British Journal of Radiology (2003) 76, 353-354
© 2003 British Institute of Radiology
doi: 10.1259/bjr/19104283
A lump in the sole of the foot
I D Lyburn1,
R F Gleeson2 and
I Watt1
Departments of 1 Clinical Radiology and 2 Orthopaedic Surgery, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
Correspondence: Current address and address for correspondence Iain D Lyburn, Department of Radiology, Cheltenham General Hospital, Cheltenham, Gloucestershire GL53 7AN, UK
 |
Introduction
|
|---|
A 47-year-old man presented with a 2 cm diameter discrete lump in the longitudinal arch of the right foot. There was no history of trauma. The lump was non-tender and had been present for about 5 years. The patient had bilateral Dupuytren's contracture. A deep trans-contracture release on the right ring finger had been performed 7 years previously. There was no previous medical history of diabetes mellitus or epilepsy. The patient's maternal grandfather had bilateral Dupuytren's contractures.
Physical examination of the hands demonstrated a residual trans-cord affecting the right ring finger and a deep cord in the left little finger. There were no deformities across the metacarpophalangeal or interphalangeal joints and no distal neurovascular deficits. In the medial aspect of the fascia of the right foot a 2 cm diameter nodular firm lump could be palpated. There was no distal neurovascular deficit. No palpable abnormality was found in the left foot.
Further evaluation of the lump in the right foot with MRI was performed (Figure 1
). What is the diagnosis?
View larger version (108K):
[in this window]
[in a new window]
|
Figure 1. MRI of the plantar aspect of the foot (a) T1 weighted image (repetition time/echo time (TR/TE) 540/14 ms) in sagittal plane. (b) T2 weighted image (TR/TE 3500/96 ms) in sagittal plane. (c) T1 weighted image (TR/TE 540/14 ms) in axial plane.
|
|
|
Discussion
|
|---|
The MRI demonstrates a 2 cm diameter lesion in the plantar aponeurosis of mixed heterogeneous, predominantly low signal on T1 weighted and T2 weighted images. In the clinical context the appearances are compatible with plantar fibromatosis (Ledderhose Disease). The lesion in this patient has currently been managed conservatively with orthopaedic footwear.
Plantar fibromatosis is characterized by the replacement of the plantar aponeurosis with fibrous tissue proliferation with subsequent slow invasion of the skin and deep structures. It is related to other superficial fibromatoses such as Dupuytren contracture and Peyronie disease [1]. Dupuytren reporting on contractile plantar and palmer lesions identified a familial tendency and the occurrence of the development of simultaneous abnormalities in the hand and foot [2]. The lesion in the foot was described later in more detail by Ledderhose [3]; plantar fibromatosis is also known as Ledderhose's Disease. Bilateral involvement is seen in 20–50% of cases. Concomitant palmar fibromatosis is seen in 10–65% of patients [1], but the two lesions may occur at separate time intervals with one preceding the other by 10 years.
Plantar fibromatosis seldom has an inflammatory proliferative phase, unlike palmer fibromatosis and although the plantar fascia extends to the plantar capsule of the metatarsophalangeal joints, contracture of the toes rarely occurs [4]. Plantar fibromatosis is often asymptomatic until the lesion has enlarged enough to cause mass effect or invades adjacent neurovascular structures or muscles [5].
Plantar fibromatosis is not usually demonstrable on plain radiographs and radioisotope bone scans demonstrate no increase in activity in the lesion or adjacent bone [1]. On MRI plantar fibromatosis appears as a nodular mass in the aponeurosis in the medial aspect of the foot adjacent to the plantar muscles [1, 5]. The mass may be poorly defined. The signal intensity is typically heterogeneous equal to or less than that of skeletal muscle on T1 weighted and T2 weighted images. Lesions may have high signal intensity on T2 weighted images reflecting increased cellularity and relatively less collagen. Enhancement with gadolinium is variable—marked enhancement is seen in up to 50% of lesions [5].
Clinically a mass on the sole of the foot can be due to various other processes, including leiomyoma, rhabdomyosarcoma, neurofibroma and liposarcoma [1]. In some cases it may be difficult to classify or even identify the lesion; however, correlation of the imaging findings with the patient's clinical history can usually suggest a more specific diagnosis [6]. In the case presented in the context of Dupuytren's contracture the most likely diagnosis is plantar fibromatosis. Fibrosarcomas may have similar appearances on imaging, but arise from muscle and affect the aponeurosis and subcutis secondarily, whereas the nodules of plantar fibromatosis are within the aponeurosis and infiltrate the subcutis.
Plantar fibromatosis with neuromuscular involvement or causing pain may be treated with wide local excision. The rate of local recurrence may be reduced by adjunctive radiotherapy. Lesions with minimal symptoms are usually treated conservatively with orthopaedic footwear [1].
Received for publication November 27, 2001.
Accepted for publication December 17, 2001.
|
References
|
|---|
- Lee TH, Wapner KL, Hecht PJ. Current concepts review: plantar fibromatosis. J Bone Joint Surg (Br) 1993;75:1080–4.[Free Full Text]
- Dupuytren G. Lecons orales de clinique chirurgicale, faites à l'Hôtel-Dieu de Paris. Paris, Germer-Baillière. 1832;5:473–82.
- Ledderhose G. Zur Pathologie der Aponeurose des Fusses und der Hand. Arch Klin Chir 1897;55:694–712.
- Pickren JW, Smith AG, Stevenson TW Jr, Stout AP. Fibromatosis of the plantar fascia. Cancer 1951;4:846–56.
- Morrison WB, Schwietzer ME, Wapner KL, Lackman RD. Plantar fibromatosis: a benign aggressive neoplasm with characteristic appearance on MR images. Radiology 1994;193:841–5.[Abstract/Free Full Text]
- Llauger J, Palmer J, Monill JM, Franquet T, Bagué S, Rosón N. MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 1998;18:1481–98.[Abstract]
Top
Introduction
Discussion
