Treating plantar fibromatosis
It's always great when a patient makes a comment that makes you re-think everything that you've learned about a condition. I was meeting with a patient today who wanted to schedule a surgery and said, "hey doc, can you take a look at this little bump on the bottom of my arch? Is that something that I should have fixed too?" What the patient was describing was a nodule in the mid arch commonly known as plantar fibromatosis. There isn't a consensus in the literature as to the origin of plantar fibromatosis but I think most foot surgeons will agree that plantar fibromatosis is due to a micro tear in the fascia that heals with an over-proliferation of scar tissue. That over-proliferation of scar tissue in the plantar fascia forms the nodule we call plantar fibromatosis. Clinically plantar fibromatosis is easy to differentiate from other conditions that may exhibit swelling in the mid arch. Plantar fasciitis is focal, subdermal, and specific to the medial or central slips of the plantar fascia.
The second thing that most foot surgeons are going to agree upon is that you steer clear of asymptomatic cases of plantar fibromatosis. The re-growth rate of plantar fibromatosis is greater than 25%. It's not uncommon to take a patient back to the OR for an additional resection of the lesion due to re-growth post-surgery.
And that's where my patient had a good point. She said, "isn't surgery just pre-meditated trauma? I mean, isn't what you do to take plantar fibromatosis out just an incentive for the fascia to over proliferate with more nodules?" She has a very valid point. Does trauma fix trauma? I think collectively, we still have a lot to learn about plantar fibromatosis.
So what non-surgical alternatives do we have? The most common non-surgical method used to treat plantar fibromatosis is the use of a supportive insert called an orthotic. Soft inserts like a gel or foam insert don't support the arch enough to unload the fascia. We've had good success in managing the symptoms of plantar fibromatosis with our SOLE Active Insoles and SOLE Active Insoles with Metatarsal Pads. As an option, some prescription orthotic labs create a cut-out in the inserts to accommodate the nodule. I find the primary treatment though is mechanical off-loading of the fascia. This can be accomplished with a semi-rigid carbon graphite orthotic.
So is the trauma of surgery actually a traumatic contributing factor to the proliferation of plantar fibromatosis? Interesting thought. I think that idea is something we'll need to watch in the literature. And maybe in time, just maybe, we'll find a better, non-surgical way to treat plantar fibromatosis.
Jeffrey A. Oster, DPM