A 65-year-old healthy woman presented with a 3-month history of a palpable painful nodule in the left foot. She felt discomfort while walking. There was no family history of similar nodules or history of trauma. The patient was taking no medication.
Physical examination confirmed the presence of a single soft palpable mass on the medial aspect of the plantar arch of the left foot (Figure 1a). Subsequent ultrasound revealed a well-defined fusiform hypoechoic nodule arising within the plantar fascia (PF) of about 1cm (Figure 1b,c). There was no vascular flow on colour Doppler (Figure 1d). The findings were compatible with plantar fibromatosis, also known as Ledderhose´s disease. No further investigation was performed with other imaging techniques.
Ledderhose´s disease, or plantar fibromatosis, is a rare, benign, hyperproliferative disorder of plantar aponeurosis first described in 1894 by Dr Georg Ledderhose [1]. Although its aetiology is not clearly defined yet, it is generally seen in middle-aged and elderly and is more common in men. It is related to other forms of fibrosing disorders, namely Dupuytren´s contracture, Peyronie´s disease, or knuckle pads [2,3]. Other conditions such as repeated trauma, diabetes, alcohol, rheumatoid arthritis, gout, HIV, and epilepsy have also been associated with this entity [2,3].
Ledderhose´s disease is characterized by local proliferation of abnormal fibrosis tissue in the PF, resulting in irregular masses or nodules [4,5]. These nodular lesions may be multiple and bilateral and typically measure less than 3cm in diameter. Normally, it tends to involve the distal two-thirds of the PF, usually in its central bundle [6]. Thus, on physical examination, patients present one or more nodules on the medial aspect of the plantar arch. Patients are normally asymptomatic; however complaints such as pain can occur after standing or walking for a long time or when the lesion enlarges and causes a mass effect or invades adjacent muscles, neurovascular bundles, or tendons [7,8].
The diagnosis is based on the symptoms and imaging modalities, such as ultrasound and magnetic resonance imaging (MRI).
In most cases, ultrasound is the imaging method of choice for initial evaluation; although MRI is effective in assessing the infiltration of surrounding tissues, and, thus, important for preoperative planning, its high cost, and low availability restrain its use [7,9].
Sonographic findings of Ledderhose´s disease typically include a single hypoechoic, well-demarcated, fusiform nodule arising from the PF, with no intrinsic vascularity on colour Doppler [6,8,9]. In our case, since the plantar swelling shows typical features of a plantar fibroma, no further investigation was performed with MRI. However, it is important to be aware of the other differential diagnosis for soft tissue swelling of the sole, ranging from several benign to malignant soft-tissue tumours. If the soft-tissue lesion arises from the plantar fascia, the hypothesis of plantar fasciitis and chronic fascial rupture should be considered. On the other hand, if the lesion arises from the other nonfascial soft-tissue structures, the differential diagnosis should include a ganglion, an inclusion cyst, foreign body granuloma, nerve sheath tumour, clear cell sarcoma or synovial sarcoma [10]. The malignant soft-tissue tumours present as a slow-growing, painless mass with internal vascularity on colour Doppler ultrasound. In these particular cases, and when a plantar nodule shows indeterminate features, MRI should be considered for characterization [10].
Treatment varies according to the evolution of the disease. Initially, conservative therapy such as physiotherapy, the use of appropriate footwear, intralesional injection of corticosteroids, and the use of non-steroidal anti-inflammatory drugs are the treatment of choice [4]. The treatment of painful or disabling lesions could be done by local excision with a wide margin or by radiotherapy. Radiotherapy is the most efficient treatment with the least recurrence rate [11]. In our case, the patient was referred to orthopedics and conservative measures were the treatment of choice.
To conclude, Ledderhose´s disease can cause foot pain, and imaging is often required to confirm the diagnosis. Ultrasound, as an inexpensive, quick, and dynamic imaging technique, should be considered the first choice for assessing this pathology.
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Ledderhose’s disease
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Based on the provided clinical photographs and ultrasound images, a clearly visible, well-defined hypoechoic nodule is noted within the plantar fascia (mainly located in the midfoot region), appearing spindle-shaped and measuring approximately 1 cm. Color Doppler examination shows no obvious blood flow signal within the lesion. This area correlates with the site of the patient’s plantar pain and tenderness. No significant calcification, bony abnormality, or other notable lesion is observed in the local subcutaneous soft tissues.
Proliferative changes of the plantar fascia can present as a hypoechoic nodule often located in the central portion of the fascia. The etiology involves abnormal fibrous tissue proliferation. Clinically, it may belong to the same fibrous proliferative disease spectrum as Dupuytren’s contracture and Peyronie’s disease.
Usually manifests as plantar pain, typically with fascia thickening or localized inflammatory changes, but it rarely forms a distinctly defined nodular lesion.
For example, a ganglion cyst or other benign soft tissue tumor. Clinically, it can appear as a similar nodule, but on ultrasound it often appears anechoic or may show internal septations; some may present minimal blood flow signal.
These lesions often grow slowly or exhibit invasive features. Color Doppler may reveal significant blood flow. The pain characteristics and growth pattern tend to be more aggressive, warranting further MRI evaluation.
Considering the patient’s age, clinical presentation (a painful plantar nodule without obvious trauma history), and ultrasound findings (a spindle-shaped, well-demarcated hypoechoic lesion in the plantar fascia, showing no apparent internal blood flow), the most likely diagnosis is Plantar Fibroma (Ledderhose’s disease). Should suspicious changes arise or if the nature of the mass needs further clarification, an MRI or histopathological examination may be performed.
1. Conservative Treatment:
2. Surgical and Other Treatments:
3. Rehabilitation and Exercise Prescription (FITT-VP Principle):
Throughout the rehabilitation process, adjustments should be made based on individual conditions (e.g., whether there is osteoporosis or cardiopulmonary considerations), and monitoring of pain and gait changes is essential to ensure safety.
Disclaimer: This report provides a medical reference-based analysis using the information currently available. It does not replace in-person consultation or professional medical judgment. If you experience discomfort or have any questions, please seek medical attention promptly and follow the advice of a specialist physician.
Ledderhose’s disease
