Ledderhose's disease
2392601
225233294
2008-07-12T16:32:19Z
99.132.202.42
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'''Ledderhose's Disease''', also known as '''Morbus Ledderhose''', '''plantar fibromatosis''', and '''plantar aponeurosis''', is a relatively uncommon<ref name="scidir">{{cite journal|author=Sharma S, Sharma A|title=MRI diagnosis of plantar fibromatosis—a rare anatomic location|journal=The Foot|volume=13|issues=4|pages=219–22|year= 2003|doi=10.1016/S0958-2592(03)00045-2}} <!--not indexed for PMID--></ref> non-malignant thickening of the feet's deep connective tissue, or [[fascia]]. In the beginning, where nodules or cords start growing along [[tendon]]s of the foot, the disease is minor, can be painful. Eventually, however, the cords thicken, the toes stiffen and bend, and walking becomes painful. The disease is named after [[Dr. Georg Ledderhose]], a [[Germany|German]] surgeon who described the condition for the first time in 1894.<ref>{{cite journal|author=Ledderhose G|title= Über Zerreisungen der Plantarfascie|journal=Arch Klin Chir|year=1894|volume=48|pages=853–856}}</ref><ref name="patuk">{{cite web |url=http://www.patient.co.uk/showdoc/40001213/ |title=Dupuytren's contracture - Patient UK |accessdate=2007-12-27 |format= |work=}}</ref> A similar disease is [[Morbus Dupuytren|Dupuytren's disease]], which affects the hand and causes bent hand or fingers.
As in most forms of [[fibromatosis]], it is usually benign and its onset varies with each patient.<ref name="bun">{{cite web|author=Bunion Busters|url=http://www.bunionbusters.com/footcare/plantar_fibromatosis.asp |title=Plantar fibromatosis |accessdate=2007-12-27}}</ref> The nodules are typically slow growing<ref name=scidir/><ref name=bun/> and most often found in the central and medial portions of the plantar fascia<ref name=scidir/>. Occasionally, the nodules may lie dormant for months to years only to begin rapid and unexpected growth.<ref name=bun/> It need only be surgically removed if discomfort hinders walking.<ref name=flatt>{{cite journal |author=Flatt AE |title=The Vikings and Baron Dupuytren's disease |journal=Proc (Bayl Univ Med Cent) |volume=14 |issue=4 |pages=378–84 |year=2001 |pmid=16369649 |doi=}} {{PMC|1305903}}</ref>
==Symptoms==
Plantar fibromatosis is most frequently present on the medial border of the sole, near the highest point of the arch.<ref name=flatt/> The lump is usually painless<ref name=flatt/> and the only pain experienced is when the nodule rubs on the shoe or floor.<ref name=bun/> The overlying skin is freely movable, and contracture of the toes does not occur in the initial stages.<ref name=flatt/>
The typical appearance of plantar fibromatosis on [[Magnetic resonance imaging]] (MRI) is a poorly defined, infiltrative mass in the aponeurosis next to the plantar muscles.<ref name="rad">{{cite web|url=http://rad.usuhs.edu/medpix/tf_case.html?&imageid=11390&pt_id=4777&topic_id=3914&quiz=no#discuss|title=Plantar fibromatosis MedPix -- Case - 4777|author=Valentine W. Curran|publisher=Dept of Radiology and Radiological Sciences, Uniformed Services University|accessdate=2007-12-28}}</ref>
Only 25% of patients show symptoms on both feet (bilateral involvement). The disease may also infiltrate the [[dermis]] or very rarely the flexor tendon sheath<ref name="whl">{{cite web|url=http://www.wheelessonline.com/ortho/ledderhose_disease_plantar_fibromatosis|title=Ledderhose Disease: plantar fibromatosis - Wheeless' Textbook of Orthopaedics|author=Jan Van Der Bauwhede MD|accessdate=2007-12-28}}</ref>
==Risk Factors==
{{see also|Dupuytren's contracture#Risk factors and possible causes}}
The histological and ultrastructural features of Ledderhose and Dupuytren's disease are the same, which supports the hypothesis that they have a common etiology and pathogenesis.<ref name=whl/> As with Dupuytren's disease, the root cause(s) of Ledderhose's disease are not yet understood. It has been noted that it is an inherited disease and of variable occurrence within families, ie. the genes necessary for it may remain dormant for a generation or more and then surface in an individual, or be present in multiple individuals in the same generation with varying degree.<ref name="drg">{{cite web|url=http://www.drgreene.org/body.cfm?id=21&action=detail&ref=649|title=Dupuytren's Contracture and Plantar Fibromatosis|author=Alan Greene MD FAAP|accessdate=2007-12-28}}</ref>
There are certain identified risk factors. The disease is more commonly associated with -
*A family history of the disease<ref name=drg/>
*Higher incidence in males<ref name=rad/>
*[[Dupuytren's contracture|Palmar fibromatosis]] 10-65% of the time.<ref name=rad/>
*[[Peyronie's disease]]<ref name=whl/>
*[[Epilepsy]] patients<ref name=flatt/>
*Patients of [[diabetes mellitus]]<ref name=whl/>
There is also a suspected, although unproven, link between incidence and [[alcoholism]], [[smoking]], [[liver]] diseases, [[thyroid]] problems, and stressful work involving the feet.
==Treatment==
Although the origin of the disease is unknown, there is speculation that it is an aggressive healing response to small tears in the plantar fascia, almost as if the fascia over-repairs itself following an injury.<ref name=bun/>
In the early stages, when the nodule is single and/or smaller, it is recommended to avoid direct pressure to the nodule(s). Soft inner soles on footwear and padding may be helpful.<ref name=bun/>
MRI and sonography (diagnostic ultrasound) are effective in showing the extent of the [[lesion]], but cannot reveal the tissue composition. Even then, recognition of the imaging characteristics of plantar fibromatoses can help in the clinical diagnosis.<ref name=scidir/>
Surgery of Ledderhose's disease is difficult because tendons, nerves, and muscles are located very closely to each other. Additionally, feet have to carry heavy load, and surgery might have unpleasant side effects. If surgery is performed, the biopsy is predominantly cellular and frequently misdiagnosed as [[fibrosarcoma]].<ref name=flatt/> Since the diseased area (lesion) is not encapsulated, clinical margins are difficult to define. As such, portions of the diseased tissue may be left in the foot after surgery. Inadequate excision is the leading cause of recurrence.<ref name=scidir/><ref name=rad/>
Post-surgical radiation treatment may decrease recurrence.<ref name=rad/> There has also been variable success in preventing recurrence by administering [[gadolinium]].<ref name=rad/> Skin grafts have been shown to control recurrence of the disease.<ref name=drg/>
In few cases shock waves also have been reported to at least reduce pain and enable walking again.{{Fact|date=December 2007}} Currently in the process of FDA approval is the injection of [[collagenase]].{{Fact|date=December 2007}} Recently successful treatment of Ledderhose with [[cryosurgery]] (also called cryotherapy) has been reported.{{Fact|date=December 2007}}
Cortisone injections, such as [[Triamcinolone]],<ref name=patuk/> and [[clobetasol]] ointments<ref name=drg/> have been shown to stall the progression of the disease temporarily, although the results are subjective and large-scale studies far from complete. The nonsurgical treatments, radiotherapy and injections of [[superoxide dismutase]], have proven to be unsuccessful in curing the disease.<ref name=drg/>
==See also==
*[[Fibromatosis]]
*[[Dupuytren's contracture]]
*[[Plantar fasciitis]]
==References==
{{reflist}}
==External links==
* [http://www.dupuytren-online.info/morbus_ledderhose.html Official Dupuytren Society Website] Describes treatments for Ledderhose's disease.
* [http://www.patient.co.uk/showdoc/40001213/ Peer-reviewed write-up of the disease and associated conditions]
* [http://www.wheelessonline.com/ortho/ledderhose_disease_plantar_fibromatosis Wheeless'textbook of orthopaedics: Ledderhose disease]
[[Category:Rare diseases]]
[[de:Morbus Ledderhose]]
[[nl:Ziekte van Ledderhose]]