Ledderhose’s Disease, also known as Plantar Fibromatosis, is a rare, benign disorder of the foot characterized by the formation of firm fibrous nodules along the plantar fascia. Over time, these nodules may enlarge, causing discomfort, difficulty walking, and sometimes significant functional limitation. Although non-malignant, the condition can be painful and recurrent. Ledderhose’s Disease often coexists with similar fibromatoses—such as Dupuytren’s contracture in the hand and Peyronie’s disease in the penis—suggesting a shared underlying mechanism.
How Common It Is and Who Gets It? (Epidemiology)
Ledderhose’s Disease is relatively rare compared to Dupuytren’s contracture. It typically occurs in middle-aged and older adults, with a higher prevalence in men than women (approximately 2:1 ratio). Bilateral involvement occurs in about 25% of cases. The condition is more common in individuals of European descent and in those with systemic conditions such as diabetes, chronic liver disease, alcohol use, epilepsy, or thyroid dysfunction. Family history of fibromatosis, especially Dupuytren’s, increases susceptibility.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause of Ledderhose’s Disease remains unclear, but it is believed to result from abnormal fibroblast proliferation and excessive collagen (type III) deposition within the plantar fascia. The process mirrors that of Dupuytren’s contracture and Peyronie’s disease.
Risk factors include:
- Genetic predisposition to fibromatoses.
- Chronic microtrauma or mechanical stress to the foot arch.
- Metabolic conditions such as diabetes and hyperlipidemia.
- Lifestyle factors like smoking and alcohol use.
- Medications, particularly anticonvulsants.
Microscopically, the condition progresses through three stages:
- Proliferative phase: Active fibroblast growth with minimal collagen.
- Active phase: Collagen bundles thicken as fibroblasts mature into myofibroblasts.
- Maturation phase: Dense fibrous tissue with large collagen bundles; little cellular activity remains.
How the Body Part Normally Works? (Relevant Anatomy)
The plantar fascia is a thick connective band extending from the heel bone (calcaneus) to the toes, supporting the foot’s arch and absorbing mechanical stress during gait. Nodular thickening within its central portion disrupts normal biomechanics, causing pain, tension, and sometimes reduced flexibility.
What You Might Feel – Symptoms (Clinical Presentation)
Patients typically report:
- Firm, slow-growing nodules in the medial or central arch of the foot.
- Pain on walking or standing, especially when barefoot.
- Tenderness when pressing the sole of the foot.
- In some cases, tightness or restricted toe extension if nodules extend distally.
- The nodules are firm, fixed, and non-mobile, unlike cysts or lipomas.
- Bilateral involvement may occur but is usually asymmetrical.
Symptoms progress gradually over months or years.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is usually clinical, supported by imaging when necessary:
- Ultrasound: Shows well-defined, hypoechoic lesions with heterogeneous internal texture within the plantar fascia. It helps assess size and depth.
- MRI: Used for detailed assessment or surgical planning. Lesions appear low on T1-weighted and variable on T2-weighted images, sometimes enhancing with contrast. MRI can identify multiple nodules and rule out malignancy or cystic lesions.
- Histology (if biopsied): Reveals fibroblastic proliferation with abundant collagen and absence of atypical or malignant cells.
Classification
Ledderhose’s Disease is typically categorized by extent:
- Stage I: Small, localized nodules.
- Stage II: Larger, painful nodules without deformity.
- Stage III: Multiple nodules causing functional limitation or contracture.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Plantar fibroma (isolated benign nodule without progressive fibrosis).
- Ganglion cyst or lipoma (mobile and softer).
- Plantar fasciitis (pain near heel insertion without nodules).
- Soft tissue sarcoma (rare, but must be ruled out in atypical or fast-growing cases).
Treatment Options
Non-Surgical (Conservative) Management
Conservative therapies are first-line and aim to reduce pain, limit progression, and improve function:
- Steroid Injections: Decrease inflammation and temporarily shrink nodules; recurrence is common.
- Topical Verapamil Gel: A calcium channel blocker that inhibits fibroblast collagen production.
- Extracorporeal Shock Wave Therapy (ESWT): Relieves pain and softens nodules, though it doesn’t shrink them.
- Radiotherapy: Effective in early stages to reduce fibroblast activity and nodule growth; side effects include skin dryness or mild irritation.
- Orthotics: Custom arch supports or soft insoles relieve mechanical pressure.
- Physical therapy: Gentle stretching of the plantar fascia improves flexibility and reduces tension.
Surgical Care
Surgery is reserved for severe or refractory cases that fail conservative management.
Procedures include:
- Local Excision: Removal of a single nodule; highest recurrence rate.
- Wide Excision: Removal of affected fascia with surrounding tissue; lower recurrence but higher risk of complications.
- Complete Fasciectomy: Removes the entire plantar fascia; lowest recurrence rate but risks include arch collapse, numbness, or painful scarring.
- Endoscopic Subtotal Fasciectomy: A minimally invasive technique showing promising results with faster recovery and fewer recurrences.
Recovery and What to Expect After Treatment
- After steroid injections or ESWT, most patients notice pain relief within weeks.
- Following surgery, weight-bearing is limited for 2–4 weeks, depending on the extent of excision.
- Full recovery can take up to 3 months.
- Recurrence occurs in up to 60% of cases, especially after limited excision. Long-term follow-up and orthotic support help maintain comfort.
Possible Risks or Side Effects (Complications)
- Painful scarring or nerve injury.
- Flattening of the foot arch (after complete fasciectomy).
- Numbness or altered sensation on the sole.
- Recurrence of nodules, sometimes multiple.
Long-Term Outlook (Prognosis)
Ledderhose’s Disease is benign and non-cancerous but chronic and often recurrent. Most patients achieve good symptom control with conservative care. When surgery is required, wide excision or subtotal fasciectomy offers the best balance between relief and recurrence prevention.
Out-of-Pocket Costs
Medicare
CPT Code 28043 – Excision of Benign Soft Tissue Tumor, Foot; Subfascial (e.g., Plantar Fibromatosis), Less than 1.5 cm: $86.83
CPT Code 28045 – Excision of Benign Soft Tissue Tumor, Foot; Subfascial, Greater than 1.5 cm: $110.01
CPT Code 28060 – Fasciotomy, Plantar, Partial or Complete (Used for Plantar Fibromatosis or Contracture): $118.09
Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover this remaining portion, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans work in coordination with Medicare to fill the coverage gap and lower patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover remaining costs like coinsurance or deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your Ledderhose’s disease developed or worsened due to a work-related injury or repetitive stress, Workers’ Compensation will cover all related medical expenses, including surgery and follow-up care. You will have no out-of-pocket costs, as the employer’s insurance carrier will handle all approved expenses directly.
No-Fault Insurance
If your condition is connected to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative rehabilitation. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on your insurance policy.
Example
Susan Green developed Ledderhose’s disease with painful nodules in her plantar fascia. She underwent partial plantar fasciotomy (CPT 28060) with an estimated Medicare out-of-pocket cost of $118.09. Since Susan had supplemental coverage through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Ledderhose’s disease?
A. Ledderhose’s disease is a rare condition characterized by the development of firm nodules on the plantar fascia of the foot, often causing pain and difficulty walking.
Q. What causes Ledderhose’s disease?
A. The exact cause is unknown, but it is associated with conditions like Dupuytren’s contracture, Peyronie’s disease, diabetes, and epilepsy, and may have a genetic component.
Q. Who is more likely to develop Ledderhose’s disease?
A. It is more commonly seen in middle-aged and older adults, and there may be a higher incidence in men.
Q. What are the symptoms of Ledderhose’s disease?
A. Symptoms include firm, slow-growing nodules in the arch of the foot, pain when walking or standing, and sometimes contractures of the toes.
Q. How is Ledderhose’s disease diagnosed?
A. Diagnosis is primarily clinical, based on physical examination, but imaging like ultrasound or MRI can help confirm the presence and extent of the nodules.
Q. What non-surgical treatments are available for Ledderhose’s disease?
A. Non-surgical options include orthotics, physical therapy, steroid injections, radiation therapy, and shock wave therapy.
Q. When is surgery considered for Ledderhose’s disease?
A. Surgery is considered when conservative treatments fail and the pain or deformity interferes significantly with daily activities.
Q. What does surgery for Ledderhose’s disease involve?
A. Surgery typically involves removal of the affected part of the plantar fascia, which may require careful post-operative rehabilitation.
Q. What is the recovery like after surgery for Ledderhose’s disease?
A. Recovery may involve several weeks of limited weight-bearing and physical therapy to regain function and reduce recurrence risk.
Q. Can Ledderhose’s disease come back after treatment?
A. Yes, there is a risk of recurrence even after surgery, particularly if the underlying contributing factors are still present.
Q. Is Ledderhose’s disease cancerous?
A. No, Ledderhose’s disease is benign and not cancerous, although the nodules can be painful and disabling.
Summary and Takeaway
Ledderhose’s Disease (Plantar Fibromatosis) is a rare, benign condition involving fibrous nodules along the plantar fascia. It commonly affects middle-aged men and may cause pain, difficulty walking, or foot stiffness. Conservative treatments such as steroid injections, orthotics, and shock wave therapy are usually effective, while surgery is reserved for persistent cases. Although recurrence is common, most patients manage symptoms well with ongoing care.
Clinical Insight & Recent Findings
A 2024 case report published in Cureus describes a 60-year-old woman with Ledderhose’s disease who experienced painful nodules along the arch of her foot.
Imaging with ultrasound confirmed a fibrotic nodule within the plantar fascia, but instead of surgery, the team pursued conservative treatment—anti-inflammatory medication, orthotics, and an intensive physical therapy program. After 20 sessions, the patient reported less pain, better mobility, and improved walking.
The study emphasizes that non-surgical care, especially when guided by ultrasound and personalized rehabilitation, can effectively reduce symptoms and improve quality of life in Ledderhose’s disease. (“Study on conservative management of Ledderhose’s disease – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Management involves orthopedic foot and ankle surgeons, podiatrists, and physical therapists. In cases requiring radiotherapy or advanced injections, collaboration with radiation oncologists or pain specialists may be necessary.
When to See a Specialist?
Seek medical evaluation if you develop painful nodules or firmness in the arch of your foot that interferes with walking or standing.
When to Go to the Emergency Room?
Emergency care is rarely needed unless there is acute trauma, infection, or sudden severe pain following an injection or surgery.
What Recovery Really Looks Like?
Conservative treatment usually brings gradual relief within 4–8 weeks. After surgery, full function typically returns within 2–3 months, although physical therapy is often required.
What Happens If You Ignore It?
Untreated Ledderhose’s Disease may lead to worsening pain, functional impairment, or progressive nodule enlargement. However, it remains benign and does not metastasize.
How to Prevent It?
There is no known prevention, but maintaining healthy weight, wearing cushioned footwear, and managing chronic conditions like diabetes or thyroid disease can reduce risk.
Nutrition and Bone or Joint Health
A diet rich in vitamin C, zinc, and omega-3 fatty acids may support collagen balance and reduce inflammation. Avoid smoking and excessive alcohol intake, as both increase fibrotic activity.
Activity and Lifestyle Modifications
Use soft-soled, cushioned shoes to reduce plantar pressure. Stretch the calf and plantar fascia daily. Limit prolonged standing or walking on hard surfaces. After treatment, gradual reintroduction to activity helps prevent recurrence.
Dr. Mo Athar
