eMedicine Specialties > Dermatology > Benign Neoplasms

Plantar Fibromatosis: Differential Diagnoses & Workup

Author: Firas G Hougeir, MD, Staff Physician, Department of Dermatology, Mayo Clinic Scottsdale
Coauthor(s): Jose M Mascaro, MD, MS, Chairman, Professor, Department of Dermatology, Hospital Clinic, University of Barcelona, Spain
Contributor Information and Disclosures

Updated: Jun 30, 2009

Differential Diagnoses

CHILD Syndrome

Other Problems to Be Considered

Scar and keloid
Sarcoma
Fasciitis
Neurofibroma
Achromic neuroid nevus and malignant melanoma
Serous tendinous cyst
Mucoid cyst
Calcinosis
Osteoma and calcaneus spur
Gout

Clinically, Ledderhose disease can be confused with posttraumatic neuroma. However, Ledderhose disease is usually bilateral, although one side may be more prominent than the other. Clear cell sarcoma must be considered when MRI findings lead to the diagnosis of Ledderhose disease.

Superficial plantar fibromatosis must be distinguished from the other types of fibromatoses (eg, juvenile aponeurotic fibroma, aggressive infantile fibromatosis), but, even histologically, this identification is often not easy. Other conditions that may mimic superficial plantar fibromatosis are deep granuloma annulare, calcinosis, mucoid cyst, and Darier-Ferrand dermatofibrosarcoma (dermatofibrosarcoma protuberans). Granuloma annulare usually involves more than one element. Calcinosis and osteoma feel harder than superficial plantar fibromatosis and are easily visible on radiographs. Mucoid cysts are renitent. They grow relatively slowly, and their sizes vary; however, the differences in size are seen on a weekly, not necessarily daily, basis. Darier-Ferrand dermatofibrosarcoma usually involves pigmented overlying skin and has a slower evolution. In any case, biopsy is necessary to confirm the diagnosis.

Hamartomatous plantar fibromatosis must be distinguished from neurofibroma, neurofibromalike melanocytic nevus, and melanoma arising in a neurofibromalike nevus. The correct diagnosis can be obtained only with microscopic examination.

Workup

Imaging Studies

  • MRI is useful in detecting plantar fibromatosis. Images show some signal intensity heterogeneity and, usually, infiltrative margins.4 MRI can show the degree of deep invasion of the plantar fibromatosis, which often reaches the aponeurosis.5
  • The MRI signal intensity and the consistency of the clinical location of Ledderhose disease enable the diagnosis to be made with reasonable confidence. However, one must consider the diagnosis of clear cell sarcoma in the differential. In effect, the 2 entities can have similar MRI findings and clinical locations.
  • For fluorine-18 fluorodeoxyglucose (FDG) imaging, see Scheler et al.6

Histologic Findings

All types of plantar fibromatosis have a dense fibrocellular tissue with mature collagen and fibrocytes in various stages of maturation, but they do not have prominent atypical features or abnormal mitotic activity. The overlying epidermis and superficial dermal tissue are usually normal, but the neoformation, which grows upward and downward, generally replaces the adipose tissue. The proliferation often involves many cellular foci surrounded by fibrous scarlike connective tracts.

In superficial plantar fibromatosis, the limits are usually undefined. Some areas may be almost acellular, with a scarlike appearance. In other areas, or in the most active early cases, the fibrocytic component can be dense, with cells closely packed together; the differential diagnosis with fibrosarcoma can be difficult in these cases. The reticulin network is often prominent. Usually, inflammation-associated infiltrate is not present. The connective stroma may involve various aspects. The stroma may be dense and fibrous; less commonly, it is loose. Sometimes, myxoid or chondroid areas can be seen. Vascularization is not a prominent feature. Local nerves and Vater-Pacini corpuscles can seem to be increased in number or size.

In juvenile aponeurotic fibroma, the cells are round or oat-shaped, and the stroma is chondroid (cartilage analogue fibromatosis). Aggressive forms are usually more cellular and have increased mitotic activity. Peripherally, the proliferation is poorly limited and penetrates the neighboring structures. Hamartomatous cerebriform plantar fibromatosis has a variable fibromalike, lipomatous, angiolipomatous, or combined structure.

The myofibroblast is the key proliferative cell in some so-called fibromatoses; therefore, these might be better named myofibromatoses. In these fibromatoses, results of tests for cytologic markers in muscle cells are positive.

In recurrent plantar fibromatosis, as in aggressive fibromatosis, tumoral cells express platelet-derived growth factor-B (PDGF-B) proto-oncogene.7 This proto-oncogene encodes the B chain of PDGF-B, a mitogen for fibrocytes, whereas normal plantar fascia, nonrecurrent plantar fibromatosis, and scars do not. Thus, the detection of PDGF-B may be a useful adjunct to the pathologic evaluation of invasive plantar fibromatosis for prognostic purposes.

Osseous metaplasia and distinct multinucleate giant cells have been reported in Ledderhose disease.8,9

More on Plantar Fibromatosis

Overview: Plantar Fibromatosis
Differential Diagnoses & Workup: Plantar Fibromatosis
Treatment & Medication: Plantar Fibromatosis
Follow-up: Plantar Fibromatosis
Multimedia: Plantar Fibromatosis
References
Further Reading
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References

  1. McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain--plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. Apr 2008;38(4):A1-A18. [Medline].

  2. Wiedemann HR, Burgio GR, Aldenhoff P, Kunze J, Kaufmann HJ, Schirg E. The proteus syndrome. Partial gigantism of the hands and/or feet, nevi, hemihypertrophy, subcutaneous tumors, macrocephaly or other skull anomalies and possible accelerated growth and visceral affections. Eur J Pediatr. Mar 1983;140(1):5-12. [Medline].

  3. Montgomery E, Lee JH, Abraham SC, Wu TT. Superficial fibromatoses are genetically distinct from deep fibromatoses. Mod Pathol. Jul 2001;14(7):695-701. [Medline].

  4. Morrison WB, Schweitzer ME, Wapner KL, Lackman RD. Plantar fibromatosis: a benign aggressive neoplasm with a characteristic appearance on MR images. Radiology. Dec 1994;193(3):841-5. [Medline].

  5. Bancroft LW, Peterson JJ, Kransdorf MJ. Imaging of soft tissue lesions of the foot and ankle. Radiol Clin North Am. Nov 2008;46(6):1093-103, vii. [Medline].

  6. Scheler J, Rehani B, Percy T, et al. Increased F-18 FDG uptake on positron emission tomography/computed tomography imaging caused by plantar fibromatosis. Clin Nucl Med. Apr 2008;33(4):280-1. [Medline].

  7. Alman BA, Naber SP, Terek RM, Jiranek WA, Goldberg MJ, Wolfe HJ. Platelet-derived growth factor in fibrous musculoskeletal disorders: a study of pathologic tissue sections and in vitro primary cell cultures. J Orthop Res. Jan 1995;13(1):67-77. [Medline].

  8. DeBrule MB, Mott RC, Funk C, Nixon BP, Armstrong DG. Osseous metaplasia in plantar fibromatosis: a case report. J Foot Ankle Surg. Nov-Dec 2004;43(6):430-2. [Medline].

  9. Evans HL. Multinucleated giant cells in plantar fibromatosis. Am J Surg Pathol. Feb 2002;26(2):244-8. [Medline].

  10. van der Veer WM, Hamburg SM, de Gast A, Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. Aug 2008;122(2):486-91. [Medline].

  11. Wapner KL, Ververeli PA, Moore JH Jr, Hecht PJ, Becker CE, Lackman RD. Plantar fibromatosis: a review of primary and recurrent surgical treatment. Foot Ankle Int. Sep 1995;16(9):548-51. [Medline].

  12. [Guideline] American College of Radiology. ACR Appropriateness Criteria chronic foot pain. American College of Radiology. 2005.

  13. [Guideline] American College of Occupational and Environmental Medicine. Ankle and foot complaints. American College of Occupational and Environmental Medicine. 2004.

  14. Allen PW. The Fibromatoses: A clinicopathological classification based in 140 cases. Am J Surg Path. 1977;1:305-21.

  15. Allen RA, Woolner LB, Ghormley RK. Soft-tissue tumors of the sole; with special reference to plantar fibromatosis. J Bone Joint Surg Am. Jan 1955;37-A(1):14-26. [Medline].

  16. Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int. Jan 1999;20(1):13-7. [Medline].

  17. Enzinger FM, Weiss SW. Fibrous proliferations of infancy and childhood. In: Soft Tissue Tumors. St Louis: Mosby; 1983.

  18. Fetsch JF, Laskin WB, Miettinen M. Palmar-plantar fibromatosis in children and preadolescents: a clinicopathologic study of 56 cases with newly recognized demographics and extended follow-up information. Am J Surg Pathol. Aug 2005;29(8):1095-105. [Medline].

  19. Godette GA, O'Sullivan M, Menelaus MB. Plantar fibromatosis of the heel in children: a report of 14 cases. J Pediatr Orthop. Jan-Feb 1997;17(1):16-7. [Medline].

  20. Mascaro JM, Torres V. Juvenile fibromatosis. Proceedings XV World Congress of Dermatology in Mexico. 1976;63-6.

  21. Pickren JW, Smith AG, Stevenson TW. Fibromatosis of the plantar fascia. Cancer. 1951;4:846.

  22. Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int. Jul 2000;21(7):563-9. [Medline].

  23. Shapiro L. Infantile digital fibromatosis and aponeurotic fibroma. Case reports of tow rare pseudosarcomas and review of the literature. Arch Dermatol. Jan 1969;99(1):37-42. [Medline].

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Further Reading

Clinical guidelines
ACR Appropriateness Criteria® chronic foot pain. 12
American College of Radiology - Medical Specialty Society.  1998 (revised 2005).  7 pages.  NGC:004618

Ankle and foot complaints. 13
American College of Occupational and Environmental Medicine - Medical Specialty Society.  1997 (revised 2004).  27 pages.  NGC:004757

Clinical trials

Health-Related Quality of Life in Patients With Dupuytren's Disease

Effects of Steroid Injection With Percutaneous Needle Aponeurotomy in Dupuytren's Contracture

Study of Proteus Syndrome and Related Congenital Disorders

Related eMedicine topics
Dupuytren Contracture (Dermatology)

Dupuytren Contracture (Orthopedic Surgery)

Dupuytren Contracture   (Physical Medicine and Rehabilitation)

Plantar Heel Pain

Skin Malignancies, Merkel Cell Carcinoma and Rare Appendageal Tumors

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Keywords

plantar fibromatosis, PF, juvenile fibromatosis, JF, Dupuytren palmar contracture, DC, Ledderhose disease, LD, juvenile aponeurotic fibroma, JAF, infantile fibromatosis, aggressive infantile fibromatosis, AIF, superficial fibromatosis, SF, cerebriform mesodermic hamartomas, Proteus syndrome, PS, fibromas, desmoid tumors, Gardner syndrome, GAF, Gardner syndrome–associated fibromatosis, deep fibromatosis, DF, hamartomatous fibromatosis

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Contributor Information and Disclosures

Author

Firas G Hougeir, MD, Staff Physician, Department of Dermatology, Mayo Clinic Scottsdale
Firas G Hougeir, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Jose M Mascaro, MD, MS, Chairman, Professor, Department of Dermatology, Hospital Clinic, University of Barcelona, Spain
Jose M Mascaro, MD, MS is a member of the following medical societies: American Dermatological Association, American Society of Dermatopathology, and International Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Neil Shear, MD, Professor and Chief of Dermatology, Professor of Medicine, Pediatrics and Pharmacology, University of Toronto Faculty of Medicine; Head of Dermatology, Sunnybrook Women's College Health Sciences Center and Women's College Hospital, Canada
Neil Shear, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics, Canadian Dermatology Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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