Therapies for Ledderhose's disease (Plantar fibromatosis or Morbus Ledderhose)

Conservative means to maintain the ability to walk are often the first line of defense against Ledderhose disease. Soft inlays of shoes have proved to reduce pain, sometimes also holes are cut into the inlays or inner soles to reduce pressure on the nodules. Which type of shoes is best suited probably depends on the specific match of foot and shoe. Further information on convenient shoes can e.g. be found in Ledderhose forums.

Besides that, below therapies might help.

Radiation therapy – Can stop the disease progression in the initial stage and can dissolve nodules, if they are still in the initial stage and tiny. In progressed stages with large nodules radiotherapy can shrink nodules in size and relief pain. Radiation therapy is also applied if surgery cannot be repeated anymore due to excessive scar tissue.

Cortizone injection - We have reports that injection of 40 to 80 mg of triamcinolol acetonid (triamcinolone; brand names e.g. Kenalog, Aristocort or Triderm) in the nodule show for some patients suitable result by decreasing both, the volume of the nodule and the pain.

Collagenase injection - Collagenase is used for treating Dupuytren contracture. Initial trials are being performed to evaluate whether this treatment can be used for plantar fibromatosis (Ledderhose disease) as well. No FDA approval yet. So far off-label use has not shown promising results forum.

Cryotherapy (cryosurgery) – We have heard of a few cases where cryotherapy has successfully been used to treat Ledderhose disease (see for example cryo_surgery_david). We view cryotherapy as a potentially promising therapy for Ledderhose but would welcome more documented cases. An overview was given by Terry Spilken on the Miami conference in 2010 (presentation on youtube). More details have been published as chapter "Cryotherapy and other therapeutical options for plantar fibromatosis" in Ch. Eaton et al. (Eds.) "Dupuytren's Disease and Related Hyperproliferative Disorders" (Springer, New York, 2012), p 401-408, available in printed form and as ebook.

Surgery – To our knowledge surgery is the only therapy that can actually remove big Ledderhose nodules. Additionally to the side effects that can appear when operating on a hand (Dupuytren's disease), the foot has to bear heavy weight and gravity pulls blood into it much more than into the hand. Unfortunately you have to expect to use crutches after surgery for quite a while and possibly not being able to drive. While some patients report that after surgery new nodules grew faster and more frequently, others report satisfying results. Some doctors advocate the total removal of the foot's fascia to avoid recurrence (in the same place) and extension (to other areas). We believe that surgery for Ledderhose is overall more critical than for Dupuytren and should be considered as last resort, though still a valuable resort.

Massaging - A few patients reported independently that intense massaging over moghts helped reducing the nodule size and relieved pain. It is unclear whether this would work for everyone and this is not an established therapy but worth mentioning.

Needle aponevrotomy (NA) – Can be useful if the toes are contracted. As this is often not the case and the problems arise rather due to the size of the nodule and its inflammation, NA is rarely applied for Ledderhose Ledderhose disease.

Shock waves – We have heard of cases where shock waves were able to soften Ledderhose nodules and reduce pain. But other patients experienced this therapy as painful and without effect.

NAC - Initial tests with N-Acetyl-L-Cysteine (= NAC, e. g. marketed as ACC) for Dupuytren's disease had shown some good results for Ledderhose but not tested with a larger number of aptients. Very experimental, not an established therapy.

 

Potential conflicts with other medication

Several patients reported that taking glucosamine forstered growth of Ledderhose nodules and cords. This is just anecdotal but patients taking glucosamine, chondroitin or similar medication, might watch whether those affect their Ledderhose disease. Phenobarbital, an epileptical medication, can foster recurrent Ledderhose: Strzelczyk A, Vogt H, Hamer HM, Krämer G. "Continuous phenobarbital treatment leads to recurrent plantar fibromatosis"  Epilepsia. 2008 May 29. The authors summarize "Our case series uniquely demonstrates that continuous phenobarbital treatment leads to recurrent plantar fibromatosis and may result in long-term disability and numerous unnecessary operations." abstract - See also effect_on Dupuytren's.

 

Grades of Ledderhose disease

Contraction is typically less of an issue for Ledderhose's disease than for Dupuytren's contracture. Therefore the extension deficit is not a good measure to classify Ledderhose disease, rather visible characteristics of the tumor are used to describe the grade of Ledderhose. These grades not necessarily resemble development stages of Morbus Ledderhose (as the Tubiana stages of Morbus Dupuytren do). Below classification has been proposed by G. J. Sammarco and P. G. Mangone "Classification and treatment of plantar fibromatosis" Foot Ankle Int. 21 (2000) p. 563-569. It is not directly related to the above mentioned therapies.

Grade 1: FOCAL disease isolated to a small area on the medial and/or central aspect of the fascia, NO adherence to the skin, NO deep extension to the flexor sheath.

Grade 2: MULTIFOCAL disease, with or without proximal or distal extension, NO adherence to the skin, NO deep extension to the flexor sheath.

Grade 3: MULTIFOCAL disease, with or without proximal or distal extension, EITHER adherence to the skin OR deep extension to the flexor sheath.

Grade 4: MULTIFOCAL disease, with or without proximal or distal extension, Adherence to the skin AND deep extension to the flexor sheath.

 


Page last modified: 12/28/2016