis, it has been approved by the FDA, but we're hoping that can come out in the market soon.
>> Debra Schindler:Okay. Hyaluronidinase. Am I saying that right?
>> <dr. carroll="" paul=""></dr.>:Hyaluronidase. So, hyaluronidase is another enzymatic injection or an enzyme that degrades, hyaluronic or hyaluronic acid. That's another building block for the tissues. So this is also present in fibromas. This is something that I use, is, I use hyaluronidase with a steroid. I do a series of injections over a span of three weeks to help shrink and soften up the mass so it becomes less symptomatic. It doesn't necessarily completely resolve or get rid of the fibroma, but it shrinks it down to a size that patients don't feel it anymore. And it's painless. There is, you know, over many years, it can come back. But I found that patients have tolerated this very well. They avoid surgery. Minimal risks with. With these injections. However, there is injection site pain. But, we're currently working on, publishing this, technique. So this is one of the ones that I have currently used the, the most. So verapamil is a topical cream or a gel. it's been studied, in Peyronie's disease as well as, deeputrins, with success. There's been nothing researched. The plantar fibroma. So, anecdotally, it's been used, and patients seem, to have reported that it's worked really well and kind of keeping the size of the fibroma at bay or hasn't really allowed it to grow or expand. This is something that's used maybe twice a day topically. Most patients use it indefinitely, meaning they'll use it for the rest of their life. You know, it's just like it's putting on a lotion or cream. You just put this cream on twice a day to the. To the mass, and it's. It's helped a lot of patients.
>> Debra Schindler:So are there side effects?
>> <dr. carroll="" paul=""></dr.>:So, with the verapamil, it's. It's a medication that's generally used, in. For, heart. So if. If you use too much of it, and it's been theorized that, you know, it could lead to. To arrhythmias, but, I don't think patients would be using it as much to reach those concentration levels. Plus, it's a topical medication, not ingesting it, so it's relatively safe. Since it's applied over the skin and not ingested.
>> Debra Schindler:Is it likely that a plant or fibromatosis patient will, at some point, also be diagnosed with dupuytrens?
>> <dr. carroll="" paul=""></dr.>:There is a high correlation between the two. At least 25% to 50% of patients with duputrins also have plantar fibromatosis. So there is a high, incidence between the two of patient having both.
>> Debra Schindler:Okay. Ah. What recommendations do you make for shoes?
>> <dr. carroll="" paul=""></dr.>:I generally recommend, orthotics, so I recommended as a first line treatment, a custom orthotic. That's something that doesn't bend, it's rigid. And patients will actually cut a hole where they have the fibroma slightly larger to the fibromya itself. So when they walk, that mass sits inside the hole, so when they walk, there's not putting any pressure on it. And I also recommend a well supported sneaker, something with extra cushion to it to help, with shock absorption. Flatter shoes tend to be a lot more, painful for patients just because there's not enough cushion there, and they're walking more directly on the mass.
>> Debra Schindler:It doesn't sound like there's a whole lot of great options for treating this. What do you tell your patients?
>> <dr. carroll="" paul=""></dr.>:So I tell my patients. Exactly what you said. Unfortunately, there's not that many great options. Surgical excision can lead to reoccurrence, and sometimes these masses can come back more painful and larger than before. I try to tell patients, the sooner we identify this, the sooner we can start conservative treatment and start with orthotics. I offer patients hyaluronidase injections in the first visit, even if it's a small, pea sized mass. They're coming here because something is bothering them. And we can shrink it down, not totally get, remove it, but get it down to where it's not symptomatic for the patients or not noticeable. Then I switch patients over to the topical verat mil gel. I say, as a prevention, use, this once or twice a day. Unfortunately, it's going to be, indefinitely, and this will help prevent it from reoccurring.
>> Debra Schindler:That's good to know that there's some prevention. What about, the risk factors you mentioned, alcohol, and alcohol abuse could lead to a, fibroma. What other risk factors are there that people might avoid?
>> <dr. carroll="" paul=""></dr.>:Uncontrolled diabetes, tends to have a higher incidence of, plantar fibromatosis. So controlling your diet, if you're a diabetic, controlling diabetes, unfortunately, one risk factor that you can't control is genetics. So if you have a family member who has this, you're at risk of getting that, too. That's something. Unfortunately, you can't control phenobarbital, which is a medication, but long term use of that. So if you're on that, I wouldn't say that's a high correlation between the two, but it can, and then obesity. So losing weight will definitely help prevent this. And if you do develop it, it'll help minimize, how painful it is.
>> Debra Schindler:What's the worst case that you've ever seen?
>> <dr. carroll="" paul=""></dr.>:Unfortunately, I've seen patients who've had multiple surgeries to excise or remove these masses, and they've reoccurred. a lot of times they reoccur, even after removing the plantar fascia. They're just removing all in the bottom of the foot so patients can get this outside of the ligament. I've seen patients who've gotten on their toes, their heel, and it's extremely painful. These masses are really solid, and painful. Some patients have undergone the radiotherapy, and they have that burning, they have tingling, they have the chronic pain from that as well. Multiple surgeries lead to a lot of scar tissue. So multiple surgeries and revisions, I've seen these patients come in, it's been debilitating.
>> Debra Schindler:You mentioned that you're getting ready to publish on treatment of, fibromatosis, but what else is in the works? What needs to happen for there to be more effective treatments?
>> <dr. carroll="" paul=""></dr.>:So that's a great question. march of this year, I actually was presenter at the CMS.
>> Debra Schindler:Ah.
>> <dr. carroll="" paul=""></dr.>:Or the Centers for Medicare Services Maintenance committee for their ICD tenco. So every disease or every issue has got a number and a labeling number which that could be identified, with a certain condition. And I currently was advocating for the creation of a new ICD, tencor, a nice association with this condition, because right now it shares the same identification as plantar, fasciitis, which probably is the reason why it doesn't get that much attention, because the same code that you use to identify plantar fasciitis is the same code that you would use to identify plantar fibromatosis. So I'm hoping that goes through where they create a whole separate identification for this, and that might gain some traction for companies to really invest into looking at this. I think that this condition is much more common than what is currently documented. We don't really know because we don't really have a good way of tracking it. And this is, you know, creating its own unique identifying number will help with that. I'm also looking into other, less invasive surgical treatments, something called endoscopic excision, meaning make small incisions. We stick a camera into the foot where we actually excise around it, and we add in one of these adjunct therapies, like a hyaluronidase or a collagenase after that to minimize the reoccurrence of it, too. So that's something that I've been, interested in looking at. But hopefully we can get a unique identifier for the plantar fibromatosis so it can gain attention.
>> Debra Schindler:I think that it was interesting that you said that there are a lot more cases than may be documented, since when you google it, there was 200,000 patients, perhaps, in the United States with, fibromatosis. But what made you want to talk about it today?
>> <dr. carroll="" paul=""></dr.>:Great question. I think what really, struck my interest in this condition? Washington. The lack of, treatment options, as well as some clinical providers are just unfamiliar with the condition, and there's a lot of patients suffering from this. And I really, dug into the literature and really went out and see what was out there. and there wasn't much. However, I, have been working with a doctor out in San Antonio, Texas, who's been, really had success with hyaluronidase injections, and he's been doing this for 20 years, and been in contact with him over the past several years. And we're actually working on publishing a paper on this technique. and there's been promising results. These, injections are a series of injections, usually three weeks apart, and they work on softening up the soft tissue mass, or the plantar fibroma, and shrinking, and not completely having it go away, but to the point where it's not symptomatic anymore for the patients, we've had patients who it's never come back for, or we've had patients, you know, five years down the road have start to get a reoccurrence, and then they go through another series of injections and they do well. It avoids surgery, it avoids scarring, the lesions don't come back as aggressive as you would see in surgical excision. And, a lot of times we have patients use the topical verapamil 15, percent gel, which is, one of the get at a compounding pharmacy, and they use it indefinitely. They use it twice, once, twice, sometimes even three times a day, and they hadn't had reoccurrence. So there is, some promising treatments that we really need to look into this more. So we're hopeful that this can provide a good solution for patients who are suffering, from this condition.
>> Debra Schindler:How does the gel work when it's under the skin?
>> <dr. carroll="" paul=""></dr.>:Yes. So it's a transdermal gel, meaning it goes through the, protective layer of the skin. And a lot of these plantar fibromas are relatively close to skin, so they're attached, they have extensions to the skin. Majority the time they don't, but they're still close proximity, and the effects of the gel are localized, and they get down to that superficial, or that shallow layer where the fibroma sits. So, because of how close it is to the skin, this gel has been shown to have concentrations around the mass which impact its growth, and has been helpful for patients.
>> Debra Schindler:Any final thoughts or takeaways for listeners?
>> <dr. carroll="" paul=""></dr.>:If you see or feel something on the bottom of your foot, I would recommend getting it investigated either by your primary care doctor, podiatrist, or, another healthcare specialist. A majority of time, it's probably going to be a benign fibroma, or one the less common, like a lipoma. but get it taken a look at, and if it becomes symptomatic, just make sure, you know, you find someone who is knowledgeable in this condition. It's fairly rare. getting to the right provider, and starting treatment early can really help minimize later on of having debilitating pain or a need for a surgical intervention. My fellowship was in an orthopedic group. I developed more of a passion for treating plantar fibromatosis with leader host disease, and I worked with an orthopedic oncologist, and I published on that. And then after fellowship, being out in practice, seeing these patients and actually seeing that there was a, there was a need for patients to get treated for this, as a lot of providers are not familiar with the condition, and so these patients have been living with pain. So I kind of really developed a passion in residency, as well as when I've been in practice here at MedStar.
>> Debra Schindler:I look forward to seeing where you take it in the future, and maybe we can talk again when you have some more information for us or some updates for solutions and remedies.
>> <dr. carroll="" paul=""></dr.>:Absolutely. More than happy to.
>> Debra Schindler:Thank you.
>> <dr. carroll="" paul=""></dr.>:Thank you for having me.
>> Debra Schindler:We've been talking with doctor Paul Carol at MedStar, Franklin Square Medical center in Baltimore. If you would like more information on plantar fibromatosis, or if you have any foot or wound concerns, call the MedStar Health Wound Healing Institute at 839 6863.
